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THE 


^TBW  YORK 


\iEDIOAL  JOUENAL 


WEEKLY  REVIEW  OF  MEDICINE, 


EDITED  BY 


FKANK  P.  FOSTEE,  M.B. 


VOLUME  LYIl. 
JANUARY   TO   JUNE,    1893,  INCLUSIVE. 


NEW  YORK: 
D.    APPLETON    AND  COMPANY, 

1,  3,  AND  6  BOND  STREET. 
1893. 


iv 


LIST  OF  ILLUSTRATIONS  IN  VOLUME  LVII. 


[N.  Y.  Med.  Jodb. 


SMITH,  J.  N.,  M.  D.,  Cuba  Landing,  Tenn. 
SOUTHWORTII,  THOMAS  S.,  M.  D. 
*SQDIBB,  E.  H.,  M.  D.,  Brooklyn. 
80NDERN,  FREDERIC  E.,  M.  D. 
SIMROC'K,  JOSEPH,  M.  D. 
STAFFORD,  JAMES.,  M.  D. 
STANTON,  S.  C,  M.  D.,  Chicago. 
STARR,  M.  ALLEN,  M.  D. 
STEINBACH,  L.  W.,  M.  D.,  Philadelphia. 
STERNBERG,  GEORGE  M.,  M.  D.,  U. 
S.  Armv. 

SULLIVAN,  J.  D.,  M.  D.,  Brooklyn. 


SWAIN,  A.  L.,  M.  D.,  New  Haven,  Conn. 

SWIFT,  GEORGE  MONTAGUE,  M.  D. 

TAYLOR,  JOHN  I.,  M.  D. 

*TA  YLOR,  HENRY  LING,  M.  D. 

TAYLOR,  ROBERT  W.,  M.  D. 

TERRY,  SAMUEL  H.,  Brooklyn. 

THOMSON,  W.  H.,  M.  D.,  LL.  D. 

TOWNSEND,  W.  R.,  A.  M.,  M.  D. 

*TUTTLE,  JAMES  P.,  M.  D. 

VAN  WATERS,  C.  C,  M.  D.,  Rensselaer 

Falls,  N.  Y. 
WAGNER,  GEORGE  M.,  M.  D.,  St  .  Louis. 


WAGNER,  CLINTON,  M.  D. 
WEIGEL,  L.  A.,  M.  D.,  Rochester,  N.  Y. 
WELT,  SARA,  M.  D. 
WHITFORD,  WILLIAM,  M.  D.,  Chicago. 
WIGGIN,  FREDERICK  II.,  M.  D. 
WILLIAMS,  II.  U.,  M.  D.,  Btiflalo. 
WILSON,  HAROLD,  M.  I).,  Detroit. 
WOOD,  WALLACE,  M.  D. 
WOOLSEY,  GEORGE,  M.  D. 
*WYCKOFF,    RICHARD    M.,   M.  D., 
Brooklyn. 

WYMAN,  HAL  C,  M.  Sc.,  M.  D.,  Detroit. 


LIST  OF  ILLUSTRATIONS  IN  VOLUME  LVII. 


PAGE 

Dr.  Taylor's  Case  of  Keloid  Facing  1 

Staining  the  White  Blood-corpuscles.    Two  Illustrations.  4 
Gynaecological  Technique,  Gynecean  Hospital,  Philadel- 
phia   55 

External  Perineal  Urethrotomy   7'-* 

Maisonneuve  Urethrotome   79 

Grooved  Tunneled  Staff   79 

Detachable  Retractor   80 

Grooved  Catheter     80 

Cataphoric  Electrode.    Two  Illustrations   112 

Hot-air  Oven   123 

Steam  Steril  zer   12.S 

Instr";r.^ut  for  irrigating  the  Uterus   144 

Pigmentary  Syphilide  Facing  177 

Spotted  Pigmentary  Syphilide  Facing  178 

Retiform  Pigmentary  Syphilide   178 

Pigmentations  Secondary  to  the  Papular  Syphilide   178 

Cylindroids  in  the  Urine.    Nine  Illustrations   186-189 

A  New  Needle   231 

Dilatation  of  the  Cervix  Uteri   240 

Uterine  Dilator   240 

Tumor  of  the  Larynx.    Three  Illustrations   242 

Abdominal  Drain-tube   258 

Nasal  Douche   268 

Rotary  Lateral  Curvature  of  the  Spine.    Twelve  Illustra- 
tions Facing  289 

Rotary  Lateral  Curvature  of  the  Spine   289 

Rotary  Lateral  Curvature  of  the  Spine.    Three  Illustra- 
tions  290 

Plaster-of-Paris  Jacket.    Two  Illustrations   291 

Spinal  Corset   294 

Rotated  Vertebral  Bodies   296 

Correction  of  Nasal  Deformities.   Eight  Illustrations. .  319-321 

Digitalis  and  Chloral  in  Pneumonia.    Five  Charts         324,  325 

Nervous  and  Mental  Mechanism.    Diagram   347 

An  Exencephalus   357 

Electro-magnet   383 

Nasal  Saeptum  Knives     383 

Thermometer  Shield   426 

Sphygmographic  Tracings   430 

Galvano-caustic  Instrument   455 

Nasal  Speculum    455 

Api)endicitiH.    Two  Illustrations   486 

Ilomoeo-osteoplasty.    Four  Illustrations   495,  496 


Induction  Coil   526 

Epithelioma  of  the  Penis   527 

Tattooing  and  its  Removal.    Two  Illustrations   546 

Air  and  Water  Irrigator   579 

Ingrown  Toe  Nail.    Six  Illustrations   580,  581 

Lacrymal  Probe   582 

Rectal  Electrode   585 

Galvanic  Battery   585 

Paralysis  Agitans.    Five  Colored  Illnstrations  Facing  629 

Paralysis  Agitans.    Seven  Sphygmographic  Tracings  ....  630 

Paralysis  Agitans,  Late  Stage   634 

Paralysis  Agitans.    Anterior  Horn  of  Spinal  Cord   635 

Paralysis  Agitans.    Atrophied  Cells   636 

Paralysis  Agitans.    Anterior  Root  of  Spinal  Cord   636 

Multiple  Epithelioma.    Six  Illustrations   639,  640 

Formation  of  the  Medullary  Canal   658 

Epithelium  of  the  Medullary  Groove  of  the  Rabbit   658 

Neuroglia  Cells   658 

Formation  of  Spongioblasts   658 

Spongioblastic  Framework  of  the  Spinal  Cord   659 

Development  of  Neuroblasts   659 

Migration  of  Neuroblasts   660 

Bundles  of  Neuroblasts   660 

Formation  of  Nerve  Roots   660 

Diagram  of  Nerve  Fibers   661 

Roots,  Fibers,  and  Collaterals   661 

Diagram  of  Course  of  Collaterals   662 

Neurons  of  Reflex  Paths  of  Spinal  Cord   662 

Ganglion  Cells  of  the  Earthworm   663 

A  New  Combined  Laryngeal  Dilator  and  Forceps   683 

Section  of  the  Cerebral  Cortex   685 

Psychic  Cells  and  their  Connections   686 

Phylogeny  and  Ontogeny  of  the  Psychic  Cells   686 

Cortical  Currents   686 

Cells  of  First  Cerebral  Layer   687 

Arcuate  Fibers   687 

Commissural  Fibers   687 

Transverse  Section  of  a  Convolution  of  the  Cerebellum.. .  688 

Longitudinal  Section  of  a  Convolution  of  the  Cerebellum.  689 

Olfactory  Bulb   689 

Cross  Section  of  the  Retina   690 

Course  of  Luminous  Impressions   691 

Auditory  Nerve  in  the  Internal  Auditory  Meatus   691 

Terminations  of  Auditory  Nerve   691 


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1 


THE  JSTEW  YORK  MEDICAL 


©riginal  Communications. 


A  REMARKABLE  CASE  OF  KELOID. 
By  R.  W.  TAYLOR,  M.  D., 

SURGEON  TO  BELLEVUE  HOSPITAL,  NEW  TORK. 

Up  to  the  present  time,  according  to  my  reading,  the 
case  of  keloid  published  by  the  late  Dr.  F.  F.  Maury  *  is 
the  most  remarkable  on  record  as  regards  the  size  of  the 
lesion.  In  that  case  the  keloidal  tumor  was  fungoid  in  ap- 
pearance and  of  about  the  size  of  a  tomato.  Other  marked 
cases  have  been  published  in  which  the  lesion,  when  of 
round  form,  has  been  of  about  the  size  of  an  English  walnut, 
or  when  in  the  form  of  a  band  or  stripe  two  or  three  inches 
long  and  perhaps  an  inch  or  more  wide.  As  ordinarily 
seen,  keloid  is,  as  stated  by  Crocker,f  "  a  firmly  elastic  tumor 
of  cicatricial  aspect,  sharply  defined,  springing  up  abruptly 
from  the  healthy  skin,  and  projecting  from  a  sixteenth  to  a 
quarter  of  an  inch  or  more."  From  these  facts  it  will  be 
seen  that  the  case  here  illustrated  and  described  is  a  most 
extraordinary  one,  and  well  worthy  of  being  placed  on  rec- 
ord. The  history  of  the  patient  presenting  these  new 
growths  is  as  follows : 

N.  C,  a  rather  light-coniplexioned  colored  wouum,  is  twenty- 
three  years  old,  born  in  the  United  States,  and  the  mother  of 
three  children.  She  is  perfectly  healthy,  caine  of  good  stock, 
and  knows  of  no  ancestors  or  relatives  who  have  suffered  from 
any  form  of  connective-tissue  new  growths.  When  she  was 
about  ten  years  old  she  suffered  many  hardships,  and  was 
the  drudge  of  the  family,  who  lived  in  Virginia.  The  patient 
was  recjuired  to  go  into  the  woods  for  fuel,  and,  having  no 
clothes  on  above  the  waist  to  protect  her,  was  frecjuently  stung 
and  torn  in  linear  stripes  by  tlie  briers  and  bushes  through 
which  she  had  tediously  and  guardedly  to  make  her  way.  In 
the  excoriations  and  bruises  thus  produced  undoubtedly  origi- 
nated the  irritative  process  which  has  resulted  in  much  marked 
fibro-cellular  new  growth,  as  may  be  seen,  nearly  encircling  the 
patient's  waist.  For  brevity  and  simplicity  we  will  consider  the 
tumors  in  their  order  from  above  downward.  Figs.  1  and  2 
show  a  large,  fist-sized  lobulated  tumor,  which  is  attached  to 
the  right  lobule  in  its  entirety  and  to  a  segment  of  the  helix. 
This  tiimor,  like  the  rest,  is  of  dark-brown  color,  mottled  with 
very  black  spots  and  patches.  It  is  densely  firm,  and  may  be 
said  to  be  moderately  elastic.  It  causes  much  inconvenience 
from  its  weight,  and  forces  the  patient  to  lie  upon  her  back  or 
left  side.  This  tumor  is  the  fourth  of  its  series,  which  are  said 
to  have  been  of  uniform  size.  The  first  one  began  upon  the 
lobule  around  the  hole  pierced  for  an  ear-ring  about  eight  years 
ago.  It  was  removed  seven  years  ago,  and  after  a  short  interval 
evidence  of  return  was  seen,  and  a  new  tumor  developed  in 
about  two  years.  Four  years  ago  tumor  number  two  was  re- 
moved, and  it  was  promptly  followed  by  number  three,  which 
in  turn  was  removed  two  years  ago.  The  third  operation  was 
soon  followed  by  a  fourth  new  growth,  and  to-day  we  see  the 
tumor  here  represented,  wliich  certainly,  judging  by  its  density 
of  texture,  must  weigh  between  half  a  ])ound  and  a  pound. 
Over  the  middle  of  the  left  clavicle  a  Iiickory-nut-sized  keloid 
may  be  seen. 


*  Photographic  Review  of  Medicine  mid  Surgery,  October,  18*70. 
\  Diseases  of  the  Skin,  London,  1888,  pp.  481  et  scq. 


JOURNAL,  jA^rARY  7,  1893. 

The  pedunculated,  lobulated,  and  disc-like  tumors  on  the 
anterior  aspect  of  the  hypogastric  region  and  lateral  portions  of 
the  trunk  are  so  naturally  shown  in  Fig.  1  that  little  descriptive 
text  is  necessary.    The  inspection  of  these  tumors  makes  a 
marked  impression  upon  those  viewing  them.    To  some  they 
give  the  impression  at  first  that  the  woman's  bowels  have  be- 
come extruded,  and  to  the  minds  of  others  the  resemblance  to  a 
mass  of  large  beef  kidneys  is  suggested.    The  tumor  on  the 
left  breast  was  disc-shaped  and  attached  to  the  thin  edge  of  the 
flattened  right  breast.   (It  was  removed  a"  day  or  two  ago.)  The 
mass  of  lobulated  tumors  seated  to  the  right  of  the  median  line 
and  around  the  umbilicus  is  irregular  and,  as  said  before,  very  sug- 
gestive, except  as  to  color,  of  a  conglomeration  of  beef  kidneys. 
Under  the  right  arm  in  Fig.  1  is  seen  an  immense  snake-like 
tumor,  the  other  end  of  which  is  seen  on  the  right  of  the  picture 
in  Fig.  2.    On  the  left  side  we  see  the  end  of  another  long  and 
very  thick  tumor  which  ends  near  the  middle  line  on  the  back. 
A  predecessor  to  this  mammoth  tumor  was  removed  twelve  years 
ago,  but  the  morbid  process  recurred.    These  tumors  on  the 
back  have  suggested  to  several  gentlemen  the  resemblance  to  a 
copperhead  snake  coiled  up.  The  description  given  of  the  color 
and  density  of  the  tumor  upon  the  ear  applies  exactly  to  those 
on  the  trunk.    In  its  development  the  ear  tumor  began  as  a 
single  mass ;  the  trunk  tumors,  however,  began  in  a  congeries  of 
pea-size  masses,  which  grew,  fused  together,  and  developed  into 
the  lesions  depicted. 

During  the  growth  of  tliese  tumors  pain  was  not  present 
until  they  had  reached  such  a  size  that  they  had  become  bur- 
densome. Then,  probably  from]traction  and  upon  pressure,  pain 
of  a  dull,  aching  character  was  felt,  for  which  the  patient  sought 
relief  in  small  but  repeated  doses  of  morphine.  Now  that  she  is 
in  the  hospital  (Bellevue),  we  are  forced  to  give  her  this  narcotic, 
but  it  is  doled  out  very  sparingly.  , 

Microscopical  examination  of  portions  of  the  ablated  tumor 
showed  the  usual  appearances  of  keloid  as  given  in  the  works 
of  Kaposi  and  Croker. 

Such,  then,  is  the  brief  history  of  this  most  remarkable 
case.  The  origin  of  these  tumors  is  undoubtedly  due  to  the 
traumatisms  already  mentioned.  By  the  authors  who  recog- 
nize a  false  and  a  true  keloid  it  will  be  termed  a  case  of  the 
former  variety.  For  my  part,  I  have  never  been  quite  sat- 
isfied with  this  division,  since  the  histological  changes  in 
both  are  precisely  similar,  and  I  am  glad  to  see  that  Crock- 
er *  thinks  that  "  the  distinction  is  probably  more  artificial 
than  real."  The  fact  of  the  matter  is  this  :  If  a  history  of 
traumatism  in  a  given  case  of  keloid  is  obtainable,  it  is  called 
false  keloid ;  if  such  is  absent,  it  is  called  true  keloid.  It  is 
very  probable  that  all  keloids  begin  in  traumatism,  and  that 
in  some  cases  the  local  injury  is  so  slight  and  ephemeral  as 
to  pass  unperceived  and  unappreciated,  and  in  others  that 
the  patient's  memory  is  at  fault  The  rapidity  of  growth 
in  this  case  is  worthy  of  mention. 

It  is  not  unusual  in  keloid  which  has  developed  on  scars 
to  see  multiple  lesions.  In  Schwimmer's  case,  which  is 
probably  one  of  scar  keloid,  there  were  one  hundred  and 
five  lesions.  I  have  a  picture  of  a  patient  of  my  own,  a 
woman  who  suffered  from  a  deep  and  generalized  ulcerative 
syphilide,  in  which  more  than  two  hundred  keloidal  plaques 
formed.  It  must  be  remembered,  however,  that  scar  keloid, 
particularly  in  syphilitic  scars,  is  not  infrequently  of  ephem- 

*  Loc.  cit. 


4 


SOUTH  WORTH:  STAINING  THE  WHITE  BLOOD-CORPUSCLES.       [N.  Y.  Med.  Joue., 


term  simply  descriptive  of  a  condition  and  in  no  sense  im- 
plying any  pathological  change. 

We  now  come  to  the  consideration  of  the  different  kinds 
of  white  cells  found  in  normal  circulating  blood,  and  here 
it  is  that  Ehrlich  and  his  disciples  have  laid  the  foundation 
for  all  subse(|uent  progress  in  the  differentiation  of  five 
cardinal  forms,  the  comprehension  of  which  will  be  facili- 
tated by  reference  to  the  accompanying  schematic  drawing 
(Fig.  1). 


A  I  II  III  IV  V 

Fig.  1.— a,  Red  blood-cell.  White  blood-cellK  :  I,  Lymphocyte.  II,  Large 
uninuclear  leucocyte,  in,  Transitional  form.  IV,  Multiniiclear.  neu- 
trophile  leucocyte  with  «  granulations.  V,  Eosinophile  cell  with  a  granu- 
lations. 

I.  Lymphocytes. — Uninuclear  small  forms,  most  nearly 
approaching  the  red  cells  in  size,  and  having  a  single  deeply 
staining  nucleus  nearly  filling  the  cell  body.  The  proto- 
plasm of  the  latter  is  represented  by  a  faint  circular  rim, 
sometimes  crescentic  and  visible  only  at  one  side,  sometimes 
spindle-shaped,  having  the  nucleus  in  the  middle.  These 
lymphocytes  were  first  proved  by  Virchow  to  be  derived  ex- 
clusively from  the  lymphatic  glands,  whence  their  name. 
They  contain  no  stainable  granules  in  their  protoplasm  and 
constitute  about  twenty  per  cent,  of  the  white  cells  in  nor- 
mal blood.  Einhorn  *  states  that  within  normal  limits  they 
.f  nay  be/'ncreased  even  as  high  as  forty-four  per  cent.,  but 
not  much  decreased.  In  pathological  cases,  however,  their 
number  may  be  markedly  reduced,  not  only  relatively  so  as 
to  be  only  ten  per  cent,  or  even  five  per  cent.,  but  also  ab- 
solutely decreased  (diabetes,  phosphorus  poisoning,  phthi 
sis,  hajmorrhagic  diathesis,  etc.).  In  lymphatic  leucannia 
they  are  both  relatively  and  absolutely  increased,  and  are 
of  great  diagnostic  importance,  fifty  2>er  cent,  or  more  be- 
ing found  in  such  cases,  or  even  ninety-three  per  cent,  in 
one  fatal  case.  In  stained  specimens  the  lymphocytes  vary 
often  considerably  in  different  cases,  sometimes  presenting 
small  dark,  in  others  slightly  larger  and  lighter  nuclei  with 
more  surrounding  protoplasm.  Variations  often  occur  rap- 
idly in  the  same  case,  but  the  significance  of  the  change  is 
not  known.  This  occasionally  complicates  the  usually  easy 
differentiation  of  forms  I  and  II.  In  those  instances  where 
the  cell  body  has  a  spindle  shape  it  perhaps  presents  its 
original  form  in  the  lymph  gland. 

II.  Uninuclear  Leucocytes. — Larger  forms  of  variable  size 
up  to  twice  the  diameter  of  a  red  cell,  having,  when  stained, 
a  single  large  ovoid,  pale  nucleus,  and  a  well-marked  bor- 
der of  protoplasm.  They  are  derived  from  the  medulla  of 
the  long  bones,  and  also,  Ehrlich  maintains,  from  the  spleen 
In  normal  blood  they  are  not  numerous,  constituting  with 
III  only  five  to  seven  per  cent,  of  the  white  cells.  Increased 
numbers  indicate  the  presence  of  cachexia.  No  stainable 
granules  occur  in  the  protoplasm  in  normal  blood. 

III.  Uninuclear  Transition  Form. — This  cell  is  derived 
from  II  and  is  similar  in  size  and  color  to  its  progenitor 


*  Fortschr.  d.  Med.,  iii. 


The  cell  body,  however,  is  sliglitly  smaller  and  its  nucleus 
more  or  less  kidney-shaped,  which  is  the  first  step  toward 
a  division  of  the  nucleus.  According  to  the  degree  of  the 
further  nuclear  development,  it  may  show  the  first  traces  of 
neutrophile  c  granulation  in  the  protoplasm  between  the 
horns  of  the  nucleus.*  Froin  this  is  evolved  the  following 
form,  which  is  the  last  of  this  subseries : 

IV.  Multinuclear  Neutrophile  Form,  with  e  Granulations. 
These  contain  a  nucleus  of  polymorphous  figure  resem- 
bling the  letters  S  V  Y  Z  E,  which  stains  rather  feebly,  or 
else  several  small  darkly  staining  nuclei  just  held  together 
by  threads,  or  in  the  mature  form  entirely  separate.  They 
contain  in  their  protoplasm  numerous  fine  dust- like  granules, 
which  stain  only  with  stains  of  neutral  reaction,  resulting 
from  a  mixture  of  acid  and  basic  colors ;  hence  they  are 
called  by  Ehrlich  polynuclear  neutrophile  cells.  They  are 
of  variable  size,  larger  than  red  cells,  but  smaller  than  the 
large  mononuclear  from  which  they  are  derived.  They 
constitute  sixty-five  to  seventy  per  cent,  of  the  while  cells, 
are  capable  of  emigration  from  the  blood-vessels  into  the 
tissues,  and  are  alone  found  in  pus.  In  leucocytosis  they 
are  the  only  form  of  white  cell  which  is  increased.  The 
neutrophile  granules  are  not  visible  in  unstained  specimens, 
nor  are  they  made  apparent  by  any  other  stains  than  those 
of  neutral  reaction.  Now,  although  the  uninuclear  leu- 
cocyte does  not  show  neutrophilic  granulations,  it  pos- 
sesses all  the  other  morphological  and  microchemical  char- 
acteristics of  the  multinuclear  cell.  In  leucsemic  blood  we 
find  the  links  necessary  to  definitely  determine  their  rela- 
tionship, for  we  find  cells  with  very  sparse  e  granulations, 
which  in  their  habitus  occupy  an  intermediate  position. 
Therefore  Ehrlich  believes  that  the  multinuclear  is  evolved 


Fig.  2  —Drawn  from  a  single  slide.  Showing  development  of  uniuuclear  into 
multinuclear  leucocytes,  a,  lymphocyte,  size  of  red  cell,  introduced  for  ccm- 
pai-ison ;  b,  large  uninuclear  leucocyte  ;  e,  transition  form :  c',  transition 
form  with  neutrophile  granulations  between  the  horns  ;  d  d' d"  d"\  multi- 
nuclear neutrophile  leucocytes  showing  various  stages  in  the  development 
of  the  nuclei  and  the  neutrophile  granulations. 

from  the  uninuclear  form.  He  shows  that  while  the 
original  large  nucleus  of  the  uninuclear  cell  is  developing 
by  the  progressive  stages  above  mentioned  into  the  four 
or  five  nuclei  of  the  multinuclear  form,  other  changes  are 
taking  place  in  the  cell  body  by  which  it  gradually  assumes 
the  neutrophile  granulation,  and  its  protoplasm  acquires  an 
increased  contractility,  which  gives  the  cell  the  amoeboid 
motion  necessary  to  pass  through  the  walls  of  the  vessels 
in  inflammation.  It  seems  probable  that  this  transforma- 
tion or  development  takes  place  after  the  uninuclear  cell 
reaches  the  general  circulation,  and  that  the  blood-forming 
organs  send  out  their  product  as  raw  material  to  be  devel- 

*  Spilling.  Ueber  Blu/uniersuchunyen  bei  Leukdmie.  Inaug,  Diss., 
1880. 


.Ian.  7,  1893.] 


SOUTHWORTH:  STAINING  THE  WHITE  BLOOD-CORPUSCLES. 


5 


ciped  in  the  nutritive  media  of  the  circulating  plasma.  If 
I  his  is  so,  it  follows,  theoretically,  that  altered  conditions 
of  the  plasma  sliould  affect  the  development  of  the  cells. 
This  is  exactly  what  Ehrlich  shows  to  occur  in  severe  ca- 
chexijB  (tuberculosis,  carcinoma),  where  in  the  impoverished 
blood  there  seems  to  be  a  stoppage  or  prolongation  of  the 
developmental  process,  for  in  cachexife  the  uninuclear  out- 
number the  multinuclear  ;  in  leuc;Bmia  the  examples  of  the 
intermediate  stages  are  well  marked  and  very  numerous. 
In  healtli  these  changes  presumably  take  place  so  rapidly  as 
to  disclose  few  traces  of  the  metamorphosis.* 

V.  Eosinophih  Cells  with  a  Oranulations. — These  are 
the  white  cells  which  strike  one  at  once  in  a  fresh  speci- 
men of  blood  as  containing  rather  large,  yellowish,  fat-like 
granules.  They  are  not  related  to  the  former  series  having 
their  origin  in  the  marrow.  Their  granules  are  easily 
stained  by  all  acid  colors,  such  as  eosin,  whence  their  name. 
Thus  stained,  the  granules  appear  of  a  purplish-red  color, 
noticeably  larger  than  those  of  the  neutrophile  cells,  while 
their  nuclei,  one  to  three  in  number,  stain  less  darkly  than 
those  of  the  multinuclear  leucocytes  If  an  eosinophile  cell 
lias  been  broken  in  the  process  of  spreading  the  cover  glass, 
the  granules  lie  loose  in  groups  and  have  been  mistaken  by 
some  observers  for  micrococci.  From  these,  however,  they 
can  be  easily  distinguished  by  their  staining  affinities. 
Eosinophile  cells  are  variously  estimated  as  constituting 
two  to  four  per  cent,  and  five  to  seven  per  cent,  of  normal 
blood.  It  is  probable  that  the  former  figures  are  most  cor- 
rect. They  are  present  in  large  numbers  both  in  blood 
and  sputum  of  asthmatic  patients,  also  in  prostatic  secre- 
tion, and  in  the  blood  of  patients  with  certain  affections  of 
the  skin  (lymphodermia,  pemphigus,  etc.)  ;  therefore  Ehr- 
lich's  f  dictum  that  they  are  formed  exclusively  in  the  mar- 
row, and  that  an  increase  in  their  numbers  points  to  chronic 
changes  in  the  blood-forming  organs,  is  now  under  discus- 
sion. Their  absolute  number  is  often  increased  to  a  high 
degree  in  myelogenous  and  lieno-myelogenous  leucaemia. 
On  the  other  hand,  the  eosinophile  cells  are  decreased  in 
severe  cachexiae  (phthisis,  lupus,  vitiuro  cordis,  anaemia, 
diabetes,  carcinoma  J) — that  is,  in  those  cases  in  which  leu- 
cocytosis  exists  with  increase  of  the  mononuclear  and  poly- 
nuclear  forms.  Von  Jaksch  believed  that  their  increase 
alone,  without  other  changes,  was  presumptive  evidence  of 
beginning  leucaemia,  but  they  have  since  been  found  to  be 
increased  in  numerous  other  conditions.*  Von  Jaksch  also 
bases  the  diagnosis  of  his  anaemia  infantum  pseudo-leu - 
caemica  in  part  upon  their  total  absence  or  greatly  lessened 
numbers.il 

Passing  now  from  the  consideration  of  normal  blood, 
there  remain  to  be  mentioned  several  stainable  forms  which, 
as  they  occur  in  the  blood  only  in  pathological  conditions, 
are  also  of  great  diagnostic  importance. 

Mast-cells,  having  y  granulations,  easily  stainable  in 

*  Ehrlich.    Ij)c.  cit.    Ztschr.  f.  klin.  Med.,  Bd.  i. 
f  Ztschr.  f.  klin.  Med.,  Bd.  i. 

\  Alderhoff.    Pmg.  med.  Woch.,  1891,  No.  8. 

*  Miiller  u.  Rieder.    Archiv  f.  klin.  Med.,  Bd.  48. 

II  Ueber  Dia{;^osis  u.  Therapie  d.  Erkraiik.  d.  Blutes.  Med.  Wander- 
Vortrager,  21,  Berlin,  18'.t<). 


basic  aniline  colors  alone  (basophile),  and  appearing  only  in 
the  blood  during  pathological  processes  (leuctemia),  and 
then  only  in  very  small  numbers.*  They  were  formerly 
supposed  to  be  derived  from  the  lymph  glands.  Ehrlich 
opposes  this  view.  He  has  found  them  in  large  numbers 
in  a  case  of  myelogenous  leucaemia. f 

Myeloci/tes. — These  are  large  uninuclear  cells  differing 
from  those  found  in  normal  blood  in  that  they  contain  e  or 
neutrophile  granulations.  While  they  are  normally  formed 
and  found  in  the  bone  marrow,  in  cases  of  myelogenous 
leucaemia  alone  do  they  escape  into  the  circulating  blood  in 
considerable  numbers.  Their  great  value  in  diagnosis  is  at 
once  apparent.^ 

Nucleated  red  cells,  whose  nuclei  are  stained  by  any  of 
the  agents  which  stain  the  nuclei  of  the  white  cells.  They 
are  easily  distinguished  from  the  latter  cells,  in  that  their 
surrounding  zone  of  protoplasm  takes  the  same  stain  as  the 
haemoglobin  of  the  other  red  cells.  Three  forms  are  distin- 
guished, corresponding  to  the  three  forms,  or  more  properly 
speaking  sizes,  of  non-nucleated  red  cells — microcytes,  nor- 
mocytes, megalocytes — and  are  called  respectively  micro- 
blasts,  normoblasts,  and  megaloblasts.  The  microblast, 
found  and  described  by  Ehrlich,*  is  very  rarely  seen. 
Normoblasts,  as  the  prefix  implies,  are  nucleated  red  cells 
of  the  average  size  of  the  ordinary  red  cell.  The  nuclei 
may  be  uniformly  dark  or  there  may  appear  an  irregular 
and  heavily  beaded  network  upon  a  lighter  background 
within  the  nucleus.  It  is  believed  with  Rindfleisch  that 
the  nucleus  escapes  from  the  red  cell  after  it  is  fully 
formed,  and,  after  gathering  about  itself  haemoglobin  _fp]r 
another  perfect  cell,  again  escapes  to  repeat  the  cycle. 
Free  nuclei  may  often  be  found  in  the  stained  blood  of 
certain  pathological  cases,  and  nucleated  reds  are  likewise 
seen  in  which  the  nucleus  is  of  dumb-bell  shape,  in  the  pro- 
cess of  division,  or  where  it  has  divided  into  two,  three,  or 
four  nuclei  before  escaping.  The  nucleated  red  cell  may 
be  found  in  all  forms  of  advanced  anaemia,  whether  trau- 
matic, secondary,  or  primary  (pernicious) ;  also  in  acute 
metallic  poisoning  (As,  P,  etc.),  and  in  leucaemia. 

Megaloblasts  or  gigantoblasts  are  very  large  nucleated 
red  cells,  having  a  paler  reticulated  nucleus  of  much  larger 
size  than  those  of  the  last  class.  The  surrounding  zone  of 
haemoglobin  also  often  stains  badly  and  has  a  dingier  color. 
Ehrlich  believes  these  to  be  a  return  to  an  embryonal  type. 
It  is  also  thought  that,  after  the  escape  of  the  nucleus  from 
the  cell,  it  dies  and  thus  ceases  to  continue  the  formative 
cycle.  They  are  therefore  pathognomonic  of  very  serious 
disturbance  in  the  cytogenic  organs,  and  are  found  only  in 
the  late  stages  of  leucaemia  and  pernicious  anaemia.  Still 
further,  their  presence  in  the  blood,  taken  together  with 
certain  other  factors,  is  absolutely  necessary  to  the  estab- 
lishment of  the  diagnosis  of  pernicious  anannia. 

Turning  now  to  the  practical  results  of  these  examina- 
tions, we  are  at  once  confronted  by  the  question :  Having 

*  Uehcr  Mcuitzellen.    Inaufc.  Dis.s.,  Berlin,  1880. 
\  Ehrlich.    Beat.  mid.  Work.,  1883,  p.  871. 
\  Ibid. 

»  Ehrlich.  Verhuull.  d.  Gesclhehaft  d.  Charite  Aerztc  z.  Ikrlin, 
1880. 


6 


SOUmWORTH:  STAINING  THE  WHITE  BLOOD-CORPUSGLES.       [N.  Y.  Med.  Jouk., 


discovered  a  certain  combination  of  factors  in  the  condition 
of  the  blood,  what  definite  diagnostic  conclusions  can  be 
drawn  from  it  ?  It  has  not  been  within  the  scope  or  pur- 
pose of  this  paper  to  treat  of  the  familiar  methods  of  esti- 
mating the  corpuscular  richness  of  the  blood  or  the  per- 
centage value  of  its  hiEraoglobin,  the  importance  and  neces- 
sity of  such  estimates  having  been  long  ago  established 
and  conceded.  Nor  is  it  contended  that  a  diagnosis  can  al- 
ways be  made  by  these  methods  of  staining  without  careful 
consideration  of  the  clinical  course  and  objective  symptoms 
in  any  given  case,  but  that  used  to  supplement  the  usual 
methods,  which  too  often  leave  us  in  doubt,  they  are  in- 
valuable in  definitely  confirming  and  often  in  alone  determin- 
ing the  diagnosis.  Eliminating  largely,  therefore,  such 
factors  as  are  still  mooted  and  incorporating  chiefly  those 
which  are  generally  accepted,  we  arrive  at  the  following- 
basis  for  diagnosis  : 

Chlorosis. — Red  cells  in  the  majority  of  cases  nearly 
normal  in  numbers,  of  average  size  and  good  shape,  but  the 
individual  corpuscles  strikingly  pale,  with  relative  decrease 
in  the  percentage  of  haemoglobin.  Rouleaux  well  formed, 
leucocytosis  slight  if  present.  In  rarer  cases  poikilocytosis 
and  marked  reduction  in  the  numbers  of  the  red  cells,  more 
likely  to  be  present  if  the  reduction  in  haemoglobin  is  below 
sixty  per  cent.  This  latter  condition  often  considered  a 
mixed  form  and  called  chloro-ana^mia. 

Simple  Ancemia,  Primari/.* — Decrease  in  the  percentage 
of  red  corpuscles  and  haemoglobin  to  approximately  the  same 
degree.  Variation  in  size  and  shape  of  the  red  cells.  No 
leucocytosis  or  change  in  white  cells. 

Secondary  Ancemia. — Decrease  in  the  percentage  of  the 
red  corpuscles  and  haemoglobin  to  approximately  the  same 
degree.  Imperfect  formations  of  rouleaux.  Leucocytosis, 
hence  increased  numbers  of  polynuclear  neutrophile  cells, 
but  also  numbers  of  large  uninuclear  leucocytes  without 
granulations.  Often  marked  variation  in  the  size  and  shape 
of  the  red  corpuscles,  microcytes  predominating.  Poiki- 
locytosis or  schistocytosis.  Nucleated  red  cells  of  normal 
size  (normoblasts).  The  intensity  of  these  changes  varies 
considerably  with  the  degree  of  the  anajmia. 

Pernicious  Anamia,  Primary. — Rouleaux  not  formed. 
Enormous  decrease  in  the  number  of  red  cells,  with  distinct 
excess  of  the  haemoglobin  percentage.  Very  marked  varia- 
tions in  shape,  poikilocytes  or  schistocytes,  also  in  size 
with  microcytes  and  megalocytes ;  the  latter  largely  pre- 
dominate. Large  red  cells  with  very  large  nuclei,  megalo- 
blasts  or  gigantoblasts.  Never  absolute  leucocytosis.  The 
excess  of  megalocytes  and  presence  of  megaloblasts  are 
considered  to  be  diagnostic. 

Pseudo-leuccemia. — In  the  early  stages  no  noticeable 
change.  In  the  later  stages  well-marked  signs  of  simple 
anjemia,  with  rather  decided  simple  leucocytes,  clearly  dis- 
tinguished, however,  from  leucaemia  by  the  absence  of 
leuctemic  changes  in  the  white  cells. 

Leuccemia  in  General. — The  earliest  sign  in  the  blood 
of  a  beginning  leucaemia  seems  to  be  an  increase  in  the 
eosinophile  cells.    It  has  been  thought  that  in  connection 


with  the  clinical  history  a  probable  diagnosis  could  be  ad- 
vanced upon  this  basis,  but  it  must  be  remembered  that  the 
eosinophile  cells  have  now  been  shown  to  be  increased  in 
many  other  conditions.*  In  advanced  cases  there  is  an  ex- 
cessive and  persistent  increase  of  leucocytes,  the  ratio  of 
white  to  red  varying  from  1  to  20  to  1  to  1.  Reduction  in 
the  red  cells  and  correspondingly  in  haemoglobin.  Faulty 
formation  and  decreased  resistance  in  the  individual  red 
cell,  with  poikilocytosis.  Formation  of  Charcot's  crystals 
in  the  drawn  blood  on  standing. 

Leucaemic  cases  may  be  divided  into  four  classes,  but 
mixed  cases  most  commonly  occur. 

Lymphatic  Leuccemia. — Predominance  of  small  uni- 
nuclear lymphocytes  over  all  other  white  cells.  Eosino- 
phile cells  decreased.  No  nucleated  red  cells.  Proportion 
of  white  to  red  seldom  above  1  to  20,  even  ante  mortem. 
Marked  anaemia. 

Lienal  Leuccemia. — Predominance  of  large  uninuclear 
leucocytes  (without  neutrophilic  granulations).  No  nucle- 
ated red  cells.  No  myelocytes.  No  increase  of  eosino- 
phile cells.  Cases  of  pure  lienal  leucaemia  have  been  re- 
ported, but  the  exclusive  involvement  of  the  spleen  with- 
out the  involvement  of  other  cytogenic  organs  has  been 
denied. 

Myelogenous  Leuccemia. — Characterized  by  the  appear- 
ance of  abnormal  forms — i.  e.,  myelocytes  or  large  uni- 
nuclear leucocytes  with  neutrophilic  granulations  formed  in 
•the  marrow  and  present  in  the  blood.  Eosinophile  cells 
much  increased,  including  large  forms  which  have  escaped 
from  the  marrow.  In  the  earlier  stages  normoblasts ;  in 
the  later  stages  megaloblasts.  In  rare  cases  the  red  cells 
show  division  of  their  nuclei. 

Lieno-myelogenous  Leuccemia. — The  most  common  of 
the  mixed  forms  presenting  the  characteristics  of  both  the 
lienal  and  myelogenous  forms. 

Upon  these  lines  the  diagnosis  of  diseases  of  the  blood 
or  blood-forming  organs  is  becoming  firmly  established. 
The  subject  is  a  living  one.  Each  month  brings  new  light 
and  reveals  further  possibilities.  Questions  once  mooted 
are  passing  from  debatable  ground  into  the  realm  of  cer- 
tainty. To  the  scientific  student  these  methods  of  staining 
open  up  a  most  interesting  and  fascinating  field  for  investi- 
gation. To  the  general  practitioner  and  careful  diagnosti- 
cian the  following  advantages  are  presented  : 

1.  Earlier  and  more  exact  diagnosis. 

2.  More  definite  prognosis. 

3.  More  intelligent  and  therefore  more  active  and  suc- 
cessful therapeutic  efforts. 

Bibliography. 

Elirlich.  Zeitschr.  f.  klin.  Med.,  Bd.  i. —  Farhenanalyt. 
Untersuchungen  z.  Hist.  u.  Klin.  d.  Blutes,  1.  Theil,  Berlin, 
1891. 

Gollasch,  Friedliinder-Eberth.  Milrosk.  Technik,  Berlin, 
1889. 

Neusser.    Wiener  klin.  Wochenschr.^' \9>9'i,  No.  4. 
Aldehoff.    Prag.med.  lfyc/ten.9cAr.,  1891,  No.  8,  p.  92. 
Ehrlich.    Charite-Annalen,  Bd.  v,  1880;   Bd.  x,  1885.— 


*  Von  Limbeck.    Griindrisn  eirur  klin.  Patholoyie  d.  Blutes.   Jena,  1892. 


*  Neusser.    Wiener  klin.  Woch.,  1892,  No.  4. 


Jan.  7,  1893.] 


ROLLER:  SUBCONJUNCTIVAL  USE  OF  COCAINE. 


7 


Archh  f.  Anat.  u.  Physiol.,  187 Q. —Ze Use hr  f.  klin.  Med.,  Bd. 
i,  18S0. 

Mi'iller  unci  Rieiler.    Archivf.  klin.  Med.,  Bd.  xlviii. 
Reinecke.    tortxchr.  d.  Med.,  1889,  iNo.  11,  p.  409. 
Virchow.    Cellular  Puthologi/.— Wir chow' a  Archie,  Bd.  5, 
p.  43. 

Max  Scliultze.    Archiv  f.  mikrosk.  Anat.,  Bd.  i,  p.  1. 

Charcot.    Comp.  rendus  de  la  Societe  de  iiologie,  1853,  p.  49. 

V.  Jakscli.    JTlin.  Diagnostik,  1889. 

Colinheini.    Vircliow's  Archiv,  Bd.  .xl,  p.  1. 

Elirlicli.  Verhandl.  d.  physiol.  Gesellschaft  z.  Berlin, 
1878-79,  No.  8,  No.  20.—  Charite-Annalen,  Bd.  xii,  1887;  Bd. 
xiii,  1888. 

Westplial.    Inaug.  Diss.,  Berlin,  1880. 
Scliwarze.    Inaug.  Diss.,  Berlin,  1880. 
Einliorn.    Fortschr.  d.  Med.,  iii. 
Spilling.    Inaug.  Diss.,  Berlin,  1880. 

Ehrlich.  Deut.  med.  Woch.,  1883,  p.  G7 1. —  Verhandl.  d. 
Gesellschaft  d.  Charite  Aerzte  zu  Berlin  vom  10.  Juni  und  9. 
Dec,  1880. 

V.  Limbeck.  Orundriss  einer  klinischen  Pathologie  des 
Blutes,  Jena,  1892. 

V.  Jaksch.  Ueber  Diagnose  ii.  Therapie  d.  Erkrankungen  d. 
Blutes.    Med.  Wander  Vortrdge,  21,  Berlin,  1890. 

19  West  Forty-sixth  Street. 


THE  SUBCONJUNCTIVAL  APPLICATION  OF 
COCAINE  m  EYE  OPERATIONS.* 
By  carl  roller,  M.  D. 

It  is  now  eight  years  since  I  published  my  first  experi- 
ments about  the  anaesthetic  properties  of  cocaine  and  its 
application  in  eye  surgery.  My  suggestion  to  use  instilla- 
tions of  a  cocaine  solution  to  produce  anaesthesia  for  oper- 
ations on  the  eyeball  met  with  general  approbation,  and 
subsequently  the  usefulness  of  cocaine  in  other  branches  of 
surgery  was  explored  by  other  investigators. 

While  in  general  surgery  the  hypodermic  application  of 
cocaine  for  the  production  of  local  anaesthesia  became  very 
extended,  in  eye  surgery  the  original  method  of  instilling 
was  generally  retained,  as  the  organ  seems  particularly  suited 
for  this  way  of  application. 

Right  in  my  first  experiments  with  animals,  and  later  in 
eye  operations,  I  noticed  the  fact  that  by  instillations  of 
cocaine  we  were  sure  to  achieve  an  anaesthesia  of  the  super- 
ficial tissues  only.  I  could  scratch,  or  burn,  or  cauterize 
the  cornea  without  the  slightest  pain,  but  the  moment  the 
iris  prolapsed  or  was  touched  with  an  instrument,  animals 
and  human  beings  gave  brisk  signs  of  pain.  In  a  great 
number  of  cases  I  succeeded  in  making  the  iris  antesthetic 
by  beginning  the  instillations  half  an  hour  before  the  opera- 
tion, but  I  did  not  succeed  every  time.  In  my  visits  to  eye 
clinics  of  different  countries  I  found  that  only  in  a  very  few 
of  them  were  instillations  begun  a  sufficient  time  before  the 
operation  to  achieve  this  end.  This  circumstance,  in  my 
opinion,  detracts  from  the  value  of  cocaine  auiesthesia  in  a 
great  number  of  eye  operations.    The  patient  does  not  care 


*  Read  before  the  meeting  of  the  American  Ophthalmological  So- 
ciety, at  New  London,  July  21,  1892. 


which  tissue  hurts  him.  He  says  he  has  pain,  and  calls  co- 
caine anaesthesia  a  beautiful  but  delusive  dream.  The  pain 
on  touching  the  iris  is  especially  troublesome  in  cataract  ex- 
tractions. The  patient,  who  has  been  promised  a  painless 
operation  and  did  not  experience  any  pain  in  cutting  the 
cornea,  is  suddenly  thrown  out  of  his  illusions  of  a  painless 
operation,  makes  sometimes  a  sudden  jerk,  and  may  thus 
endanger  the  success  of  the  operation. 

In  squint  operations  one  can  notice  every  time  that  the 
patient  does  not  feel  the  conjunctival  cut,  but  does  react 
quickly  when  the  tendon  is  seized  with  the  hook  or  forceps 
and  divided. 

Very  soon  after  my  first  communication  I  began  using 
subconjunctival  injections  in  squint  operations,  and  during 
my  time  of  assistantship  to  Professor  Snellen  I  performed 
many  tenotomies  and  advancements  of  muscles,  all  with  the 
subconjunctival  application  of  cocaine.  If  the  latter  is  ap- 
plied in  this  way,  the  operation  can  be  made  perfectly  pain- 
less, and  we  have  the  double  advantage  of  sparing  the  pain 
to  the  patient  and  not  bringing  discredit  on  a  good  drug. 

I  proceed  in  the  following  way :  After  having  rendered 
the  conjunctiva  anaesthetic  by  the  instillation  of  a  four-per- 
cent, sol  ution,  I  insert  the  speculum  and,  by  means  of  a  mouse- 
toothed  forceps,  seize  a  fold  of  the  conjunctiva  over  the 
tendon  to  be  operated  upon.  The  needle  of  a  hypodermic 
syringe  is  inserted  through  this  fold  into  the  subconjunc- 
tival tissue  as  deep  as  possible,  and  a  few  drops  of  a  two- 
per-cent.  solution  of  cocaine  are  injected.  For  injections  I 
use  a  two-per-cent.  solution  in  preference  to  a  four  or  five- 
per-cent.  solution.  I  consider  0*05  (two  thirds  of  a  erfin)  _ 
as  the  utmost  limit  for  adults  that  can  safely  be  applied  as 
an  injection  if  the  locality  of  injection  is  on  the  head,  while 
on  the  limbs  double  the  amount  may  be  allowed.  But  I  am 
careful  to  keep  a  good  part  within  this  limit.  With  a  solu- 
tion of  two  per  cent.,  and  even  of  one  per  cent.,  an  entirely 
satisfactory  anassthesia  can  be  produced  if  the  solution  is 
well  distributed  over  the  field  of  operation,  and  I  attribute 
it  to- this  use  of  weak  solutions  that  I  have  not  encountered 
yet  any  alarming  accidents  from  the  use  of  cocaine. 

After  the  injection  the  speculum  is  removed  from  the 
eye  and  the  eye  is  closed,  so  that  the  artificial  oedema  of 
the  conjunctiva  is  given  time  to  disappear,  which  it  does  in 
about  five  minutes.  The  disappearance  may  be  helped  by 
a  little  rubbing.  If  you  have  prepared  a  patient  in  this 
way,  you  can  perforin  the  operation  without  the  slightest 
pain — whether  it  be  tenotomy  or  advancement. 

In  iridectomies  and  cataract  operations  I  have  been  in 
the  habit  of  instilling  a  four-per-cent.  solution  every  five 
minutes,  beginning  twenty  to  thirty  minutes  before  the 
operation.  During  this  time  I  keep  the  eye  closed  to  pre- 
vent evaporation,  with  subsequent  haziness  and  desquama- 
tion of  epithelium.  In  most  cases  I  have  succeeded  fairly 
well  in  making  the  iris  anaesthetic.  But  I  have  not  suc- 
ceeded every  time,  and  especially  the  hard  eyes  in  subacute 
or  chronic  glaucoma  have  withstood  the  action  of  the  drug, 
as  the  latter  in  this  class  of  eyes  is  not  absorbed  by  the 
cornea  in  sufficient  quantity  to  penetrate  into  the  anterior 
chamber. 

In  the  beginning  of  this  year  Professor  Snellen,  of 


8 


SULPHATE  OF  CODEINE  IN  THE  MORPHINE  HABIT. 


[N.  Y.  Med.  Joub., 


Utrecht,  communicated  to  me  in  a  private  letter  that  he 
was  using  the  cocaine  in  the  form  of  subconjunctival  injec- 
tions for  cataract  operations.*  He  writes :  "  In  cataract 
operations  we  inject  the  cocaine  under  the  conjunctiva  on 
the  upper  part  of  the  eye,  and  the  artificial  cheraosis  makes 
it  easy  to  form  a  conjunctival  flap,  which  latter  proceeding 
I  have  adopted,  since  I  operate  always  without  iridectomy." 

Following  this  suggestion,  I  have  used  the  subconjunc- 
tival application  of  cocaine  in  a  number  of  cases  where  I 
had  to  perform  the  operation  of  iridectomy  or  extraction 
of  cataract,  and  I  am  well  satisfied  with  the  results  at- 
tained. The  anaesthesia  was  complete ;  there  were  no  dis- 
advantages. I  proceed  in  the  following  way :  First  I  in- 
still a  few  drops  of  a  four-per-cent.  solution  and  wait  sev- 
eral minutes,  after  which  the  instillation  is  repeated.  Now 
I  insert  the  speculum  and,  by  means  of  a  sterilized  hypo- 
dermic syringe,  inject  a  few  drops  of  a  two-per-cent.  solu- 
tion of  cocaine  under  the  conjunctiva,  next  to  that  part  of 
the  cornea  where  I  intend  to  make  the  section.  This  will 
be  the  upper  part  in  most  cases.  The  solution  has  been 
sterilized  previously  by  boiling  it,  and  the  hypodermic  syr- 
inge by  rinsing  with  alcohol  and  then  with  a  two-per-cent. 
carbolic-acid  solution.  After  the  injection  the  speculum  is 
removed,  and  one  has  to  wait  from  five  to  ten  minutes  for 
the  artificial  a?deina  at  the  place  of  injection  to  subside,  as 
it  possibly  would  be  in  the  way  of  the  knife.  If  it  is  slow 
to  disappear,  gentle  rubbing  will  hasten  it.  The  anaesthe- 
sia thus  attained  is  complete,  and  will  contribute  to  dimin- 
ish that  percentage  of  prolapse  of  the  iris  that  still  adheres 
to  our  statistics  of  cataract  extraction.  My  experience 
Avith  the  subconjunctival  application  of  cocaine  in  iridecto- 
mies and  extractions  of  cataract  is  so  far  limited,  only  com- 
prising two  cases  of  cataract,  one  case  of  chronic  glaucoma, 
and  two  cases  of  iridectomy  for  other  causes.  Neverthe- 
less, I  venture  to  consider  this  method  a  safe  one,  having 
to  my  knowledge  no  disadvantages,  and  therefore  recom- 
mend it  to  you  for  a  trial. 
32  East  Sixtieth  Street. 


THE  CURE  OF  THE  MORPHINE  HABIT 
BY  SULPHATE  OF  CODEmE. 

The  motive  for  concealing  the  name  of  the  author,  as 
well  as  the  name  of  the  patient,  in  the  present  paper  arises 
partly  from  the  belief  that  the  facilities  for  observing  the 
course  of  the  case  and  the  train  of  subjective  symptoms  re- 
lated are  such  as  to  leave  the  impression  that  the  account 
must  have  been  drawn  from  a  direct  personal  experience ; 
while,  among  a  circle  of  immediate  acquaintances  by 
whom  this  paper  might  chance  to  be  read,  the  publishing 
of  the  author's  name  would,  from  known  associations,  at 
once  reveal  the  identity  of  the  patient. 

Nothing  so  detracts  from  the  respectability  of  genuine 
reformation  as  the  constant  vaunting  of  discreditable  ante- 

*  Professor  Snellen  has  also  described  his  way  of  proceeding  in  a 
communication  concerning  caiaract  operations  in  the  Annaks  d'ocii/i- 
Mqui',  January,  1892,  p.  75. 


cedents  in  the  face  of  victory.  Be  it  said  to  the  credit  of 
the  confirmed  opium  victim  that  he,  of  all  others,  is  least 
prone  to  indulge  in  this  sort  of  deplorable  pride,  even  in 
those  rare  instances  where  the  breaking  of  the  habit  single- 
handed  represents  an  inward  struggle  and  achievement 
compared  with  which  the  exploits  of  Napoleon  sink  into 
insignificance.  To  prevent,  then,  the  imputations  above 
liinted  at  on  the  one  hand,  as  well  as  to  avoid  any  violation 
of  confidence  on  the  other,  the  exceptional  course  is  adopted 
of  offering  this  paper  anonymously. 

Whoever  has  been  placed  in  a  position  to  keenly  appre- 
ciate the  dregs  of  bitterness  in  the  opium  habit  must  have 
an  increased  respect  for  the  drug  as  well  as  a  wholesome 
fear  of  it.  But  a  knowledge  of  its  fearful  power  for  evil 
should  not  efface  a  recognition  of  its  enormous  utility.  Its 
power  over  nerve  tissue  in  these  two  relations  is  beyond 
comparison  with  that  of  any  other  known  agent. 

If  there  is  any  fact  in  Nature  which  the  physician  should 
recognize  more  than  another  it  is  that  there  is  nothhig  in- 
herentlij  good  in  pain.  It  is  the  unerring  index  to  an  injury 
and  the  cry  for  protection.  As  it  is,  in  some  form  or  de- 
gree, an  almost  invariable  accompaniment  of  every  disorder 
of  function  or  morbid  change  of  structure,  its  demands  can 
only  be  disregarded  with  circumspection. 

This  monitor  continues  its  warnings  so  long  as  there  is 
any  hope  of  benefit  from  measures  to  mitigate  it,  or  until  its 
appeals  are  drowned  in  death  and  destruction  of  tissue. 

An  aching  tooth  ceases  to  ache  when  suppuration  and 
destruction  of  the  pulp  supeivene.  The  acute  pain  of  a 
palmar  abscess,  if  left  alone,  lasts  till  the  delicate  organ 
is  wrecked  in  suppuration  and  necrosis  of  tendon  and  peri- 
osteum. 

Acute  peritonitis,  unrelieved,  holds  the  patient  in  agony 
till  a  sudden  cessation  of  pain  and  an  ominous  quiet  indi- 
cate internal  suppuration  and  gangrene. 

An  acute  meningitis  continues  its  piercing  appeals  till 
effusion  takes  place  and  pain  is  drowned  in  coma. 

From  this  direct  association  of  pain  with  reparable  in- 
jury is  derived  the  well-known  principle  of  therapeutics 
that  measures  which  relieve  suffering  are  calculated  in  a 
corresponding  degree  to  protect  from  injury  by  allaying  irri- 
tation and  inflammation.  The  careful  stopping  of  a  cavi- 
ty may  save  the  pulp  of  the  tooth.  Early  incision  and  the  re- 
lief of  tension  may  stop  the  pain  of  a  palmar  abscess  and  save 
the  hand.  Opium  in  all  painful  abdominal  affections  *  and 
even  in  the  painful  stage  of  meningitis,  besides  relieving 
pain,  has  a  most  salutary  effect ;  while,  in  the  late  stages, 
or  where  from  intense  sepsis  there  is  absence  of  pain, 
with  necrosis  from  the  start,  it  is  worse  than  useless. 

While  it  is  at  times  obligatory  to  allow  pain  to  endure, 
it  can  only  be  for  ulterior  and  more  important  objects.  Be- 
cause of  the  imperfect  means  at  our  command,  it  is  impos- 
sible to  relieve  every  passing  discomfort  without  often  in- 

*  There  is  scarcely  an  exception.  How  much  suffering  and  disaster 
might  have  been  avoided  had  opium  in  labor  been  popularized  as  much 
as  that  abomination,  ergot !  As  a  palliative  and  o.xytocic  I  have  always 
found  morphine  in  labor  far  more  convenient  and  superior  to  chloro- 
form. The  intelligent  physician  will  no  more  give  ergot  in  labor  than 
he  will  give  it  to  facilitate  the  passage  of  a  gall-stone. 


Jan.  7,  1893.] 


SULPHATE  OF  CODEINE  IN  TEE  MORPHINE  HABIT. 


9 


curring  the  risk  of  some  more  serious  inconvenience  in  the 
future.  It  is  better  to  endure  a  little  rheumatic  twinge 
than  take  a  hypodermic  of  morphine  and  be  sick  at  the 
stomach  all  next  day. 

Yet  the  great  principle  enunciated  at  the  start  stands 
fast  nevertheless,  and,  as  the  existence  of  pain  is  almost  co- 
equal with  the  presence  of  disease,  so  it  is  that  opium,  the 
most  powerful  drug  at  our  command  for  relieving  it,  stands 
at  the  head  of  the  pharmacopoeia. 

The  history  of  the  inception  and  course  of  the  opium 
habit  is  always  much  the  same.  It  is  first  a  fascination, 
which  gradually  merges  into  a  daily  necessity.  I  say  this 
of  the  opium  habit.  Fortunately  for  humanity,  there  is  a 
wide  variation  in  this  respect,  so  far  as  the  first  use  of  the 
drug  is  concerned.  Those  to  whom  the  first  dose  of  opium 
proves  dangerously  seductive  must  be  the  rare  exceptions. 
To  a  healthy  person  unaccustomed  to  its  use,  the  fitful 
slumber,  the  disagreeable  languor,  nausea,  and  headache  apt 
to  follow  a  full  dose  of  opium  generally  fully  counterbal- 
ance the  slight  pleasurable  excitement  at  first  derived.  Its 
use  is  not  apt  to  be  persisted  in  unless  demanded  for  the 
relief  of  visceral  pain  or  some  nervous  irritation.  Like  the 
tobacco  habit,  the  opium  habit  with  most  people  requires 
to  be  learned,  and  a  longer  period  of  education  is  required 
with  the  latter  drug  than  with  the  former.  The  period  of 
most  acute  diseases  is  too  short  for  any  serious  danger  in 
this  respect.  Besides,  with  the  natural  relief  from  pain 
and  the  rapid  re-establishment  of  nutrition  at  the  time  of 
convalescence,  the  withdrawal  of  the  anodyne  is  scarcely 
noticed.  In  those  cases  of  typhoid  fever  attended  with 
much  restlessness  and  nervous  irritation  it  may  be  used 
continuously  in  moderate  doses  for  a  period  of  two  or  three 
weeks  with  the  happiest  result.  The  peculiar  vague  and 
deep-seated  unrest  in  this  condition  resembles  in  character, 
but  not  in  degree,  the  feeling  produced  by  the  withdrawal 
of  opium  from  a  person  accustomed  to  it.  The  accuracy 
with  which  morphine  allays  this  distress  I  believe  to  afford 
a  strong  presumption  in  favor  of  its  use.  Experience 
seems  to  me  to  prove  that  its  use  in  these  cases  is  far  more 
protective  and  much  more  conservative  of  nervous  force 
than  any  special  antipyretic. 

As  an  account  of  those  rare  cases  where  the  first  use  of 
opium  comes  like  a  spiritual  revelation,  nothing  can  ever 
exceed  the  classic  description  by  De  Quincey.* 

Perhaps  some  original  peculiarity  of  a  high-strung 
nervous  constitution,  coupled  with  the  remote  effects  of 
early  privation  and  suffering  and  an  existing  painful  neural- 
gic affection  of  some  weeks'  duration,  served  to  render  him 
an  easy  captive. 

It  is  only  a  subject  of  this  sort,  or  one  who  has  become 
suflSciently  habituated  to  the  drug  to  make  it  somewhat  of 
a  necessity,  who  is  prepared  to  thoroughly  appreciate  the 
beneficent  sensations  which  it  produces.  A  lady  once  told 
me  that  her  dose  of  morphine  always  made  her  feel  "so 
perfectly  natural,"  "  I  know  that  to  be  the  way  one  always 
ought  to  feel,"  etc.  Imagine  one  of  these  people  deprived 
of  the  accustomed  allowance  for  eighteen  or  twenty-four 

*  Confcssiom  of  an  English  Opium  Eater. 


hours.  There  is  a  feeling  of  deep  unrest,  a  volume  of 
bodily  sensations — all  of  discomfort.  The  pupils  are  di- 
lated, the  eyes  and  nose  watery.  He  sneezes,  yawns,  and 
stretches.  There  is  intense  weariness  on  endeavoring  to  fix 
the  attention  or  engage  in  conversation.  The  weariness 
deepens  into  a  dull,  gnawing  ache  in  the  lumbar  region, 
down  the  sciatics,  and  especially  in  the  calves.  He  forces 
and  drags  himself  about,  discharging  his  duties  in  a  per- 
functory and  half-hearted  manner.  Every  difliculty  or 
trouble  seems  fearfully  real.  The  mind  is  gloomy  and  he  is 
discouraged. 

He  resorts  to  the  usual  solace  and  support — that  is,  the 
prick  of  a  needle — and  in  ten  minutes  *  there  is  a  change 
in  his  spirits  as  subtle  as  a  simple  change  of  opinion.  He 
now  stands  firmly  on  his  feet;  the  tread  is  again  elastic. 
There  is  a  feeling  of  self-reliance  and  physical  well-being 
which  he  feels  must  be  a  simple  revival  of  some  primeval 
state  of  health. f  The  intellect  is  not  clouded  by  drowsi- 
ness or  dreams  of  grandeur  and  glory,  but  there  is  simply  a 
sweet  calm  stealing  through  the  heart  like  a  benediction. 
He  looks  up,  and  through  the  serene  light  the  Angel  of 
Hope  descends  smiling,  with  outstretched  wings  over  all  his 
prospects.  There  is  an  undaunted  faith  in  some  ultimate 
happy  solution  of  every  difficulty.  There  is  a  superb  steadi- 
ness and  clearness  of  intellect.  All  demands  are  met  with 
alacrity  and  with  the  feeling  that  the  sunshine  within  is  shed- 
ding its  influence  without.  It  is  here  that  I  wish  to  enter  a 
protest  against  the  misuse  of  the  term  morphinomania.  A 
patient  in  the  condition  above  described  can  be  considered  in 
no  sense  a  maniac.  The  term,  if  allowable  at  all,  can  only 
be  applied  with  a  modified  meaning  to  those  who,  fasci- 
nated by  the  enchanting  effects,  voluntarily  yield  to  the 
drug  only  at  intervals,  and  then  against  every  dictate  of 
better  judgment.  Even  here  there  is  scarcely  any  true 
maniacal  impulse,  as  such  persons  may  be  saved  by  exposure, 
or  reprimand,  or  full  information  as  to  the  danger.  AVith 
the  confirmed  daily  devotee  the  judgment  is  clear,  the  voli- 
tion unimpaired,  and  may  be  and  frequently  is  exercised  to 
overcome  the  habit  with  a  rigor  unequaled  in  the  ordinary 
demands  of  life.  He  simply  yields  to  opium  as  he  must  to 
the  daily  demands  of  Nature.  It  is  common  to  hear  those 
ignorant  of  the  internal  conditions  in  these  cases  speak  re- 
freshingly of  will-power.  "  All  that  is  required  is  to  exer- 
cise a  little  will-power  for  a  few  days."  Let  one  of  these 
philosophers  close  the  mouth  and  nose  and  exercise  a  little 
will-power  against  the  habit  of  respiration  for  but  three 
minutes;  or  let  him  do  like  the  Russian  exile,  and  go  on  a 
hunger  strike. 

The  terrible  suffering  produced  by  withdrawing  opium 

*  I  have  known  surprising  ignorance  to  be  displayed  by  physi- 
cians as  to  the  time  retiuired  for  a  hypodermic  to  taiie  effect  in  re- 
peating the  dose  in  ten  or  even  three  minutes.  With  morphine  in- 
jected well  into  the  subcutaneous  tissue,  it  requires  twenty-five  minutes 
by  the  watch  to  obtain  the  full  sedative  efiEect.  It  is  not  advisable  to 
repeat  the  dose  inside  of  thirty  five  minutes.  The  first  stimulating 
effect  is  almost  invariably  to  cause  nausea  and  one  or  two  momentary 
accessions  of  pain  or  spasm,  as  in  colic  or  asthma. 

f  This  idea  is  expressed  in  somewhat  different  words  by  De  Quincet' 
in  the  writing  alluded  to.  It  is  difficult  to  express  accurately  a  com. 
inon  experience  without  unconsciously  plagiarizing  to  some  extent. 


10 


SULPHATE  OF  CODEINE  IN  THE  MORPHINE  HABIT. 


[N.  Y.  Med.  Jouk., 


is  no  more  an  indication  of  mania  than  the  convulsions  of 
a  man  who  is  strangling.  The  symptoms  of  abstinence  are 
often  loosely  construed  as  the  deleterious  effects  of  the  drug 
itself.  The  idea  is  held  out  that  as  soon  as  the  morphine 
is  got  out  of  the  system  recovery  will  be  complete.  On  the 
contrary,  as  soon  as  elimination  is  complete,  the  storm  of 
abstinence  will  be  at  its  height. 

As  the  months  wear  on,  the  nervous  system  becomes 
gradually  obtuilded  to  the  more  exquisite  effects  previously 
indicated.  The  patient  now  resorts  to  the  drug  to  escape 
the  plain  physical  distress  which  follows  upon  any  attempt 
at  abstinence.  Such  attempts  are  doubtless  numerous  with 
the  average  morphine-taker,  for  he,  of  all  others,  begins  to 
recognize  the  direful  condition  into  which  he  has  descend- 
ed. He  now  barely  recovers  his  accustomed  cheerfulness 
under  the  influence  of  a  fresh  dose.  He  has  lost  weight ; 
the  complexion  is  sallow ;  sleep  is  uneasy  and  disturbed  by 
dreams  of  grandeur,  which  are  at  the  same  time  always  de- 
pressing. He  wanders  through  gorgeous  halls  and  palaces, 
but  the  air  is  heavy  and  oppressive ;  or  wends  his  way  by 
endless  hours  through  magnificent  Roman  baths,  but  is  sti- 
fled by  the  steam,  till  he  wakes  with  a  start,  drenched  with 
perspiration. 

During  the  early  months  of  the  habit  the  dosage  is  apt 
to  be  rapidly  increased  in  an  effort  to  preserve  the  pleasur- 
able state  of  mind  at  first  depicted.  As  this  charm  is  lost 
sight  of  and  the  toxic  symptoms  begin  to  appear,  the  pa- 
tient often  returns  with  more  or  less  effort  to  a  compara- 
tively small  daily  allowance.  With  this  reduction  the  health 
visibly  improves,  but  any  attempt  to  totally  abandon  the 
drug,  and  such  attempts  may  be  numerous,  reveals  at  once 
the  supreme  difficulty  of  the  undertaking.  He  dreads  to 
appear  ill  without  adequate  cause,  and  some  demand  upon 
his  energy  at  the  wrong  time  always  leads  him  to  postpone 
the  effort  to  some  more  convenient  day.  This  waiting  for 
an  opportunity  is  like  waiting  for  a  convenient  day  on 
which  to  die. 

There  is  perhaps  no  more  trying  spectacle  encountered 
by  the  medical  man  than  the  suffering  produced  by 
the  treatment  of  the  morphine  habit  by  ordinary  meth- 
ods. Men  with  severe  injuries  or  even  fatal  wounds  suf- 
fer some  pain,  weakness,  and  thirst,  but  gradually  find 
some  easy  position  and  may  lie  quiet  without  complaint. 
The  throes  of  childbirth  at  the  severest  stage  are  mitigated 
by  moments  of  repose  and  recuperation  ;  besides,  all  these 
conditions  are  matters  for  legitimate  relief.  With  the 
opium  sufferer  the  only  treatment  consists  in  cruelly  with- 
holding the  sole  means  of  effectual  relief  while  the  unre- 
mitting access  of  agony  presents  a  picture  harrowing  in  the 
extreme,  and  may  proceed  to  collapse  and  stoppage  of  the 
heart's  action.  I  have  used  the  words  effectual  relief  in  the 
foregoing  passage  advisedly;  for  I  will  venture  to  say  that 
nothing  in  common  practice  has  heretofore  been  devised, 
either  in  the  different  methods  of  withdrawal,  immediate, 
rapid,  or  gradual,  or  in  the  whole  list  of  drugs  used  as  sub- 
stitutes, which  serves  perceptibly  to  lessen  the  suffering. 
While  atropine  may  be  of  value  in  resuscitating  a  person 
with  acute  opium  poisoning,  there  is  nothing  in  reason  or  ex- 
perience to  prove  that  it  is  of  the  slightest  value  in  the 


treatment  of  the  chronic  habit.  The  disturbance  of  vision 
and  the  dryness  of  the  throat  simply  add  to  the  volume  of 
discomfort.  Strychnine  I  believe  to  ultimately  aggravate 
the  trouble.  The  revulsion  from  cocaine  leaves  the  patient 
worse  than  before.  Acetanilide  and  the  coal-tar  deriva- 
tives have  only  a  slight  and  temporary  effect,  while  the  de- 
pressing influence  on  the  heart's  action  is  objectionable. 
Coffee  is  of  undoubted  value  in  the  preliminary  struggle  of 
reducing  morphine  to  a  minimum,  especially  to  alleviate  the 
giddiness  and  depression  on  first  rising  in  the  morning. 
Here  also  light  alcoholics  may  be  of  value  at  times,  but 
brandy  is  apt  to  produce  weakness  of  the  will  and  an  in- 
creased desire  for  morphine.  Bromidia  at  night  may  help 
in  reducing  the  allowance.  At  the  height  of  the  supreme 
struggle,  which  follows  on  the  second  and  third  day  after 
total  suspension,  all  these  agents  are  of  no  perceptible 
value.  The  whole  list  of  hypnotics  produce  drowsiness 
without  allaying  the  intense  distress  and  muscular  spasms 
which  harass  and  prevent  sleep.  The  list  of  heart  tonics 
may  stimulate  the  pulse,  but  do  not  mitigate  pain.  The 
valerianate  of  ammonium,  mentioned  by  De  Quincey,  I  have 
not  observed  to  be  of  any  value.  It  is  here  that  we  may 
realize  the  immense  gulf  between  opium  and  the  rest  of  the 
pharmacopoeia. 

It  was  while  attempting  to  treat  a  patient  long  addicted 
to  morphine  by  hypodermic  injection  that  I  noticed  in  a  lay 
paper  an  incidental  allusion  to  the  cure  of  the  morphine  habit 
by  the  sulphate  of  codeine.*  Unfortunately,  I  have  never 
been  able  to  correspond  satisfactorily  with  the  author  of 
this  hint  in  regard  to  the  matter.  The  standard  literature 
on  the  therapeutic  uses  of  codeine  I  have  found  to  be  scant 
and  unsatisfactory,  for  it  is  generally  reckoned  to  be  identi- 
cal in  effect  with  morphine,  but  less  powerful.  During  one 
of  the  numerous  attempts  to  abandon  morphine  in  the  case 
above  mentioned,  when  the  suffering  had  become  intolera- 
ble, I  determined  to  try  codeine  as  a  substitute.  A  hypo- 
dermic injection  of  one  grain  of  the  sulphate  dissolved  in 
hot  water  was  given,  with  the  most  satisfactor)'  result. 
Aside  from  accounts  of  experiments  on  the  lower  animals,  I 
think  I  am  in  a  position  to  assert  from  my  own  experience 
with  this  drug  that  no  amount  of  codeine  is  identical  in  ef- 
fect with  any  amount  of  morphine.  The  effect  in  the  case 
under  consideration  was  little  short  of  magical.  In  half  an 
hour  the  severe  pain  in  the  lumbar  region  and  down  the 
sciatics  had  completely  subsided,  and  the  patient,  after  ex- 
pressing an  instinctive  belief  that  the  necessary  stepping 
stone  across  the  chasm  had  been  found,  arose  from  his 
couch  and  went  about  his  vocations  as  usual.  This  relief 
continued  for  four  hours.  The  difference  in  effect  between 
morphine  and  codeine  under  these  conditions  becomes  vivid- 
ly apparent.  An  eighth  of  a  grain  of  morphine  will  relieve  the 
peculiar  pain,  but  there  is  added  a  certain  positive  effect  on 
the  cerebrum,  and  the  patient  is  aware  that  he  has  again 

*  Since  the  events  recorded  in  this  article  tool£  place  I  have  noticed 
a  brief  reference  in  the  Medical  Annual  to  a  paper  by  Gitterinan  on  the 
use  of  codeine  as  a  substitute  in  treatment  of  the  morphine  habit  (Medizi- 
nal-Zcitung,  p.  121).  There  are  no  details,  and  I  have  not  been  able  to 
secure  his  original  paper.  These  are  the  only  two  references  to  the 
subject  I  have  seen. 


Jan.  7,  1893.] 


SULPHATE  OF  CODEINE  IN  THE  MORPHINE  HABIT. 


taken  morphine.  After  one  grain  of  sulphate  of  codeine  the 
pain  simply  fades  away  ;  the  effect  is  much  less  profound, 
and  the  patient  does  not  feel  as  if  he  had  taken  anything. 

The  codeine  treatment  was  subsequently  followed  up 
systematically,  one  to  two  grains  being  given  every  three 
hours,  according  to  the  urgency  of  the  symptoms.  This 
course  was  continued  during  the  first  five  or  six  days,  then 
the  intervals  were  gradually  lengthened  till  on  the  fourteenth 
day  it  was  dropped  entirely  without  any  great  difficulty.  I 
think  the  ultimate  easy  success  of  this  treatment  lay  in  the 
comparatively  prolonged  use  of  the  codeine,  allowing  time 
for  the  substitution  of  one  habit  for  the  other.  I  should 
hardly  expect  any  benefit  from  its  use  in  any  attempt  at 
very  rapid  reduction.  After  having  gradually  reduced  the 
morphine  to  a  minimum,  say  one  half  or  one  quarter  of  a 
grain  in  twenty-four  hours,  the  codeine  may  be  substituted. 
During  the  period  when  the  storm  from  total  abstinence 
from  morphine  would  be  at  its  height  the  codeine  must  be 
used  with  corresponding  freedom  ;  ten  or  twelve  grains  in 
twenty-four  hours  were  used  in  this  case.  On  account  of 
its  comparative  insolubility,  it  is  best  used  by  heating  with 
the  required  amount  of  water  in  a  spoon  over  a  spirit  lamp, 
and  the  solution  should  be  injected  immediately  before  it 
cools  sufficiently  to  allow  recrystallization.  There  is  no  dan- 
ger of  an  overdose,  as  the  barrel  of  an  ordinary  hypodermic 
syringe  will  hardly  hold  more  than  two  grains  in  solution. 

During  a  period  of  ten  or  fourteen  days  the  patient  is 
instinctively  aware  of  a  change  going  on  in  his  constitution. 
There  is  a  partial  but  permanent  recovery  of  tone  in  the 
nervous  system  which  gives  confidence  in  the  final  result. 
In  dropping  the  codeine  on  the  fourteenth  day  the  discom- 
fort was  at  its  height  in  twenty-four  hours.  In  thirty-six 
hours  the  victory  was  practically  won.  There  was  some 
restlessness  in  the  evening  and  fore  part  of  the  night,  which 
was,  however,  comparatively  bearable.  Acetanilide  and 
brorao-caffeine  for  a  little  occipital  headache,  quinine  for  a 
slight  lumbar  pain,  and  bromidia  at  night  did  good  service. 
In  this  case  morphine  had  been  used  hypodermically  for 
nineteen  months,  as  high  as  seven  or  eight  grains  a  day 
being  taken  for  a  considerable  tinie.  In  three  weeks  from 
the  time  the  morphine  was  dropped  the  cure  was  practically 
complete,  and  that  without  the  exercise  of  more  than  ordi- 
nary fortitude  and  without  abandoning  the  daily  duties. 
The  one  fact  that  the  habit  was  voluntarily  abandoned  by 
this  method  where  other  attempts  had  signally  failed  speaks 
volumes  in  its  favor.  The  patient  has  long  since  ceased  the 
use  of  even  milder  hypnotics  and  continues  to  enjoy  the  most 
perfect  health. 

A  word  about  relapses.  There  is  nothing  under  heaven 
which  will  prevent  a  healthy  man  from  relapsing  into  old 
habits  or  forming  new  ones  equally  bad  if  he  is  willing 
to  do  so.  There  seems  to  be  an  impression  among  medical 
men  that  any  attempt  to  cure  the  morphine  habit  by  an 
easy  method  is  more  apt  to  be  followed  by  relapse  than  if 
the  horrible  and  barbarous  method  of  immediate  suspension 
is  adopted.  The  only  difficulty  is  to  break  the  habit  by 
any  means  whatever.  Observation  has  convinced  me  that 
the  enslaved  condition  results  from  a  change  of  nutrition, 
and  consequent  loss  of  tone  of  the  cerebro-spinal  system 


from  long  dependence  upon  an  artificial  support.  Many  of 
the  characteristic  symptoms  of  deprivation  are  due  evi- 
dently to  a  lack  of  the  usual  inhibitory  influence  of  the 
cerebro-spinal  system  over  the  sympathetic  (dilatation  of 
the  pupils,  increased  peristaltic  action,  etc.).  Further,  the 
early  effects  of  morphine  are  to  afford  an  artificial  rest  or 
support  to  the  centers  of  sensation,  causing  the  fictitious 
feeling  of  tonicity  and  well-being.  When  this  support  is 
at  last  withdrawn,  these  centers  of  sensation  are  left  in  a 
state  of  abnormal  irritability  toward  the  multitude  of  bodily 
stimuli  which  normally  give  rise  to  the  muscular  sense,  and 
a  state  of  irritation  and  voluminous  discomfort  arises  which 
constantly  approaches  collapse.  From  these  considerations 
it  is  unreasonable  to  suppose  that  the  old  state  of  malnutri- 
tion from  prolonged  use  of  opium  can  be  at  once  re-estab- 
lished, and  the  patient  correspondingly  enslaved,  by  a  single 
dose  of  morphine  months  or  years  after  the  habit  has  been 
abandoned.  If  one  who  had  once  been  a  morphine- eater 
were  suffering  from  the  passage  of  a  biliary  calculus,  I  can 
see  no  reason  why  a  hypodermic  should  not  be  allowed. 
The  danger  lies  in  chronic  painful  affections,  or  in  original 
defects  of  the  nervous  system. 

In  the  foregoing  account  the  words  opium-eater,  mor- 
phine victim,  etc.,  have  been  used  indifferently.  Owing  to 
the  comparatively  large  percentage  of  morphine  in  opium, 
as  well  as  the  predominating  power  of  this  alkaloid,  the 
opium  victim  is  practically  a  raorphine-eatej'.  In  a  com- 
munication on  the  subject  kindly  sent  me  by  Messrs. 
Powers  &  Weightman,  of  Philadelphia,  they  state  that  no 
opium  is  admitted  to  this  country  containing  less  than  nine 
per  cent,  of  morphine.  The  percentage  of  codeine  is  said  to 
vary,  and  they  have  kept  no  record  of  the  various  propor- 
tions in  different  kinds  of  opium.*  Contrary  to  the  asser- 
tion made  in  the  United  States  Dispensatory,  they  say  that 
at  present  they  export  no  codeine  to  France.  The  ordinary 
therapeutic  uses  of  codeine  seem  to  be  confined  chiefly  to 
allaying  the  cough  of  phthisis  and  the  treatment  of  diabetes. 
Besides,  it  is  a  favorite  substitute  with  some  physicians  for 
morphine. 

It  is  not  to  be  understood  that  the  author  of  this  paj)er 
would  impose  the  exact  line  of  treatment  laid  down  in  the 
case  related.  It  is  to  be  remembered  that  while  codeine 
does  not  altogether  prevent  the  recovery  from  morphine,  it 
probably  retards  it.  But  this  little  prolongation  of  the 
treatment  is  more  than  counterbalanced  by  the  escape  from 
suffering.  Other  cases  might  require  a  somewhat  longer 
period  of  substitution  before  a  cure  could  readily  be  ef- 
fected. In  one  other  case,  where  it  was  recommended  for 
the  morphine  habit,  it  was  used  as  a  substitute  for  three 
months.  The  morphine  was  originally  required  in  this  case 
for  persistent  vomiting,  followed  by  hepatitis  with  inflam- 
matory symptoms  lasting  for  eight  months.  The  habit  had 
been  kept  up  for  four  years.  The  patient,  having  gone  to  the 
country,  was  accidentally  deprived  of  the  use  of  codeine,  and 
continued  without  it  for  four  days  without  any  character- 
istic symptoms  of  privation.  While  he  was  returning  lionje 
an  attack  of  vomiting  supervened,  attributed  by  the  patient 

*  It  is  stated  in  Potter's  Materia  Medica  to  vary  from  three  to  five 
per  cent. 


12 


BEANE:   TESTS  FOR  GLUCOSE  IN  THE  URINE. 


[N.  Y.  Med.  Johb., 


to  overexertion,  irreoular  eating,  and  exposure  to  heat.  Since 
that  time  morphine  or  codeine  has  been  used  moderately. 
I  think  the  interval  of  four  days  mentioned  above  again 
speaks  well  for  the  treatment,  as  the  fourth  day  is  too  late 
for  severe  symptoms  of  deprivation  to  begin. 

When  codeine  is  relinquished  it  is  advisable  that  the 
patient  be  relieved  of  ordinary  duties  for  a  few  days,  and 
avoid  all  sources  of  annoyance  as  far  as  practicable.  But 
strict  confinement  and  enforced  inactivity  should  be  avoided 
if  possible.  On  the  contrary,  there  are  times  when  vigor- 
ous exercise  will  relieve  restlessness,  especially  calisthenics 
before  going  to  bed. 

In  conclusion,  let  me  say  that  if  any  one  subject  to  the 
morphine  habit  expects  any  golden  specific  to  bear  him 
back  to  health  without  som2  effort  and  some  sacrifice  he 
will  be  disappointed.  It  is  hardly  possible  in  the  nature  of 
things  that  the  laws  of  conservation  and  compensation  of 
the  material  world  should  have  no  counterpart  in  conditions 
governing  the  nutrition  of  nerves  of  sense. 

The  sole  advantage  of  the  treatment  above  given  lies  in 
the  fact  that  the  penalty  may  be  paid  in  installments.  This 
is  not  possible  by  any  gradual  reduction  of  morphine  alone, 
as  the  supreme  difliculty  consists  in  renouncing  the  last 
traces.  To  those  who  may  attempt  for  the  first  time  a  cure 
by  this  method,  the  inconvenience  may  seem  greater  than 
this  account  would  lead  one  to  suppose.  Let  them  try  any 
other  method  generally  practiced.  It  is  chiefly  by  compari- 
son with  other  methods  that  its  value  becomes  apparent, 
and  in  this  respect  it  is  difficult  to  speak  of  it  in  terms  of 
moderation. 


THE  COMPARATIVE  CLINICAL  VALUE  OF 
SEVERAL  TESTS  FOR 
GLUCOSE  IN  THE  URINE. 
By  frank  DUDLEY  BEANE,  A.  M.,  M.  D. 

The  following  conclusions  are  based  in  part  upon  the 
experiments  and  observations  about  to  be  detailed : 

1.  There  is  no  reliable  reagent  for  proving  the  presence 
in  the  urine  of  a  smaller  quantity  of  glucose  than  0'025  per 
cent.  (1  in  4,000  parts). 

2.  Therefore  the  contention  that  a  smaller  quantity  oc- 
curs in  the  urine  during  physiological  or  pathological  con- 
ditions can  not  be  considered  proved. 

.3.  Normal  human  urine  contains  minute  quantities  of 
reducing  substances.  Whether  or  not  a  part  thereof  is 
glucose  can  not  be  determined  by  our  present  analytical 
means.* 


*  And  despite  Wedenski's  {ZUchr.  f.  phys.  Chem.,  1888,  xiii,  112) 
use  of  Baumann's  discovery,  that  benzoyl  chloride  forms  insoluble 
compounds  with  the  carbohydrates,  which  allowed  him  to  separate  from 
normal  urine  a  body  giving  the  grape-sugar  reaction.  V.  Briicke,  See- 
gen,  Abels,  and  Salkowski  also  succeeded,  by  means  of  concentrating 
the  urine  and  the  use  of  the  same  reagent,  in  extracting  such  a  minute 
quantity  that  v.  Jaksch  {Clinical  Diagnosis,  Lond.,  1890,  pp.  224  and 
230)  says :  "  It  can  not  act  as  a  disturbing  factor  even  in  the  most 
sensitive  tests  to  be  described."  The  fact  of  benzoyl  chloride  founing 
conjpounds  (as  yet  unknown)  with  the  carbohydrates  would  render  it 
incapalile  of  proving  the  original  presence  of  glucose  in  the  urrnc. 


4.  The  Oliver-Mulder  indigo-carmin,  the  Johnson-Braun 
picric-acid,  Franqui  and  Van  de  Vyvere's  potassic-bismuth, 
and  Briicke's  bismuth-iodide  tests  are  unreliable  and  mis- 
leading. 

5.  The  ammonia-lead  test  is  reliable  for  quantities  at 
and  above  0"20  per  cent. 

6.  liinhorn's  fermentation  test  (modified)  is  practically 
reliable  for  as  little  as  O'lO  per  cent,  of  glucose  in  the 
urine. 

7.  Worm-Miiller's  (modified  Fehling's)  and  Salkowski's 
(modified  Troramer's)  tests  are,  under  certain  conditions,  re- 
liable for  0-05  per  cent,  and  upward. 

8.  Nylander's  bismuth  solution  in  expert  hands  will  de- 
tect 0-025  per  cent. ;  in  careful  hands  will  prove  trustworthy 
for  0-05  per  cent,  and  upward. 

9.  The  phenylhydrazin-hydrochlorate  test,  as  modified 
by  Ultzmann  and  Bond,  yields  reliable  results  for  quantities 
as  small  as  0*025  per  cent.,  and  is  the  best  single  test 
known. 

These  experiments  were  undertaken  to  clear  up  the 
following — 

Insueance  Case. — A  professional  man,  aged  thirty-seven 
years,  American,  spare,  tive  feet  nine  and  a  half  inches,  weigh- 
ing one  hundred  and  twenty-two  pounds  (never  exceeded  one 
hundred  and  thirty-five  pounds;  past  twelve  years'  winter  weight, 
one  hundred  and  twenty  to  one  hundred  and  twenty-two;  sum- 
mer weight,  one  hundred  and  fourteen  to  one  hundred  and  nine- 
teen) ;  nervous  temperament.  Parents  living  at  age  of  seventy- 
two  years.  Sole  hereditary  predisposition,  indigestion.  Al- 
ways enjoyed  health  till  summer  of  1883;  then  an  attack  of 
nervous  prostration  from  worry  and  overwork,  repeated  in  win- 
ter of  1885  from  same  causes.  Care  and  rest,  with  a  sojourn 
in  the  country  during  the  two  succeeding  summers,  brought  fair 
health,  permitting  the  steudy  performance  of  the  duties  of  a 
busy  life.  Habits  always  excellent.  Never  used  tobacco ;  alco- 
holic drinks  never  indulged  in  as  a  beverage.  Applicant  anaemic, 
partly  due  to  indoor  confinement.  Physical  examination  showed 
the  absence  of  organic  disease.  Digestion  fair,  but  frequent  in- 
digestion attacks.  General  functions  normal.  Never  any  in- 
ordinate appetite  or  thirst;  rather  sparing  of  fluids,  partly  from 
habit,  partly  from  "  dyspepsia  of  liquids."  Daily  quantity  of 
urine  excreted,  about  750  c.  c.  to  800  c.  c.  Rejection  having  fol- 
lowed the  report  of  the  medical  examiner  of  one  of  the  three 
large  insurance  companies  of  this  city,  in  which  (afterward 
learned)  was  stated  '"the  presence  of  sugar  in  the  urine,"  these 
experiments  were  conducted  under  the  conditions  of  absolute 
cleanliness  of  utensils,  purity  of  chemicals,  accuracy  of  measur- 
ing and  weighing,  filtration  to  clearness  of  all  urine  tested,  and 
such  other  details  as  shall  appear.  Time,  December  14,  1888, 
to  February  12,  1889. 

A.  Summary  of  AppUcanfs  SpecimeuH. — Twenty-one  sam- 
ples. Specific  gravity  at  60°  F.  from  1-020  to  1-032.  Albumin 
free.  Indigo-carmine,  eleven  reactions,  five  negatives ;  picric 
acid,  potassic-bismuth,  and  Frolin's  reagent,  reaction  in  all  speci- 
mens tested ;  arnraonia-lead  (7),  Fehling's  (9),  Salkowski's  (2), 
the  Bond- Ultzmann  (18),  and  Einhorn's  (5),  all  negatives  where 
employed  ;  Nylander's,  four  reactions  (specific  gi-avity  1-031  and 
1-032),  seventeen  negatives;  Worm-Miiller's,  one  reaction  (spe- 
(•ifio  gravity  1-032),  fourteen  negatives. 

The  a[)plicant's  diet  was  largely  cereal  and  vegetable. 

Deductions.  —  Fehling's,  Nylander's,  and  Worm-Miiller's 
(controlled  in  the  doubtful  reactions  by  the  charcoal-filtration 
or  by  M6hu's  evaporation  processes)  tests  speak  negatively, 


Jan.  7,  1893.] 


BE  ARE:   TESTS  FOR  GLUCOSE  IN  TEE  URINE. 


13 


while  Einliorn's  and  the  Bond-Ultzmaim  coiichisively  prove  the 
absence  of  glucose  and  the  untrustwortliiness  of  the  other  tests 
(excepting  the  ammonia-lead). 

Memoranda. — One  specimen  reacted  to  the  indigo,  picric, 
and  potassic-bismuth  tost  after  the  charcoal  jjrocess,  altljough 
Worm-Muller's  and  the  Bond-Dltzmann  were  negativ^e  through- 
out. Another  specimen  persisted  to  react  to  the  indigo  after 
Mehu's  (1)  evaporation  process,  although  negative  to  Worm- 
Miiller's  test. 

Note. — December  1,  1891.  The  applicant's  urine  has  been  and  is 
free  from  all  questionable  reactions  to  Nylander's  and  Worm-Miiller's 
tests,  by  reason  of  reform  in  diet,  and  his  health  has  been  and  is  good. 
In  March,  1890,  a  policy  was  issued  by  the  third  prominent  company 
with  a  full  knowledge  of  the  facts. 

To-further  test  the  value  of  the  indigo,  picric,  and  Frohn's 
reagents,  samples  were  obtained  from  five  healthy  young 
men,  one  healthy  woman,  three  young  men  with  indigestion, 
one  female  neurastheniac,  one  male  octogenarian  with  chronic 
cystitis.  The  diet  in  all  cases  was  mixed,  with  a  leaning  to- 
ward animal  food. 

B.  Summary  of  Miscellaneous  Cases. — Twenty-seven  sam- 
ples. Specific  gravity  at  60°  F.,  1'012  to  1-033.  Indigo-car- 
mine, nine  reactions,  six  negatives;  picric  acid,  eiglit  reactions, 
one  negative;  Frohn's,  ten  reactions,  two  negatives;  Worm- 
Miiller's,  ten  doubtful  reactions,  ten  negatives ;  and  all  nega- 
tives, where  employed,  to  ammonia-lead  (17),  Salkowski's,  Bond- 
Dltzmann's  (10),  Einhorn's  (1). 

The  general  result  demonstrates  the  unreliability  of  the 
first  three  tests,  the  absence  of  glucose  having  been  proved  by 
the  Bond-Cltzmann  as  well  as  by  Worm-Milller's  and  Sal- 
kowski's following  the  charcoal  filtration  process,  the  latter 
having  been  employed  in  all  samples  giving  the  most  marked 
reactions  and  the  highest  specific  gravity. 

C.  Diabetic  Urines. — Diluted  diabetic  urine  next  engaged  at- 
tention. 

Sample  1 — pale  yellow,  acid,  1-039  at  60°  F.,  faint  trace  of 
albumin  by  heat  and  nitric  acid;  glucose,  by  modified  Einhorn's 
method,  equals  ^'S  per  cent. 

No.  2 — pale  yellow,  acid,  1-036,  slight  trace  of  albumin  by 
heat  and  nitric  acid;  glucose,  by  the  Cole-Chandler  (2)  meth- 
od, equals  six  per  cent. 

These  specimens  were  diluted  with  normal  urines ;  specific 
gravity  at  60°  F.  of  1010  and  1-016. 

General  Result. — Twenty-five  specimens.  Failure  of  indigo- 
carmine,  Frohn's,  Worm-Miiller's,  and  Salkowski's  to  demon- 
sti-ate  0-025  per  cent.,  although  the  Bond-Ultzmann  and  picric 
acid  gave  unmistakable  reactions. 

All  the  other  tests  (save  ammonia-lead),  which  began  at 
0-20  per  cent.,  reacted  to  0-0.5  per  cent,  and  upward. 

Finally,  attention  was  directed  to  artificial  glucosic  urine. 
The  glucose,  chemically  pure,  manufactured  by  Troramsdorfif, 
of  Erfurt,  Germany,  was  dissolved  in  normal  urines;  specitic 
gravity  at  60°  F.,  I'OIO  and  1-020,  to  the  .strength  of  one  per 
cent.,  this  latter  further  diluted  with  the  same  urines  to  the  re- 
quired percentage. 

D.  Artificial  Glucosic  Urines. — Thirty  five  specimens.  The 
general  result  was  the  same  as  with  the  preceding  urines,  ex- 
cept that  Nylander's  test  (not  used  with  the  diabetic  specimens) 
gave  faint  reactions  to  0-025  per  cent. 

We  may  now  profitably  consider  the  tests  in  tlie  order 
of  their  vahie. 

PlIENYLIIYDRAZIN  OF  BoND  AND  UlTZMANN  (3).  In  15 

c.  c.  of  urine,  in  an  eight-inch  test-tube,  dissolve  by  agitation 
one  gramme  phenylhydrazin  hydrochlorate  and  two  grammes 


sodic  acetate,  in  coarse  powder.  Gently  raise  to  boiling 
point,  which  maintain  for  half  a  minute,  set  aside  for  a 
quarter  to  twenty-four  hours,  according  to  amount  of  glu- 
cose suspected,  and  examine  the  sediment  with  X  200, 
better  X  300.  Minute  quantities  of  glucose  being  suspected, 
I  obtained  more  positive  results  within  twenty-four  hours 
by  using  25  c.  c.  urine  with  the  usual  quantity  of  chemicals. 

The  "classical  method"  (Fischer's)  was  found  to  pre- 
sent no  advantages,  and  is  more  troublesome. 

The  phenylglucosazon  (glucose  in  combination)  may  be 
recognized  as  sheaves,  sprays,  or  stars  of  delicate  yellow 
needle-iike  crystals,  precisely  like  those  of  tyrosin  (occa- 
sionally leucin),  excepting  the  color,  the  (two)  latter  always 
being  white.  As  tyrosine  and  leucine  very  rarely  appear  in 
the  urine  (in  acute  liver  atrophy  or  other  equally  pronounced 
and  alarming  diseases),  the  distinction  is  simple. 

Various- sized  reddish  and  yellowish  globules,  constantly 
present  in  profusion  in  the  field,  sliow  the  phenyl  salt  to 
be  in  excess. 

Remarks. — Introduced  by  E.  Fischer  (4),  afterward  ap- 
plied by  P.  Grocco  (5)  and  R.  von  Jaksch  (6)  to  pathologi- 
cal urine,  this  test,  despite  its  comparatively  recent  discov- 
ery, is,  as  modifed  by  the  late  Professor  Ultzmann  and  Dr. 
Bond  (3),  considered  the  most  sensitive  and  reliable 
known  (6).  Dr.  Penzoldt  (7),  however,  declares  "  there 
are  other  substances  liable  to  occur  in  the  urine  which 
give  the  same  reaction  " — referring  probably,  though  not 
stated,  to  potassium  glycuronate  crystals. 

From  numerous  experiments  Dr.  Bond  maintains  that : 
(1)  Normal  urine  does  not  respond  to  this  test ;  (2)  the  latter 
will  surely  detect  one  fortieth  (0-025)  per  cent,  of  diabetic 
sugar ;  (3)  other  substances,  save  albumin  (which  must  first 
be  removed  if  present  in  any  amount),  do  not  disturb  its 
sensitiveness ;  (4)  alkaline  or  acid,  cloudy  or  clear,  urine 
may  be  used ;  (5)  if  [typical]  crystals  are  found,  the  proof 
of  the  presence  of  sugar  is  absolute  ;  (6)  it  requires  no 
special  skill  to  prepare  and  examine  the  specimen. 

My  experiments  fully  confirm  Dr.  Bond's  statements, 
provided  typical  crystals  be  the  sine  qua  non. 

Typical  refers  solely  to  needle-like  yellow  crystals,  ar- 
ranged as  sheaves,  half- sheaves,  stars,  or  sprays,  the  essen- 
tial feature  being  delicate  needles. 

Without  heeding  this  caution,  a  novice  might  wrongly 
interpret  the  significance  of  numerous  reddish-yellow,  short 
acicular  offshoots  from  the  reddish  phenylhydrazin  globules 
forming  stellar  drops.  These  have  no  diagnostic  signifi- 
cance. 

They  were  only  detected  in  samples  referred  to  at  A, 
the  specific  gravity  of  which  was  1-027  and  higher,  and  not 
prior  to  forty-eight  and  seventy-two  hours  after  prepara- 
tion. In  three  of  these  samples  (specific  gravity,  r025, 
1-030,  r031),  in  addition  to  the  stellar  drop.s,  were  de- 
tected reddish-yellow  and  yellow  broad,  thick  (a  few  long 
and  more  slender)  crystals ;  some  isolated,  but  the  majority 
overlapping  or  superimposed,  which,  save  for  color,  exactly 
resembled  crystals  of  hippuric  acid  and  neutral  calcium 
phosphate. 

In  two  samples,  included  in  B,  from  a  robust  country 
lad  in  perfect  health  (specific  gravity  urine  =  r030  and 


14 


BEANE:   TESTS  FOE  GLUCOSE  IN  THE  URINE. 


[N.  Y.  Med.  Jook., 


1-033),  the  crystals  and  stellar  drops  just  described  were 
also  discovered  after  forty- eight  and  seventy-two  hours. 

None  of  these  atypical  crystals  was  discovered  in  speci- 
mens made  from  diabetic  or  artificial  glucosic  urines. 

Regarding  the  reaction  of  phenylhydrazin  muriate  with 
cane  sugar,  in  testing  with  a  "granulated"  sugar  solution, 
I  found  the  resulting  crystals  arranged  more  like  straws  in 
a  whisk-broom,  the  handle  being  cut  short  off.  There  was 
no  appearance  of  sheaves,  save  in  immense  clusters,  even 
these  looking  like  brooms  (handles  cut  off)  with  their  broad 
apices  set  in  apposition.  There  were  no  sprays ;  simply 
single,  slender  crystals  crossing  each  other.  Therefore, 
with  attention  to  details,  a  ditferentiation  can  be  made. 

Alone  and  uncontrolled,  the  Bond-Ultzmann  test  may 
be  considered  as  the  most  reliable  one  known.  Clinically 
it  meets  the  most  exacting  demands,  as  the  presence  of 
O'SYS  gramme  in  the  daily  total  quantity  of  urine  passed 
(viz.,  1,500  c.  c,  the  highest  normal  average)  could  possess 
little  or  no  significance  physiologically  or  pathologicall}^  (a 
sign  of  excessive  ingestion  of  the  carbohydrates  and  their 
imperfect  appropriation). 

While  difficult  to  discriminate  between  the  next  two 
tests,  with  proper  precautions,  one  being  as  sensitive  and 
reliable  as  the  other,  on  account  of  keeping  qualities  and 
ease  of  manipulation,  we  will  first  refer  to — 

Nylander's  Solution  (8). — Basic  bismuth  nitrate,*  2 
grammes ;  sodic  potassic  tartrate,  4  grammes ;  sodic  hy- 
drate (purified  sticks),  8  grammes;  distilled  water,  100  c.  c. 
Rub  the  solids  to  a  coarse  powder,  add  a  little  water  to 
form  a  paste,  then,  stirring  briskly  meanwhile,  gradually 
add  the  balance  of  the  water.  Let  stand  for  five  min- 
utes to  complete  the  solution.  Filtration  gives  a  per- 
fectly clear  solution.  Add  1  c.  c.  of  this  to  10  c.  c.  of 
urine,  boil  for  two  minutes  in  an  eight-inch  test  tube.  If 
a  light-gray  to  black  precipitate  form,  it  may  be,  usually 
is,  due  to  the  presence  of  glucose.  If  albumin  is  present, 
it  must  first  be  removed  (heat  and  a  drop  or  two  of  hydric 
acetate,  and  filtration).  This  formula  is  also  found  in  the 
books  as  Almen's  solution. 

Remarks. — An  expert,  by  careful  comparison  with  a 
non-glucosic  urine  of  like  specific  gravity,  can  detect  0'025 
per  cent,  of  glucose,  the  reaction,  of  course,  being  faint. 
But  a  urine  containing  0'05  per  cent,  shows  a  plainly  recog- 
nizable grayish  tint  in  the  flocculent  precipitate. 

Professor  Penzoldt  (7)  supports  the  originator's  claim 
that  in  normal  urine  it  gives  negative  results  in  the  larger 
proportion  of  cases. 

In  samples  from  a  large  number  of  persons — the  specific 
gravity  ranging  from  1-027  to  1-034,  the  color  yellow  to 
brownish-red  (Vogel) — the  writer  has  obtained  negative 
results  with  Nylander's  solution,  whereas  Worm-Miiller's 
and  Salkowski's  reagents  gave  a  discernible  cupric-hydrate 
precipitate.  The  charcoal-filtration  process  was  followed 
by  negative  results. 

While  Nylander's  is  without  doubt  the  best  qualitative 
"  reduction  "  test  yet  known,  its  originator  and  others  ad- 
rait  a  reaction  with  what  should  be  considered  normal 


*  V.  .Jaksch  {loc.  cit.)  says  "basic /leniitrate." 


urine.  This  has  occurred  to  the  writer  in  samples,  very 
numerous,  of  high  specific  gravity,  from  business  men  (sus- 
taining constant  and  burdensome  mental  strain),  which 
were  proved  to  be  free  from  glucose  by  the  charcoal-filtra- 
tion process  and  the  Bond-Ultzmann  test.  V.  Jaksch  (6) 
says  it  will  react  to  "melanin,  melanogen,"  and  many 
other  reducing  substances  (page  228). 

Since  the  experiments  herein  detailed  were  made,  more 
than  two  years'  daily  experience,  including  some  insurance 
cases  and  hundreds  of  others,  in  all  varieties  of  conditions, 
has  confirmed  the  estimate  above  formed  of  Nylander's  test 
(with  and  without  the  charcoal  control). 

And  here  would  seem  to  be  the  proper  place  to  speak 
of— 

The  Charcoal-Filtration  Process. — Seegen  (9)  years 
ago  pointed  out  the  value  of  filtration  through  chemically 
pure  animal  (blood)  charcoal  as  a  means  of  eliminating 
some  of  the  reducing  substances  other  than  glucose,  notably 
uric  acid,  creatin,  creatinin,  and  urinary  coloring  matter. 
While  the  charcoal  retains  a  minute  quantity  of  glucose, 
this  can  be,  nearly  if  not  wholly,  recovered  by  stirring  the 
filter  and  charcoal  with  a  small  quantity  of  distilled  water 
in  an  evaporating  dish,  bringing  the  whole  to  near  the  boil- 
ing point,  throwing  the  whole  upon  a  filter  (or  simply  pass- 
ing 25  or  30  c.  c.  warm  distilled  water  through  the  char- 
coal), and  testing  the  filtrate.  To  demonstrate  the  delicacy 
of  this  process  with  specimens  containing  0-05  per  cent,  of 
glucose,  I  obtained  unmistakable  evidences  of  its  presence 
in  the  filter-charcoal  filtrate  [i.  e.,  filtrate  No.  2). 

With  this  method  as  a  control  in  conjunction  with  Ny- 
lander's or  Worm-Miiller's  test,  repeated  experience  has 
convinced  me  that  there  is  but  little  to  be  desired.  By  its 
use  0-05-per-cent.  urines  show  an  unmistakable  light-gray 
reaction.  Clinical  needs,  therefore,  would  seem  to  be  fully 
satisfied. 

The  purity  of  the  charcoal  (Eiraer  and  Amend's  C.  P. 
from  blood)  was  tested  thus :  Mixed  with  distilled  water, 
boiled  and  filtered,  the  filtrate  tested  by  Nylander's,  Worm- 
Miiller's,  and  Salkowski's  reagents  with  negative  results  (not 
the  slightest  change  in  colors). 

A  word  upon  Bottger's  test  is  demanded.  It  is  errone- 
ously described  by  a  deservedly  popular  work  (10)  upon 
uranalysis  as  "  adding  an  equal  volume  of  liquor  potassa3  or 
sodse,  then  a  pinch  of  ordinary  subnitrate  of  bismuth,  and 
boiling  for  a  couple  of  minutes."  First,  this  is  not  Bott- 
ger's, but  Franqui  and  Van  de  Vyvere's  test  (11) ;  second, 
it  gives  a  misleading  reaction  with  urines  of  high  color  and 
specific  gravity,  although  absolutely  free  from  glucose. 
Salkowski  and  Penzoldt  warn  against  this  error;  my  ex- 
periments emphasize  it  (see  A  and  B).  Dr.  Tyson  is  not 
as  well  pleased  with  it  as  formerly. 

Bottger's  Test  (12). — Mix  equal  volumes  of  urine  and 
a  solution  of  sodic  carbonate  (crystals,  1  ;  distilled  water, 
3  parts) ;  add  a  few  grains  of  bismuth  subnitrate  and  boil 
for  two  minutes. 

The  tablets  offered  by  Messrs.  Parke,  Davis,  &  Co.,  in 
their  "  bedside  urinary-test  case,"  are  a  very  convenient 
form  for  making  use  of  Bottger's  test,  and  their  case  is  for 
bedside  testing  indispensable  to  the  careful  practitioner. 


Jan.  7,  1893.] 


BEANE:   TESTS  FOR  GLUCOSE  IN  THE  URINE. 


15 


Almost  coequal  in  value  are  Worm-Miiller's  modifica- 
tion of  Fehling's  and  Salkowski's  modification  of  Trom- 
mer's  test.  The  former  possesses  slightly  the  greater  deli- 
cacy, and  is  the  easier  of  manipulation. 

Worm-Muller's  Test  (13). — Solution  No.  1 :  Cupric 
sulphate,  2-50  grammes;  distilled  water,  100  c.  c.  Mix 
and  filter.  Solution  JVo.  2:  Potassic-sodic  tartrate,  10 
grammes ;  sodic  hydrate,  4  grammes ;  distilled  water,  to 
100  c.  c.    Mix  and  filter. 

Five  cubic  centimetres  of  urine  (clear  and  free  from 
albumin  *)  in  a  six-inch  test-tube,  and  a  mixture  of  2'50  c.  c. 
of  solution  No.  2  and  1'50  c.  c.  to  3  c.  c.  of  solution  No.  1 
(specific  gravity  less  than  r020,  use  1"50  c.  c.  ;  from  1,020 
to  1'025,  use  2  c.  c.  ;  to  1'030,  use  2*50  c.  c. ;  beyond  which 
use  3  c.  c.  of  No.  1)  in  a  similar  tube.  Boil  the  contents 
of  both  tubes,  suspending  the  boiling  simultaneously  in 
each,  wait  twenty  to  twenty-five  seconds,  then  pour  the 
urine  into  the  tube  containing  the  reagent. 

When  the  amount  of  glucose  is  very  slight  (0*05  per 
cent.),  wait  five  to  ten  minutes  to  allow  the  phosphates  to 
subside,  when  the  supernatant  liquid  will  be  seen  to  be  tur- 
bid from  a  very  fine  yellowish-green  or  light  yellowish-red- 
dish-green suspended  substance,  which  is  cuprous  hydrate. 
Even  in  dealing  with  as  delicate  a  test  as  this  the  operator 
can  readily  recognize  the  reaction  by  comparison  with  a 
sample  of  normal  urine,  of  a  similar  specific  gravity,  treated 
by  this  method.  When  the  urine  contains  a  larger  per- 
centage (O'lO  and  upward),  the  usual  reddish-yellow  or  yel- 
lowish-red precipitate  is  at  once  formed,  cuprous  hydroxide 
or  oxide. 

Remarks. — This  is  the  best  modification  of  Fehling's 
test  which  has  come  to  the  writer's  notice,  being  the  least 
liable  to  error  from  other  reducing  substances  than  glucose. 
But  this  source  of  error  occasionally  occurs,  as  a  recent 
insurance  case  demonstrated.  The  urine  was  1*030,  super- 
acid, with  uric-acid  deposit,  -^g  ^  „  q  albumin  (due  to  pus), 
gave  a  0-05-per-cent.  reaction  to  Worm-Miiller's,  but  was 
negatived  by  Ny lander's  and  the  charcoal- filtration  process. 
The  applicant  was  without  the  slightest  symptom  or  sign  of 
physical  derangement.  Probably  pyrocatechin  was  the  dis- 
turbing substance. 

Salkowski's  Test  (14). — Solution  1 :  Dissolve  100 
grammes  of  sodic  hydrate  (purified,  in  sticks)  in  300  c.  c. 
of  distilled  water ;  if  there  is  any  sediment,  carefully  decant 
the  solution. 

Solution  2:  Cupric  sulphate,  chemically  pure,  10 
grammes  in  distilled  water  100  c.  c.  To  9  c.  c.  urine  add 
3  c.  c.  of  solution  1  in  an  eight-inch  test-tube,  then  the  so- 
lution 2,  drop  by  drop,  shaking  the  mixture  after  each, 
until  the  copper  ceases  to  dissolve.  Slowly  heat  to  a  little 
below  the  boiling  point  (be  especially  careful  as  to  this), 
and  if  glucose  be  present  the  usual  greenish,  or  yellow,  or 


*  The  removal  of  even  as  minute  a  quantity  of  albumin  as  tyouct 
(Tanret's,  or  picric  acid,  ornitric-magncsian  [Roberts's]  contact  method, 
with  or  without  heat)  is  essential,  as  one  case  demonstrated,  Salkowski's 
test  having  produced  a  dirty  reddish-gray  precipitate,  with  a  few  spots 
of  yellow  cupric  oxide  interspersed.  While  the  presence  of  sT)',nT  albu- 
min has  not  interfered  with  Nylander's  and  Biittger's  tests,  the  rule 
to  remove  all  albumin  should  always  be  followed. 


reddish  hydroxide  of  copper  will  be  seen,  first  in  the  upper 
stratum,  then  throughout  the  liquid.  Here,  as  directed  un- 
der Worm-Miiller's  test,  where  only  a  minute  quantity  of 
glucose  is  present,  the  test-tube  should  be  set  aside  for  five 
to  ten  minutes  to  allow  the  subsidence  of  the  flocculent 
phosphates. 

Two  minutes'  maintenance  near  (but  avoiding  the  ac- 
tual) boiling  point  will  suffice  in  all  cases. 

Remarks. — This,  while  a  little  more  troublesome  and 
less  uniform  than  the  preceding  test,  will  in  experienced, 
careful  hands,  demonstrate  0'05  per  cent,  of  glucose.  It  is 
open  to  the  same  sources  of  errors  as  all  "  reduction  "  tests. 

It  may  be  profitable  to  here  consider  the 

Reduction  Substances. — They  may  be  divided  into — 

Group  I.  Normal  Urine  Constituents  or  Eliminates. — 
Uric  acids  and  urates,  creatin,  creatinin,  indican,  other 
coloring  matters,  inosit,  lactose  (galactose),  levulose,  "  al- 
kapton,"  alkapton-like  bodies,  Leo's  unnamed  substances 
(15),  melanin,  melanogen,  pyrocatechin,  proto-catechuic, 
uroleucic,  urozanthic,  and  glycosuric  acids,  and  others. 

Group  II.  Medicinal  Agents. — Antipyrine,  benzol,  bro- 
mobenzol  and  nitrobenzol,  benzoic  acid,  camphor,  chloral, 
chloroform,  copaiba,  cubebs,  exalgine,  glycerin,  hydroquinol, 
morphine,  orthonitrotuluol,  phenacetin,  phenol,  salicylic  acid 
and  salicylates,  sandal  oil,  the  turpentines,  as  well  as  others 
which  are  creeping  into  notice. 

Even  the  phenylglucozon  crystals  may  be  simulated  by 
potassium  glycuronate  in  urine  which  has  been  treated  by 
phenylhydrazin  hydrochlorate. 

It  is  well  to  remember  that  maple  sugar  (Christopher  [1^]-, 
confirmed  by  the  writer  in  a  sample  of  Vermont  sugar  from 
the  maker  and  unquestionably  unadulterated),  the  unre- 
fined sugars,  molasses,  and  syrups  contain  a  large  percent- 
age of  glucose.  If  ingested  in  large  quantity,  a  small  part 
may  be  eliminated  in  the  urine  even  during  health.  Rhu- 
barb taken  as  food  will  also  cause  a  reaction  from  the  bis- 
muth tests  (Salkowski)  (14). 

To  review  the  detailed  reactions  of  the  above-named 
substances  in  the  urine  would  exceed  the  scope  of  this  arti- 
cle. An  excellent  reference  to  several  will  be  found  in  an 
article  by  Dr.  T.  Barton  Brune  (15). 

Aside  from  levulose  (heretofore  only  detected  in  combi- 
nation with  glucose,  consequently  to  be  disregarded)  and 
galactose  (only  found  in  the  urine  of  nursing  women),  the 
disturbances  due  to  substances  of  Group  I  may  be  elimi- 
nated by  careful  and  successive  testing  with  Nylander's 
(before  and  after  the  charcoal-filtration  process),  the  fer- 
mentation, and  the  Bond-Ultzmann  tests. 

Questioning  the  patient  and  a  new  sample  (after  the 
proper  interval)  will  remedy  an  error  due  to  the  presence  of 
those  of  Group  II. 

The  Fermentation  Test  comes  next  as  far  as  delicacy 
is  concerned,  and,  barring  (theoretically)  levulose,  is  second 
to  none  for  reliability. 

With  Einhorn's  apparatus  (17),  washed  fresh  yeast, 
properly  diluted  acid  urine,  and  a  temperature  of  65°  F. 
to  80°  F.,  the  detection  of  as  little  as  O'lO  per  cent,  of 
glucose  is  certain,  despite  much  that  has  been  written  by 
way  of  theoretical  criticism.    Even  a  very  recent  critic- 


16 


BEANE:   TESTS  FOR  GLUCOSE  Ih  THE  URINE. 


[N.  Y.  Med.  JonB., 


after  a  considerable  experience,  acknowledges  (18)  it  to  be 
practically  correct  for  quantities  under  one  per  cent. 

The  following  method,  after  considerable  experiment- 
ing with  others,  gives  the  best  results  : 

Method. — After  a  preliminary  testing  (perfectly  clear 
and  albumin-free  urine)  with  Nylander's.or  Worm-Miiller's 
solution,  observe  Einhorn's  rules  for  dilution  in  accordance 
with  specific  gravity  or  a  rough  estimate  of  the  amount  of 
glucose  present.  If  alkaline,  render  the  urine  (diluted  or 
not)  faintly  acid  with  a  five-per-cent.  solution  of  tartaric 
acid  ;  boil  so  as  to  remove  contained  air,  and  cool.  With 
a  glass  rod  gently  stir  10  c.  c.  of  this  with  a  pea-sized  mass 
of  fresh  compressed  yeast,  half  a  cake  of  which  has  been 
mixed  with  25  or  30  c.  c.  of  distilled  water  and  filtered. 
Fill  Einhorn's  apparatus  (No.  1)  and  set  aside  in  a  warm 
place  (near  a  register,  stove,  coil,  warm  wall,  or  closet) 
with  a  thermometer  for  guidance  for  sixteen  to  twenty- 
four  hours,  the  temperature  ranging  from  65°  F.  to  80° 
F.  P'ill  another  tube  (No.  2)  with  distilled  water  or  nor- 
mal urine  of  low  specific  gravity  -}-  a  trifle  of  glucose 
-|-  some  of  the  same  yeast,  and  set  aside  with  the  former  as  ! 
a  control  test  for  the  activity  of  the  yeast,  evidenced  by 
the  formation  of  gas  within  this  second  Einhorn  tube. 

Gas  formed  in  tube  No.  1  is  proof  of  the  presence  of 
glucose  in  the  following  amounts  : 

A  minute  or  medium-sized  bubble  =  O'lO  per  cent. 

0-2  c.  c.  =  0-20  "  " 
0-4    "    =  0-25   "  " 
1-8  c.  c.  to  2-2    "    =  0-50  "  " 

3-  0    "    "  3-5    "    =  0-75   "  " 

4-  5    "    "  5-0    "    =  1-00   "  " 
Errors  from  impurities  of  yeast  and  aerated  alkaline 

urine  are  hereby  eliminated. 

Remarks. — The  simplicity  and  convenience  of  this  meth- 
od far  exceed  those  of  Fehling's  titration  and  its  modifica- 
tions ;  its  accuracy  is  fully  equal  to  the  latter,  with  its 
necessary  correction-calculations,  as  over  two  years'  per- 
sonal experience  and  comparisons  have  demonstrated.  Cer- 
tain it  is  that  Einhorn's  method,  as  here  outlined,  serves  all 
clinical  and  practical  purposes. 

The  writer  has  not  tested  Roberts's  (19)  fermentation 
method,  but  its  simplicity  and  clinical  accuracy  (when  one 
possesses  properly  made  urinometers)  would  seem  to  be  be- 
yond question.  An  excellent  paper  upon  the  subject  has 
lately  appeared  (20). 

The  Ammonia-lead  Test. — This  has  been  referred  to 
in  some  works  as  Dr.  Penzoldt's,  but  the  latter  says  (7)  his 
knowledge  came  from  Dr.  Dittmer,  who  saw  it  in  Ludeke's 
pharmacy  in  Berlin.  The  author  could  not  be  ascertained. 
Nevertheless,  Hager's  Pharm.  Praxis,  ii,  855,  refers  to  it. 

Method. — To  10  c.  c.  of  urine  in  an  eight-inch  test-tube 
add  ten  drops  of  ammonium  hydi'ate,  shake,  tlien  two  to 
three  drops  of  liquor  plumbi  subacetatis,  which  will  form  a 
white  curdy  precipitate.  Cautiously  heat  to  near  the  boil- 
ing point  for  two  minutes  without  producing  bubbles  or 
"  bumping,"  accomplished  by  care  and  practice.  The  pres- 
ence of  glucose  is  indicated  by  a  faint  pinkish-yellow  to  a 
brownish-red  or  purple  tint  to  the  precipitate.  To  be  char- 
acteristic the  pink  tint  must  appear. 


Remarks. — My  experience  corroborates  Dr.  Penzoldt's, 
that  this  reaction  does  not  occur  in  urines  free  from  glucose 
even  when  concentrated  and  possessing  a  specific  gravity  of 
1'033.  Its  sensitiveness  does  not  exceed  the  detection  of 
0'20  per  cent,  of  glucose  ;  O'lO  per  cent,  gave  thoroughly 
doubtful  reactions  (yellowish).  While  reliable  and  com- 
paratively easy  of  execution,  Nylander's,  Worm-Miiller's, 
and  Einhorn's  are  more  searching. 

Now  we  may  deal  with  those  tests  which  our  experi- 
ments have  demonstrated  to  be  inaccurate  and  misleading 
despite  their  popularity.  These  conclusions  are  supported 
by  Penzoldt  (7)  and  v.  Jaksch  (6). 

The  special  source  of  error  lies  in  the  fact  that  with 
normal  urine  when  added  in  certain  quantity  the  character- 
istic reactions  occur,  so  that  the  proof  of  the  presence  of 
glucose  simply  depends  upon  the  degree  of  color  in  relation 
to  the  quantity  of  urine  tested. 

The  Indigo-carmin-soda  Test  (21). — In  thirty  min- 
ims of  distilled  water  dissolve  one  indigo-sodic  tablet  in  a 
test  tube  by  gentle  heat.  (If  the  urine  is  very  acid,  also 
!  add  a  sodic-carbonate  tablet.*)  To  this  blue  solution  add, 
from  a  pipette,  one  drop  of  urine ;  keep  the  fluid  near  212° 
F.,  without  active  ebullition,  for  one  minute.  If  no  change, 
add  another  drop  of  urine  and  heat  again.  If  glucose  is 
present,  the  fluid  changes  successively  to  violet,  purple,  red, 
or  yellow  in  proportion  to  the  amount  contained. 

N.  B. — Normal  urine  produces  a  reaction  (purple  or 
red)  when  five  to  eight  drops  are  added.  But  one  drop 
producing  a  change  in  color  is  proof  that  sugar  is  present 
in  abnormal  quantity.  "  Its  indications  may  be  accepted 
as  infallible." 

Agitation  of  the  tube  during  heating  retards,  vigorous 
shaking  actually  prevents  the  reaction,  even  when  a  large 
percentage  is  present  (being  due  to  contact  with  the  oxygen 
of  the  air). 

Oliver  (22)  maintains  that  this  test  is  not  affected  by 
any  of  the  normal  urinary  constituents,  albumin,  blood,  bile, 
leucin,  mucus,  peptone,  pus,  tyrosine,  ammoniacal  or  decom- 
posing albuminous  urine,  or  even  a  weak  solution  of  am- 
monium sulphide  ;  but  that  dextrin,  inosite,  glucose,  lactose, 
ferrous  and  ferric  sulphate,  gallic  and  tannic  acid  do  cause 
the  reaction.  He  has  also  adapted  it  to  quantitative  analy- 
sis. He  recommends  test-papers,  but  the  tablets  of  Messrs. 
Parke,  Davis,  &  Co.  are  equally  reliable,  the  writer  hav- 
ing tested  both,  as  well  as  the  pure  chemical  (in  solution), 
with  uniform  results. 

Remarks. — A  reference  to  A  and  B  recalls  that  in  thirty- 
one  samples  of  normal  urine  where  used,  this  test  reacted  in 
twenty,  ranging  from  violet  to  yellow  and  proportionate  to 
the  height  of  the  specific  gravity. 

Upon  what  these  reactions  in  concentrated  urine  depend 
has  not  been  determined. 

Since  five  to  eight  drops  of  normal  urine  of  medium 
specific  gravity  react,  some  experimenters  (23)  claim  that 
normal  urine  consequently  contains  a  minute  trace  of  glu- 
cose ;  others  (24),  equally  eminent,  deny  this. 


*  Unless  the  urine  is  rendered  decidedly  alkaline  with  sodic  carbon- 
ate an  erroneous  negative  result  may  occur. 


Jan.  7,  1893.] 


BEANE:    TESTS  FOR  GLUCOSE  IN  THE  URINE. 


17 


Our  results,  C  and  T),  would  seem  to  support  the  latter, 
since  0*025  per  cent,  of  diabetic  as  well  as  artificial  glucosic 
urines  failed  to  affect  the  reagent,  whether  in  paper,  tablet, 
or  pure  chemical. 

Reacting  in  two  thirds  of  the  specimens  of  glucose-free 
urines  and  failing  to  show  the  presence  of  0'025  per  cent, 
of  glucose,  the  conclusion  is  irresistible  that  it  is  "  unrelia- 
ble," and,  since  so  largely  accepted  as  infallible,  "  mislead- 
ing." It  has  a  "  negative  "  value,  since  non-reacting  urine 
may  be  accepted  as  practically  free  from  glucose  (accepting 
0'05  per  cent,  as  the  lowest  pathological  unit).  In  this 
sense  it  may  be  useful  as  a  preliminary  test. 

The  Picric-acid  Test  is  also  very  popular,  and  was 
favorably  referred  to  in  life-insurance  examiners'  hand- 
books until  recently. 

Method  (10). — To  5  c.  c.  of  urine  add  3  c.  c.  of  a  satu- 
rated solution  of  picric  acid  and  2  c.  c.  of  potassic  hydrate 
(specific  gravity,  r065).  Boil  for  a  minute.  If  glucose  be 
present,  a  dark  mahogany-red  color  will  result. 

N.  B. — The  light  cherry-red  hue  of  normal  urine  treated 
the  same  way  is  somewhat  deepened.  Dr.  Johnson  estimat- 
ing the  change  as  equal  to  that  occurring  in  a  solution  of 
0-5  to  O'V  grain  to  the  fluidounce  (equal,  in  round  numbers, 
^'^  T'oVs'  Tou)  glucose.  This  the  writer  confirmed  in 
normal  urine  of  1"020  specific  gravity.  Dr.  Johnson  claims 
that  uric  acid,  the  urates,  and  albumin  exercise  no  disturb- 
ing influence,  but  that  an  excess  of  creatin  does  (25). 

Remarks. — Dr.  Penzoldt's  criticism  (7)  is  wholly  apropos. 
"...  The  judgment  of  the  observer,  at  best,  has  to  be  based 
upon  the  depth  of  tint.  Consequently  the  test  lacks  sharp- 
ness. ...  It  can  not  be  recommended "  for  amounts  less 
than  0'20  to  0"25  per  cent.,  as  even  Dr.  Johnson's  figures 
and  these  experiments  demonstrate.  But  all  the  specimens 
(in  which  used)  in  A  and  B,  save  one  with  a  specific  gravity 
of  1-012,  showed  a  reaction  (in  all  a  decidedly  deeper  tint 
than  occurs  in  normal  urine).  In  C  and  D  there  were  no 
failures.  In  dealing  with  0'05  and  0-025  per  cent,  there 
might  have  been  a  difference  of  opinion  between  two  oper- 
ators, as  the  tint  being  deeper  than  results  from  a  0-1-per- 
cent, solution  of  glucose — i.  e.,  Dr.  Johnson's  "  normal." 

Frohn's  Reagent. — To  remove  the  elements  which  in 
certain  cases  disturb  the  accuracy  of  Bottger's  test.  Pro- 
fessor Briicke  (2G)  recommended  the  use  of  Frohn's  reagent, 
which  is  made  as  follows  :  "  A  gramme  and  a  half  of  freshly 
precipitated  basic  bismuth  nitrate  is  mixed  with  twenty 
grammes  of  water  and  heated  to  boiling  ;  then  seven 
grammes  of  iodide  of  potassium  and  twenty  drops  of  hy- 
drochloric acid  are  added.   The  reagent  is  orange-red  "  (10). 

Method. — With  equal  quantities  of  water  and  urine,  re- 
spectively in  two  test-tubes,  add  hydric  chloride  to  the  for- 
mer until  a  drop  of  Frohn's  reagent  fails  to  produce  cloudi- 
ness. Then  add  this  (just  determined)  quantity  of  acid  to 
the  urine,  adding  two  or  three  drops  of  the  reagent,  and 
filter.  Boil  the  filtrate,  no  longer  cloudy  on  adding  hydric 
chloride  or  the  reagent,  a  minute  or  two  with  an  excess  of 
a  ten-per-cent.  solution  of  sodic  or  potassic  hydrate.  "  If 
a  gray  or  black  color  results,  or  such  a  precipitate  is  formed, 
the  presence  of  sugar  is  proved  beyond  a  doubt"  (10). 

Remarks. — In  every  sample  in  which  it  was  used  (save 


two,  specific  gravity  1-013)  in  experiments  A  and  B  it  gave 
decided  reactions  ;  the  higher  the  specific  gravity  the  deeper 
the  precipitate  (from  light-gray  to  black).  While  capable 
of  reacting  to  0-05  per  cent,  diabetic  and  0-025  per  cent, 
artificial  glucosic  urine  (see  C  and  D),  the  former  experi- 
ments demonstrate  that  in  highly  acid  urines  of  high  spe- 
cific gravity  it  fails  to  support  the  claims  of  its  adapter. 
Its  unreliability  was  further  emphasized  by  its  reaction  in 
one  sample  (1-028)  after  the  charcoal  process  (a  light-gray 
precipitate),  and  in  another  (1"02'7)  after  Mchu's  evapora- 
tion process  (grayish-black  precipitate).  While  as  sensi- 
tive as  any,  it  is  not  so  convenient  as  Nylander's  or  Worm- 
Muller's. 

No  attempt  was  made  to  ascertain  the  value  of  the  color 
tests  of  Molisch  (alpha-naphthol  and  thymol)  and  of  Agos- 
tini  (auric  chloride),  as  they  both  react  upon  the  same  prin- 
ciple as  indigo-carmine  and  picric  acid — i.  e.,  to  a  certain 
proportion  of  normal  urine. 

The  practical  deductions  for  the  physician,  if  not  the 
chemist,  from  the  present  survey  of  the  subject,  would 
seem  to  be : 

1.  For  qualitative  testing,  Nylander's  and  Worm-Miiller's 
methods  are  worthy  of  confidence  and  should  be  the  first 
resort. 

2.  Doubt  arising,  the  charcoal  or  Bond-Ultzmann  meth- 
od is  competent  to  decide  the  question. 

3.  For  quantitative  analysis  the  fermentation  method, 
as  detailed,  gives  results  sutficiently  accurate  for  the  most 
exacting  clinical  demands. 

Bibliographical  References. 

1.  M6hu,  C.  J.  M.  Revue  de  chimie  clinique,  1877,  xlviii, 
485. 

Process. — Evaporate  the  urine  [100  c.  c]  to  a  syrupy  consist- 
ence [5  c.  c]  over  a  water-bath;  cool;  add  ninety  per  cent,  of 
alcohol  [10  c.  c] ;  stir  thoroughly ;  filter  and  evaporate  the  al- 
cohol. The  residue,  redissolved  in  distilled  water  [10  c.  c],  may 
be  tested.  The  creatinin — a  great  inconvenience — may  be  re- 
moved by  adding  to  the  alcoholic  liquid  a  little  zinc  chloride, 
setting  aside  twenty-four  liours  before  filtering  and  making  the 
test.  Mehii  also  advises,  in  doubtful  cases,  another  method — 
viz.,  to  the  urine  add  one  twentieth  of  its  volume  of  the  solu- 
tion of  basic  lead  acetate  of  the  shops ;  filter ;  add  powdered  an- 
hydrous neutral  sodic  carbonate;  and,  after  agitation  and  sepa- 
ration of  the  lead  precipitate,  concentrate  the  colorless  liquid 
to  one  tenth  of  its  volume ;  filter  and  test  the  filtrate  with 
Worm-Mtiller's  or  Nylander's  reagent.  [Both  methods  were 
tested.] 

2.  Cole,  P.  C.  Tests  for  Diabetes  Mellitus.  Medical  Rec- 
ord, 1888,  ii,  475. 

Process. — Put  10  c.  c.  of  solution  of  cnprio  sulphate,  chemi- 
cally pure  (17-319  grammes  in  500  c.  c.  of  distilled  water),  into 
a  300  c.  c.  Florence  flask  ;  add  40  c.  c.  of  distilled  (or  boiled) 
water ;  then  about  two  thirds  of  a  gramme  of  acid  tartaric, 
chemically  pure;  make  solution;  add  sufficient  ten-per-cent. 
solution  of  potassic  hydrate  until  a  permanent  decp-XAao  color  is 
obtained.  Phice  flask  on  retort  stand  and  boil.  If  any  change 
(save  intensified  blue)  occur,  tlie  chemicals  are  at  fault,  and  the 
process  must  be  repeated  with  freshly-made  solutions.  Dilute 
10  c.  c.  of  urine  with  90  c.  c.  of  distilled  water.  While  the  test- 
solution  is  boiling,  add,  drop  by  drop,  the  diluted  urine  from  t 
burette.    When  uearing  the  end  of  the  operation,  interrupt  tho 


18 


KLOMAN:   THE  RADICAL  CURE  OF  HERNIA. 


[N.  y.  Mkd.  JotTK., 


boiling  for  a  few  moments,  so  as  to  better  judge,  from  subsi- 
dence of  the  copper  precipitate,  when  the  point  of  saturation 
has  occurred,  as  evidenced  by  the  total  discharge  of  the  blue 
color  of  the  supernatant  liquid.  The  cubic  centimetres  of  urine 
used  :  grammes  glucose  found  ;:  100  :  per  cent,  of  ghicose,  is 
the  formula  for  quantitative  computation.  This  is  certainly  an 
improvement  upon  Fehling's  method. 

3.  Bond,  A.  K.  A  Study  of  the  Phenylhydrazin  Test  for 
Sugar  in  the  Urine,  as  applied  by  Ultzmann.  Medical  News., 
1887,  li,  146. 

4.  Fischer,  Emil.  Berichte  de/r  deutsch.  chem.  Gesellsch., 
Berlin,  xvii,  579. 

5.  Grocco,  P.  Annali  di  chem.  appl.  alia  farmacia^  IxxiX) 
258. 

6.  Von  Jaksch,  Rudolf.  Mittheil.  des  Wiener  med.  Doct.- 
(7oZi.,  Band  x.  Also  Zeitschr.  f.  U.  Med.,  1886,  xi,  20;  and 
Clinical  Diagnosis.,  London,  1890,  pp.  222-229. 

7.  Penzoldt,  F.  An  abstract  of  Aeltere  und  neuere  Harn- 
prohen,  und  ihr  practischer  Werth.  Kurze  Anleitung  zur  Ilarn- 
untersuchung  in  der  Praxis  fiXr  Aerize  und  Studierende,  second 
edition,  Jena,  1886,  in  The  American  Druggist,  December,  1886, 
p.  175  ;  January  and  February,  1887,  pp.  17  and  26. 

8.  Nylander,  E.  Alkalisk  vismuttlOsing  siisom  reagens  pa 
drufsocker  i  urin  [Alkaline  Solution  of  Bismuth  as  a  Reagent  for 
Grape-sugar  in  the  Urine].  Upsala  Ldkaref.  Fork.,  1882-'83, 
xviii,  442-445  ;  and  Zeitschr.  f.  physiol.  Chemie,  1884,  viii, 
175. 

9.  Seegen,  J.  Centralblatt  f.  d.  med.  Wissenscha/t.,  No.  5, 
1872.  Also  see  Thudichum's  Pathology  of  the  Urine,  London, 
second  edition,  pp.  441-445. 

10.  Tyson,  James.  A  Guide  to  the  Practical  Examination  of 
the  Urine,  Philadelphia,  seventh  edition,  1891,  83  et  seq. 

11.  Wilder,  Hans  M.  List  of  Tests  {Reagents).  P.  W.  Bed- 
ford, New  York,  1885. 

12.  Bottger,  R.    Jour.f.  fraTct.  Chemie,  1857,  Ixx,  432. 

13.  Worm-MuUer,  J.,  und  Hagen,  J.  Ueber  den  Vorgang 
bei  der  Trommer'schen  Probe.  Archiv  f.  d.  ges.  Physiol.,  Bonn, 
1880,  xxii,  391-405;  also  Pflilger's  Archiv,  1882,  xxvii,  107. 

14.  Salkowski,  E.  Ueber  die  Verbindungen  des  Trauben- 
suckers  mit  Kupperoxydhydrat.  Zeitschr.  f.  physiol.  Chemie, 
Strassburg,  1879,  iii,  79-97.  Also  Leube  and  Salkowski.  Die 
Lehre  vom  Ham,  Berlin,  1882. 

The  same.  Centralblatt  f.  d.  med.  Wissensch.,  1885,  xxiii, 
433. 

15.  Brune,  T.  Barton.  Sugar  Testing,  with  Special  Refer- 
ence to  "  Alcaptonuria."    Maryland  Med.  Jour.,  1889,  41-44. 

16.  Christopher,  H.  Cane  Sugar  and  Glucose.  St.  Joseph 
Medical  Herald,  1889,  vii,  No.  3,  75-77. 

17.  Einhorn,  Max.  Fermentation  as  a  Practical  Qualitative 
and  Quantitative  Test  for  Sugar  in  the  Urine.  Medical  Record, 
1887,  xxxi,  91-94. 

18.  Guttmann,  Paul.  Zur  quantitativen  Zuckerbestimmung 
im  Harn  mittels  Giihrung.    Deutsche  med.  Woch.,  1890,  p.  8. 

19.  Roberts,  William.  On  a  New  Giinioal  Method  of  esti- 
mating the  Quantity  of  Sugar  in  Diabetic  Urine.  Edinhurgh 
Med.  Jour.,  October,  1861,  326.    Also  Lancet,  1862,  i,  508. 

20.  Manges,  Morris.  The  Quantitative  Estimation  of  Sugar 
with  Roberts's  Fermentation  Test.  Medical  Record,  1891, 
xxxix,  505-507. 

21.  Parke,  Davis,  &  Go.  Instructions  for  the  Use  of  Urinary 
Test  Tablets  for  the  Clinical  Examination  of  the  Urine  at  the 
Bedside.    Detroit  and  New  York,  pamphlet. 

22.  Oliver,  George.  Bedside  Urine  Testing.  Third  edition, 
London, 1885. 

28.  V.  Brucke,  Ernst.  Vorles.  iiber  Physiologic,  1875,  sec- 
ond edition ,  i,  375. 


Bence-Jones.    Journal  of  the  Chemical  Society,  1862,  p.  22. 
Pavy,  F.  W.    Points  connected  with  Diabetes.  London, 
1879. 

24.  Seegen,  J.  Der  Diabetes  mellitus,  2.  AuQ.,S.  224.  Also 
Thudichum's  work  (see  Reference  No.  9). 

Wormley,  T.  G.  Referred  to  by  Dr.  T.  B.  Brune  (see  Refer- 
ence No.  15). 

Penzoldt,  F.    (See  Reference  No.  7.) 
V.  Jaksch,  R.    (See  Reference  No.  6.) 

25.  Jolmson,  George  and  G.  S.  The  Kreatinins.  Proceed, 
of  the  Royal  Sac,  1887,  xlii,  365. 

26.  V.  Brilcke,  Ernst.  Proceed,  of  the  Amer.  Pharmaceut. 
Assoc.,  1877,  p.  287. 

27  West  Eleventh  Street. 


THE  RADICAL  CURE  OF  HERNIA 
BY  HYPODERMIC  INJECTION. 
By  WILLIAM  0.  KLOMAN,  M.  D., 

BALTIMORE. 

For  a  number  of  years  past  various  remedies — such  as 
the  fluid  extract  of  white-oak  bark,  tincture  of  iodine,  etc. 
— have  been  used  in  attempting  the  permanent  occlusion  of 
hernial  rings  and  canals,  but  they  have  all  proved  to  be  of 
temporary  value  and  have  failed  in  their  purpose. 

In  the  month  of  May  of  the  present  year  I  investigated 
a  new  treatment  for  this  purpose — the  discovery  of  Dr. 
Charles  E.  McCandliss,  of  Atlanta,  Ga.  I  was  very  incredu- 
lous at  first  in  regard  to  its  utility,  but  the  doctor,  in  con- 
versation, made  such  positive  statements,  spoke  so  ration- 
ally, and  laid  before  me  proofs  of  cures  which  had  lasted 
for  two  years,  that  I  felt  inclined  to  give  him  the  opportu- 
tunity  of  showing  what  his  treatment  could  accomplish,  and 
furnished  him  with  two  cases — one  a  double  inguinal  hernia. 
On  the  left  side  the  ring  measured  about  two  inches ;  the 
hernia  was  oblique,  and  would  pass  into  the  scrotum  when 
unprotected ;  on  the  right  side  the  hernia  was  direct,  of 
smaller  size,  and  constituted  a  bubonocele.  This  man  was 
an  old  soldier,  a  volunteer  in  the  late  war,  and  had  been 
ruptured  for  thirty  years.  The  other  case  was  an  oblique 
inguinal  hernia  of  about  five  years'  duration  and  of  moder- 
ate size. 

Both  of  these  cases  were  cured  by  the  1st  of  July,  and 
the  last-mentioned  case  had  then  been  doing  without  his 
truss  for  over  two  weeks,  working  daily  (which  he  also  did 
during  his  treatment),  and  on  the  day  of  my  investigation 
he  assured  me  he  had  lifted  a  weight  of  three  hundred 
pounds  without  perceiving  any  protrusion  of  hernia  or  feel- 
ing any  weakness. 

Since  then  I  have  seen  at  least  ten  other  cases  treated 
and  without  a  single  failure.  Some  of  these  cases  had 
worn  a  variety  of  trusses,  none  of  which  had  been  able  to 
retain  the  hernia. 

Several  gentlemen,  prominent  citizens  of  Baltimore,  have 
been  treated  successfully,  one  of  whom  has  especially  stated 
to  me  that  he  had  bought  a  dozen  kinds  of  truss,  none  of 
which  had  protected  him,  but  that  the  hernia  would  pro- 
trude;, especially  when  he  was  at  stool.  He  had  also  been 
treated  before  by  some  hypodermic  method  and  unsuccess- 


Jan.  7,  1893.J 


LEADING  ARTICLES. 


19 


fully.  He  now  goes  without  a  truss  or  any  support,  and 
considers  himself  radically  cured. 

The  injections  are  made  into  the  edges  of  the  hernial 
ring,  and  each  one  causes  a  growth  of  new  tissue,  which 
can  be  distinctly  felt  with  the  finger  placed  over  it.  These 
injections  ai'e  made  at  intervals  of  three  or  four  daj-s  until 
the  hernial  ring  is  fully  sealed.  The  ring  has  then  the  feel 
of  a  patch  of  firmer,  more  solid  substance  than  the  sur- 
roundings. The  pain  caused  by  these  injections  is  incon- 
siderable— no  more  than  an  ordinary  hypodermic  injection 
into  the  arm,  except  when  made  into  the  firmer  tissue  of 
Poupart's  ligament ;  here  sometimes  complaint  is  made  of 
soreness,  but  I  have  never  seen  any  inflammation  produced. 
The  patient  loses  no  time  while  under  treatment.  It  is,  of 
course,  absolutely  essential  that  a  truss  be  worn  while  under 
treatment  which  must  be  able  to  retain  the  hernial  protru- 
sion. 

These  treatments  are  now  given  at  the  Baltimore  Her- 
nia Institute.  Male  and  female  patients  are  treated,  the 
latter  at  their  homes. 

Altogether  about  thirty  cases  have  been  and  are  being- 
treated,  and  so  far  no  case  has  been  unsuccessful. 

I  have  recently  seen  a  young  man,  who  has  been  cured 
at  the  institute,  who  had  strangulation  of  his  hernia  a  few 
days  before  undergoing  treatment.  He  has  never  had  any 
pain  or  untoward  symptom. 

This  method  will  commend  itself  to  both  physicians  and 
patients,  since  the  advantages  over  operative  procedures  are 
so  obvious. 

November  1,  1892. 


The  Third  Congress  of  American  Physicians  and  Surgeons. — The 

first  meeting  of  the  executive  committee  was  held  on  December  27,  1892, 
in  Philadelphia.  The  committee  was  organized  by  the  election  of  Dr. 
William  Pepper,  of  Philadelphia,  as  chairman  and  Dr.  Newton  M.  Shaf- 
fer, of  New  York,  as  secretary.  The  following  officers  of  the  congress 
were  elected :  Dr.  Alfred  L.  Loomis,  of  New  York,  president ;  Dr 
William  H.  Carmalt,  of  New  Haven,  secretary ;  Dr.  John  S.  Billings,  of 
the  army,  treasurer;  and  Dr.  Samuel  C.  Busey,  of  Washington,  chair- 
man of  the  committee  of  arrangements.  It  was  decided  to  hold  the 
next  meeting  in  Washington  in  May,  1894. 

The  Death  of  Dr.  W.  Chew  Van  Bibber,  of  Baltimore,  took  place 
on  December  14th,  in  the  sixty -ninth  year  of  his  age.  His  literary 
work  was  considerable,  and  he  was  for  several  years  one  of  the  editors 
of  the  Maryland  and  Virginia  Medical  Journal.  He  was  a  lover  of  his 
profession,  valued  as  a  consultant,  and  with  a  temperament  full  of  sun- 
shine, sympathy,  and  helpfulness  to  the  poor.  He  was  in  active  prac- 
tice up  to  the  day  of  his  death,  which  occurred  quite  suddenly  in  his 
office. 

The  Death  of  Dr.  Fitch  E.  Oliver,  of  Boston,  which  occurred  early 
in  December,  removed  one  of  the  former  editors  of  the  Bo.<ito)i  Medical 
and  Surgical  Journal.  His  term  of  service  in  that  capacity  ended  in 
1864.  In  1848,  he,  with  Dr.  Morland,  translated  Chomel's  lectures  on 
pathology.  He  was  for  ten  years  a  member  of  the  visiting  staff  of  the 
City  Hospital.    His  age  was  ninety-one  years. 

The  Death  of  Dr.  Robert  Crawford,  of  Cooperstown,  Pennsylvania, 

who  for  fifty  years  had  been  one  of  the  leading  physicians  of  northwest- 
ern Pennsjlvania,  took  place  on  Christmas  morning.  Dr.  Crawford 
was  especially  well  known  to  the  older  members  of  his  profession,  and 
was  highly  esteemed  for  his  social  qualities  as  well  as  for  his  ability. 

Change  of  Address. — Dr.  Leopold  Stieglitz,  to  No.  133  East  Sixty- 
first  Street. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Revieio  of  Medicine. 

Published  by  Edited  by 

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


NEW  YORK,  SATURDAY,  JANUARY  7,  1893. 


ANOTHER  QUARANTINE  BILL. 

Refebknoe  was  made  in  the  Journal  for  December  10th  to 
a  proposed  national  quarantine  bill  that  liad  been  introduced 
into  the  House  of  Representatives  by  Mr.  Payne,  and  the  de- 
sirability of  the  measures  provided  for  by  that  bill  was  ques- 
tioned. 

We  have  recently  received  a  copy  of  a  bill  that  has  been  in- 
troduced into  the  Senate  by  Mr.  Harris  and  been  reported  by 
the  Committee  on  Epidemic  Diseases.  It  is  entitled  A  Bill 
Granting  Additional  Quarantine  Powers  and  Imposing  Addi- 
tional Duties  upon  the  Marine-Hospital  Service.  It  provides 
that  no  vessel  from  any  foreign  port  shall  enter  any  United 
States  port,  except  in  accordance  with  the  provisions  of  the  act 
and  with  such  rules  and  regulations  of  State  and  municipal 
health  authorities  as  may  be  made  in  pursuance  of  or  consist- 
ent with  the  act,  a  penalty  being  imposed  if  the  act  is  violated. 
All  vessels  clearing  from  a  foreign  port  for  a  United  States  port 
must  have  a  sanitary  certificate  regarding  the  cargo,  passen- 
gers, and  crew;  and  the  President  is  authorized  to  detail  any. 
medical  officer  of  the  Government  to  serve  in  the  office  of  the 
consul  at  any  foreign  port  for  the  purpose  of  making  the  neces- 
sary inspection.  The  Marine- Hospital  Service  shall  co  operate 
with  and  aid  State  and  municipal  boards  of  health  ;  and  where 
there  are  no  quarantine  regulations  or  where  local  quarantine 
regulations  are  deemed  insufficient  to  prevent  the  introduc- 
tion of  contagious  or  infectious  diseases  into  the  United 
States  from  foreign  countries,  or  into  one  State  from  another, 
regulations  made  by  the  Marine-Hospital  Service  shall  be 
enforced.  Consular  officers  shall  make  weekly  reports  to  that 
service  of  tlie  sanitary  condition  of  their  stations,  and  they 
shall  enforce  such  rules  and  regulations  as  may  be  furnished 
them.  On  the  arrival  of  an  infected  vessel  at  a  port  not 
provided  with  proper  facilities  for  disinfection,  the  Marine- 
Hospital  Service  may  remand  it  to  the  nearest  national  quaran- 
tine station.  It  is  provided  that  the  President  may  suspend 
immigration  from  countries  in  which  cliolera  or  yellow  fever 
exists,  and  the  act  of  1879  establishing  the  National  Board  of 
Health  is  repealed. 

There  is  no  man  in  eitlier  branch  of  Congress  more  familiar 
with  the  history  of  national  legislation  in  sanitary  matters  than 
Senator  Harris;  and  presumably  he  considers  that  this  is  as 
comiirehcnsive  a  bill  as  can  be  passed  at  this  time.  In  fact,  it 
virtually  allows  matters  to  remain  in  statu  quo.  As  long  as 
States  and  municipalities  have  the  right  to  exact  quarantine 
fees,  so  long  will  tliey  maintain  quarantine  establishments. 
We  have  already  given  some  of  the  reasons  for  the  creation  of 


20 


LEADING  ARTICLES.— MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Med.  Joue., 


a  national  quarantine,  and  the  advantage  of  having  medical  ofH- 
cers  stationed  at  consular  offices  is  but  a  feature  of  the  system 
that  should  be  enacted. 


METHODS  OF  ADMINISTERING  TAR. 

Dr.  William  Mukrkll,  of  the  Westminster  Hospital,  Lon- 
don, commends  the  use  of  tar  in  winter  cough  and  not  a  few 
other  complaints.  As  he  remarks  in  the  MeiHcal  Press  and  Cir- 
cular for  November  30,  1892,  tlie  remedy  has  an  ancient  his- 
tory and  would  be  used  much  more  freely  if  it  were  not  for  the 
many  difficulties  in  the  way  of  its  administration.  He  states 
that  he  has  recently  had  his  attention  called  to  tabloids  of  tar 
containing  a  grain  each,  and  these  appear  to  him  to  be  the  best 
form  in  which  to  administer  the  drug.  These  tabloids  contain 
the  whole  of  the  constituents,  they  are  palatable,  and  they  dis- 
integrate quickly.  The  usual  plan  has  been  to  swallow  three 
or  four  of  these  tabloids  every  four  hours,  but  this  is  not  so 
good  as  to  suck  one  frequently — in 'fact,  every  time  the  spasms 
of  coughing  recur. 

Dr.  Murrell  refers  briefly  to  the  "tar-water"  treatise  of 
Bishop  Berkeley,  called  Siris,  a  book  that  ran  through  sev- 
eral editions  and  was  translated  into  almost  every  European 
language.  The  bishop  thought  he  had  found  a  cure-all  in  tar- 
water,  some  of  the  popular  uses  of  which  he  had  picked  up  dur- 
ing his  residence  in  Rhode  Island.  Some  great  personages  sub- 
scribed their  concni'rence  in  the  allegations,  or  part  of  them,  of 
the  distinguished  philosopher,  but  the  tar-water  had  a  short 
life.  In  1875,  however,  Dr.  Murrell  brought  up  the  subject 
again  by  recording  a  number  of  cases  of  winter  cough  and  bron- 
chial catarrh  iu  the  treatment  of  which  tar  had  been  an  impor- 
tant substance,  and  since  that  time  papers  and  reports  of  cases 
by  the  scoi-e  "have  appeared  in  almost  every  medical  journal 
all  over  the  world." 

Concerning  a  certain  patented  preparation  used  in  this 
country.  Dr.  Murrell  writes  that  it  has  not  been  wanting  in 
efficacy;  it  is  simply  a  solution  of  tar  in  old  Jamaica  rum.  It 
is  more  palatable  than  some  of  the  other  tar  mixtures,  but 
winter  cough  is  a  very  persistent  trouble,  and  "if  a  wineglass- 
ful  of  this  concoction  were  taken  every  time  the  patient 
coughed  he  would  stand  a  very  good  chance  of  never  seeing  the 
summer  again." 

Regarding  the  use  of  tar  in  capsules  or  perles,  Dr.  Murrell 
has  not  had  much  experience.  He  notes  that  the  European 
profession  has  made  an  increasing  employment  of  the  dragees 
de  Christianie  mi  goudron  de  Norvege,  but  remarks  that  they 
are  expensive  and  not  adapted  to  the  tastes  of  his  own  country- 
men. For  them,  therefore,  he  welcomes  the  introduction  of  the 
palatable  and  soluble  tabloids  of  tar. 


MINOR    PA  RA  GRA  PES. 

STATE  CARE  OF  THE  INSANE. 

In  Governor  Flower's  message  to  the  Legislature  he  speaks 
of  the  State  care  of  the  insane  in  a  knowing  and  ai)proving 


manner,  referring  to  that  policy  as  "  a  most  praiseworthy  phi- 
lanthropy." He  truly  says  that  "corruption,  extravagance, 
and  the  improper  injection  of  politics  into  hospital  management 
will  be  constant  foes,  which,  if  not  combated  and  overcome, 
will  bring  reproach  upon  the  State  and  prevent  the  accomplish- 
ment of  much  good."  He  recommends  that  all  money  paid 
out  for  expenses  should  be  paid  on  the  controller's  warrant, 
believing  that  this  will  act  as  a  check  on  any  extravagance  of 
asylum  officials. 


THE  CLYSTER  IN  AFRIC4. 

In  the  course  of  a  recent  exhibition  of  photographs  taken 
in  Afri  ca,  as  Progris  medical  recounts,  M.  Marcel  Monnier 
showed  an  African  method  of  administering  eneniata.  The  im- 
plement employed  is  made  of  a  gourd  with  two  reeds  stuck  into 
it  on  opposite  sides.  The  sick  person  reclines  on  an  assistant's 
knees  in  the  attitude  of  a  swimmer.  One  of  the  reeds  is  in- 
serted into  the  rectum,  and  the  operator,  taking  the  other  one 
into  his  mouth,  blows  forcibly  through  it,  thus  driving  the  ene- 
ma out  of  the  gourd  and  into  the  patient. 


TYPHUS  FEVERJIN  NEW^jYORK. 

While  the  present  outbreak  of  typhus  in  New  York  can  not 
yet  be  called  alarming,  the  appearance  of  cases  in  widely  sepa- 
rated parts  of  the  town  within  the  last  few  days  seems  to  call 
for  the  utmost  strengthening  of  the  sanitary  authorities'  hands 
and  for  all  the  vigilance  that  those  officers  are  capable  of.  We 
hope  to  be  able  to  record  next  week  that  at  least  no  considera- 
ble further  spread  of  the  disease  has  taken  place. 


ITEMS,  ETC. 

Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  case* 
and  deaths  reported  during  the  two  weeks  ending  January  1,  1893  : 


DISEASES. 

Week  ending  Dec.  27. 

Week  ending  Jan.  1. 

Cases. 

Deaths. 

Cases. 

Deaths. 

0 

1 

63 

1 

20 

7 

16 

12 

118 

8 

112 

6 

Cerebro-spinal  meningitis. . . . 

1 

1 

1 

2 

102 

3 

86 

10 

87 

17 

132 

63 

6 

0 

2 

1 

The  New  York  Orthopaedic  Hospital. — We  would  remind  our  read- 
ers that  the  annual  series  of  lectures  will  be  given  this  year  on  Mon- 
day and  Thursday  afternoons  from  January  12tb  to  February  20th,^ 
inclusive. 

The  Celtic  Medical  Club,  of  New  York. — Dr.  Constantine  J.  Mac- 
guire  has  been  elected  president;  Dr.  Joseph  Gray,  vice-president;  and 
Dr.  Joseph  Merrigan,  secretary. 

The  Death  of  Dr.  Beriah  A.  Watson,  of  Jersey  City,  is  announced 
to  have  taken  place  on  Thursday,  the  22d  ult.,  in  the  fifty-sixth  year  of 
his  age.  Dr.  Watson  was  a  graduate  of  the  Medical  Department  of  the 
University  of  the  City  of  New  York,  of  the  class  of  1861,  and  one  of 
the  surgeons  to  St.  Francis  Hospital. 

Society  Meetings  for  the  Coming  Week : 

Monday,  January  9th :  New  York  Academy  of  Medicine  (Section  in 
General  Surgery);  Lenox  Medical  and  Surgical  Society  (private);, 


Jan.  7,  1893.] 


PROCEEDINOS  OF  SOCIETIES. 


21 


New  York  Ophthaliuological  Society  (private) ;  New  York  Medico- 
historical  Society  (private) ;  New  York  Academy  of  Sciences  (Sec- 
tion in  Cliemistry  and  Technology) ;  Boston  Society  for  Medical  Im- 
provement (annual) ;  Gynsecological  Society  of  Boston  ;  Burlington, 
Vt.,  Medical  and  Surgical  Club  ;  Norwalk,  Conn.,  Medical  Society 
(private) ;  Baltimore  Medical  Association. 

TuKSDAV,  January  10th  :  New  York  Medical  Union  (i)rivate) ;  Kings 
County,  N.  Y.,  Jledical  Association  ;  Medical  Societies  of  the  Counties 
of  Chautauqua  (semi-annual),  Chenango  (annual),  Clinton  (annual — 
Plattsburgh),  Erie  (annual — Buffalo),  (ienesee  (semi- annual — Bata- 
via),  Greene  (quarterly),  Jefferson  (annual — Watertown),  Living- 
ston (semi-annual),  Madison  (semi-annual),  Oneida  (semi-annual — 
Rome),  Onondaga  (semi-annual — Syracuse),  Ontario  (quarterly),  Os- 
wego (semi-annual — Oswego),  St.  Lawrence  (annual),  Schenectady 
(annual — Schenectady),  Schuyler  (annual),  Steuben  (semi-annual), 
Tioga  (annual — Owego),  Wayne  (semi-annual),  and  Yates  (semi-an- 
nual), N.  Y. ;  Norfolk,  Mass.,  District  Medical  Society  (Hyde  Park) ; 
Newark,  N.  J.,  and  Trenton  (private),  N.  J.,  Medical  Associations; 
Baltimore  Gymecological  and  Obstetrical  Society ;  Northwestern 
Medical  Society  of  Philadelphia. 

Wkdnesday,  January  11th :  New  York  Surgical  Society  ;  New  York 
Pathological  Society  ;  Metropolitan  Medical  Society  (private) ;  Medi- 
cal Societies  of  the  Counties  of  A.lbany  and  Dutchess  (annual — 
Poughkeepsie),  N.  Y.  ;  Tri-States  Medical  Association  (Port  Jervis), 
N.  Y. ;  Pittsfield,  Mass.,  Medical  Association  (private);  Hampshire 
District  (quarterly — Northampton)  and  Worcester  District  (Worces- 
ter), Mass.,  Medical  Societies ;  Bennington  County,  Vt.,  and  Hoosic, 
N.  Y.,  Medical  Society  (annual — Arlington) ;  Philadelphia  County 
Medical  Society  ;  Kansas  City  Ophthalmological  and  Otological  So- 
ciety. 

Thursday,  January  12th :  New  York  Academy  of  Medicine  (Section  in 
Paediatrics) ;  Society  of  Medical  Jurisprudence  and  State  Medicine, 
New  York;  Brooklyn  Pathological  Society;  Medical  Societies  of  the 
Counties  ot  Cayuga,  Fulton  (annual — Johnstown),  and  Rensselaer 
(annual),  N.  Y. ;  South  Boston,  Mass.,  Medical  Club  (private) ;  Patho- 
logical Society  of  Philadelphia. 

Friday,  January  13th  :  New  York  Academy  of  Medicine  (Section  in 
Neurology) ;  Yorkville  Medical  Association  (private) ;  German  Medi- 
cal Society  of  Brooklyn  ;  Medical  Society  of  the  Town  of  Saugerties, 
N.  Y. 

Saturday,  January  llflh  :  Obstetrical  Society  of  Boston  (private). 


JProcecbinigs  cf  <§oncths. 


NEW  YORK  STATE  MEDICAL  ASSOCIATION. 

Ninth  Annual  Meeting^  held  in  Kew  York  on  Tuesday^  Wednes- 
day, and  Thursday,  JVovember  15,  16,  and  17,  1892. 

The  President,  Dr.  Judson  B.  Andrews,  of  Buffalo,  in  the  Chair. 

(Coniinucd  from  vol.  Ivi,  page  752.) 

A  Plea  for  the  Early  Extirpation  of  Tumors.— Dr.  John 
W.  S.  GouLEY,  of  New  York  County,  then  read  a  paper  on  this 
subject.    (See  vol.  Ivi,  page  589). 

Dr.  Charles  Phelps  said  that,  as  tiiere  seemed  little  doubt 
as  to  the  translunnation  of  tumors,  there  should  be  no  question 
of  the  i)ropriety  of  the  early  extirpation  of  all  tumors.  There 
was  no  more  danger  of  extension  because  of  tlie  thorough  re- 
moval of  tlie  growth  than  there  would  be  if  it  had  been  allowed 
to  remain. 

Dr.  Joseph  D.  Bryant,  of  New  York  County,  said  tliat,  if 
the  diagnosis  was  made  more  promptly,  and  less  sentiment  in- 
dulged in,  both  by  the  patient  and  by  the  family  physician,  the 
death-rate  following  operations  for  tumors  would   be  very 


greatly  decreased.  Again,  early  removal  of  a  tumor,  as  of  the 
breast,  often  prevented  great  mutilation,  such  as  would  be  re- 
quired if  tlie  operation  were  postponed  to  a  later  stage.  He 
would  nor  say  that  all  small  msevi  should  be  removed,  but  he 
would  advise  their  removal  if  they  continued  to  grow. 

A  New  Method  of  Intestinal  Anastomosis.— Dr.  Benja- 
min M.  liit'KET'iS,  of  Cincinnati,  made  some  remarks  on  tbis- 
subject,  and  demonstrated  the  mode  of  performing  the  opera- 
tion. The  method  had  first  been  proposed  by  Dr.  J.  P.  Mur- 
phy, of  Cliicago,  in  a  paper  read  before  the  Mississippi  Valley 
Medical  Association.  He  used  a  metal  '"  button  "  modeled  after 
a  well-known  form  of  glove  fastening  in  which  one  portion 
fitted  into  the  other  like  a  plug  into  a  socket.  This  plug  was,, 
of  course,  made  with  a  central  opening.  The  gut  was  simply 
gathered  around  each  half  of  the  button  with  a  thread,  and; 
then  the  two  jwrts  were  joined  together,  leaving  the  button  on 
the  inside,  so  that  it  might  slough  away  and  escape  through  tlie 
gut. 

Componnd  Depressed  Fracture  of  the  SkulL— Dr.  George 
D.  Kahlo,  of  Indiana,  presented  a  report  of  fifty  cases  which  had 
been  treated  in  the  Harlem  Hospital,  New  York,  during  the  past 
five  years.  He  considered  the  chisel  abetter  and  safer  instrument 
than  the  trephine  to  use  in  operating  in  these  cases,  and  quoted, 
Gerster  and  the  late  Professor  von  Volkmann  as  being  of  the 
same  opinion.  The  chisel  had  been  objected  to  on  the  ground, 
that  the  blows  of  the  mallet  were  apt  to  cause  serious  concus- 
sion of  the  brain,  but  in  the  cases  reported  in  which  this  method 
of  operating  had  been  adopted  no  symptoms  of  concussiou  had 
been  observed.  It  reduced  to  a  minimum  the  amount  of  bone 
removed  and  was  particularly  applicable  to  most  cases  of  linear 
fracture  with  depression,  or  where  it  was  simply  desired  to 
cleanse  the  fissure  from  septic  material.  Except  in  cases  where 
there  seemed  to  be  a  special  liability  to  the  development  of  sup- 
puration, the  author  favored  the  use  of  sterilized  water  and  ~ 
sterilized  dressings — in  otiier  words,  aseptic  rather  than  anti- 
septic surgery  for  cases  of  brain  injury. 

The  Address  in  Surgery  was  delivered  by  Dr.  Frederic 
S.  Dennis,  of  New  Y'ork  County,  who  took  for  his  subject  The 
Achievements  of  American  Surgery. 

Memoranda,  Practical  and  Suggestive,  was  the  title  of  a 
paper  by  Dr.  Henry  D.  Didama,  of  Unondaga  County.  He  di- 
vided his  paper  into  four  parts,  as  follows : 

Early  Aspiration  in  Pleuritis. — The  writer  had  pursued  a 
plan  of  treatment  somewhat  ditferent  from  that  usually  recom- 
mended. He  advised  the  use  of  anodynes  and  strapping  of  the 
chest  while  the  pain  was  severe;  quinine,  iron,  and  strychnine, 
if  the  patient  was  in  poor  condition ;  and  aspiration  alter  the 
acute  symptoms  had  subsided  and  percussion  indicated  the  pres- 
ence of  fluid,  even  if  it  did  not  exceed  an  estimated  half-pint. 
No  eflfort  was  made  to  leave  a  portion  of  the  effusion  to  be  re- 
moved by  the  absorbents.  In  a  reasonably  extensive  experience 
he  had  found  this  treatment  eminently  satisfactory.  The  follow- 
ing were  some  of  its  advantages  :  The  fluid  was  easily,  quickly, 
and  safely  removed  without  increasing  the  local  inflammation, 
weakening  the  patient,  or  retarding  recovery ;  it  prevented 
carnification  of  the  lung,  and  those  tender  .adhesions  which,  in 
late  aspiration,  eventuated  in  deformity  and  hfemorrhage  into 
the  pleural  cavity ;  it  prevented  congestion  of  the  lung  and 
dilatation  of  the  right  ventricle;  and  in  cases  of  tubercular 
pleuritis  it  tended  to  prevent  or  arrest  general  bacillary  in- 
fection. 

Mineral  Waters,  Crude  and  Refined. — Tlie  author  said  that 
many  of  the  waters,  like  those  of  Saratoga,  (Jarlsbad,  and  Crab 
Orchard,  contained  a  cathartic  salt  in  such  quantity  that  from 
half  a  pint  to  a  quart  would  act  as  an  efficient  laxative,  and 
they  could  be  taken  daily  without  injury  for  an  indefinite  po- 


22 


BOOK  NOTICES. 


[N.  Y.  Med.  Johe. 


riod.  A  salino  solution  wliich  was  so  diluted  that  its  specific 
gravity  was  less  than  that  of  the  serum  passed  off  largely  by  the 
kidneys,  instead  of  acting  as  a  laxative.  Most  of  the  really 
valuable  mineral  springs  contained  ingredients  which  in  quality 
or  quantity  were  detrimental.  The  various  lithia  springs  con- 
tained such  a  small  proportion  of  lithia  that  one  must  imbibe 
one  or  two  gallons  of  the  water  to  obtain  a  medium  dose  of  this 
substance.  Ideal,  refined,  artificial  mineral  waters  might  be 
readily  and  cheaply  made  by  any  capable  chemist.  It  should 
not  be  forgotten  that  no  salt  of  lithium  was  equal  in  its  solvent 
power  over  uric  acid  to  the  same  quantity  of  citrate  of  [)otas- 
sium. 

CongMng  made  easty  in  Bronchiectasis. — Several  cases  of 
bronchiectasis  were  cited  in  which  very  marked  relief  had  been 
obtained  by  following  these  directions:  The  patient  was  told 
that  by  lying  in  bed  or  on  a  lounge,  with  one  hand  on  the  floor 
and  the  head  almost  reaching  there,  the  dilated  bronchus,  or 
"  pocket,"  would  be  inverted,  and  the  fluid  accumulated  there 
would  run  out  almost  of  itself  or,  at  any  rate,  when  aided  by  a 
short  spell  of  coughing.  The  patient  was  to  practice  this  meth- 
od four  or  five  times  daily  so  as  to  anticipate  the  filling  up  of 
the  pocket.  This  idea  of  "  coughing  down-hill "  he  had  derived 
from  a  small  pamphlet  published  nearly  fifty  years  ago  by  the 
poet,  Nathaniel  P.  Willis,  who  had  stated  that  he  had  cured 
himself  of  consumption  by  this  original  device  and  by  horseback 
exercise.  In  all  probability,  his  supposed  consumption  had  been 
bronchiectasis,  but  his  suggestion  was  none  the  less  valuable, 
and  the  writer  had  known  great  relief  and  comfort  to  be  ob- 
tained by  this  gravity  treatment  in  cases  of  phthisis  when  large 
cavities  and  excessively  annoying  cough  were  present. 

The  Insurance  Sponge. — Under  this  head,  he  considered  the 
avaricious  tendencies  of  life-insurance  companies  which  sought 
to  obtain  valuable  services  from  physicians  without  paying  for 
them.  Such  a  c(»mpany,  he  said,  belonged  to  the  family  Octopo- 
da  or  Millipoda.  It  had  a  head  center,  with  grasping  arms 
which  extended  to  immense  distances,  agents  as  "  suckers,"  and 
medicine  men  as  "tentacles"  or  feelers.  Through  its  agents  it 
sucked  into  its  meshes  such  an  enormous  surplus  of  nutriment 
that  it  permitted  its  chief  sucker  to  retain  fifty  per  cent,  of  the 
premium  blood  drawn  from  the  veins  of  each  newly  captured 
victim,  while  its  corpulent  head  center  a[)propriated  an  amount 
of  this  same  vital  fluid  which,  if  transmuted  into  coin,  would 
equal  from  ten  thousand  to  seventy  thousand  ducats  annually. 
The  tentacles  decided  as  to  the  sanitary  condition  of  the  victim, 
but  they  received  scanty  pabulum  for  their  services,  which 
were,  or  should  be,  of  the  greatest  value. 

( To  be  concluded.) 


i0ok  Octrees. 


Hygiene  and  Public  Health.     By  Louis  C.  Parkes,  M.  D., 
D.  P.  II.,  Lond.  Univ.,  Fellow  of  the  Sanitary  Institute,  etc. 
Third  Edition,  with  Illustrations.    Philadelphia:  P.  Blakis- 
ton.  Son,  &  Co.,  1892.    Pp.  xx  to  523.    [Price,  $2.75.] 
We  are  very  glad  to  see  that  the  appearance  of  the  third 
edition  of  this  excellent  work,  within  three  years  from  the  pub- 
lication of  the  first,  sustains  the  commendation  we  originally 
bestowed  ui)on  it. 

There  are  many  changes  in  this  edition,  the  volume  being 
increased  by  fifty-two  ])ages  and  five  illustrations  being  added. 
In  the  chapter  on  water  there  are  several  additions.  The  au- 
thor deprecates  the  use  of  water-meters  in  the  houses  of  the 


poor.  He  calls  attention  to  the  infection  of  water  in  mains  by 
escaped  coal  gas  in  the  soil,  mentions  the  polarite  filter  and 
Anderson's  filtration  process,  and  gives  tests  for  iron  and  zinc 
in  the  water. 

In  the  chapter  on  the  collection,  removal,  and  disposal  of 
excreta  and  other  refuse  there  are  many  additions,  among  the 
most  inijjortant  of  which  are  an  illustrated  section  on  the  joints 
of  lead  pipes  and  a  description  of  the  method  of  determining 
the  quantity  of  chlorine  in  tidal  water  into  which  there  is  sew- 
age precipitation.  Shone's  system  of  pneumatic  sewage  ejection 
is  des('ribed  and  the  use  of  deodorants  in  sewage  preci[)itation 
advised. 

In  the  chapter  on  air  and  ventilation  the  author  advances 
the  opinion  that  the  immunity  of  sewer-men  to  disease  is  the 
result  of  an  acquired  resistance.  A  section  on  smoke  preven- 
tion is  added  that  does  not  solve  that  problem,  and  Vogel's  test 
for  carbonic  oxide  in  the  air  is  described  and  recommended. 

The  chapter  on  climate  and  meteorology  has  been  enhanced 
by  a  section  on  weather  observations  that  describes  the  signifi- 
cance of  the  isobars  of  the  weather  maps. 

The  chajiter  on  the  communicable  diseases  has  been  brought 
into  accord  with  the  latest  discoveries  in  bacteriology. 

The  sections  on  di])htheria  and  on  epidemic  influenza  have 
been  augmented  by  abstracts  of  the  researcdies  made  by  Dr. 
Thorne  Thorne  and  Dr.  Parsons  respectively  on  these  diseases. 

The  propulsion  system  of  ventilation  is  now  considered  the 
best  that  can  be  used  for  hospitals. 

In  the  chapter  on  statistics  reference  is  made  to  the  fact 
that  the  annual  birth-rate  in  England  and  Wales  has  steadily 
declined  since  1876. 

The  book  deserves  commendation  as  being  one  of  the  best 
works  on  hygiene  that  can  be  placed  in  the  hands  of  the  stu- 
dent. 

Ilygieytic  Measures  in  Relation  to  Infections  IHseases.  Com- 
prising in  Condensed  Form  Information  as  to  the  Cause  and 
Mode  of  spreading  certain  Diseases,  the  Preventive  Measures 
that  should  be  resorted  to,  Isolation,  Disinfection,  etc.  By 
George  H.  F.  Nuttall,  M.  D.,  Ph.  D.  (Gottingen),  Associate 
in  Hygiene  and  Bacteriology,  Johns  Hopkins  University  and 
iIosi)ital.  New  York  and  London :  G.  P.  Putnam's  Sonsi 
1893.    Pp.  xi  to  112. 

In  this  littile  book  the  difference  between  disinfectants,  anti- 
septics, and  deodorants  is  explained,  the  various  disinfectants 
are  referred  to  and  their  applicability  and  usefulness  are  stated, 
well  arranged  practical  directions  for  disinfection  are  given,  and 
there  is  an  alphabetically  arranged  list  of  certain  infectious  dis- 
eases with  reference  under  each  to  the  preventive  measures  that 
should  be  resorted  to.  There  is  a  final  section  on  surgical  dis- 
infection. 

The  author  has  brought  together  the  latest  information  on 
these  topics,  and  the  only  criticism  that  we  would  make  on  the 
book  is  that  he  might  have  condemned  the  German  method  of 
cleaning  down  tlie  walls  of  an  infected  room  with  glutinous 
brown  bread.  There  are  several  other  articles  that  are  equally 
efficient  in  cleansing  walls,  and  that  do  not  involve  the  risk  of 
furthering  infection. 

The  book  is  not  only  useful  to  the  practitioner,  but  particu- 
larly available  for  the  trained  nurse  or  intelligent  layman. 

BOOKS,  ETC.,  RECEIVED. 

A  Handbook  of  Pathological  Anatomy  and  Histology.  With 
an  Introductory  Section  on  Post-mortem  Examinations  and  the 
Methods  of  Preserving  and  Examining  Diseased  Tissues.  By 
Francis  Delafield,  M.  D.,  LL.  D.,  Professor  of  the  Practice  of 
Medicine,  College  of  Physicians  and  Surgeons,  Columbia  Col- 


Jan.  7,  1893.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


23 


lege,  New  York,  and  T.  Mitchell  Piudden,  M.  D.,  Professor  of 
Pathology  and  Director  of  the  Laboratories  of  Histology,  Pa- 
thology, and  Bacteriology,  College  of  Physicians  and  Surgeons, 
Columbia  College,  New  York.  Fourth  Edition.  Illustrated  by 
Three  Hundred  Wood  Engravings  printed  in  Black  and  Colors. 
New  York  :  William  Wood  and  Company,  1892.  Pp.  svii-.3 
to  715. 

Syphilis  and  the  Nerv'ous  System  :  being  a  Revised  Reprint 
of  the  Lettsominn  Lectures  for  1890,  delivered  before  the  Medi- 
cal Society  of  London.  By  W.  R.  Cowers,  M.  D.,  F.  R.  C.  P., 
F.  R.  S.,  Consulting  Physician  to  University  College  Hospital. 
Philadelpiiia:  P.  Blakiston,  Son,  &  Co.,  1892.  Pp.  viii-9  to 
131.    [Price,  $1.] 

Notes  on  the  Newer  Remedies,  their  Therapeutic  Applica- 
tions and  Modes  of  Administration.  By  David  Cerna,  M.  1)., 
Ph.  D.,  Demonstrator  of  Pijysiology  in  the  Medical  Department 
of  the  University  of  Texas,  Galveston.  Philadelphia:  W.  B. 
Saunders,  1893.    Pp.  viii-17  to  177. ,  [Price,  $1.25  ] 

Studien  zur  Physiologie  und  Pathologie  des  Blutes  nnd  der 
Lymphe.  Von  Dr.  M.  Lowit.,  o.  6.  Professor  der  allgemeinen 
und  experimentellen  Pathologie  in  Innsbruck.  Mit  zvvei  litho- 
graphischen  Tafeln.  Jena:  Gustav  Fischer,  1892.  Pp.  141. 
[Preis,  4  Mark  50  Pf.] 

Report  of  the  Surgeon-General  of  the  Army  to  the  Secretary 
of  War,  for  the  Fiscal  Year  ending  June  30,  1892. 

Ty[)hoid  Fever  in  the  Light  of  Modern  Research.  Facts  and 
Doubts  about  Cholera.  By  L.  Bremer,  M.  D.,  St.  Louis,  Mo. 
With  Two  Phototypes. 

The  Weight  of  the  Body  in  its  Relation  to  the  Pathology 
and  Treatment  of  Clubfoot.  By  A.  B.  Judson,  M.  D.,  New 
York.  [Reprinted  from  the  Boston  Medical  and  Surgical  Jour- 
nal.'] 

Some  Practical  Points  in  the  Diagnosis  of  Spinal-cord  Le- 
sions. By  Frederick  Peterson,  M.  D.,  New  York.  [Reprinted 
from  the  Medical  Record.] 

A  Plea  for  a  more  Conservative  Treatment  of  Nasal  Affec- 
tions. By  Reuben  Jeffery,  M.  D.  [Reprinted  from  the  Brook- 
lyn Medical  Journal.] 

Multiple  Benign  Cystic  Epithelioma  of  the  Skin.  By  J.  A. 
Fordyce,  M.  D.  [Reprinted  from  the  Journal  of  Cutaneous  and 
Gen  ito-urinnry  Diseases.] 

Vaginal  Hysterectomy  and  High  Amputation,  or  Partial  Ex- 
tirpation by  Galvano-cautery,  in  Cancer  of  Cervix  Uteri.  An 
Inquiry  into  their  Relative  Merits.  By  John  Byrne,  M.  D., 
Brooklyn. 

The  Collegiate  Degree  as  an  Evidence  of  Fitness  for  the 
Study  of  Medicine.  By  L.  Harrison  Mettler,  A.  M.,  M.  D.,  Chi- 
cago, 111.  [Reprinted  from  the  Bulletin  of  the  American  Acade- 
my of  Medicine.] 

Twenty-third  Annual  Report  of  the  State  Board  of  Health 
of  Massachusetts. 

Cholerabehandlung  und  Infusionstherapie.  Von  Dr.  J.  Mi- 
chael. [Sonderabdi'uck  aus  der  Deutschen  medicinischen  Woch- 
enschrift.] 

Verschiedenheit  des  Krankheitsverlaufes  der  Cholera  in  den 
verschiedenen  Epidemien.  Von  Dr.  J.  Michael,  in  Hamburg. 
[Sonderabdruck  aus  der  Deutsche  Medizinal- Zeitung .] 

Subcutane  Infusion  bei  Cholera  und  acuter  Anamie.  Von 
Dr.  J.  Michael,  in  Hamburg.  [Sonderabdruck  aus  der  Deutschen 
medicinischen  Woohenschrift.] 

Les  salpingites.  Par  M.  le  Dr.  Lnndan.  [Extrait  des  An- 
nales  publi^es  par  la  Society  royale  des  sciences  m6dicales  et 
naturelles  de  Bruxclles.] 

Du  traitement  des  suppurations  rebelles  du  sinus  maxillaire. 
Par  le  Docteur  A.  Cartaz.  [Extrait  de  la  Revue  Internationale 
de  rhinologie,  etc.] 


Purpura  Usemorrhagica.  By  B.  K.  Rachford,  M.  D.,  New- 
port, Ky.    [Reprinted  from  the  Medical  J^ews.] 

Anaemia  of  Tuberculosis.  By  B.  K.  Rachford,  M.  D.,  New- 
port, Ky.    [Reprinted  from  the  Archives  of  Pediatries.] 


Jleports  on  tht  jProgrcss  of  Iflcbrcine. 


PSYCHIATRY. 

By  FREDERICK  PETERSON,  M.  D., 

PATHOLOGIST  TO  THE  KEW  YORK  CITY  LUNATIC  ASYLUMS;  PROFESSOR  OP 
NERVOUS  DISEASES  IN  THE  UNIVERSITY  OF  VERMONT. 

Psychoses  of  Toxic  Origin.— Professor  Wagner,  of  Gratz 
(Jaltrl.f.  Psych.,  Bd.  x,  Heft  2  and  3),  describes  first  in  his  paper 
the  neuritic  and  post-febrile  psychoses.  In  certain  acute  psy- 
choses he  has  been  able  to  discover  a  rudimentary  polyneuritis. 
He  discusses  some  oases  of  acute  insanity  following  tuberculin 
injections,  and  pellagra  and  ergotism,  and  believes  that  the  class 
of  toxic  psychoses  will  be  enlarged  by  more  exact  study  of  acute 
mental  disorders.  Very  possibly  many  cases  of  acute  psychosis 
are  due  to  auto-intoxications  arising  from  absorption  from  the 
intestinal  tract,  as  observed  intestinal  disturbances  and  peculiar 
conditions  of  the  urine  must  lead  one  to  suppose.  All  acute 
toxic  psychoses  appear  under  the  same  form  as  an  acute  mania, 
and  tend  to  run  into  amentia. 

On  the  same  lines  Knorr  {AUg.  Zeitschr.f.  Psych.,  xlviii,  6) 
describes  several  cases  of  toxic  insanity,  among  them  four  due 
to  alcohol,  which  presented  an  acute  hallucinatory  form  of  in- 
sanity, beginning  with  auditory  hallucinations  and  tending  to 
develop  persecutory  delusions,  and  to  which  he  gives  tlie  name, 
following  von  Speyr  and  Tuczek,  of  acute  alcoholic  })aran</ia. ' 
All  the  patients  recovered.  In  addition,  he  gives  the  history  of 
a  case  of  morphine-cocaine  insanity  and  one  of  influenza  psy- 
chosis which  ran  the  same  course  as  his  alcoholic  cases. 

Dr.  Henry  M.  Hurd  {Am.  Journal  of  Insanity,  J'lly,  1892) 
reviews  some  of  the  literature  of  post-febrile  insanity,  and  re- 
lates three  cases — one  of  maniacal  excitement  following  ovari- 
otomy, one  of  insanity  with  systematized  delusions  arising  in 
pneumonia,  and  one  of  melancholia  developing  during  conva- 
lescence from  typhoid  fever.  He  would  divide  all  cases  of  post- 
febrile insanity  into  three  classes — those  due  to  shock,  those 
produced  by  specific  poisons,  and  those  consequent  upon  anaemia 
and  nervous  exhaustion.  Under  the  second  heading  he  would 
comprise  the  delirium  of  fevers,  both  intermittent  and  exan- 
thematous,  of  pneumonia,  and  of  uraemia  ;  the  transient  insanity 
of  influenza;  the  mental  confusion  of  multiple  neuritis;  the  de- 
lirium of  iodoform,  salicylic  acid,  and  chronic  alcoholic  poison- 
ing; and  the  delirium  of  puerperal  fever. 

Dr.  Theodore  H.  Kellogg  {Journal  of  Kerr,,  and  Ment.  Dis., 
October,  1892)  contributes  a  thoughtful  article  upon  the  toxic 
origin  of  insanity,  making  the  following  subdivisions: 

I.  From  Mineral  Poisons  and  Certain  Drugs. — 1,  lead ;  2, 
mercury;  3,  arsenic;  4,  chloral;  5,  bromide  of  potassium;  6, 
iodoform ;  7,  paraldehyde. 

II.  From  Vegetable  Poisons. — 1,  opium;  2,  belladonna;  3, 
cannabis  indica;  4,  hyoscyamus;  5,  stramonium;  6,  tobacco; 
7,  cocaine;  8,  conium;  9,  erythroxylon  coca;  10,  astragalus 
Hornii;  11,  secale  cornutuiii. 

III.  From  Intoxicants  and  No.viou.<i  Gases. — 1,  alcohol;  2, 
ether ;  3,  chloroform ;  4,  carbonic  oxide ;  5,  sulphurous-acid 
gas. 

IV.  From  Eruptive  Fevers.,  Diathetic  States,  and  other  Dis- 
eases.— 1,  typhoid  fever;  2,  small-pox;  3,  scarlet  fever;  4,  in- 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  y.  Med.  Jouk., 


termittent  fever;  5,  rheumatism;  6,  gout;  7,  lith!Bii)ia ;  8, 
puerperal  state;  9,  la  grippe;  10,  cancer;  11,  syphilis;  12, 
tuberculosis. 

V.  From  Self-intoxications. 

Regarding  the  last  group,  the  author  says  that  some  mental 
disorders  are  caused  by  the  absorption  of  putrefactive  alkaloids 
supposed  to  be  formed  by  the  action  of  bacteria  on  organic  mat- 
ter (ptomaines)  and  basic  substances  resulting  from  metabolic 
changes  in  the  tissues  (leucomaines).  It  has  long  been  known 
to  physiologists  that  certain  excretions  contain  substances 
poisonous  to  the  organisms  excreting  them,  and  it  is  not  sur- 
prising that  autogenous  poisons  should  be  found  in  the  excre- 
tions of  the  human  body.  He  quotes  Bouchard  to  the  effect 
that  a  sufficient  amount  of  jioisonous  alkaloids  is  daily  formed 
in  the  intestines  to  prove  fatal  if  absorbed.  The  albumoses  are 
among  the  most  powerful  of  autogenous  poisons,  and  K6|)pen, 
Kollnitz,  and  Furstner  have  found  albumosuria  in  cases  of  in- 
sanity. 

The  reviewer  has  recently  published  {Bost.  Med.  and  Surg. 
Jour..,  Oct.  6,  1892)  the  details  of  three  cases  of  acute  mania,  in 
all  of  which  the  patients  recovered,  caused  in  rubber-workers  by 
the  inhalation  of  bisulphide  of  carbon,  the  first  cases  of  purely 
psychic  disorder  that  have  been  described  as  due  to  this  sub- 
stance, although,  as  is  well  known,  a  polyneuritis  is  not  an  un- 
common result  of  its  inhalation. 

Dr.  J.  Wiggleswortli  {Brit.  Med.  Jour.,  1892,  No.  1,646)  has 
just  described  two  cases  of  acute  mania  due  to  the  inhalation  of 
sulphureted  hydrogen.  One  of  the  patients  recovered  ;  the  other 
remained  permanently  insane. 

General  Paralysis  in  a  Boy.— Very  few  cases  of  general 
paralysis  appearing  before  the  age  of  twenty  have  been  re- 
corded. Charcot  and  Dutil  {Arch,  de  neuroL,  March,  1892)  de- 
tail the  history  of  a  case  which  they  consider  indubitable. 
There  was  no  luetic  history,  but  a  strong  neuropathic  taint  in 
the  family.  The  lad  was  well  until  the  age  of  fourteen,  when 
there  began  a  gradual  development  of  tremor  of  the  bands, 
stammering  of  speech,  silliness  of  manner,  and  mental  enfeeble- 
ment.  At  the  time  of  examination  he  was  in  his  seventeenth 
year.  He  was  apathetic  and  dull,  he  walked  clumsily,  and  his 
naind  was  much  impaired.  The  knee-jerks  were  exaggerated, 
the  pupils  were  unequal,  and  his  articulation  was  imperfect. 
There  were  tremor  of  the  hands  and  fibrillation  in  the  tongue, 
in  the  lips,  and  sometimes  in  the  facial  muscles.  He  had  pe- 
culiar attacks  of  formication,  beginning  in  tlie  riglit  foot  and 
gradually  involving  the  whole  right  side  (sensory  epilepsy). 

Syphilis  and  General  Paralysis.— The  relationship  of  the 
luetic  process  to  paretic  dementia,  so  often  discussed  by  alienists, 
has  recently  received  further  consideration  by  several  authors. 
Among  otliers,  E.  A.  Homen  has  described  a  peculiar  typical 
disease  in  three  sisters  in  the  form  of  a  progressive  dementia 
accompanied  by  extensive  vascular  changes  which  indicated 
hereditary  syphilis  {Arch.f.  Psychiatrie  und  Nervenhranhheiten, 
xxiv,  1). 

Commenting  upon  this,  Sommer  advanced  the  hypothesis 
that  all  cases  of  tabes  and  progressive  paralysis  not  due  to  indi- 
vidually acquired  syphilis  must  be  considered  as  endogenous  de- 
generation from  hereditary  syphilis  {Gtrlbl.  fiir  Nervenheilh. 
und  Psyeh.,  October,  1892). 

Jacobson,  of  Copenhagen  {Jour,  of  Ment.  Science,  April, 
1892),  presents  the  statistics  of  one  hundred  cases  of  general 
paralysis  in  women,  in  thirty-seven  per  cent,  of  which  syphilis 
was  certainly  present,  and  in  .all  probability  sixty-five  per  cent, 
were  really  suffering  from  this  disease.  Comparing  this  with 
other  setiological  factors,  such  as  alcoholism  (twenty-seven  per 
cent.)  and  heredity  (twenty-eight  per  cent.),  he  decides  that 
syphilis  is  by  far  the  most  important  cause  of  paralytic  dementia. 


Oebeke,  of  Bonn  {Zeitschr.  f.  Psych.,  xlviii),  found  fifty- 
seven  per  cent,  of  his  cases  of  general  paralysis  to  be  syphilitic, 
whereas  only  twelve  per  cent,  of  all  other  forms  of  insanity  had 
a  luetic  origin. 

Dr.  H.  M.  Bannister  {Jour,  of  Nerv.  and  Ment.  Bis.,  Decem- 
ber, 1891),  in  an  fetiological  analysis  of  two  hundred  and  thirty- 
four  cases  of  general  paralysis,  found  over  seventy  per  cent,  of 
the  patients  undoubtedly  affected  with  syphilis,  and  adding  cases 
where  lues  was  probable  though  not  certain,  the  percentage  was 
increased  to  nearly  eighty-nine  per  cent.  Over  fifty  of  those 
that  were  infected  with  syphilis  were  also  intemperate.  The 
author  looks  upon  syphilis  and  alcohol  as  the  most  frequent 
antecedents  of  paralytic  dementia. 

The  reviewer  has  pointed  out  {Medical  Record,  May  21, 
1892)  that  in  Egypt,  where  there  is  no  more  common  disease 
than  syphilis,  there  are  no  cases  of  general  paresis  to  be  found 
among  the  native  Egyptians  at  all — a  fact  that  should  lead  us  to 
be  slow  in  regarding  this  process  as  the  leading  aetiological 
factor  in  paralytic  dementia,  and  pai'ticularly  to  avoid  giving 
too  much  credence  to  the  rather  remarkable  hypothesis  of  Som- 
mer's  noted  above. 

Affections  of  Speech  in  the  Insane.— In  the  American 
Journal  of  Insanity  for  July,  1892,  Dr.  T.  H.  Kellogg  contributes 
an  interesting  article  to  the  rather  meager  and  scattered  litera- 
ture of  this  subject.  He  classifies  the  affections  of  speech  in 
the  insane  as  follows: 

I.  Lesions  involving  centers  or  tracts. 

I.  Paretic  speech.  2.  Alcoholic  or  other  toxic  disorder 
of  speech.  3.  Scanning  speech.  4.  Organic  dementia  with 
various  forms  of  aphasia.  5.  Speech  defects  in  idiocy  and  im- 
becility. 

II.  Speech  aflfections  the  immediate  outcome  of  the  physical 
disease. 

1.  The  formation  of  new  words.  2.  Echo  speech.  3.  Rhym- 
ing and  repetitive  speech.  4.  Histrionic  speech,  including  gest- 
ure language.  5.  Retarded  and  accelerated  speech.  6.  Mutism. 
V.  Abulic  speech. 

The  chief  characteristics  of  paretic  speech  are  retardation, 
indistinctness,  repetition  of  syllables  or  words,  failure  of  labial 
or  liugual  sounds,  tremor  of  voice,  nasal  intonation,  and  ex- 
plosive utterance. 

In  alcoholic  speecii  there  is  no  inco-ordination,  but  there  are 
motor  impairment  and  natural  failure  of  innervation.  In  other 
words,  the  speech  of  general  paralysis  is  ataxic,  that  of  alcohol- 
ism truly  paretic. 

Scanning  speech  in  its  most  typical  form  is  found  only  in 
insanity  complicated  with  multiple  sclerosis;  but  there  is  a 
species  of  scanning  utterance  found  both  in  alcoholic  and  paretic 
dementia. 

In  organic  dementia  there  may  be  motor  aphasia,  agraphia, 
word-bhndness,  and  word-deafness. 

In  idiocy  and  imbecility  the  affections  are  due  to  arrest  of 
development ;  speech  may  be  entirely  wanting  or  limited  to  a 
few  half-articulate  sounds.  Sometimes  there  is  automatic  repe- 
tition of  words  for  hours  or  days  together,  as  in  some  chronic 
states  of  insanity.  Logorrhoea  and  mutism,  as  well  as  echo 
speech,  are  noted  in  imbeciles  at  times. 

The  coining  of  new  words  is  most  common  in  imbecility, 
paranoia,  and  chronic  mania. 

Echo  speech  is  noted  in  congenital  mental  weakness,  termi- 
nal dementia,  paranoia,  and  hysterical  and  epileptic  insanity. 

Rhyming  is  commonest  in  pubescent  insanity,  paranoia,  and 
chronic  mania. 

The  intonation  and  gesture  of  histrionic  speech  are  found  in 
most  forms  of  insanity,  tragedy  in  melancholia,  comedy  in 
chronic  mania,  buffoonery  in  imbecility  or  partial  dementia. 


J:iu.  7,  1893.] 


REPORTS  OK  THE  PROGRESS  OF  MEDICINE. 


25 


Alcoholic  and  i)aretic  demerits  usually  furnish  the  best  ex- 
amples of  retardation  of  sijeech-rate,  though  it  is  occasionally 
uiot  with  in  epileptic  insanity. 

Accelerated  speech  is  chiefly  presented  in  maniacal  cases. 

Mutism,  apart  from  stuporous  states  and  idiocy,  is  rare, 
though  occasionally  due  to  the  influence  of  delusions. 

Abiilic  speech  is  most  common  in  hysterical  and  epileptic 
insanity,  in  paranoia,  and  in  the  instinctive  insanity  of  child- 
hood. It  is  a  morbid  tendency  to  commit  improprieties  of 
speech.  The  jjatient  is  impelled  to  be  impudent,  profane,  or 
obscene,  and  is  unable  to  control  the  impulse. 

Mental  Disturbance  from  Sulphur  Compounds.— Dr.  B. 

W.  Richardson  has  a  very  suggestive  editorial  in  the  Anclepiad 
tor  the  third  quarter  of  1892  upon  the  effect  of  mercaptan  or 
sulphur  alcohol  upon  the  nervous  sjstem  and  mind.  A  person 
brought  under  its  influence  has  a  desire  for  sleep,  a  strange, 
unhappy,  dreamy  sensation  as  from  some  actual  or  impending 
trouble,  succeeded  by  an  extreme  sense  of  muscular  fatigue,  so 
that  the  limbs  feel  too  heavy  to  be  lifted,  with  depression  and 
slowness  of  pulse — efi^ects  lasting  for  several  hours  until  the  sul- 
phur is  eliminated.  These  experiments  were  conducted  in  1870. 
He  further  noted  at  that  time  that  this  and  other  sulphur  com- 
pounds might  be  readily  constructed  in  the  living  animal  tissues, 
and  that  there  was  oi)ened  to  physicians  a  new  field  of  inquiry 
relative  to  the  presence  of  sulphur  in  the  expired  air  or  other 
excretions  ot  patients.  He  believes  that  the  breaking  up  of 
albuminous  textures  in  disease  is  often  attended  by  the  forma- 
tion of  volatile  sulphureted  organic  compounds.  Remember- 
ing how  minute  a  proportion  of  sulphur  alcohol  will  produce 
mental  depression  bordering  upon  suicidal  propensity,  it  might 
be  inferred  that  the  formation  of  sulphur  compounds  of  this 
character  in  the  body  would  account  for  many  examples  of  ex- 
cessive temporary  prostration.  In  a  further  research  he  came 
to  the  conclusion  that  the  influence  exerted  over  nervous  matter 
by  the  element  sulphur,  in  disintegration,  was  so  marked  in 
mental  aberration  that  it  was  inevitable  that  melancholia  and 
other  nervous  atfections,  attended  with  or  without  paralysis  of 
voluntary  muscles,  must  some  day  be  ascribed  to  the  presence  of 
compounds  of  this  element ;  that  there  was  abundant  evidence 
from  odor  alone  of  the  presence  of  mercaptan  in  the  excretions 
from  the  lungs,  the  skin,  and  the  alimentary  canal ;  and  that 
here  were  indications  for  a  rational  explanation  of  insane  con- 
ditions produced  as  deliriums  from  intoxication  by  poisons  de- 
velo[)ed  in  tlie  vital  organic  chemistry. 

Chorea  and  Insanity.— In  the  Johns  Hopkins  Hospital  Re- 
ports, vol.  ii,  No.  6,  Dr.  H.  J.  Berkley  describes  a  case  of  chorea 
insaniens,  which  is  maniacal  excitement  arising  in  an  ordinary 
chorea,  in  a  way  similar  to  its  occurrence  as  a  complication  of 
rheumatism  at  times.  The  case  was  that  of  a  young  woman,  aged 
twenty-seven,  a  teacher,  of  fairly  good  family  history.  A  brother 
had  had  chorea  for  a  month  in  childhood.  She  bad  twice  suf- 
fered from  articular  rheumatism — once  at  the  age  of  sixteen  and 
once  at  the  age  of  twenty-three.  During  the  second  attack 
she  was  delirious  for  five  weeks  and  had  choreoid  movements. 
She  was  admitted  with  such  movements  affecting  most  of  the 
voluntary  muscles  of  the  extremities,  face,  and  body.  Articu- 
lation was  ditficult.  The  movements  were  violent  and  she  tossed 
from  one  side  of  the  bed  to  the  other  continually.  Her  mind 
was  clear  until  eleven  days  after  admission,  when  maniacal  ex- 
citement began  and  continued,  with  more  or  less  retrogression 
and  exacerbation,  until  her  death,  some  eighteen  days  after  ad- 
mission. The  case  is  particularly  valuable  for  the  very  careful 
autopsy  and  microscopic  examination  of  the  nervous  system. 
The  paramount  changes  were  meningo-vascular — such  as,  in  the 
opinion  of  the  author,  could  only  be  produced  by  some  patho- 
genic germ  or  its  soluble  products. 


Dr.  R.  M.  Phelps  (Jour,  of  Nen.  and  Ment.  Dis.,  October, 
1892)  reports  briefly  thirteen  cases  of  hereditary  chorea  gathered 
together  from  various  insane  asylums.  In  all  of  these  cases 
there  seemed  to  be  a  tendency  to  dementia.  The  author  be- 
lieves that  hereditary  chorea  is  not  so  rare  in  this  country  as 
generally  supposed,  and  that,  as  insane  asylums  receive  the 
greater  i)roportion  of  these  cases,  the  pathology  of  the  disease 
might  well  be  studied  there. 

Mental  Aberration  and  Nasal  Disorders.— Dr.  Carpenter, 
in  an  interesting  paper  in  the  Jour,  of  the  Am.  Med.  Association, 
Nov.  5, 1892,  shows  the  intimate  relations  existing  between  mor- 
bid conditions  of  the  nose  and  diseases  of  the  central  nervous 
system.  We  can  not  do  better  than  quote  from  the  author's 
paper  in  order  to  show  how  extensive  this  relationship  is  : 

"  Neuralgia,  partial  paresis,  hypereesthesia,  analgesia  of  the 
extremities,  epilepsy,  chorea,  and  accompanying  chronic  naso- 
pharyngeal catarrh,  are  readily  explained  through  reflex  irrita- 
tion, and  subside  when  proper  treatment  is  given  the  catarrh. 

"  The  sequels  of  naso-pharyngeal  catarrh  are  reflex  cough, 
sneezing,  stenosis  of  nasal  cavities,  ocular  catarrh,  asthenopia, 
aural  catarrh,  headache — either  frontal,  vertical,  or  occipital — 
nasal  polypi,  tonsillitis,  enlarged  tonsils,  hypertrophy  of  the  sub- 
maxillary, anterior,  and  posterior  cervical  glands,  patulency  of 
Eustachian  tubes,  hasmorrhage  from  the  throat — either  the 
naso-pharynx,  larynx,  or  trachea — epistaxis,  laryngitis,  trache- 
itis, bronchitis,  and  catarrhal  plithisis,  neuralgia  or  numbness 
of  the  limbs  or  trunk,  anassthesia  or  hypersesthesia  of  the  skin, 
paresis  of  arm  and  forearm,  dyspepsia,  hay  fever,  irritability, 
melancliolia,  partial  loss  of  memory  or  intellectual  faculty,  in- 
somnia, frightful  dreams,  agoraphobia,  vertigo,  palpitation  of 
the  heart,  neurasthenia,  stammering,  suicidal  tendency,  asthma, 
chorea,  epilepsy,  loss  of  taste,  anosmia,  anaamia,  anorexia,  deaf- 
ness, reflex  irritation  of  the  genito-urinary  organs,  an  abundant 
discharge  of  nasal  mucus  or  sneezing  during  coitus,  aphonia,  ery- 
thema and  herpes  of  the  nasal  integument  and  lining,  tinnitus 
aurium,  otalgia,  dysphagia,  and  constipation.  In  cases  of  naso- 
pharyngeal catarrh  of  long  standing  there  is  a  tendency  to  irri- 
tation, catarrhal  inflammation  or  debility  of  all  the  mucous  mem- 
branes of  the  body." 

This  will  be  suggestive  reading  to  the  oculist  and  gyno3colo- 
gist  who  may  each  be  rival  claimants  of  the  same  domain. 

The  Prognosis  of  Acute  Mania.— Some  of  the  conclusions 
arrived  at  by  Willerding  relative  to  the  results  in  cases  of  acute 
mania  are  valuable  and  instructive  {Review  of  Insanity  and 
Nervous  Disease,  September,  1891,  quoting  Zeitschr.  fur  Psy- 
chiatrie,  1891).  Seventy  per  cent,  recover  after  an  average 
duration  of  several  months.  Heredity  is  not  necessarily  an  un- 
favorable omen.  In  mania  due  to  disease,  alcoholism,  or  preg- 
nancy, the  prognosis  as  to  duration  and  recovery  is  good.  Mania 
arising  from  slight  injuries  to  the  head  generally  ends  in  recovery. 
Return  of  the  menses,  with  concomitant  mental  improvement, 
indicates  early  recovery.  Youth  augurs  well  for  a  case  of  acute 
mania.  In  the  recurrent  form  the  probability  of  lasting  cure  is 
small.  The  prognosis  is  bad  in  a  case  of  long  standing.  A 
sudden  onset  is  unfavorable,  except  in  cases  occurring  in  preg- 
nancy or  as  a  result  of  head  injury.  A  sudden  arrest  of  ma- 
niacal excitement  must  raise  the  fear  of  the  recurrent  form,  or 
of  an  early  relapse.  Great  increase  in  weight  before  the  be- 
ginning of  the  quiet  stage  is  unfavorable.  The  worse  the  attack 
the  graver  the  ])rognosis.  Paralysis  and  convulsions  must  be 
looked  uj)on  as  serious  complications. 

Atypical  Forms  of  Paralytic  Dementia.— In  the  Jour,  of 
the  Am.  Med.  Assoc.,  Sept.  4,  1892,  Dr.  J.  G.  Kiernan  discusses 
some  of  the  impure  forms  of  paresis  as  observed  by  himself  and 
other  alienists.  Typical  general  paresis  develojis  in  a  normal 
organization.    But  in  an  organism  already  suffering  from  a 


26 


MISCELLANY. 


[N.  Y.  Med,  Jouh., 


neurosis  due  to  phthisis,  gout,  syphilis,  rheumatism,  lead-poison- 
ing, sunstroke,  heredity,  ataxia,  or  other  causes,  the  course  of 
general  paresis  may  be  atypical.  Foville  has  called  attention 
to  cases  of  paralytic  dementia  in  which  there  were  alternations 
of  maniacal  exaltation  and  melancholic  depression,  and  has  pro- 
posed to  call  them  paresis  d  douUe  forme.  The  resemblance  of 
such  cases  to  circular  insanity  may  be  very  great.  When  intel- 
lectual disorder  is  added  to  the  maniacal  exaltation  of  circular 
insanity  there  may  exist  grandiose  illusions  similar  to  those  of 
general  paralysis.  Even  when  there  is  no  delusion  the  resem- 
blance may  be  very  great.  Sometimes  in  general  paresis  there 
is  no  speech  or  motor  disorder.  Again  there  may  be  a  certain 
degree  of  tremulousness  of  speech  in  circular  insanity.  Falret 
has  noted  in  some  cases  of  the  latter  disease  pupillary  derange- 
ments and  epileptoid  and  apoplectoid  attacks.  Regis  maintains 
that  the  paretic  is  benevolent,  kind-hearted,  generous,  even 
prodigal,  while  the  circular  lunatic  is  wicked,  irritable,  ironical, 
and  clever  in  injuring  everybody.  But  the  author  claims  to 
have  observed  the  opposite  of  these  qualities  in  the  two  dis- 
orders respectively.  The  duration  of  the  alternating  type  is 
longer  than  that  of  typical  dementia  paralytica.  Paresis  due 
to  lues,  trauma,  phthisis,  sunstroke,  saturnism,  and  in  particular 
heredity,  is  exceedingly  apt  to  assume  this  circular  character. 
The  rheumatic  and  gouty  types  have  prolonged  remissions. 

Official  Public  Supervision  of  Prisons  by  Alienists.— Dr. 
Jules  Morel,  Commissioner  in  Lunacy  for  Belgium,  gave  an  in- 
teresting account  to  the  Psychological  Section  of  the  British 
Medical  Association  in  July  last  (Journal  of  Mental  Science, 
October,  1892)  of  the  creation  of  a  medico-psychological  service 
in  his  country  in  connection  with  the  prisons.  Three  alienists 
have  been  appointed  to  supervise  the  mental  condition  of  pris- 
oners. He  contended  that  prisons  always  contain  a  certain  pro- 
portion of  insane  people  among  their  in7nates,  and  he  advocated 
the  importance  of  having  them  looked  after  in  other  countries 
as  they  were  in  his  own.  The  aim  of  the  alienists  appointed  by 
the  Belgian  Government  was  to  remove  and  to  certify  the  men- 
tal cases  to  asylums,  and  to  call  the  attention  of  the  prison  offi- 
cials to  any  doubtful  cases.  The  system  had  worked  mo.st 
favorably  in  Belgium,  and  had  been  the  means  of  giving  many 
prisoners,  whose  insanity  had  not  previously  been  recognized,  a 
fair  chance  of  recovery. 

Intestinal  Disinfection  in  Some  Forms  of  Acute  Insanity. 
—A  paper  read  by  Dr.  John  Macpherson  before  the  British 
Medical  Association  in  July  last  (abstract  in  Journal  of  Ment. 
Science,  October,  1892)  will  be  read  with  interest  by  those  who 
find  intestinal  antisepsis  valuable  in  certain  nervous  diseases. 
The  author  was  inclined  to  criticise  the  too  great  employment 
of  narcotics  in  asylums,  often  leading  to  the  emaciation  of  the 
patient  and  the  depression  of  his  vitality.  It  was  a  matter  of 
common  knowledge  that  acute  attacks  were  frequently  averted 
by  the  simple  exhibition  of  a  purgative,  for  constipation  un- 
doubtedly tended  to  the  exacerbation  of  the  symptoms  of  acute 
mental  disease,  and  an  instantaneous,  though  perhaps  tempo- 
rary, improvement  followed  the  relief  of  a  loaded  intestine.  As 
pointed  out  by  Brunton,  nux  vomica  in  small  doses  acted  in 
some  cases  as  a  mild  hypnotic;  and  Bell,  in  his  work  on  the 
nervous  system,  had  given  notes  of  a  case,  among  others,  where 
a  man  was  cured  at  once  of  a  painful  nervous  affection  by  a  sim 
pie  purgative.  We  must  not  forget  the  depression  accompany- 
ing hepatic  derangement,  nor  that  form  of  mental  depression 
which  we  might  describe  as  visceral.  He  pointed  out  that  the 
acid  of  the  gastric  juice  was  primarily  and  chiefly  antiseptic,  and 
that  where  this  secretion  was  perverted,  as  in  acute  mental  dis- 
ease, its  antiseptic  power  was  diminished.  The  line  of  treatment 
he  now  advocated  was  the  exhibition  of  anti.septics  to  remedy 
this  defect.    He  selected  a  suitable  case,  washed  out  the  stom- 


ach, and  then  gave  a  dose  of  calomel  varying  from  two  and  a 
half  to  four  grains  at  night,  with  a  mild  cathartic  in  the  morn- 
ing. This  was  followed  by  the  exhibition  of  mild  laxatives  daily. 
On  the  second  day  naphthalin,  in  ten-grain  doses,  three  times 
daily,  was  given  between  meals,  gradually  increasing  the  dose 
until  eighty  grains  were  administered  during  the  twenty-four 
hours.  He  had  never  noted  any  harmful  effect  from  these  doses. 
The  author  gave  details  of  cases  illustrating  the  value  of  this 
method  of  treatment.  During  the  treatment  nitrogenous  foods 
were  eliminated  as  much  as  possible  from  the  patient's  dietary. 
In  thirty  acute  cases  thus  treated  there  had  been  no  apparent 
interference  with  tiie  general  health.  The  action  of  the  drug 
in  preventing  and  removing  anajmia  was  very  marked.  The 
bodily  weight  increased  steadily.  The  tendency  of  the  skin  to 
pigmentation  in  melancholia  was  checked,  and  the  skin  lost  its 
dry  appearance.  The  promotion  of  sleep,  however,  was  one  of 
the  most  gratifying  results,  for,  when  fully  under  the  influence 
of  naphthalin,  the  patients  slept  normally  and  naturally  for 
seven  or  eight  hours  and  the  sleep  was  undoubtedly  not  nar- 
cotic. He  considered  the  remedy  of  great  value  in  acute  melan- 
cholia. He  pointed  out  that  naphthalin  had  reduced  the  sul- 
phates in  the  urine,  and  that  the  faeces  of  patients  treated  with 
it  were  devoid  of  smell  was  evidence  of  its  antiseptic  efiects. 


Railway  Surgery. — At  the  second  annual  meeting  of  the  New  York 
State  Association  of  Railway  Surgeons,  held  in  New  York  city  on  Novem- 
ber 14,  1892,  the  president.  Dr.  George  Chaffee,  of  Brooklyn,  delivered 
the  following  address  (published  in  the  Railway  Age  and  Northwestern 
Railroader  for  December  16,  1892) : 

This  being  the  first  meeting  of  our  society  since  its  organization  one 
year  ago,  we  may  perhaps  be  pardoned  for  briefly  referring  to  this 
topic.  In  looking  over  the  field  in  1891  I  thought  that  I  could  see  room 
and  work  for  a  State  society  of  railway  surgeons.  I  wrote  to  many  sur- 
geons of  the  State,  asking  their  opinion  in  regard  to  organizing  a  State 
society.  Answers  to  nearly  every  letter  were  received,  and  not  one 
contained  a  word  of  discouragement.  All  were  in  favor  of  organiza- 
tion. A  programme  was  arranged  and  the  first  meeting  called  for  Oc- 
tober 27,  1891,  at  Bensonhurst,  and  the  society  was  organized  with 
twenty-two  charter  members.  Several  topics  of  interest  to  railway  sur- 
geons were  also  discussed  at  that  meeting.  The  calling  of  that  meet- 
ing and  the  organization  of  a  State  society  by  one  of  our  noted  surgeons 
would  not  have  been  counted  very  much  of  a  task ;  but  when  we  con- 
sider that  the  meeting  was  called  by  a  stranger — for  I  had  never  had 
the  pleasure  of  meeting  one  of  our  members  before  October  27,  1891 — 
you  can  at  once  see  that  it  was  the  object  of  that  meeting,  railway  sur- 
gery, and  not  the  founder  of  this  society,  that  brought  out  such  a  full 
attendance. 

This  thought,  the  object  of  our  meeting,  brings  us  to  the  interesting 
topic  of  railway  surgery.  I  offer  no  apology  for  the  terms  railway  sur- 
gery and  railway  surgeon.?.  Railway  and  accidental  surgery,  aided  by 
antiseptic  measures,  are  fast  becoming  a  special,  distinct,  and  popular 
branch  of  surgery.  It  was  while  practicing  on  the  plains  of  Nebraska 
that  I  received  an  introduction  to  this  line  of  surgery.  And  here  allow 
me  to  say  that  indirectly  we  aie  indebted  to  the  West  for  the  organiza- 
tion of  this  society.  I  was  young  and  inexperienced,  but  my  first  case 
was  in  need  of  no  service  except  from  the  coroner.  The  victim,  a 
young  lad,  had  attempted  to  step  upon  the  front  platform  of  the  last 
car  as  a  train  was  slowing  up  at  a  station.  His  foot  slipped,  he  lost  his 
hold,  and  I  saw  him  as  he  fell,  with  both  arms  extended  and  resting 
with  his  neck  across  the  rail.  Four  car  wheels  passed  over  his  neck 
and  arms.  To  me  the  point  of  interest  in  this  case  was  the  condition 
in  which  the  skin  was  left ;  the  bones  of  his  neck  and  arms  were  finely 


Jan.  7,  1893.] 


MISCELLANY. 


27 


crushed,  but  the  skin  over  the  injured  parts  remained  unbroken.  Prac- 
tice with  the  wood  and  iron  construction  gangs  and  along  the  line  with 
employees  and  patrons  after  a  road  has  been  put  in  operation  has  con- 
vinced nie  that  there  is  such  a  thing  as  railway  surgery. 

Up  to  the  present  time  the  literature  of  this  branch  of  surgery  is 
limited.  Aside  from  the  proceedings  of  the  National  Association  of 
Railway  Surgeons  I  believe  but  two  works  have  been  published — one, 
Railway  Surgery,  by  Dr.  C.  B.  Stemen,  of  Fort  Waynne,  the  otlier. 
Railway  Injuries,  a  reprint  from  Wooir.i  Monograplis,  by  Herbert  W. 
Page.  Since  June,  1891,  a  vast  amount  of  current  literature  on  this 
subject  has  been  published  by  the  National  Association  of  Railway 
Surgeons  in  the  Railwai/  Age.  ^Vhile  this  may  not  be  considered 
strictly  ethical,  for  the  Railway  Age  is  not  a  medical  journal  and  our 
papers  are  read  by  few  medical  men  other  than  railway  surgeons,  still 
the  selection  of  the  Railvny  Age  by  that  body  of  surgeons  has  already 
accomplished  a  great  work  which  could  have  been  reached  in  no  other 
way. 

1.  It  has  given  us  a  weekly  journal  on  railway  surgery. 

2.  It  has  in  one  year  been  instrumental  in  more  then  quadrupling  the 
membership  of  that  society. 

3.  It  has  enabled  the  management  of  great  corporations  to  become 
better  acquainted  with  the  character  of  services  rendered  by  their  sur- 
geons and  has  rendered  the  relations  between  them  more  cordial. 

When  surgeons  of  note  from  our  large  cities  are  elected  to  honorary 
membership  in  the  national  association,  I  would  suggest  that,  in  addi- 
tion to  their  certificate  of  honorary  membership,  they  be  supplied  each 
year  with  the  same  form  of  ticket  as  regular  members.  Last  May  our 
national  membership  tickets  alone  were  good  for  transportation  on 
many  through  lines.  The  Philadelphia  and  Reading  was,  I  believe,  the 
first  Eastern  line  after  the  Chesapeake  and  Ohio  to  make  this  very  liberal 
offer.  I  believe  that  in  1894  a  membership  ticket  will,  if  the  location 
of  the  meeting  requires  it,  secure  for  its  holder  transportation  from  the 
Statue  of  Liberty  to  the  Golden  Gate  and  return.  And  here  is  the  point 
I  desire  to  make.  If  those  experienced  surgeons  are  supplied  with  tickets 
good  for  the  trip  to  the  meetings  of  our  State  and  national  associations, 
many  of  them,  I  trust,  may  be  induced  to  meet  with  us  and  take  part  in 
the  discussion  of  papers,  which  is  often  the  most  valuable  and  interesting 
part  of  a  paper.  In  this  way  the  literature  of  railway  surgery  will  re- 
ceive a  contribution  the  practical  value  of  which  to  surgeons,  corpora- 
tions, and  their  patrons  is  beyond  estimation.  With  the  names  of  such 
surgeons  on  our  programmes  the  papers  will  be  looked  after  by  journals 
of  surgery  and  we  shall  be  known  as  a  scientific  body.  In  a  general 
way  much,  and  perhaps  too  much,  has  been  written  about  injuries  to 
the  spine.  I  am  certain  that  railway  corporations  must  realize  that  too 
much  of  it  has  been  carefully  read  by  a  class  of  people  for  whom  it  was 
never  intended.  Injuries  to  the  spinal  cord  and  coverings,  including  the 
osseous  framework,  is  a  field  offering  great  inducements  for  original 
work.  And  for  the  man  who  could  climb  to  fame  upon  this  ladder  the 
transverse  and  spinous  processes  would  seem  to  offer  peculiar  advan- 
tages. Surgeons,  and  especially  those  doing  railway  surgery,  are  very 
much  in  need  of  a  standard  of  some  system  of  examination  and  means 
of  diagnosis  that  will,  when  called  to  examine  cases  of  spinal  injury, 
enable  them  to  separate  real  from  alleged  injuries. 

Of  late  the  surgical  department  has  become  of  great  importance  in 
the  railway  service  of  this  country.  No  railway  system  is  complete 
without  this  department.  In  putting  a  surgical  department  in  order 
the  first  thing  to  be  done  by  the  management  is  the  selection  of  a  chief 
surgeon.  The  chief  surgeon  is  the  person  and  the  only  person  to  select 
his  staff  of  assistants  for  surgical  service  along  the  line.  The  mistake 
is  often  being  made  by  the  management  of  some  corporations  of  dis- 
pensing with  the  services  of  chief  surgeon.  Such  a  staff  of  surgeons  is 
without  an  oflicial  head,  and  must  fail  to  fully  accomplish  the  end  for 
which  it  has  been  established.  With  due  respect  to  general  managers 
and  superintendents  of  railways  in  their  official  capacities,  they  are  cer- 
tainly out  of  place  when  they  undertake  to  manage  the  office  of  chief 
surgeon  and  give  directions  in  the  practice  of  surgery  and  in  the  trans 
portation  of  surgical  cases.  Corporations  with  such  a  staff  of  surgeons 
as  I  have  described  should  not  allow  the  good  work  to  go  unfinished. 
In  times  of  accident  and  a  serious  wreck,  the  staff  will  require  the  ad- 
vice and  counsel  of  a  chief  surgeon ;  the  management,  as  well  as  its 


excited  and  injured  patrons,  will  derive  comfort  and  benefit  from  the 
directions  of  an  experienced  leader. 

What  railway  of  the  East  would  think  of  asking  a  chief  surgeon 
from  the  West  to  superintend  its  line  ?  What  railway  of  the  West 
would  think  of  asking  a  general  manager  from  the  East  to  take  charge 
of  its  surgical  department  ? 

A  chief  surgeon  has  an  important  and  valuable  work  'to  perform. 
In  selecting  his  staff  he  must  choose  men  who  are  willing  to  study  and 
work,  willing  to  discard  old  and  useless  methods  and  accept  those  new 
and  valuable,  thus  keeping  pace  with  the  rapid  changes  in  the  technique 
of  modern  surgery. 

Excellent  papers  have  been  written  and  many  suggestions  made  ou 
the  subject  of  relief  trains.  As  yet  in  the  East  very  little  has  been 
done  in  a  practical  way  toward  filling  a  long-felt,  and  in  times  of  a 
wreck  a  sore  and  extremely  painful,  want.  Generally  speaking,  I  do 
not  favor  the  selection  of  frightful  examples  and  the  holding  of  them 
up  as  object  lessons,  bst  in  considering  relief  trains  I  believe  that  sucli 
a  remedy  is  clearly  indicated.  Let  us,  if  you  please,  hastily  recall  a  few 
of  the  wrecks  which  have  shocked  and  startled  this  whole  country,  begin- 
ning with  the  one  at  Ashtabula,  Ohio,  in  1876,  where  Mr.  and  Mrs.  P.  P. 
BUss,  with  many  others,  perished  ;  the  Spuyten  Duyvil  disaster  of  1881, 
where  so  many  school  children  on  their  way  to  this  city  lost  their  lives ; 
the  disaster  at  Chatsworth,  111.,  in  1887,  where  the  second  section  of  an 
excursion  train,  nearly  all  sleepers,  crashed  through  a  burning  bridge  at 
midnight;  the  one  at  Ravenna,  Ohio,  July  3,  1891;  at  Hastings,  this 
State,  last  Christmas  eve,  and  the  one  at  Harrisburg,  Pa.,  last  summer. 
Accidents  of  this  character  are  liable  to  visit  any  corporation  doing  a 
passenger  business,  and  when  a  message  bearing  news  of  such  an  oc- 
currence is  received  it  certainly  will  be  a  satisfaction  and  comfort  to 
corporations  and  patrons  alike  if  the  management  is  in  a  position  to  dis- 
patch a  well-equipped  relief  train  to  the  scene  of  the  wreck.  A  relief 
or  ambulance  car,  as  described  in  the  Railway  Age  in  1891,  with  its 
doors  placed  at  each  corner  instead  of  at  each  end  of  the  car,  so  as  to 
admit  a  stretcher  with  ease,  with  small  operating-room,  stretchers,  cots, 
and  necessary  surgical  supplies,  would  to  my  mind,  with  two  additions, 
constitute  an  ideal  relief  train.  In  fact,  it  would  be  a  portable  railway 
hospital.    The  two  additions  I  would  propose  are : 

1.  I  would  suggest  that  the  interior  of  the  relief  car  and  all  its  fur- 
nishings be  so  constructed  of  suitable  material,  with  complete  drainage, 
as  to  allow  of  its  being  thoroughly  flushed,  thus  making  it  as  near  asep- 
tic as  possible. 

2.  Such  a  relief  car,  no  matter  how  many  surgeons  may  be  on  duty 
when  it  starts  for  the  scene  of  a  wreck,  would  certainly  be  incomplete 
without  a  trained  nurse.  Such  relief  cars  should  be,  and  I  hope  soon 
will  be,  distributed  at  convenient  points  along  the  line  of  every  road, 
and  connected  with  the  railway  hospitals  of  every  line  in  America.  And 
this  brings  us  to  the  topic  of  railway  hospitals. 

To  surgeons  connected  with  hospitals  in  our  Eastern  cities  it  may 
appear  out  of  order  to  write  upon  this  topic.  I  presume,  however,  that 
the  views  of  our  friends  from  Jersey  City  will  not  differ  materially  from 
my  own,  that  city  now  being  the  terminus  of  so  many  trunk  lines. 
Again,  as  in  the  case  of  chief  surgeons,  in  order  to  find  well-appointed 
railway  hospitals  we  must  journey  West,  and  we  shall  not  look  in  vain ; 
for  after  reaching  St.  Louis  and  Omaha  we  shall  find  on  every  hand 
splendid  hospitals  devoted  entirely  to  the  service  of  railway  surgery. 
These  hospitals  are  maintained  by  monthly  assessments  of  from  twenty- 
five  to  fifty  cents  for  each  employee.  When  misfortune  overtakes  one 
of  these  men  and  a  hand  or  foot,  an  arm  or  leg  is  crushed,  he  has  the 
satisfaction  of  knowing  that  he  will  be  taken  to  an  institution  specially 
j)repared  for  treating  such  cases,  that  his  bills  are  paid  in  advance,  that 
he  has  but  one  thing  to  do — viz.,  to  aid  Nature  and  his  surgeons  in  work- 
ing out  the  repair.  Although  this  service  is  paid  for  by  the  patient,  the 
adoption  of  such  a  system  shows  tender  care  and  forethought  on  the 
part  of  corporations,  and  experience  has  shown  that  an  injured  person 
with  such  surroundings  is  not  at  all  likely  to  dream  of  damage  suits — 
an  item  of  no  small  account,  for  in  many  cases  enough  has  been  paid 
by  corporations  to  build  and  equip  suitable  hospitals  along  their  entire 
lines. 

The  hospital  plan  is  able  to  stand  alone.  Reference  to  annual  re- 
ports ia  ample  proof  of  the  character  of  work  that  is  being  done.  The 


28 


MISCELLANY. 


[N.  Y.  Med.  Joub. 


only  apology  I  oifer  for  considering  this  topic  in  my  paper  is  to  once 
more  bring  it  before  this  association  and  to  the  notice  of  the  manage- 
ment of  our  Eastern  lines.  Our  large  Eastern  cities  may,  like  Eastern 
lines,  be  rather  slow  to  see  the  need  of  railway  hospitals.  This  is  a 
question,  howevei',  which  lies  directly  between  the  chief  surgeon  and  gen- 
eral manager  of  every  line.  New  York,  the  metropolis  of  America,  with 
her  great  hospitals,  both  general  and  special,  is  not  yet  quite  ready  to 
add  another  to  her  long  list.  New  York's  peculiar  location  will  for  a 
time  delay  the  coming  of  a  railway  hospital.  But  when  more  time  has 
been  consumed  in  national  legislation,  and  the  historic  Hudson  has  been 
spanned  by  a  mighty  bridge,  making  the  metropolis  a  railway  terminus 
and  revolutionizing  passenger  traffic,  then,  and  perhaps  not  until  then, 
will  New  York  see  and  feel  the  need  of  railway  hospitals  and  relief 
trains. 

Forty  years  ago  but  few  men  could  foresee  that  gynaecology  would 
become  one  of  the  most  popular  specialties  of  our  profession.  Those 
of  you  who  are  familiar  with  the  life  of  J.  Marion  Sims  know  with  what 
opposition  he  met  when  he  came  to  New  York  and  undertook  to  gratify 
the  ambi^on  of  his  life  by  establishing  the  Woman's  Hospital.  To-day 
the  world  knows  that  he  was  finally  successful,  and  the  great  work  he 
started  will  go  on  forever.  If  the  establishment  and  promotion  of  rail- 
way surgery  in  the  East  as  a  distinct  branch  of  surgery  did  not  rest  with 
those  directly  interested,  one  whose  ambition  leads  him  in  this  direction 
might  expect  as  strong  opposition  as  did  the  one  whose  name  we  have 
mentioned.  F'ortunately,  as  we  have  already  stated,  the  hospital  ques- 
tion is  one  to  be  agitated  and  settled  mainly  between  chief  surgeons  and 
corporations.  And  resting  in  a  position  so  favorable  I  predict  that 
within  ten  years  New  York  city  will  have  a  railway  hospital,  and  that 
classes  attending  our  post-graduate  schools  will  be  instructed  in  railway 
surgery  at  the  New  York  railway  hospital. 

To  repeat,  and  in  conclusion,  I  desire  to  say  that  I  think  the  Railway 
Age  is  a  journal  that  should  be  read  by  railway  surgeons  and  general 
managers.  It  is  a  journal  of  high  order,  and  he  who  reads  it  will  be 
instructed.  A  surgical  department  is  just  as  necessary  to  a  railway  cor- 
poration as  a  family  physician  is  to  the  family  that  is  fortunate  enough 
to  secure  one  in  whom  it  has  confidence.  Every  general  manager  has, 
I  believe,  the  right,  if  he  so  desires,  to  select  a  chief  surgeon  for  his 
system.  The  chief  surgeon  will,  in  turn,  look  after  his  staff  and  the 
establishment  of  the  department.  There  is  no  car  on  any  line  of  more 
importance  or  needed  any  more  in  its  season  than  the  relief  car.  Any 
day-coach  may  be  remodeled  so  as  to  make  an  elegant  but  inexpensive 
relief  car.  No  corporation  having  commenced  to  set  the  surgical  de- 
partment in  order  will  rest  from  its  labors  without  a  suitable  number  of 
hospitals.  And  for  fear  that  this  work  may  at  first  sight  appear  too 
great,  I  will  say  that  hospitals  need  be  placed  only  at  about  every  one 
hundred  miles  along  the  line.  And  here,  as  in  the  case  of  relief  cars, 
the  cost  need  not  be  high.  In  many  instances  at  division  towns  a  por- 
tion of  a  building  already  in  possession  of  the  corporation  may  be  so  re- 
modeled as  to  answer  all  the  requirements  of  an  emergency  room,  and 
where  necessary  a  cozy  hospital  may  be  erected  with  the  expenditure  of 
but  a  very  few  dollars  of  the  company's  money.  Surgical  departments 
not  only  save  money  for  a  corporation,  but  the  day  is  coming  when  they 
will  assist  in  drawing  first-class  patronage.  What  employee  would  not 
work  with  better  grace  when  he  knows  that  so  much  has  been  done  for 
his  comfort  when  sick  and  injured  ?  What  traveler  would  not  secure 
transportation  over  a  line  thus  protected,  leaving  competing  lines  whose 
management  look  upon  such  departments  as  unnecessary  ? 

In  retiring  from  the  office  to  which  you  so  kindly  elected  me  I  wish 
to  thank  you  for  the  honor,  but  I  feel  that  my  work  for  this  society  and 
for  railway  surgery  in  the  East  has  but  just  commenced.  In  performing 
the  duties  of  the  office  I  have  tried  to  please  all  and  at  the  same  time 
do  work  that  would  place  this  association  firmly  upon  scientific  feet,  and 
I  desire  to  thank  our  friends  and  members  for  their  hearty  support.  As 
time  passes  I  shall  ever  look  with  pride  upon  the  growth  and  prosperity 
of  the  New  York  State  Association  of  Railway  Burgeons. 

The  New  York  Academy  of  Medicine. — The  programme  for  the 
meeting  of  Thursday  evening,  the  5th  inst.,  included  a  paper  entitled 
A  Contribution  to  Cerebral  Surgery ;  Diagnosis,  Localization,  and  Op- 
eration for  the  Removal  of  Three  Tumors  of  the  Brain,  with  some  Com- 


ments upon  the  Surgical  Treatment  of  Brain  Tumors,  by  Dr.  Charles 
McBurney  and  Dr.  M.  Allen  Starr. 

At  the  next  meeting  of  the  Section  in  General  Surgery,  on  Monday 
evening,  the  9th  inst.,  Dr.  Willy  Meyer  is  to  read  a  paper  entitled  In- 
cision of  Retropharyngeal  Abscess,  according  to  Antiseptic  Principles, 
from  the  Neck ;  and  Dr.  Howard  Lilienthal  will  present  one  entitled 
What  is  the  Site  of  Infection  producing  Epitrochlear  Glandular  En- 
largement ? 

At  the  next  meeting  of  the  Section  in  Genito-urinary  Surgery,  on 
Tuesday  evening,  the  10th  inst.,  Dr.  F.  Tilden  Brown  will  read  a  paper 
on  the  Treatment  of  Posterior  Urethritis;  and  Dr.  Samuel  Alexander 
will  read  one  on  the  Abuse  of  Intravesical  Injections. 

At  the  next  meeting  of  the  Section  in  Paediatry,  on  Thursday  even- 
ing, the  12th  inst.,  there  will  be  discussions  of  surgical  subjects  as  fol- 
lows :  The  Best  Methods  of  dre.«sing  Fractures  of  the  Thigh  in  Infants 
— the  Indications  for  Each,  by  Dr.  R.  H.  Dawbarn ;  and  the  Best 
Method  of  securing  a  Good  Result  in  Fracture  of  the  Clavicle  in  "Run- 
about Children,"  by  Dr.  Reginald  H.  Sayre. 

At  the  next  meeting  of  the  Section  in  Neurology,  on  Friday  evening, 
the  13th  inst.,  Dr.  Joseph  Collins  will  read  a  paper  on  Acute  Myelitis 
and  Hsematomyelia. 


To  Contributors  and  Correspondenta. —  The  attention  of  aR  who  purpote 

favoring  us  with  communications  m  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  ahoays  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  mmt  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  t/ie  article  is  sent  to  us  ;  (S)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  a.s  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wkhes  complied  with  must  be  distinctll' 
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new  conditions  can  be  considered  after  the  manuscript  has  been  pui 
into  the  type-setters^  hand^.  We  are  often  constrained  to  decline 
articles  which,  altho^igh  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  jourrud,  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,  whether  intended  for  publication  or  not,  must  contain  the 
writer'' s  name  and  address,  not  necessarily  for  publication.  No  at' 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor- 
respondents asking  for  information  that  we  are  capable  of  giving, 
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respondent informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author^s  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi- 
vidual practitioners. 

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

Newspapers  and  other  puldicatiom  conlaining  matter  which  the  person 
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to  our  readers  will  be  considered  as  doing  them  and  ics  a  favor,  and, 
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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  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad- 
dreated  to  the  publishers. 


THE  JN^EW  YORK  MEDICAL  JOURNAL,  January  14,  1893. 


(ii^rtginal  Communications. 


A  CLINICO-PATHOLOGICAL  STUDY  OF 
INJURIES  OF  THE  HEAD, 

WITH  SPECIAL  REFERENCE  TO 
LESIONS  OF  THE  BRAIN  SUBSTANCE* 
By  CHARLES  PHELPS,  M.  D., 

SUEGBON  TO  BKLLEVDE  ANB  ST.  VINCENT'S  HOSPITALS. 

Two  years  ago  I  read  before  this  association,  in  the 
course  of  a  general  discussion  upon  cerebral  surgery,  a 
very  brief  paper  upon  cerebral  contusion.  Since  thai  time  a 
very  considerable  number  of  cases  of  serious  injuries  of  the 
head,  almost  all  of  which  have  involved  lesion  of  the  brain 
substance,  have  come  under  my  observation.  They  pre- 
sent so  many  points  of  interest  and  importance  that  I  have 
ventured  to  ask  renewed  attention  to  an  extension  of  the 
same  subject.  In  no  department  of  surgery  are  more 
problems  yet  unsolved,  and  in  no  department  are  the  re- 
suits  of  careful  study  likely  to  be  of  more  absorbing  interest 
or  of  greater  professional  value. 

Attention  has  been  largely  directed  to  cerebral  localiza- 
tion, and  to  certain  surgical  procedures  founded  upon  the 
indications  it  has  afforded.  Such  operations  upon  the 
brain  have  been  conspicuously  successful,  and  have  been 
justly  reckoned  among  the  triumphs  of  modern  surgery. 
When  guided  by  the  disclosures  of  physiological  experi- 
ment and  aided  by  the  application  of  recognized  aseptic 
laws,  operations  upon  the  brain  have  been  devised  and  suc- 
cessfully executed  which  in  the  immediate  past  would  have 
been  not  dnly  impossible  but  incre<lible.  It  is  equally 
true  that  these  operations  are  still  limited  in  number  and 
application.  The  instances  in  which  brain  lesions  can  be  ac- 
curately defined  and  located  and  afterward  made  subject  of 
operation  with  reasonable  prospect  of  success  are  compara- 
tively infrequent.  The  lesions  which  are  of  such  nature,  so 
well  defined  in  outline,  or  so  situated,  in  view  of  demon- 
strated localization  of  brain  function,  that  their  diagnosis  can 
be  made  with  reasonable  certainty,  are  few  enough  in  the 
first  instance ;  those  which  are  within  reach  of  the  surgeon's 
knife  are  fewer  still ;  and  those  in  which  the  patient  ulti- 
mately survives  constitute  but  a  small  proportion  of  the 
originally  scanty  number.  It  is  not  strange,  however,  that 
operations  which  invade  the  very  penetralia  of  the  human 
organism  should  fascinate  by  their  audacity,  and  that,  when 
successful,  they  should  dazzle  the  modest  workers  in  more 
prosaic  fields  of  labor.  It  is  also  possible  that  the  ardor  with 
which  the  diagnosis  and  relief  of  local  lesions  of  the  brain 
have  been  pursued,  in  the  light  of  functional  localization, 
may  tend  to  distract  attention  from  those  general  patho- 
logical conditions  which  are  of  so  much  greater  frequency. 
The  study  of  cerebral  topography,  moreover,  has  been  so 
much  more  effectively  prosecuted  by  the  physiologist  than 
by  the  pathologist,  that  perhaps  the  results  of  clinical  and 


*  Read  before  tbe  New  York  State  Medical  Association,  November 
16,  1892. 


pathological  work  have  been  practically  if  not  theoretically 
underrated.  It  is  certainly  proper  at  the  present  time  to 
more  generously  supplement  physiological  experimentation 
by  both  ante-mortem  and  post-mortem  observations  made 
upon  the  human  subject.  For  this  purpose,  cerebral  trau- 
matism, which  this  series  of  cases  illustrates,  affords  pecul- 
iar advantages,  since  death  results  from  the  establishment 
of  lesions  in  a  previously  healthy  brain,  and  since  it  pre- 
sents itself  with  suflScient  frequency  for  purposes  of  com- 
parison. 

The  cases  which  I  propose  to  subject  to  analysis  are  one 
hundred  and  twenty-four  in  number,  and,  with  two  or  three 
exceptions,  have  been  previously  unreported.  They  have 
occurred  mainly  in  my  service  in  two  hospitals,  and  in  the 
last  two  years.  They  include  all  cases  of  injuries  of  the 
head  which  I  have  seen  during  the  time  specified,  and  if 
they  are  preponderatingly  of  one  character,  they  are  proba- 
bly still  representative  of  the  whole  class  to  which  they  be- 
long. Wounds  of  the  scalp  have  not  been  included  because 
they  are  not  only  surgically  insignificant,  but  have  no  ne- 
cessary relation  to  the  deeper-seated  injuries  which  it  is 
proposed  to  consider.  In  a  previous  paper  upon  a  subject  of 
an  entirely  different  character,  I  found  it  convenient  to  ab- 
stract the  histories  of  the  several  cases  upon  which  it  was 
based.  I  pursue  the  same  course  in  the  present  instance 
in  order  to  afford  a  means  of  verification  of  such  conclu- 
sions and  generalizations  as  I  may  establish,  and  at  the 
same  time  to  make  record  of  a  large  amount  of  material 
which  may  be  of  service  hereafter  to  students  of  the  same 
class  of  injuries.  I  shall  not  attempt  a  reading  of  these 
histories,  but  shall  leave  them  to  appear  in  the  archives  of 
the  association  for  future  consultation.  They  are  arranged 
in  accordance  with  the  nature  and  result  of  the  primary 
injury. 

FRACTURES  AT  THE  BASE. 

Case  I. — Male,  aged  forty-five ;  fell  iu  the  street ;  admitted 
to  alcoholic  ward;  wild  delirium,  requiring  niechauical  re- 
straint; hiBmorrhage  from  left  ear;  wound  in  posterior  parietal 
region;  liigli  temperature;  coma;  death  in  forty-eight  hours. 

Mecropsy. — Fracture  at  the  base,  with  complete  separation 
of  the  left  temporal  bone  into  its  constituent  parts — squamous, 
petrous,  and  mastoid.  Slight  laceration  of  left  parietal  lobe  at 
a  point  corresponding  to  seat  of  external  injury.  At  a  corre- 
sponding ()oint  upon  opposite  parietal  lobe  there  was  extensive 
laceration  3'5  inches  x  r5  inch  in  diameter. 

Case  II. — Male,  aged  forty;  said  to  have  fallen  from  his 
truck;  no  superficial  injury;  delirium,  which  was  considered 
alcoholic;  refused  treatui<  nt;  delirium  continued  next  day,  and 
he  committed  suicide  by  drowning. 

Secropsy. — Fracture  at  base  extending  from  left  parietal 
eminence  to  foramen  magnum.  Superficial  laceration  of  right 
temp'To-sphenoidal  lube  ijy  contre-coup. 

These  two  cases  have  been  previously  reported. 

Case  III. — Male,  aged  fifty;  fell  from  steps  to  sidewalk; 
scalp  woimd  in  right  posterior  superior  parietal  region;  haem- 
orrhage from  right,  ear,  and  later  from  rij;ht  nostril;  coma; 
stertor  ;  rigidity  of  all  the  limbs ;  left  jtiipil  dilated.  In  twelve 
hours  complete  left  hemi|)Iegia  supervened,  and  hajmorrhage- 
from  right  ear  renewed.  Stertor  and  rigidity  disiip|)eared,  and 
left  pupil  became  normal.    Unconsciousness  and  incontinence: 


30 


PHELPS:  INJURIES  OF  TEE  HEAD. 


fN.  Y.  Mkd.  Joue., 


of  urine  continued  from  time  of  admission  till  death  from  ns- 
thenia  at  the  end  of  six  days. 

Necropsy. — Fracture  at  base,  beginning  at  point  of  injury 
and  extending  through  right  petrous  portion  and  middle  fossa 
to  apex  of  opposite  petrous.  Lacerations  of  left  frontal  and 
riglit  temporo-sphenoidal  lobes  inferlorly  and  laterally.  Tiiick 
clot  over  left  Irontal  and  temporal  lobes  laterally,  growing 
thinner  as  it  extended  toward  base  and  vertex.  Whole  brain 
intensely  hyperaemic. 

Case  IV. — Male,  aged  twenty-two;  cause  of  injury  un- 
known; compound  depressed  fracture  external  to  right  parietal 
eminence;  semi-comatose,  irrational,  articulation  indistinct; 
respiration  continued  slow  and  irregular  for  three  days.  The 
depression  was  found  on  trephination  to  be  of  the  external  table 
only.  Two  days  after  adinission,  complete  paralysis  of  ex- 
tensors of  rigiit  hand,  paresis  of  right  arm,  and  right  facial 
paralysis,  involving  both  mouth  and  eyelid.  All  these  paralyses 
afterward  varied  in  degree  from  time  to  time,  and  the  mental 
condition  varied  from  rationality  to  noisy  delirium.  He  was 
usually  restless,  and  became  unconscious  for  two  days  before 
death.  Temperature  on  admission,  101°,  and  remained  above 
100°  for  a  week.  Then  declined  to  99°-)-  during  another 
week.  Two  days  before  death  it  rose  steadily  from  103°  to 
109°.    Died  in  forty-five  days. 

Necropsy. — Fissure  extending  from  point  of  depression  into 
right  middle  fossa.  Subacute  arachnitis  and  excessive  cerebral 
hyi)erEemia;  surface^of  brain  at  point  of  fracture  unchanged,  but 
beneath  it  was  a  large  cavity  containing  reddish  semi  fluid  ma- 
terial, and  brown  detritus  from  subcortical  laceration. 

Oase  V. — Male,  aged  thirty-five;  cause  of  injury  unknown  ; 
scalp  wound  ovei' occipital  protuberance;  patient  under  influ- 
ence of  drink ;  would  not  answer  questi(ms;  grew  stupid,  and 
in  three  hours  became  nnconscious;  mechanical  restraint  neces- 
sary. Temperature  soon  after  adinission  was  102°,  and  in  ten 
hours  became  105°,  receded  to  101-8°,  and  then  I'ose  steadily  to 
106'G°.    He  died  twenty-niue  hours  after  admission. 

Necropsy. — Hiematoma  covered  whole  calvarium.  No  frac- 
ture of  vertex,  but  a  slight  fissure  existed  along  the  posterior 
border  of  tlie  right  petrdus  portion  of  temporal  bone  from  contre- 
conp.  Thin  coaguium  and  fluid  blood  covered  upper  surface 
of  both  cerebra  (meningeal  contusion).  Lacerations  of  under 
surface  of  left  frontal  (large)  and  temporo-sphenoidal,  of  inner 
border  of  right  frontal,  and  of  under  surface  of  right  temporo- 
sphenoidal  lobes.    The  last  was  as  large  as  a  hickory  nut. 

Case  VI. — Male,  aged  thirty-eight ;  knocked  down  by  a  blow 
upon  the  head  from  a  club;  scalp  wound  in  right  parietal  re- 
gion. He  was  stupid,  and  could  not  answer  questions  coher- 
ently, lieft  pupil  slightly  dilated  and  eyes  directed  slightly  to 
the  right.  Next  day  incoherent,  delirious,  and  had  delusions 
and  muscular  tremor,  pupils  irregular,  pulse  frequent  and  inter- 
mittent. Temperature  on  admission  103°,  five  hours  later  102°, 
rose  to  ]06'2''.    Died  in  twenty-four  hours. 

Necropsy. — Linear  fracture  through  whole  length  of  right 
parietal,  right  occipital,  and  petrous  portion  of  temporal  bone 
into  middle  fossa.  Considerable  laceration  of  under  surface  of 
left  frontal  and  temporo-sphenoidal  lobes. 

Case  VII. — Male,  aged  forty-five;  fell  upon  the  sidewalk, 
.•striking  the  back  of  tiie  head.  Admitted  afi;er  twenty-four 
liours.  ffidema  under  and  about  an  old  cicatrix  behind  the 
Tight  ear,  and  underneath  this  an  extensive  comminuted  frac- 
ture. Two  pieces  of  bone  were  removed  and  one  elevated,  and 
;a  large,  firm  epidural  clot  extracted  as  far  as  possible.  The 
patient  was  in  a  condition  of  stupor;  pupils  irregularly  dilated; 
articulation  difficult ;  muscles  generally  rigid  ;  gait  ataxic  when 
ihe  attempted  to  walk;  sensibility  diminislied;  and  urine  incon- 
tinent.   His  condition  improved  for  four  days  after  operation.  ' 


temperature  decreased,  mental  condition  became  clearer,  and 
muscular  rigidity  lessened.  There  was  copious  serous  discharge 
from  the  right  ear,  followed  by  right  facial  paralysis.  On  the 
fifth  day  temperature  rose  from  normal,  muscular  rigidity  again 
increased,  and  he  again  became  stupid.  The  next  day  he  be- 
came unconscious,  and  in  an  hour's  time  he  had  eighteen  general 
convulsions,  and  died  the  following  morning.  His  temperature 
did  not  exceed  99'8°  till  the  fifth  day.  On  the  morning  of  his 
death  it  was  105°. 

Nearopsy. — Fracture  at  the  base.  The  whole  central  portion 
of  the  occii)ital,  from  the  foramen  magnum  upward,  and  poste- 
rior portion  of  both  parietal  and  right  temporal  bones,  forming 
an  irregular  circle  two  inches  and  a  half  to  three  inches  in 
diameter,  were  broken  into  large  fragments,  two  of  which  had 
been  removed  during  life.  The  mastoid  and  outer  part  of  the 
petrous  portion  of  the  right  temporal  bone  could  be  removed 
by  the  fingers  with  the  use  of  very  little  force.  This  line  of 
fracture  ran  through  the  tympanic  cavitv,  so  that,  after  removal 
of  the  outer  fragment,  the  carotid  canal  and  aqueductus  Fallopii 
could  be  seen  in  the  section  filled  with  coagula.  A  large  epi- 
dural clot  was  situated  beneath  the  occipital  fracture,  extending 
half  an  inch  beyond  its  margin.  A  large  subdural  clot  filled 
the  right  inferior  occijjital  fossa,  extending  to  the  foramen  mag- 
num. The  cavity  of  the  posterior  part  of  the  great  longitudinal 
sinus  was  occupied  by  a  thrombus,  and  its  walls  were  infiltrated 
with  blood.  There  was  a  large,  partially  decomposed  thrombus 
in  the  torcular  Herophili,  extending  through  the  right  lateral 
into  the  petrosal  sinus  and  internal  jugular  vein.  The  whole 
internal  surface  of  the  dura  beneath  the  seat  of  the  external 
hsemorrliage  was  lined  by  a  firmly  coagulated  clot,  with  an  in- 
flammatory exudation  around  it.  A  portion  of  the  surface  of 
the  right  occipital  lobe  posteriorly  was  softened,  showed  minute 
hfiemorrhages,  and  was  torn  away  in  the  removal  of  the  dura. 
The  meshes  of  the  pia  mater  over  a  large  [jart  of  the  parietal 
and  occipital  lobes  posteriorly  were  distended  with  slightly  tur- 
bid serum.  There  w'as  a  small  laceration  on  the  under  surface 
of  each  frontal  lobe,  and  a  larger  one,  three  quarters  of  an 
inch  in  diameter,  existed  in  the  right  cerebellum  at  a  point  cor- 
responding to  the  site  of  the  thickest  part  of  the  subdural 
hsemorrhage. 

Case  VIII. — Male,  aged  seventy-six  ;  cause  of  injury  un- 
known; admitted  to  alcoholic  ward,  and  transferred  to  surgical 
service  same  day.  Patient  unconscious  from  the  time  he  was 
found  in  the  street.  Stertor;  muscles  rigid  on  both  sides;  both 
pupils  very  strongly  contracted,  the  left  one  the  more  so.  Scalp 
oedematous  in  right  parietal  region.  Fissure,  extending  from 
posterior  and  inferior  part  of  right  parietal  into  occipital  bone, 
discovered  by  incision.  There  was  no  change  in  the  general 
symptoms  up  to  the  time  of  death,  two  days  and  six  hours  after 
admission.  The  left  pupil  continued  to  be  the  more  strongly 
contracted,  and  muscular  rigidity  continued  to  be  more  strongly 
marked  on  the  right  side.  Consciousness  was  not  regained. 
Temperature  on  admission,  100-4° ;  rose  steadily  to  103-8° ;  post 
mortem,  102°. 

Necropsy. — Fracture  at  base  extended  to  right  jugular  fora- 
men, and  then  turned  backward  to  foramen  magnum.  Slight 
epidural  and  considerable  subdural  hsemorrhage  at  point  where 
fracture  began.  Slight  serous  efi'usion  into  pia.  Thrombus  in 
torcular  Herophili,  extending  into  right  occipital  sinus  and 
through  petrosal  sinus  into  jugular  vein.  The  whole  inferior 
surface  of  the  brain  covered  with  blood.  Superficial  laceration 
along  the  anterior  border  of  left  temporo-sphenoidal  lobe  from 
median  line  outward.  Largo  clot  could  he  seen  bulging  out- 
ward, behind  a  thin  conical  layer,  along  the  whole  length  of 
external  border  of  left  frontal  lobe.  Well-marked  lacerations 
upon  anterior  border  of  both  frontal  lobes,  and  also  upon  their 


\ 


Jan.  U,  1893.] 


PEELPS:  INJURIES  OF  THE  HEAD. 


31 


inferior  surfaces  along  the  longitudinal  fissure.  Optic  chiasm 
surrounded  by  a  clot,  which  extended  backward  as  far  as  ante- 
rior border  of  the  pons  Varolii.  Upon  section  along  external 
border  of  left  frontal  lobe,  a  clot  of  great  size  was  disclosed, 
which  occupied  almost  the  whole  substance  of  the  left  frontal 
and  teiiii)oro-sj)lienoidal  lobes,  from  the  third  frontal  convolu- 
tion backward.  This  hajmorrhage  had  broken  through  into  the 
lateral  ventricles  nnd  thence  into  the  occipital  lobes,  which  were 
also  filled  with  great  pools  of  fluid  blood. 

Case  IX. — Male,  aged  forty  ;  fell  into  the  hold  of  a  vessel; 
semi-conscious  when  found;  hfemorrhage  from  both  nostrils 
and  from  right  ear;  regained  consciousness  next  day  ;  four  days 
later  delirious  and  irritable;  back  of  neck  rigid;  abdomen  re- 
tracted ;  death  at  end  of  five  days.  Cheyne-Stokes  respiration 
supervened.  Temperature  for  seventy-two  hours,  99'2°  to  99'8° ; 
fourth  day,  103-2°;  fifth  day,  104-8°. 

Necropsy. — Contusion  over  right  mastoid  revealed  on  raising 
the  scalp.  Fracture  at  base  in  three  fissures  :  extending  from 
this  point,  two  (fine)  across  petrous  portion,  and  a  third  con- 
necting them  posteriorly  across  occipital  bone.  Deep  linear 
laceration,  extending  across  inferior  surface  of  right  cerebellum, 
near  outer  border.  Subdural  haimorrhage  over  whole  left  cere- 
brum, superiorly  and  laterally;  most  copious  in  middle  lateral 
region.  Laceration  of  antero-inferior  border  of  left  frontal 
lobe.  White  substance  of  left  cerebrum  much  congested,  and 
with  punctate  extravasations  throughout  its  extent. 

Case  X. — Female,  aged  eight;  fell  two  stories;  partially  un- 
conscious; left  hemiplegia,  and  hiemorrhage  from  left  nostril; 
depressed  fracture  over  left  frontal  eminence.  Patient  became 
irritable,  and  the  bone  was  elevated  an  hour  later.  Died  with- 
in twenty-four  hours.  • 

Necropsy.— Goror\a]  suture  separated  on  the  right  side.  A 
fissure  extended  through  right  parietal  eminence  and  another 
through  frontal  bone.  Base  fractured  across  body  of  sphenoid 
into  left  middle  fossa.  Other  fissures  through  right  middle  and 
anterior  fossae,  external  to  orbital  plate.  Epidural  hsemorrhage 
on  left  side  anteriorly  and  in  temporal  region.  Lacerations  in 
right  frontal  lobe  and  in  right  fissure  of  Rolando  and  in  left 
temporo  sphenoidal  lobe. 

Case  XL — Male,  aged  twenty  nine;  fell  fifteen  feet  into 
the  hold  of  a  vessel  and  struck  on  his  head.  Coma,  stertor ; 
left  pupil  markedly  dilated  and  right  pupil  contracted;  para- 
plegia, hajmorrhnge  from  left  ear  and  nose  and  under  left  con- 
junctiva, and  contusion  over  left  eye.  Died  in  five  minutes  after 
admission. 

Neci'opKy. — Epidural  hremorrljage,  blood  still  fiuid.  Frac- 
ture extending  downward  and  forward  from  beliind  left  parietal 
eminence,  across  petrous  portion,  through  middle  fossa,  trans- 
versely across  anterior  fossa,  and  terminating  at  inner  extrem- 
ity of  lesser  wing  of  right  splienoid.  Slight  cortical  haemorrhage 
on  left  side,  and  slight  lacerations  of  under  surface  of  left  frontal 
and  temporo-sphenoidal  lobes. 

Case  XIL — Female,  aged  twenty-three;  jumped  from  fifth- 
story  window.  Contusions  of  left  hip  and  shoulder  and  over 
right  parietal  eminence ;  slight  hsemorrhage  from  nose  and  left 
ear;  temperature,  99"4° ;  incontinence  of  urine  and  faeces;  right 
hemiplegia.    Death  in  two  days. 

Necropsy. — Fracture  extending  from  right  parietal  eminence 
to  foramen  magiuuu,  of  right  petrous  portion  eutire  length,  and 
of  left  petrous  for  two  inches ;  laceration  of  left  parietal  lobe 
beneath  parietal  eminence. 

Case  XIII.  —  Male,  aged  forty-six;  fell  five  stories.  Coma, 
stertor,  pupils  normal;  pulse  and  respiration  normal.  Death 
in  five  days. 

Necropsy. — Contusion  over  right  parietal  eminence;  frac- 
ture extending  from  this  point  downward  and  forward,  anterior 


to  [jetrous  i)ortion,  and  through  sella  turcica;  subarachnoid 
hsemorrhage  over  both  hemispheres;  laceration  of  under  sur- 
face of  left  temporo-sphenoidal  lobe. 

Case  XIV. — Male,  aged  fifty;  knocked  down  by  a  blow  in 
the  face  and  fell  upon  the  back  of  his  head.  Patient  became 
unconscious,  but  shortly  afterward  walked  to  the  hospital  i 
contusion  over  right  parietal  eminence ;  dazed;  no  other  symp- 
toms; walked  home;  had  severe  pain  in  the  head  for  three 
hours  after  the  injury,  then  became  gradually  unconscious  till 
four  hours  later,  when  coma  was  complete  and  death  occurred 
at  the  end  of  another  hour. 

Necropsy. — Wound  of  lip  and  contusion  of  forehead  ;  fissure 
of  external  table,  very  fine,  beginning  in  right  inferior  occipital 
fossa  and  running  aci-oss  right  petrous  portion  ;  slight  epidural 
haemorrhage  about  the  middle  of  the  fracture ;  upon  left  side,  large 
subdural  extravasation  ui)on  lateral  border  of  parietal  and  frontal 
lobes,  extending  upward  and  also  downward  into  middle  fossa; 
also  some  extravasation  into  pia  and  several  slight  contusions 
of  brain  substance;  skull  thin,  and  angles  and  processes  upon 
its  inner  surface  unusually  sharp  and  prominent. 

Case  XV. — Male,  aged  forty;  cause  of  injury  unknown. 
Coma;  respiration  slow  and  full ;  right  pupil  dilated,  left  con- 
tracted ;  reflexes  lost ;  had  been  seen  to  move  the  left  side ;  pulse 
became  slower  and  breathing  more  labored.  Died  in  nine  Lours 
and  a  half. 

Necropsy. — Contusion  in  left  parietal  region ;  fracture  from 
this  point  extending  by  two  fissures  into  anterior  and  middle 
fossffi ;  large  epidural  haemorrhage  from  rupture  of  left  middle 
meningeal  artery ;  slight  laceration  of  left  parietal  lobe  at  point 
where  fracture  began,  and  another  upon  lateral  border  of  right 
temporo-sphenoidal  lobe. 

Case  XVL — Male,  aged  fifty-five;  fell  upon  the  street. 
Unconscious;  respiration  labored;  left  pupil  slightly  dilated; 
slight  liajmorrhage  from  left  ear;  slight  rigidity  of  left  side. 
He  was  still  stupid  upon  admission,  but  could  give  his  name. 
Temperature,  99°.  Dilatation  of  left  pupil  and  rigidity  of  left 
side  increased,  and  afterward  tiiere  was  complete  paralysis  of 
left  lower  extremity,  wLile  left  arm  remained  slightly  rigid ; 
left  hemiplegia  was  finally  complete.  He  died  in  twenty-one 
hours.    Temperature,  101"2°. 

Necropsy. — Contusion  of  scalp  over  left  occipito-parietal 
suture ;  skull  thin ;  stellate  fracture,  originating  about  the  cen- 
ter of  left  parietal  bone;  fissures  extending  upward,  across  base 
of  occipital  and  along  the  upper  border  of  petrous  portion  of 
temporal  bone  into  the  middle  fossa;  subdural  liaimorrhage 
covered  right  hemisphere  ;  under  and  lateral  surfaces  of  right 
temporo  sphenoidal  lobe  extensively  lacerated;  under  surface 
of  both  frontal  lobes  lacerated  along  the  median  fissure  ;  these 
lacerations  were  recent ;  upon  the  under  surface  of  the  left  tem- 
poro-sphenoidal lobe  there  was  a  deep  laceration,  irregular  in 
outline,  but  about  an  inch  in  its  several  diameters;  there  were 
also  small  and  deep  lacerations  upon  its  anterior  border  and 
upon  the  under  surface  of  the  left  frontal  lobe.  All  these  lacera- 
tions upon  the  left  side  extended  through  tlie  cortex,  contained 
no  recent  clot,  but  were  covered  with  a  grayish-yellow  viscid 
substance,  and  were  bounded  by  a  considerable  area  of  yellow 
softening.  They  evidently  antedated  the  fiiuil  and  fatal  injury. 
Section  of  tlie  brain  disclosed  marked  hyperaunia. 

Case  XVII. — Male,  aged  fifty;  cause  of  injury  unknown. 
Unconscious;  pulse,  66 ;  respiration  full  and  slow;  right  pupil 
dilated,  the  left  contracted,  neither  one  responding  to  light ; 
he  had  been  seen  to  move  the  left  side  of  the  body ;  stertor 
supervened  and  death  occurred  in  eleven  hours. 

Necrojixy. — Contusion  of  left  ])arietal  region  disclosed  by  in- 
cision ;  two  fissures  originated  from  this  point,  one  extending 
into  the  anterior  and  the  other  into  the  ])osterior  fossa;  large 


32 


PHELPS:  INJURIES  OF  TEE  HEAD. 


[N.  Y.  Med.  Jodk., 


epidural  clot  from  rupture  of  left  rniiklle  meningeal  artery;  gen- 
eral contusion  ;  liyperfflmia. 

Case  XVIII. — Male,  aged  tliirteen  ;  fell  two  stories.  Haemor- 
rhage from  right  ear;  uneonsciou-* ;  irritable  when  disturbed; 
consciousness  regained  in  tfiirty  minutes;  jjulse  78,  intermit- 
tent; teuiperature,  98°  ;  depressed  fractures  below  right  tem- 
poral ridge;  elevated  next  day;  three  fissures,  one  backward, 
one  forward,  and  one  downward;  dura  incised;  only  subarach- 
noid haemorrhage;  temperature,  101-8°.  Next  day  patient  irri- 
table and  somnolent ;  urine  incontinent;  temperature  slightly 
increased  (102°).  On  second  day  after  operation  he  was  de- 
lirious, and  temperature  rose  steadily  till  evening,  when  it  was 
105  4°.  On  the  third  day  the  skin  was  hot  and  he  was  very 
restless  and  sensitive  to  external  impressions;  his  pupils  were 
moderately  dilated  and  reacted  slowly.  From  this  time  he  was 
in  deep  coma;  temperature  varied  from  104° -f-  in  the  morning 
to  105° -f  in  the  evening  till  death  on  the  evening  of  the  seventh 
day,  when  it  was  106'5°. 

yecropxy. — Skull  thin.  No  pus  in  the  wound  or  in  the 
small  brain  cavity  which  had  been  disclosed  by  the  ante-mor- 
tem operation  when  the  depressed  bone  was  elevated.  Sub- 
dural hfeinorrhage  in  the  opposite  (left)  occipito-parietal  region. 
An  effusion  of  thick  green  pus  beneath  the  arachnoid  covered 
the  lateral  and  superior  surfaces  of  the  right  occipital  and 
parietal  lobo^,  but  did  not  extend  forward  to  within  an  inch  of 
the  cranial  opening  left  by  the  ante-mortem  operation.  A  sub- 
dural effusion  of  similar  tiiick  green  pus  was  coextensive  with 
the  whole  right  inferior  occipital  fossa.  There  was  a  deep 
laceration,  an  inch  in  diameter,  upon  the  lateral  border  of  the 
left  temporo-sphenoidal  lobe,  which  involved  the  subcortical 
tissue.  At  a  point  directly  beneath  the  opening  left  by  the  re- 
moval of  the  depressed  bone  there  was  a  cavity  in  the  brain 
substance  as  large  as  a  hickory  nut  which  opened  by  its  whole 
extent  upon  the  cerebral  surface.  (As  this  surface  was  intact 
at  time  of  operation,  the  cavity  must  be  ascribed  to  a  direct 
contusion,  subcortical,  not  involving  superficial  laceration,  and 
to  a  subsequent  giving  way  of  the  cerebral  cortex  under  the 
influence  of  arterial  pulsation,  and  in  the  absence  of  normal  re- 
pressive force  exerted  by  the  skull  and  dura.)  The  whole 
brain  substance  and  meningeal  vessels  were  intensely  hyper- 
semic,  and  there  were  numerous  minute  extravasations  from 
general  contusion.  There  was  no  meningeal  or  ventricular 
serous  effusion.  A  fissure  extended  from  the  central  point  of 
fracture  through  the  petrous  portion  of  the  temporal  and  infe- 
rior occipital  fossa  to  the  foramen  magnum. 

Ca.se  XIX.— Male,  aged  nineteen;  fell  three  stories  through 
a  hatchway  ;  unconscious;  irritable  when  disturbed  ;  pulse,  80  ; 
temperature,  100°;  profuse  hasmorrhage  from  left  ear,  which 
continued  twenty-four  hours,  and  was  then  followed  by  serous 
discharge.  At  the  end  of  twenty-four  honrs  patient  was  still 
unconscious,  pupils  were  largely  dilated  and  movable,  and  he 
had  general  convulsive  movements,  most  marked  in  the  right 
leg.  During  the  second  day  coma  was  more  profound  and 
general  convulsive  movements  ceased,  but  he  had  one  prolonged 
general  convulsion,  which  was  repeated  on  the  third  day,  the 
movements  being  most  violent  on  the  left  side.  The  left  pupil 
continued  from  the  first  day  to  be  more  contracted  than  the 
right.  Died  in  three  days  and  six  hours.  Temperature  con- 
tinued to  rise  from  time  of  admission,  and  reached  107'2°. 

NecropHij.  —Large  haematoma  in  substance  of  left  temporal 
muscle.  Fracture  extended  from  left  squamous  portion  of  tem- 
poral bone  into  middle  fossa,  and  by  a  wide  fissure  along  the 
anterior  border  of  the  petrous  portion  to  the  sella  turcica. 
Largo  epidural  and  subdural  clots  in  left  middle  fossa.  Kight 
cerebrum  covered  by  a  thin  s'lbdural  coaaulum.  In  the  left 
mid'Jlo  fossa  diffluent  brain  substance  clung  to  the  dura  as  it 


was  removed.  Large  and  deep  laceration  of  the  lateral  border 
of  the  left  temporo-sphenoidal  lobe  and  of  the  lateral  border 
and  contiguous  inferior  surface  of  the  right  tempore  sphenoidal 
lobe.  Small  and  deep  laceration  at  junt^tion  of  right  parietal 
and  occipital  lobes.  All  these  lacerations  extended  into  the 
subcortical  tissue. 

Case  XX. — Male,  Bged  sixty-two;  cause  of  injury  unknown  ; 
found  unconscious  in  an  ice  wagon  with  his  head  lying  on  a 
cake  of  ice.  Contusion  of  left  parietal  region,  and  both  eyes 
much  ecchymosed.  Subconjunctival  haemorrhage  at  outer 
part  of  left  eye.  Muttered  incoherently  when  disturbed.  Slight 
temixtrary  rigidity  of  right  arm.  Restless  and  irritable  all  day, 
and  roused  sufficiently  in  the  evening  to  give  a  name  and  ad- 
dress, both  of  which  proved  to  be  incorrect.  Condition  under- 
went little  change  till  death — at  the  end  of  seven  days  and  seven 
hours.  Temperature  high  on  admission — 101°;  in  firty-eight 
hours,  104'6°  to  104"8°;  seventy-eight  hours  later  it  receded  to 
101  2° ;  in  forty  eight  hours  more  it  varied  from  101°  to  102°-|-, 
and  then  rose  steadily  to  107° -I-  at  the  time  of  death. 

Necropsy. — Skull  thin;  fracture  of  left  anterior  and  middle 
fossaj,  apparently  beginning  with  a  comminution  of  orbital  plate 
of  left  frontal  bone  about  its  center.  At  this  point  two  or  three 
small  fragments  were  displaced  upward  with  fine  fissures  run- 
ning off  in  different  directions.  One  fissure  ran  outward  and 
upward  into  left  squamous  portion  of  temporal  bone;  another 
ran  backward  from  the  crista  galli  through  the  bodies  of  the 
ethmoid  and  sphenoid,  through  the  optic  foramen  and  along  the 
anterior  border  of  the  petrous  portion  ;  and  the  third  ran  through 
the  riaht  optic  foramen  into  the  squamous  portion  of  the  right 
temporal.  The  optic  nerves  were  uninjured.  There  was  a  little 
blood  extravasated  over  right  occipital  and  lower  part  of  right 
parietal  lobes.  The  left  frontal  lobe  was  completely  excavated 
by  a  laceration,  which  was  bounded  everywhere  by  a  thin 
layer  of  unaltered  cortex,  except  interiorly,  near  the  anterior 
border,  where  it  was  covered  in  only  by  the  meninges.  It  was 
separated  from  the  ventricle  by  a  thin  sreptum  of  brain  sub- 
stance. This  cavity  contained  commingled  blood,  clot,  and 
brain  detritus.  There  was  also  a  laceration  of  the  anterior  two 
thirds  of  the  external  lateral  border  of  the  right  cerebellum,  and 
an  extravasation  the  size  of  a  robin-shot  existed  in  the  center  of 
the  right  corpus  striatum.  There  was  no  clot  anywhere  at  the 
base  of  the  brain  and  no  further  lesions. 

Case  XXI. — Male,  aged  twenty-seven;  fell  seventeen  feet 
into  the  hold  of  a  vessel,  striking  his  face  and  stomach.  Thirty 
minutes  later  an  officer  found  him  lying  upon  the  dock  uncon- 
scious and  bleeding  from  the  mouth  and  nose.  In  the  interval 
which  had  elapsed  he  was  said  to  have  been  excited  and  abu- 
sive. He  was  seen  upon  the  dock  and  twice  afterward  during 
the  night  at  the  station-house  by  ambulance  surgeons,  who  re- 
fused to  take  him  to  a  hospital,  because,  in  their  opinion,  he 
was  simply  drunk  and  in  no  want  of  surgical  treatment.  The 
next  morning  he  was  taken  to  court  by  two  policenjen.  He  was 
then  conscious,  and,  in  their  inexpert  opinion,  rational.  He  was 
unable  to  stand  or  walk,  and  was  carried  between  them  on 
their  arms  into  a  street-car  and  into  court.  He  was  duly  sen- 
tenced for  intoxication,  but  by  an  inspiration  of  somebody  he 
was  halted  on  his  way  to  the  Island  and  placed  in  the  alcoholic 
ward  at  Bellevue.  A  little  later  he  was  transferred  to  a  surgi- 
cal ward.  At  that  time  he  was  weak,  his  jiulse  slow,  and  res- 
piration labored.  There  was  much  ecchymosis  of  the  eyes,  and 
the  lids  could  be  separated  only  with  great  difficulty.  There 
was  subconjunctival  hcemorrhage  of  both  eyes,  and  the  arms 
were  rigid,  tuore  especially  the  right.  Pupils  normal.  The 
patient  soon  grew  restless,  and  had  muttering  delirium,  inconti- 
nence of  urine,  and  Cheyne-St(dies  respiration.  Temperature, 
104-8°.    Depres.sed  fracture  easily  felt  in  right  frontal  bone. 


Jan.  14,  1893.] 


PHELPS:  INJURIES  OF  THE  HEAD. 


33 


The  same  afternoon  he  was"  trephined,  and  the  fracture  found  to 
be  atellate,  with  a  depression  an  inch  by  half  an  inch  in  diameter. 
The  inner  table  was  driven  through  the  dura.    Pulse  and  respi 
ration  temporarily  imjjroved,  hut  lie  grew  weaker,  and  died  eight 
hours  after  admission  to  the  ward.    Temperature,  106°. 

Necropsy. — I  am  indet>ted  to  the  report  of  Dr.  VV.  S.  Jen- 
kins, late  of  the  coroner's  office.  There  was  a  linear  fracture  in 
the  temporal  bone  three  indies  long,  extending  upward  and 
backward  from  the  anterior  margin.  There  was  a  stellate 
fracture  in  the  frontal  bone  to  the  right  of  the  median  line  and 
an  inch  above  the  superciliary  ridge.  On  the  inner  surface  of  the 
skull  the  fracture  extended  across  both  orbital  plates,  through 
the  ethmoid  and  body  of  the  sphenoid  bone,  and  on  both  sides 
through  the  anterior  fossa  and  through  the  left  middle  fossa 
nearly  to  the  petrous  portion  of  the  temporal  bone.  The  nasal 
bones  were  also  fractured.  These  fractures  were  nearly  all 
comminuted.  There  was  no  considerable  haemorrhage  in  the 
cranial  cavity.  The  upper  surfaces  of  both  hemisplieres  were 
lacerated,  especially  at  seat  of  fracture. 

Case  XXII. — Male,  aged  thirty-nine;  fell  from  niizzen  top 
to  deck,  and  struck  upon  right  temporal  region:  admitted  half 
an  hour  later;  unconscious,  and  bleeding  from  right  ear;  ster- 
torous breathing;  pulse  full  and  bounding;  lacerated  wound  in 
right  parietal  region.  He  had  pulmonary  oedema,  for  which  he 
had  ali'eady  been  bled  from  the  arm  by  the  ship's  surgeon. 
Died  in  two  hours. 

Necropsy. — Hseraatoma  over  whole  right  side  of  the  head. 
Multiple  fissures  of  the  base  (six  in  number),  involving  both 
sides  and  all  the  fossae.  The  primary  fissure,  of  five  which 
were  connected,  began  as  a  wide  fissure  behind  and  a  little  to 
the  left  of  the  foramen  magnuin,  and  narrowed  to  a  hair's 
breadth  as  it  ran  forward  to  the  right  superciliary  ridge.  A 
sixth  and  entirely  independent  fissure  ran  backward  from  the 
crista  galH  on  the  left  side  through  the  optic  foramen  to  the 
sella  turcica.  There  were  slight  lacerations  of  under  surface  of 
both  frontal  and  right  temporo-sphenoidal  lobes,  which  occa- 
sioned slight  subdural  lijemorrhage.  Upon  the  upper  and  lat- 
eral surfaces  of  the  hemispheres,  especially  the  left,  and  at  the 
base,  an  epidural  haemorrhage  of  larger  size  existed  in  the  infe- 
rior occipital  fossae,  and  pressed  npon  the  pons  and  medulla. 

Case  XXIII. — Male,  aged  forty;  found  at  foot  of  cellar 
stairs,  unconscious  and  restless,  with  a  large  lacerated  scalp 
wound,  which  had  bled  freely,  and  several  wounds  of  the  face. 
Admitted  to  the  alcoholic  ward  on  the  diagnosis  of  ambulance 
surgeon  of  another  hospital,  still  unconscious.  The  scalp  wound 
was  in  the  parieto-occipital  region,  to  right  of  median  line,  and 
the  most  extensive  face  wound  was  over  the  right  malar  bone. 
As  he  did  not  "  clear  up,"  he  was  transferred  to  a  surgical  ward 
four  days  afterward.  He  was  then  nearly  comatose,  quiet  un- 
less disturbed,  his  pupils  normal,  and  respiration  slow  and  regu- 
lar. Temperature,  102'2°;  pulse,  96.  Temperature  next  day 
was  104-6°,  103*6°,  and  106°;  and  on  the  morning  after  it  was 
105°  and  107°,  when  he  died  without  further  symptoms  five 
days  and  a  half  after  reception  of  injury. 

Necropsy. — Fracture  at  base,  through  petrous  portion  of  left 
temporal  bone,  extending  to  foramen  magnum.  Laceration  of 
left  temporal  and  frontal  lobes,  with  cortical  haemorrhage. 

Case  XXIV. — Female,  aged  thirty-eight;  habitual  criminal ; 
jumped  from  the  third  tier  of  the  Tombs  Prison  to  the  flagging 
below,  thirty  feet  or  more;  punctured  wound  in  left  occipito- 
parietal region  ;  unconscious;  haemorrhage  from  left  car;  pujuls 
moderately  dilated,  more  especially  the  left;  and  vomiting  per- 
sistent. Temperature,  98-9°.  The  next  morning  the  patient 
was  conscious,  rational,  and  the  haemorrhage  had  nearly  ceased. 
In  the  evening  she  was  slightly  delirious,  and  the  following  day 
required  mechanical  restraint  till  <iuietod  by  sedatives.  ]>oth 


pupils  became  widely  dilated,  the  left  still  continuing  more  di- 
lated than  the  right,  and  they  were  only  slightly  responsive  to 
strong  artificial  light.  This  ocular  condition  continued  till  her 
death.  The  abdomen  was  painful  and  swollen.  Her  mind  re- 
mained clear,  but  apathetic,  till  the  sixth  day,  when  she  fell  into 
a  stupor.  On  the  same  day  all  the  extremities  became  paretic 
and  partially  anaesthetic.  Up  to  this  time  the  muscular  power 
had  been  normal.  The  paresis  and  anae.-thesia  were  most  marked 
on  the  right  side.  The  j)ulse  was  rapid,  quick,  and  feeble.  A 
day  later  the  left  foot  and  right  hand  were  less  paretic,  and  her 
mind  was  clear,  but  the  senses  blunted.  She  answered  ques- 
tions slowly  and  after  an  interval,  and  complained  of  pain  in 
the  head.  On  the  eighth  day  she  was  restless  and  irritable,  and 
had  some  right  facial  paralysis,  while  power  in  the  left  foot 
and  right  hand  was  still  further  improved.  The  ninth  day  she 
was  delirious  and  unconscious.  On  the  eleventh  day  she  no 
longer  moved  or  spoke,  and  paid  no  attention  to  an  explorative 
incision.  On  the  fifteenth  day  she  died  from  asthenia.  The 
temperature  remained  below  100°  till  the  close  of  the  fourth 
day,  when  it  rose  to  103°.  After  that  it  varied  from  100°  to 
102° -f  ;  usually  was  101° 4-  till  the  twelfth  day,  when  it  rose 
to  104°,  and  was  from  103°  to  104-5°  till  she  died. 

Necropsy. — Head  large  and  unsymmetrical,  and  skull  thick. 
No  lesion  of  the  scalp  or  of  the  bone  before  removing  the  cal- 
varium.  The  occiput  was  disproportionately  large,  and  the 
right  occipital  fossae  were  much  larger  than  the  left.  The  left 
middle  and  anterior  fossae  were  rather  larger  than  the  right. 
A  fissure  began  at  a  point  in  the  squamous  portion  of  the  left 
temporal  bone,  beneath  the  external  wound,  and,  passing  through 
the  anterior  surface  of  the  petrous  portion,  terminated  in  the 
optic  foramen.  This  fissure  was  not  0|)en,  but  the  fragments 
were  quite  movable.  There  was  no  epidural  haemorrhage,  but 
pressure  was  made  upon  the  facial  nerve  by  interosseous  haem- 
orrhage as  a  result  of  the  fracture.  There  was  no  meningitis, 
and  scarcely  the  usual  amount  of  serum  in  the  meshes  of  the 
pia.  There  were  slight  lacerations  upon  the  under  surface  of 
the  right  temporo-sphenoidal  lobe,  and  one  somewhat  larger 
upon  its  external  border,  from  which  a  moderate  amount  of 
blood  had  spread  upward  over  the  occipital  lobe,  barely  reach- 
ing the  parietal.  Upon  .section,  the  cerebral  vessels  were  found 
to  be  distended  with  blood,  which  flowed  from  the  punda 
vasculosa.  The  veins  could  be  seen  in  congei-ies  and  filled  with 
coagula.  The  brain  substance  was  softened  and  oudematous,  so 
that  the  serum  followed  the  knife.  The  ventricles  were  dis- 
tended with  serum.  Subsequent  microscopic  examination  of 
the  brain  tissue  in  the  recent  state  disclosed  no  inflammatory 
changes.  There  was  a  considerable  extravasation  of  blood  be- 
hind the  peritonaeum  on  the  right  side,  but  no  injury  of  the 
viscera.  There  were  no  serous  efl'usions  in  the  cavities  of  the 
body,  and  no  chronic  visceral  lesions. 

Case  XXV. — Male,  aged  thirty -seven.  Cause  of  injury  un- 
known ;  scalp  wound  in  right  posterior  temporal  region  ;  haem- 
orrhage from  right  ear;  mental  condition  stupid,  but  conscious- 
ness retained  ;  incontinence  of  urine  and  fieces.  The  patient 
had  been  drinking  to  excess.  On  tlie  next  day  he  had  active 
delirium,  with  tremulous  muscles  and  delusions  and  intervals  of 
semi-unconsciousness.  On  the  sixth  day  there  was  general  mus- 
cular rigidity,  stertor,  and  muttering  delirium.  The  right  pupil 
was  slightly  contracted,  with  slight  serous  discharge  from  right 
ear  and  slight  right  facial  paralysis.  UnconsciousnerS  followed. 
On  the  eighth  day  there  were  two  slight  convulsions  involving 
both  arms,  the  face,  and  eyes.  The  face  was  drawn  to  the 
right  and  the  eyes  turned  upward.  Paralysis  of  right  arm  and 
face  succeeded,  and  a  little  later  the  surface  temperature  of  the 
left  side  was  found  to  be  102°,  while  that  of  the  right  side  was 
normal.    Rectal  temperature,  105-6°,  which  soon  declined  to 


34 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Jocb., 


lOi'S".  Death  two  hours  later.  Post-mortem  temperature, 
106°.  The  temperature  varied  from  100^  to  102°  till  fourth 
day,  then  from  103°  to  104°  to  last  day,  when  it  was  as  noted 
above. 

Necropsrj. — Fissure  across  petrous  portion  of  right  temporal 
bone.  Largo  subarachnoid  serous  effusion.  Thin  cortical  layer 
of  blood  covering  whole  of  parietal  and  occipital  lobes  on  both 
sides  of  the  brain.  Meningeal  vessels  congested.  Brain  struc- 
ture everywhere  cedomatous.  Minute  vessels  filled  with  eoagula. 
Fluid  blood  in  anterior  cornu  of  left  lateral  ventricle.  Lacera- 
tion of  upper  and  outer  surface  of  right  frontal  lobe,  and  upon 
upper  and  outer  surface  and  posterior  border  of  left  occipital 
lobe.  A  third  laceration  existed  at  the  base  of  the  brain  upon 
either  side  of  the  median  fissure  of  the  cerebellum.  Neither  of 
these  lacerations  was  larger  than  a  walnut,  and  neither  involved 
a  rupture  of  the  meninges,  though  they  all  reached  the  surface 
of  the  brain. 

Case  XXVI. — Male,  aged  twenty-three,  thrown  from  a 
wagon.  The  ambulance  surgeon  found  him  dizzy  and  feeling 
ill.  He  had  no  other  symptoms  except  a  scalp  wound  in  right 
temporal  region.  After  admission  to  hospital  he  was  entirely 
conscious  and  dictated  a  letter.  There  was  hfeniorrhafee  from 
right  ear  and  nostril.  Temperature,  100°.  No  other  symptoms. 
Soon  afterward  lie  vomited  blood  copiously  and  became  un- 
conscious with  stertor,  and  died  in  four  hours  from  time  of 
admission. 

J^ecropny. — Depressed  fracture  of  right  frontal  bone  an 
inch  from  median  line  and  just  anterior  to  coronal  suture,  tri- 
angular in  form  with  apex  extending  to  superciliary  ridge.  One 
fissure,  originating  in  this  depression,  ran  through  right  orbital 
plate,  and  greater  and  lesser  wings  of  sphenoid,  into  middle 
fossa ;  another  one  ran  through  squamous  into  petrous  portion 
of  temporal  bone,  terminating  upon  its  anterior  surface.  There 
was  an  epidural  clot  extending  over  lateral  aspect  of  right 
frontal  lobe  into  the  middle  fossa.  This  portion  of  the  frontal 
lobe  was  much  flattened  and  compressed.  There  was  no  sub- 
dural hemorrhage  and  no  superficial  laceration  of  the  brain. 
There  was  a  small  effusion  of  blood  in  the  meshes  of  the  pia  on 
either  side  of  the  medulla,  behind  the  pons,  parallel  to  the  an- 
terior columns.  The  whole  brain  was  hyperfemic  with  a  multi- 
tude of  punctate  extravasations,  and  the  minute  vessels  were 
filled  witli  eoagula.  Upon  section,  a  number  of  extravasations 
were  found  in  the  substance  of  the  pons,  mainly  in  the  trans- 
verse fibers,  but  some  in  the  longitudinal  fibers  of  the  crura. 
The  smaller  ones  were  of  tiie  size  of  a  robin-shot.  The  largest 
one  was  half  an  inch  long  by  a  quarter  of  an  inch  wide,  and  was 
just  below  the  surface  on  the  right  external  border  of  its  in- 
ferior surface. 

Case  XXVIl. — Male,  aged  thirty  ;  cause  of  injury  unknown  ; 
unconscious;  coma  continued  till  death;  hsematoma  of  scalp 
at  vertex;  ecchymosis  at  base,  right  side;  slight  haemorrhage 
from  right  nostril;  stertor;  pulse,  130,  irregular  and  weak; 
temperature,  94°;  rose  to  102°  some  hours  later;  both  eyes 
protruded  and  both  pupils  were  dilated,  left  pupil  most  mark- 
edly so;  some  rigidity  of  right  side  ;  died  same  day  in  eight  to 
ten  hours  after  admission  into  the  hospital. 

Nearopny. — Fracture  through  petrous  [)ortion  of  right  tem- 
poral into  the  occipital  bone  and  into  middle  fossa.  No  frac- 
ture of  vertex.  Epidural  clot  in  right  inferior  occipital  fossa. 
Thin  subdural  clot  over  both  frontal  lobes,  especially  over  left, 
extending  nearly  to  fissure  of  Rolando.  Small  laceration  of 
left  frontal  lobe  on  its  under  surface  near  anterior  border. 

Case  XXVIII. — Female,  aged  forty-five,  fell  ten  feet  upon 
her  head ;  scalp  wound  in  right  parietal  region;  temperature, 
98'8°.  Twenty  minutes  after  admission  leit  lower  extremity 
became  paretic,  patellar  reflexes  lost.    Three  days  later  tem- 


perature suddenly  rose  from  99° -1-  to  102°.  Next  day  patient 
became  delirious.  Evening  temperature,  105'2° ;  following 
morning,  106°.    Death  five  days  after  rece[)tion  of  the  injury. 

Necropsy. — Fracture  beginning  in  squamous  portion  of  right 
temporal  bone,  extended  through  both  anterior  fo.ssng,  involving 
greater  wing  of  right  sphenoid  and  both  orbital  plates.  Sub- 
dural clot,  the  size  of  a  pigeon's  egg,  occupied  the  left  middle 
fossa.  Laceration  of  inferior  surface  of  left  temporo-sphenoidal 
lobe. 

Case  XXJX. — Female,  aged  sixty-six;  found  unconscious 
at  foot  of  cellar  stairs;  supposed  to  have  been  thrown  down. 
Scalp  wound  in  left  inferior  temporal  region;  left  malar  bone 
fractured  and  left  side  of  face  much  contused ;  coma,  stertor, 
and  frothing  at  the  mouth;  moist  bronchial  r^iles;  right  pupil 
dilated,  left  pupil  invisible  from  ecchymosis;  right  up[>er  ex- 
tremity anaesthetic  and  soon  became  paralyzed;  temperature, 
101-6°.  Three  hours  later  the  patient  was  apparently  moribund. 
On  the  following  day  she  was  conscious  and  rational  and  the 
paralysis  and  anaesthesia  had  (lisa|)pcared ;  the  pupils  were  nor- 
mal; urine  incontinent;  temperature,  99°-(-.  For  a  week's 
time  her  condition  remained  practically  unchanged,  except  that 
her  temperature  gradually  rose  to  103°  and  in  the  last  three  days 
gradually  fell  to  100°,  and  that  the  subconjunctival  haemorrhage 
increased.  Iler  mental  condition  was  apathetic,  and  she  could 
be  rarely  induced  to  make  a  monosyllabic  answer  to  a  question 
asked.  On  the  eighth  day  she  suddenly  became  unconscious.  Her 
temperature  rose  to  104"8°  and  within  two  hours  fell  to  102'8°. 
She  became  weaker  and  died  during  the  ninth  day,  her  tem- 
perature having  again  risen  to  106°.  Ten  minutes  post  mortem 
it  was  105-2°. 

Necropsy. — An  open  fissure  extended  through  both  tables  of 
the  bone  from  a  little  above  and  to  the  left  of  the  external  oc- 
cipital tubercle  to  the  left  foramen  lacerum  posterius.  There 
was  moderate  subarachnoid  serous  effusion.  There  was  an  ap- 
parent laceration  on  the  median  aspect  of  the  left  frontal  lobe, 
the  real  character  of  which  only  became  obvious  upon  further 
examination.  The  interior  of  both  frontal  lobes  was  disorgan- 
ized and  destroyed,  having  been  broken  down  by  subcortical 
laceration.  On  the  left  side  the  clot  was  very  solid,  and  the 
external  layers  of  fibrin  on  its  inferior  aspect  were  partially 
decolorized.  Tt  had  broken  through  into  the  anterior  part  of 
the  lateral  ventricle  and  also  through  the  cortex  on  the  median 
surface,  involving  for  a  space  of  half  an  inch  the  motor  arm 
area  and  the  sensorial  center  below  it  in  the  gyrus  fornicatus. 
It  was  this  which  at  first  sight  seemed  to  be  an  independent 
lesion.  The  clot  in  the  right  frontal  lobe,  which  was  of  equal 
size,  had  nowhere  broken  through  the  cortex  or  into  tlie  lateral 
ventricle.  There  was  no  cortical  hemorrhage,  although  there 
was  a  deep  laceration  on  the  posterior  border  of  the  left  cere- 
bellum. The  interior  of  the  brain  generally  was  softened  and 
reddened  in  patches. 

Case  XXX.— Fetnale,  aged  fifty;  no  history;  admitted  as 
case  of  apoplexy.  Small  lacerated  scalp  wound  in  left  posterior 
parietal  region  ;  slight  haemorrhage  from  both  nostrils;  patient 
unconscious;  movements  sluggish ;  left  pupil  dilated,  right  con- 
tracted ;  incontinence  of  urine  and  faeces;  face  flushed;  visible 
pulsations  of  carotids ;  fine  linear  fracture  running  toward  the 
base  discovered  by  incision  ;  tetnperature,  101°  ;  at  night,  101-8°  ; 
next  day,  101-2°  to  101°;  then  rose  steadily  to  106-8°  on  the 
next  day,  when  death  ensued,  three  days  and  a  half  after  ad- 
mission, without  consciousness  having  at  any  time  been  regained. 
Post-mortem  temperature,  109°.  On  the  last  day  of  life  sensi- 
tiveness of  the  corneas  was  markedly  diminished  and  sensation 
was  evidently  blunted  all  over  the  body. 

Necropsy. — -A  fissure  extended  from  left  of  occipital  protuber- 
ance through  posterior  fossa  and  petrous  bone  to  foramen  ovale. 


Jan.  U,  1898.] 


PHELPS:  INJURIES  OF  THE  HEAD. 


35 


There  was  a  large,  firm  subdural  clot,  three  fluidounces  by 
measurement,  in  the  anterior  fossra,  and  a  slight  subdural 
haemorrhage  into  right  posterior  fossa  around  the  foramen 
magnum.  A  deep  laceration  extending  below  the  cortex,  on 
the  under  surface  of  the  left  cerebellum,  made  an  excavation 
three  quarters  of  an  inch  broad  from  the  posterior  nearly  to  the 
anterior  border.  Another  extensive  laceration  deeply  excavated 
the  inferior  portion  of  the  right  frontal  and  extended  into  the 
external  border  of  the  right  temporo-sphenoidal  lobe.  Hajmor- 
rhage  from  the  latter  laceration  reached  the  vertex  anteriorly 
and  filled  the  fissure  of  Sylvius.  Another  laceration  existed  in 
the  middle  portion  of  the  gyrus  fornicatus,  filled  with  brain 
detritus  and  coagulum,  and  extended  through  the  cortex.  This 
was  oval  in  form  and  half  an  inch  in  diameter.  There  was  some 
general  contusion  of  both  hemispheres,  most  marked  in  posterior 
portions. 

Case  XXXI. — Male,  aged  forty-five;  thrown  from  a  horse 
and  struck  upon  his  head.  He  was  temporarily  unconscious, 
but  on  the  arrival  of  the  ambulance  was  able  to  stand,  and  said 
he  felt  very  well.  He  again  became  unconscious  on  his  way  to 
the  hospitfil.  His  pupils  were  contracted  and  his  pulse  barely 
perceptible.  He  suddenly  became  cyanotic  and  died  twenty- 
five  minutes  later. 

Necropsy. — Hsematoma  of  scalp  in  left  occipital  region ; 
blood  fluid;  stellate  fracture  of  calvarium  with  center  in  left 
upper  occipital  region,  and  with  fissures  extending  downward 
into  foramen  maenura,  forward  into  middle  fossa,  and  upward 
and  laterally;  epidural  clot  in  occipital  region;  subdural  haamor- 
rhage  in  inferior  occipital  fossa  compressing  the  medulla ;  ex- 
tensive subarachnoid  haemorrhage  over  temporo-sphenoidal  and 
frontal  lobes  on  both  sides,  with  laceration  of  inferior  surface  of 
right  frontal  and  temporo-sphenoidal  lobes,  and  in  slighter  de- 
gree of  same  region  on  the  left  side. 

Case  XXXII. — Male,  aged  thirty-four ;  struck  by  a  brick 
falling  from  the  fourth  story.  Compound,  comminuted,  de- 
pressed fracture  of  the  right  parietal  bone  extending  into  the 
base;  hfemorrhage  from  right  ear;  patient  conscious  and  with- 
out general  symptoms ;  temperature,  100'4°,  and  became  normal ; 
depressed  bone  elevated;  no  injury  of  dura.  After  twenty- 
three  days  subcortical  abscess  of  brain  developed,  with  left 
hemiplegia  and  anaesthesia.  Dura  incised  and  abscess  evacuated. 
Died  sixteen  hours  later.    Temperature,  108°. 

Necropsy. — Fissure  through  whole  length  of  anterior  surface 
of  right  petrous  portion  of  temporal  bone;  no  superficial  cere- 
bral laceration ;  subcortical  abscess  cavity  of  small  size,  which 
had  been  evacuated  ante  mortem  through  the  angular  gyrus. 
This  case  is  fully  reported  in  the  New  York  Medical  Journal, 
March  29, 1890. 

Case  XXXIII. — Male,  aged  thirty-three ;  cause  of  injury  un- 
known. Consciousness  lost  and  never  regained ;  scalp  wound  in 
left  posterior  parietal  region  ;  hemorrhage  from  left  ear ;  both 
pupils  dilated,  but  the  right  contracted  later;  pulse,  60;  mus- 
cles relaxed  and  later  became  rigid.  Death  in  twelve  hours. 
Temperature  on  admission,  99'6°  ;  later,  98'6°  to  100'4°;  one 
hour  post  mortem,  1012°. 

Necropsy. — Semicircular  fracture  of  squamous  portion  of  left 
temporal  bone,  with  fissure  extending  into  anterior  surface  of 
petrous  portion ;  deep,  well-defined  laceration,  laterally  and 
posteriorly,  of  left  temporo-sphenoidal  lobe,  from  which  a  thick 
clot  extended  over  the  occipital  region;  brain  in  all  its  parts 
excessively  hyperscmic;  on  section,  the  surface  was  repeatedly 
bathed  in  blood  as  it  was  each  time  wiped  away ;  no  punctate 
extravasation  or  coagiila  in  minute  vessels. 

Case  XXXIV. — Male,  aged  forty;  said  to  have  fallen  down 
one  flight  of  stairs.  Scalj)  wound  in  right  occipito-parietal  re- 
gion ;  hremorrhage  from  the  nose  and  later  occurrence  of  haema- 


temesis ;  unconsciousness;  stertor;  pulse,  96  and  full;  respira- 
tion, 18;  temperature,  100°;  pupils  normal  till  just  before 
death,  when  they  dilated ;  restlessness;  incontinence  of  urine; 
temperature  rose  gradually  to  102-6°  one  hour  ante  mortem. 
Died  in  fourteen  hours. 

Necropsy. — Linear  fracture  in  right  parietal  bone  and  ex- 
tending through  middle  fossa  and  greater  wing  of  sphenoid ; 
small  epidural  clot  and  larger  subdural  clot  beneath  the  site  of 
fracture  ;  dura  ruptured  ;  cortical  laceration  an  inch  and  a  quar- 
ter by  three  quarters  of  an  inch  in  anterior  and  inferior  part  of 
right  parietal  lobe;  another  laceration  involved  anterior  half  of 
middle  temporal  convolution  on  the  same  side.  The  whole 
brain  very  hyperaemic,  most  markedly  so  on  left  side  posteriorly. 
In  almost  the  exact  center  of  the  left  cerebellum  there  was  a 
laceration  about  the  size  of  a  pea  filled  with  fluid  blood. 

Case  XXXV. — Male,  aged  forty;  fell  sis  stories.  Abrasion, 
about  left  eye;  unconscious;  pulse  and  resi)iration  too  rapid  to 
be  counted;  temperature,  101°;  both  pupils  strongly  con- 
tracted ;  rigidity  of  both  lower  and  the  right  upper  extremities; 
temperature  in  articulo  mortis,  100-4° ;  two  hours  post  mortem, 
99° -f  and  pupils  dilated. 

Necropsy. — No  superficial  injury  upon  any  part  of  the  body 
except  the  abrasion  noted.  An  extravasation  of  blood  existed 
below  the  scalp,  covering  the  whoie  left  parietal  region.  Sepa- 
ration of  coronal  suture,  left  side,  from  about  its  middle  point, 
extending  outward  and  terminating  in  a  fissure  which,  in  the 
middle  fossa,  divided  into  two  lines,  one  lost  in  the  greater 
wing  of  the  sphenoid,  the  other  at  the  petro-raastoid  junction. 
No  epidural  or  subdural  haemorrhages.  Cortical  haemorrhages 
from  meningeal  contusion — one  covering  left  frontal  and  parie- 
tal lobes  superiorly  and  laterally,  another  covering  right  parietal 
and  occipital  lobes  on  either  side  of  their  junction.  No  lacera- 
tion on  the  surface  of  tlie  brain,  or  in  any  part,  except  one  three 
eighths  by  one  fourth  of  an  inch  in  the  left  corpus  striatum, 
subcortical,  and  at  junction  of  middle  and  posterior  thirds.  Ex- 
cessive general  hyperaemia. 

Case  XXXVI. — Male,  aged  sixty-five;  fell  into  the  hold  of  a 
vessel;  hseinorrhage  from  the  ears  and  into  subconjunctival  tis- 
sue; conscious  for  twenty-four  hours;  both  pupils  dilated; 
temperature  high;  died  in  forty-eight  hours. 

Case  XXXVII — Male,  aged  sixty;  knocked  down  by  a 
truck;  scalp  wound  in  right  posterior  occipital  region.  A 
linear  fracture  running  backward  and  downward  was  discov- 
ered by  incision.  Patient  unconscious  and  restless.  Pupils  con- 
tracted; pulse,  66;  very  slight  movements  of  right  side  of 
body;  no  facial  paralysis;  spoke  only  in  monosyllables.  In  a 
short  time  right  hemiplegia  became  complete,  pulse  weaker, 
temperature  lower,  and  there  was  a  slight  general  convulsion 
lasting  about  ten  seconds.  Four  hours  later,  coma  was  pro- 
found, pupils  small  and  irresponsive,  pulse  and  respiration  very 
irregular,  and  restlessness  ceased.  The  patient  was  treidiined 
over  left  motor  area.  The  fissure  was  found  to  extend  down- 
ward behind  the  mastoid.  Epidural  haemorrhage  disclosed,  and, 
after  incision  of  dura,  subdural  hfemorrhage.  He  died  three 
hours  later,  and  eleven  hours  after  reception  of  injury. 

Case  XXXVIII. — Male,  aged  forty;  cause  of  injury  un- 
known; contusions  behind  both  ears;  free  haemorrhage  from 
right  ear,  and  during  the  night  from  both  ears  and  mouth  ; 
pupils  contracted;  pulse  full  and  slow;  breathing  labored;  tem- 
perature, 99-2°;  became  105°.  He  did  not  regain  conscious- 
ness, and  died  six  hours  after  admission. 

Case  XXXIX. — Male,  aged  twenty;  fell  thirteen  feet;  large 
haematoma  in  left  posterior  parietal  region;  unconscioua;  ooz- 
ing from  left  ear  and  nose;  pupils  contracted,  and  eyes  turned 
persistently  to  the  right;  mouth  drawn  slightly  to  the  right; 
breathing  irregular ;  vomiting  free  ;  extremities  cold  and  muscles 


36 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Joob., 


relaxed;  urine  incontinent ;  temperature,  99-5°.  Soon  after  ad- 
mission haemorrhage  from  nose  ceased,  but  continued  from  the 
ear.  Patient  could  be  roused  partially  but  with  difficulty,  became 
restless,  and  moved  his  right  side  rather  less  freely  than  the  left. 
Temperature,  101°.  Two  hours  after  admission  breathing  be- 
came stertorous,  and  tonic  spasms,  beginning  in  the  right  arm, 
became  general.  Two  attacks  of  opisthotonos  followed,  and 
ceased  after  thirty  minutes.  Left  pupil  became  tlie  larger,  while 
the  right  eye  still  turned  to  the  right  on  exposure.  Tetiipera- 
ture,  105°;  pulse,  96;  respiration,  32,  and  of  the  Cheyne- 
Stokes  variety.  An  hour  later,  coma  was  profound,  with  slow 
and  stertorous  respiration.  Temperature,  106-6°.  Respiration 
became  insufficient,  four  to  the  minute,  and  face  cyanotic. 
Death  occurred  in  four  hours.  Pupils  post  mortem  were  wide- 
ly dilated. 

Case  XL. — Male,  aged  thirty  ;  fell  three  stones  to  the  pave- 
ment; four  ribs  fractured  on  the  right  side;  contusion  over 
right  eye,  and  slight  right  subconjunctival  ha3morrhage ;  un- 
conscious; skin  cold  and  moist;  pulse,  120;  temperature,  100°. 
Pulse  became  weaker  and  respiration  more  labored,  and  denth 
ensued  in  five  hours  and  a  half  after  reception  of  injury.  No 
pulmonary  symptoms. 

Case  XLL — Male,  aged  forty;  cause  of  injury  unknown; 
extensive  contusion  over  right  parietal  region ;  hsemorrliage 
from  right  ear  and  nose;  unconscious;  stertor;  died  in  four 
hours  and  a  half. 

Case  XLIL  — Female,  aged  forty-seven;  fell  on  the  street  in 
a  convulsion  during  a  debauch  ;  had  other  convulsions  before 
admission;  left  side  of  head  and  eyelid  much  contused  ;  mental 
condition  stupid;  pupils  normal;  breathing  stertorous;  pulse, 
108;  convulsions  continued  during  the  day  and  night;  no  in- 
terval of  consciousness.  During  the  morning  a  severe  ha!mor- 
rhage  occurred  from  the  mouth  without  pi'evious  warning.  In 
the  afternoon  ])ulse  and  respiration  became  frequent.  The 
blood  which  came  from  the  mouth  was  bright  in  color,  non- 
aerated,  and  said  to  be  more  tiian  eight  ounces  in  amount.  The 
next  day  tiie  convulsions  were  diminisheii  in  frequency  and 
were  general,  but  more  severe  in  the  right  arm.  No  initial 
symptom  noted.  Both  arms  were  rigid  and  head  constantly 
turned  to  the  right.  There  were  in  all  twenty-three  convul- 
sions. Death  occurred  in  thirty-eight  hours.  Temperature, 
one  hour  after  admission,  102'4°  ;  morning  of  next  day,  105'6°; 
later,  107-4°,  106-3°,  107-8°— the  last,  one  hour  before  death. 

Case  XLIIL — Male,  aged  seventeen;  fell  one  story;  large 
haematoma  on  left  frontal  region ;  unconscious  till  death ;  hajm- 
orrhage  from  nose,  mouth,  and  left  ear,  and  under  conjunctiva 
of  both  eyes;  pupils  ecjually  dilated;  slight  convulsive  move- 
ments of  right  side  soon  terminating  in  right  hemiplegia,  with 
rigidity  of  left  side;  death  from  pulnioiiary  oedema  occurred  in 
five  hours;  temperature,  one  hour  before  death,  was  105-4°. 

Case  XLIV. — Male,  aged  thirty-seven;  jumped  from  a  fourth- 
story  window  to  the  street  while  drunk;  lacerated  scalp  wound 
in  left  posterior  parietal  region,  and  fissure  running  from  it  into 
posterior  fossa;  both  })Upils  widely  dilated;  patient  loud  and 
abusive  in  language;  slight  left  facial  paralysis;  incontinence 
of  urine;  pulse,  118,  soon  becoming  irregular  and  almost  im- 
perceptible. The  patient  became  quiet,  and  a  little  later  coma- 
tose. Temi)er;iture,  97  6°  by  rectum.  Three  hours  after  ad- 
mission he  iiad  three  clonic  spasms  of  right  arm  at  varying 
points.  Died  in  six  hours  after  admission  while  under  ether, 
given  for  reduction  of  a  dislocated  hip. 

Case  XLV. — Male,  aged  thirty;  struck  by  a  falling  ladder ; 
hajmorrhage  Irom  mouth  and  nose,  and  blood  and  brain  matter 
exuded  from  the  right  ear;  both  eyes  protruded,  the  right  eye 
the  more  so;  both  pu|)ils  contracted  and  irresponsive  to  light, 
riglit  facial  paralysis;  respiration  stridulous.    Right  pujjil  soon 


began  to  dilate  slowly.  Temperature,  100° ;  pulse,  93.  Patient 
remained  unconscious  till  death,  two  hours  after  injury. 

Case  XLVI. —  Female,  aged  thirty-five;  fell  down  stairs; 
admitted  next  day,  still  unconscious;  ecchymosis  in  left  poste- 
rior parietal  region ;  haamorrhage  from  left  ear ;  left  eye  pro- 
truded; left  pu[)il  dilated.  Temperature,  101°;  pulse  slow. 
Vomiting  profuse.  Next  day  paresis  of  whole  right  side ;  urine 
incontinent;  some  pulmonary  redeina.  On  the  third  day  rigidi- 
ty ot  the  muscles  of  the  back  of  the  neck.  Haemorrhage  from 
the  ear  continued  a  week,  lessening  in  amount  and  becoming 
serous  in  character.  Patient  continued  unconscious  till  death, 
at  the  end  of  ten  days,  from  asthenia.  Temperature  ranged 
from  100°  to  102°  till  the  morning  of  the  eighth  day,  when  it 
suddenly  rose  from  101°  to  103°.  From  this  time  it  rose,  with 
morning  depressions,  steadily  to  107-4°  on  the  day  of  her  death. 

Case  XLVIL — Male,  aged  thirty-five;  cause  of  injury  un- 
known ;  found  unconscious;  small  haematoma  on  left  temple ; 
haemorrhage  profuse  from  both  ears ;  evidence  of  previous 
haemorrhage  from  both  nostrils;  pulse  scarcely  perceptible; 
stertor ;  pupils  both  equally  dilated ;  complete  relaxation  of 
limbs,  and  no  response  to  peripheral  irritation.  Left  facial  pa- 
ralysis was  developed  two  hours  before  death,  which  occurred 
in  six  hours  without  restoration  of  consciousness.  Temperature 
on  admission  was  98-6°,  rose  to  99° -f  ;  pulse,  64  to  128 ;  respira- 
tion, 24. 

Case  XLVIIL — Male,  aged  twenty-four;  fell  down  stairs; 
wound  over  right  eye  ;  haemorrhage  from  right  nostril ;  coma ; 
stertor;  pupils  contracted;  temperature,  98'5°;  pulse,  120; 
no  paralysis  or  muscular  rigidity  ;  reflexes  normal ;  fracture  of 
left  thigh.  Clonic  spasm  of  left  side  five  hours  after  admission. 
Death  in  ten  hours  after  reception  of  injury.  Hourly  tempera- 
ture, 100°,  101°,  102-4°,  102-4°,  103°,  104-4°,  105°,  106-4°.  Thirty 
minutes  post  mortem,  108-8°. 

Case  XLIX. — Male,  aged  four;  fell  two  stories,  striking 
the  back  of  the  head ;  small  scalp  wound  just  above  external 
occipital  protuberance  :  large  haematoma  above  each  ear  ;  pro- 
fuse haemorrhage  from  both  ears  and  mouth  and  hsematemesis » 
depressed  fracture  could  be  felt  beneath  the  wound  ;  uncon- 
scious ;  right  pupil  dilated ;  neither  pupil  responsive ;  slight 
rigidity  of  muscles  of  right  side.  Temperature,  100-8° ;  pulse 
and  respiration  very  rapid  ;  respiration  became  Cheyne-Stokes. 
Died  in  four  hours. 

Case  L. — Male,  aged  fifty-nine;  fell  two  stories  through  an 
elevator  and  struck  his  head ;  contusion  about  right  ear  and 
nose ;  unconscious  for  ten  days ;  haemorrhage  from  right  ear 
and  nose  and  under  right  conjunctiva ;  stertor;  pupils  irregu- 
lar. At  the  end  of  a  week  restless,  and  required  to  be  kept  in 
bed  by  an  attendant.  Discharge  from  ear  straw-colored.  At 
the  end  of  two  weeks  patient  entirely  conscious.  Ten  days 
later  he  walked  a  little  and  began  to  recognize  people,  and  after 
another  ten  days  he  was  mentally  recovered. 

Case  LI. — Male,  aged  thirty-three ;  thrown  from  a  truck 
and  received  a  blow  upon  the  head;  scalp  wound  in  left  tem- 
poral region  ;  profuse  haemorrhage  from  left  ear;  pupils  regu- 
lar, lie  was  semi-comatose,  but  conscious  and  rational,  next 
day.  and  two  days  later  became  delirious.  Haemorrhage  from 
the  ear  ceased  on  the  sixth  day,  delirium  continued  a  week,  and 
vertigo  for  upward  of  three  weeks.  No  further  symptoms  were 
developed. 

Case  LI  I. — Male,  aged  thirty- five;  struck  on  the  head  by  a 
brick  falling  eight  stories ;  not  made  unconscious ;  compound, 
comminuted,  depressed  fracture  at  right  temporo-parietal  junc- 
tion ;  squamous  portion  of  temporal  much  comminuted,  and  one 
large  fragment  driven  into  the  brain;  haemorrhage  from  right 
ear  and  nostril ;  right  pupil  contracted  ;  little  or  no  shock.  He 
recovered  with  some  deafness  remaining  in  right  ear. 


Jan.  14,  1893.J 


PHELPS:   INJURIES  OF  THE  HEAD. 


37 


Cask  LIII. — Male,  aged  thirty-five;  fell  down  stairs  while 
drunk;  coma;  stertor;  ha3raorrIiage  from  left  ear,  which  con- 
tinued twenty-four  hours;  pupils  contracted.  Regained  con- 
sciousness in  twelve  hours.  Five  days  later,  left  facial  paraly- 
sis, both  upper  and  lower  face  involved,  and  food  accumulated 
between  cheek  and  jaw  ;  ptosis,  etc.  No  loss  of  sense  of  taste. 
He  entirely  recovei-ed  from  paralysis,  and  suffered  only  from 
occasional  vertigo. 

Case  LIV. — Male,  aged  nineteen;  thrown  from  his  horse 
while  riding,  and  struck  on  the  back  of  his  head ;  contused 
wound  in  right  occipital  region  ;  profuse  hemorrhage  from  right 
ear ;  pupils  contracted;  unconscious  till  after  his  removal  to  his 
house,  a  distance  of  two  miles.  He  then  had  severe  nausea  and 
vonnting,  and  was  sonmolent  for  several  hours.  The  next  morn- 
ing his  pulse  and  temperature  were  normal,  and  he  suffered 
from  severe  pain  in  the  head,  which  continued  for  three  days. 
Haemorrhage  from  the  ear  ceased  at  the  same  time.  There  was 
no  rise  at  any  time  in  pulse  or  temperature.  At  the  end  of  ten 
days  there  was  still  some  pain  and  tenderness  on  deep  pressure 
just  abvoe  and  behind  the  ear.    His  recovery  was  complete. 

Case  LV. — Male,  aged  forty-four ;  said  to  have  fallen  and 
been  struck  by  a  plank;  admitted  to  alcoholic  ward,  and  next 
day  transferred  to  surgical  service  when  he  had  partially  recov- 
ered consciousness.  The  left  upper  and  lower  extremities,  which 
had  been  rigid,  had  become  hemiplegic  and  anesthetic.  There 
was  an  abrasion  of  the  nose,  a  contusion  of  the  lott  eye,  and  a 
hsematoma  of  the  right  posterior  parietal  region.  Three  days 
later  the  left  hemiplegia  had  become  complete;  movements 
from  the  bowels  were  conscious  but  involuntary;  bladder  con- 
trolled ;  temperature,  99°.  His  mental  condition  had  been  un- 
changed since  he  recovered  consciousness.  He  answered  ques- 
tions rationally,  and  never  varied  in  his  explanation  of  the  man- 
ner in  which  his  injury  had  been  received.  He  talked  con- 
stantly and  rambled  in  his  speech.  Upon  incision,  an  open  fis- 
sure was  disclosed,  which  ran  obliquely  across  the  right  parietal 
bone,  from  the  anterior  superior  angle,  and  into  the  occipital  as 
far  as  it  could  be  conveniently  traced.  There  was  no  depression. 
A  large  opening  was  made  through  the  bone  by  trephining  and 
use  of  the  rongeur.  An  epidural  clot  was  found  to  extend  from 
the  coronal  suture  in  front  to  the  superior  occipital  fossa  be- 
hind, and  from  the  median  line  to  the  middle  fossa,  and  was  an 
inch  and  a  half  in  thickness  in  its  central  portions.  This  clot, 
when  removed,  measured  four  ounces  and  a  half  by  volume, 
and  left  a  large  cavity,  the  result  of  cerebral  compression.  The 
dura  was  apparently  uninjured.  As  haemorrhage  was  free  from 
some  inaccessible  point  beneath  the  bone,  the  cavity  was  tem- 
porarily packed  witli  gauze.  Two  hours  after  the  operation  he 
could  move  the  left  leg.  Twelve  hours  later  there  was  sensa- 
tion in  tiie  left  arm.  The  next  day  sensation  was  perfect,  move- 
ments of  the  left  arm  still  restricted,  and  movements  of  the 
bowels  occurred  which  were  controlled.  Temperature,  98  5°. 
The  second  day  the  brain  had  regained  the  volume  it  had  lost 
by  compression,  and  his  mental  condition  was  apparently  nor- 
mal. In  four  days  he  was  in  all  respects  entirely  well,  except 
for  his  external  wound. 

Case  LVl. — Male,  aged  twenty-three;  thrown  from  his 
horse  and  sustained  a  depressed  fi-actureof  the  left  frontal  bone 
two  inches  above  the  orbit.  Partial  loss  of  consciousness; 
haemorrhage  from  nose  and  mouth ;  pupils  normal ;  f<kin  pale 
and  moist,  and  extremities  cold;  two  or  three  hours  later  pro- 
jectile vomiting  and  hiomatemesis.  There  was  slight  ecchymosis 
of  the  left  upi)er  eyelid  before  the  vomiting;  after  it  both  eye- 
lids became  excessively  ecchymotic,  and  at  the  &ame  time  the 
outer  half  of  the  left  conjunctiva  became  filled  with  blood. 
The  temperature  was  usually  about  99°,  never  above  100-5°. 
He  had  temporary  amblyopia,  and  no  other  results  followed. 


Case  LVII. — Male,  aged  forty-five;  knocked  down  and 
beaten  about  the  head ;  lacerated  scalp  wounds  in  left  fronto- 
parietal region;  coma;  h.Bmorrhage  from  both  no.'^trlls;  pu- 
pils normal ;  pulse,  100.  He  recovered  j)artial  consciousness 
in  one  hour,  and  became  excessively  irritable ;  full  conscious- 
ness returned  next  day,  and  he  was  removed  from  the  hos- 
pital. 

Case  LVIII. — Male,  aged  twenty-six  months;  fell  four 
stories;  extensive  scalp  wound  in  right  occi|)ital  region;  re- 
peated vomiting;  h.emorrliage  from  right  ear.  Three  hours 
later  he  became  restless,  had  clonic  spasms  upon  the  right  side, 
and  gradually  lost  consciousness.  There  was  apparent  complete 
right  hemiplegia;  movements  of  the  left  side  were  easily  in- 
duced ;  pulse  130  and  weak  ;  breathing  stertorous.  Conscious- 
ness gradually  returned  within  twelve  hours,  and  no  paralysis 
remained.    There  were  no  further  symptoms. 

Case  LIX. — Male,  aged  thirty ;  fell  from  elevated  railroad 
to  sidewalk,  striking  upon  left  side  of  head  and  face  ;  contusion 
over  left  eye;  serai-conscious;  hamorrhage  from  right  ear; 
pulse  and  respiration  slow.  The  next  day  patient  recovered 
consciousness  enough  to  discover  that  he  had  become  blind  in 
the  left  eye.  He  responded  slowly  to  (juestions  and  slept  most 
of  the  time.  Ophthalmoscopic  examination  of  the  left  retina 
was  negative.  The  left  pupil  would  not  respond  to  direct  ex- 
posure to  light,  but  would  contract  with  the  other  pupil  on 
simultaneous  exposure.  In  the  opinion  of  Dr.  P.  A.  Callan,  the 
blindnc-ss  was  due  to  pinching  of  the  optic  nerve  by  a  fracture 
involving  the  optic  foramen.  Fifteen  days  later  Dr.  Callan 
found  commencing  atrophy  of  the  optic  nerve.  Eight  days 
after  the  injury  there  was  partial  left  facisl  paralysis,  and  the 
tongue  deviated  to  the  right.  He  complained  of  pain  over  the 
left  eye  and  behind  the  right  ear.  A  slight  sero  sanguinolent 
discharge  began  to  flow  from  both  ears,  continued  for  some  days, 
ceased,  and  reappeared  from  the  right  ear.  Tempertiture  on 
admission  was  99°,  rose  to  100°,  and  afterward  varied,  usually 
from  99°  to  normal. 

The  patient,  a  man  of  unusual  intelligence,  stated,  after  his 
recovery,  that  for  five  weeks  after  his  accident  he  was  unable 
to  recollect  the  attendant  circumstances  or  anything  that  hap- 
pened about  that  time  or  afterward ;  that  his  mental  condition 
was  one  of  great  confusion.  After  that  period  his  memory  was 
restored  and  his  mental  confusion  disappeared.  His  recovery 
was  ultimately  complete,  with  the  exception  of  the  loss  of  sight 
of  the  left  eye. 

The  diagnosis  made  was :  Fracture  of  the  frontal  bone,  com- 
mencing on  the  left  side,  extending  through  the  anterior  fossae 
and  through  the  right  middle  fossa  and  petrous  portion,  involv- 
ing the  left  optic  foramen  and  lacerating  the  prefrontal  lobe. 

Case  LX. — Male,  aged  forty-seven;  was  knocked  down  by  a 
blow  and  his  head  struck  heavily  upon  the  pavement ;  slight  con- 
tusion upon  lip  and  over  right  eye;  pulse,  7'2  ;  temperature, 
100'2°;  unconscious;  stertor;  pupils  normal;  soon  became 
delirious  and  was  unable  to  articulate.  He  remained  in  a  con- 
dition of  stupor  and  delirium  for  ten  days;  required  meclianical 
res  raint.  He  was  unable  to  articulate,  and  wjis  dysphagic; 
attempted  to  drink  his  urine.  His  mental  conditinu  and  power 
of  articulation  then  improved  for  two  weeks,  though  he  de- 
veloped left  facial  paralysis,  involving  lower  face ;  dysphagia 
disappeared.  There  was  then  an  interval  of  a  few  days,  when 
he  was  irritable,  restless,  and  disposed  to  wander  about  the 
ward  at  night.  His  temperature  varied  from  100°  to  normal, 
and  was  usually  at  the  higher  (mint.  From  this  time  he  became 
([uiet  and  conversed  intelligently,  though  his  mind  wandered. 
He  had  no  rc<'ollection  of  his  injury,  of  what  preceded  it,  or  of 
anything  tiiat  occurred  afterward.  He  failed  to  recognize  his 
location  or  to  appreciate  his  surroundings.    His  memory  of 


38 


PHELPS:  INJURIES  OF  THE  HEAD. 


( N.  Y.  Mki).  Jodh., 


more  distant  events  was  better,  but  still  defective,  llis  laugh 
was  vacant,  and  there  was  some  perceptible  loss  of  power  on 
tlie  left  side.  He  continued  in  a  demented  condition  and  inci- 
dentally a  dipsomaniac  till  his  removal  to  an  insane  asylum 
within  the  last  month,  two  years  after  the  injury. 

Case  LXf. — Male,  ag'ed  twenty-two;  fell  two  stories  and 
struck  right  side  of  the  iiead  and  face  and  right  shoulder;  con- 
tusions of  those  regions  and  fracture  of  acromion ;  uncon- 
scious; hfemorrhage  from  right  ear,  and  four  hours  later  from 
the  nose;  regained  consciousness  in  five  hours;  haemorrhage 
from  ear  ceased  in  three  days;  temperature,  101°  to  100°;  nor- 
mal after  four  days. 

Case  LXII. — Maie,  aged  twenty-two;  fell  three  stories; 
contusions  of  right  side  of  head,  face,  and  eye;  hajmorrliage 
from  right  ear  and  mouth;  unconscious;  pulse  slow  and  full 
(60);  breathing  labored;  temperature,  101°;  pupils  normal. 
Respiration  soon  became  easier,  but  the  patient  was  irritable  and 
restless.  He  did  not  regain  consciousness  for  five  days,  during 
which  time  lie  continued  to  bo  irritable  when  disturbed,  and 
was  not  wholly  rational  for  five  days  longer.  Toward  the  end 
of  the  second  week  his  articulation  became  thick  and  right 
lower  facial  paralysis  became  evident.  At  the  same  time  a 
swelling  without  discoloration  of  the  left  side  of  the  face,  which 
bad  been  i)resent  since  admission,  perceptibly  increased,  but 
soon  aftervk^ard  disappeared.  The  facial  paralysis  persisted  and 
the  difficulty  of  articulation  increased.  His  mental  condition 
varied,  but  progressively  deteriorated.  There  was  slowness  of 
perception  and  hesitation  in  expression.  His  laugh  was  silly 
and  his  manner  vacant.  There  also  seemed  to  be  a  sensory 
aphasia  at  a  late  period.  In  reply  to  questioning  about  the 
manner  of  his  accident,  he  would  talk  about  taking  a  basket  of 
clan)s  from  Koster  &  Bial's.  He  might  say  "  Koster  &  Rial's," 
but  was  quite  likely  to  say  "  Koster  and  clams."  At  the  begin- 
ning of  the  second  month  there  was  a  sudden  change.  His 
mind  in  a  day  became  clear;  he  knew  where  he  lived  and  that 
he  was  in  a  hospital.  He  conversed  rationally  about  his  acci- 
dent and  how  it  occurred.  He  lost  his  delusions  and  rested 
quietly  at  night,  though  his  speech  was  still  a  little  indistinct  and 
his  facial  paralysis  had  not  entirely  disappeared.  Temperature 
after  the  third  day  was  rarely  above  99°  and  oftener  below  it. 
His  recovery  was  ultimately  complete. 

Case  LXIII. — Male,  aged  forty  ;  foil  five  steps  of  a  stairway  ; 
walked  home;  hajmorrhage  from  right  ear;  had  two  convul- 
sions next  day  and  was  then  taken  to  the  hospital;  hasniorrhage 
from  the  ear  still  continued;  stupid;  muttering;  two  other  con- 
vulsions, most  marked  on  the  right  side,  followed  by  mild  de- 
lirium through  the  night.  No  previous  history  of  epilepsy  or 
excesses  in  drink.  Temperature,  101 '2°.  Three  days  later  pa- 
tient was  still  stupid,  said  little  and  that  incoherently,  and  was 
'delirious.  Temperature  had  ranged  from  10r2°  to  100'6°.  He 
■was  transferred  to  Bellevue,  and  there  became  wildly  delirious 
for  three  days,  and  then  quiet  and  rational.  Temperature,  98-8°. 
No  further  history  noted  ;  no  other  symptoms. 

Case  LXIV. — Male,  aged  forty-two;  cause  of  injury  un- 
known. Semi-conscious  and  drunk  ;  liajmorrhago  from  right 
ear  which  continued  eight  days;  menibrana  tympani  ruptured; 
.violent  mania  for  two  days  and  mild  delirium  two  days  longer; 
'temperature,  100°.  Four  days  afterward  he  suffered  pain  in 
the  head;  had  occasional  delusions;  his  mental  processes  were 
•slow,  and  his  tongue  deviated  to  the  right;  urine  and  faeces 
incontinent.  In  the  second  week  he  became  rational  and  only 
.  occasionally  soiled  the  bed.  His  tongue  still  deviated.  At  the 
•end  of  a  month  he  no  longer  had  symptoms;  even  the  deafness 
had  iinprove<l.  Temperature  second  day,  103°;  gradual  de- 
cline to  99°  in  four  days.  After  seventh  day  habitually  normal 
to  99°. 


Case  LXV.— Male,  aged  forty;  fell  down  a  gang  plank. 
Unconscious;  luemorrhagc  from  both  ears,  more  from  the 
right;  pulse,  100;  temperature,  100°.  After  some  hours  con- 
sciousness returned  and  he  was  able  to  speak.  Delirious  through 
the  night.  On  the  next  day  his  tongue  deviated  to  the  right ;  pu- 
pils dilated,  left  more  so  than  the  right;  mind  still  clouded; 
temperature,  99'6°.  Four  days  later  he  was  rational.  No  fur- 
ther symptoms. 

Case  LXVI. — Male,  aged  twenty-three ;  walked  out  of  a 
window  while  sleeping  and  fell  three  stories  to  a  stone  pave- 
ment below,  striking  an  iron  fence  on  the  way  down.  He  re- 
mained unconscious  for  fifteen  or  twenty  minutes.  On  admis- 
sion, there  was  a  wound  of  the  external  right  ear.  "While  this 
wound  was  being  dressed  a  very  profuse  serous  discharge  began 
from  this  ear  and  continued  for  several  days.  Pupils  and  respi- 
ration normal ;  severe  vertigo,  aggravated  on  attempting  to  arise 
or  on  opening  his  eyes;  he  vomited  several  times ;  pulse,  90; 
temperature,  99°.  On  the  fourth  day  he  had  upper  and  lower 
incomplete  facial  paralysis  which  continued  for  a  week's  time. 
On  the  eighth  day  he  had  three  epileptiform  convulsions  and 
one  on  the  next  day.  The  head  and  eyes  were  first  turned  to 
the  right,  then  the  arms  and  finally  the  legs  were  involved.  On 
the  twentieth  day  he  began  to  have  severe  pain  in  the  right  ear, 
and  as  the  mastoid  region  later  became  swollen  and  inflamed,  it 
was  trephined  for  exploi'atiou  with  negative  result.  The  tem- 
perature but  once  exceeded  99°.  The  mastoid  inflammation 
disappeared  at  once  after  trephination.  Recovery  was  com- 
plete. 

Case  LXVII. — Male,  aged  fifteen ;  kicked  in  the  back  of  the 
head  by  a  horse.  No  apparent  external  injury ;  profuse  haemor- 
rhage from  right  ear  ;  was  moaning  and  restless ;  became  de- 
lirious after  a  few  hours;  afterward  irrational  and  incoherent; 
irritable ;  temperature,  100° ;  delirious  or  irrational  for  five 
days;  temperature,  100°  to  102°;  removed  from  hospital  in 
two  weeks;  temperature,  99°;  still  had  delusions. 

(.'ase  LXVIII. — Female,  aged  six;  fell  two  stories  to  pave- 
ment ;  unconscious;  lacerated  wound  over  right  eye  and  hema- 
toma ;  contusion  of  face;  severe  hasmorrhage  from  mouth  and 
nose  and  hsematemesis ;  subconjunctival  hiemorrhage  in  both 
eyes;  pupils  dilated;  stertor;  respiration  frequent;  tempera- 
ture, 99°  ;  reflexes  lost ;  incontinence  of  urine  and  faeces  ;  sur- 
face irritation  caused  violent  convulsions;  initial  symptom  in 
the  eyes,  continued  twenty-four  hours;  also  haemorrhage  from 
nose  and  mouth.  After  that  time  all  the  symptoms  disappeared, 
and  patient  was  out  of  bed  on  the  tenth  day ;  temperature  rose 
in  three  hours  from  admission  to  103"2°;  fell  to  98'6°  on  the 
second  day. 

Case  LXIX. — Male,  aged  four;  struck  by  some  falling  ob- 
ject; contusions  over  left  frontal  and  right  parietal  eminences; 
haemorrhage  from  mouth,  nose,  and  both  ears,  and  continued 
from  left  ear  for  five  days ;  unconscious ;  left  pupil  dilated ; 
left  facial  paresis;  temperature,  99°;  somnolent  forty-eight 
hours,  but  rational  when  roused;  incontinence  of  urine  and 
faeces;  temperature,  100°  on  second  day  and  100  4°  on  third 
day;  did  not  get  below  100°  till  tenth  day;  pulse  usually  120; 
sym])toms  gradually  disappeared. 

Case  LXX. — Male,  aged  forty ;  fell  one  story  to  pavement, 
striking  back  of  his  head ;  scalp  wound  in  right  occipital  re- 
gion;  hffimorrhage  from  left  ear;  left  pupil  dilated;  soon  be- 
came normal;  unconscious;  partially  restored  in  ambulance; 
on  admission,  restless  and  delirious;  temperature,  99'4°  ;  pulse, 
60;  respiration  rapid ;  moved  right  side  only;  incontinence  of 
urine  and  faeces.  Temperature  ranged  during  the  first  week 
from  100°-f-  to  101°;  then  became  99°-|-  in  the  morning,  and 
at  end  of  second  week  became  normal ;  pulse  varied  from  62  to 
54;  required  continuous  mechanical  restraint  for  four  days  and 


Jan.  14,  1893.]  BULL:   TUMORS  OF  TEE  ORBIT  AND  NEIGHBORING  CAVITIES. 


39 


at  niirlit  for  one  month.  Ilis  inind  underwent  tlie  typical 
changes  (see  remarks  on  diagnosis),  and  became  ultimately  com- 
pletely restored. 

( To  lie  continued.) 


TUMORS  OF  THE  ORBIT  AND 
NEIGHBORING  CAVITIES.* 
By  CHARLES  8TEDMAN  BULL,  A.  M.,  M.  D., 

PROFB  -SOR  OF  OPHTU  ALMOLOG  Y  IN  THE  UNIVERSITT  OF  THE  CITY  OP  NEW  YORK ; 
SURGEON  TO  THE  NEW  YORK  EYE  AND  EAR  INFIRMARY. 

Case  I.  Spindle-cell  Sarcoma  of  Periosteum  of  Orbit. — T.  D. 
S.,  a  boy,  aged  four  years  and  a  half,  was  brought  to  me  by  Iiis 
parents  in  the  latter  part  of  January,  1876,  with  the  following 
history :  lie  was  a  large  child  for  his  age,  of  the  average  men- 
tal development,  and  had  always  been  robust  in  health.  There 
was  no  unlavorable  fiimily  history  to  be  elicited  after  careful 
questioning,  and  no  evidence  of  inherited  syphilis  in  the  child. 
For  several  months  the  parents  had  noticed  a  slight  swelling  at 
the  outer  angle  of  the  left  orbit,  accompanied  by  slight  redness 
of  the  eyeball  and  some  swelling  at  the  outer  angle  of  the  upper 
lid.  These  symptoms  gradually  increased,  but  there  was  no 
complaint  of  pain  and  no  evidence  of  any  disturbance  of  \nsion. 
When  I  saw  the  child  there  was  a  very  perceptible  orbital 
growth  at  the  outer  angle,  which  seemed  to  involve  the  upper 
and  outer  parts  of  the  orbit.  The  left  eye  was  pushed  down- 
ward and  inward,  but  not  forward,  and  its  motility  was  decid- 
edly limited  upward  and  outward.  Tiie  upper  lid  was  slightly 
swollen  and  drooped  a  little,  but  could  be  freely  opened  and 
shut.  The  growth  was  entirely  non-sensitive.  The  media  were 
perfectly  clear,  the  iris  reacted  promptly,  and  the  ophthalmo- 
scopic examination  was  negative.  Vision  was  apparently  nor- 
mal. There  was  a  slight  mucous  discharge  from  the  conjunc- 
tiva. A  careful  rhinoscopic  examination  revealed  nothing  ab- 
normal. No  history  of  any  injury  could  be  obtained.  The  boy 
was  carefully  watched,  and  by  the  middle  of  February  the 
symptoms  had  all  increased.  The  eye  was  displaced  downward 
more  decidedly  and  motility  upward  was  entirely  lost.  For 
two  days  the  child  had  complained  of  some  pain.  The  pre- 
auricular gland  on  the  left  side  had  become  swollen  and  some- 
what painful.    Ophthalmoscopic  examination  negative. 

By  the  1st  of  March  all  the  symptoms  were  much  increased 
in  severity.  A  slight  ulceration  of  the  cornea  appeared  just 
above  the  center.  The  motility  of  the  eye  was  limited  in  all 
directions.  The  pre-auricular  gland  was  very  much  enlarged, 
but  there  was  no  other  glandular  infiltration.  The  orbital 
margin  was  swollen,  and  the  swelling  extended  up  on  the  fore- 
head and  backward  into  the  temporal  fossa.  There  was  little 
or  no  protrusion  of  the  eye  forward  and  the  lids  could  still  be 
opened.  A  diagnosis  was  made  of  pure  orbital  tumor,  probably 
starting  in  the  periosteum,  and  owing  to  the  somewhat  rapid 
increase  of  the  sym})toms  and  the  high  fever  of  the  last  two 
days  it  was  decided  to  operate  and  attempt  to  save  the  eye. 

On  March  3d  the  left  external  canthus  was  split,  the  incision 
being  carried  outward  upon  the  temple  for  somewhat  more  than 
an  inch.  The  left  temporal  artery  was  divided  and  at  once 
ligated.  The  upper  lid  was  then  carefully  dissected  upward 
and  turned  over  upon  the  forehead.  After  the  bleeding  had 
been  checked,  the  orbital  periosteum  was  found  very  much 
thickened  on  the  outer  and  upper  walls  of  the  orbit.  The  in- 
filtration also  involved  the  orbital  tissue  as  far  back  as  the 
finger  could  extend,  but  did  not  seem  to  involve  the  capsule  of 

*  Read  before  the  New  York  State  Medical  Association,  November 
16,  1892. 


the  eyebiill.  The  latter  was  pushed  carefully  toward  the  nasal 
side  and  held  there.  An  incision  was  then  made  through  the 
periosteum  along  the  superior  orbital  margin,  and  the  peri- 
osteum was  then  carefully  stripped  up  from  the  bone  on  the 
upper  and  outer  walls  of  the  orbit  as  far  back  as  the  knife  and 
force[)S  could  reach.  This  was  removed  in  strips,  and  with  it 
also  the  orbital  tissue  and  the  lacrymal  gland.  The  periosteum 
was  also  removed  from  the  frontal  bone  and  temporal  fossa  as- 
far  as  it  seemed  to  be  infiltrated,  and  the  pre-auricular  gland  was 
carefully  dissected  out  and  removed.  The  orbital  cavity  was- 
then  washed  out  with  a  mild  solution  of  zinc  chloride  and  the 
upper  lid  brought  down  in  j)lace,  and  the  lines  of  incision  ac- 
curately coapted  and  sutured.  Atropine  was  instilled  and  the 
eye  closed  with  the  ordinary  dressings  then  in  use.  For  the 
first  three  days  there  was  considerable  reaction,  the  lids  being^ 
much  swollen  and  the  wound  discharging  considerable  pus,  so 
that  one  or  two  stitches  had  to  be  removed.  The  cornea  be- 
came generally  hazy,  but  did  not  slough,  and  eventually  cleared 
up  remarkably. 

On  March  15th  a  purulent  discharge  af)peared  from  the  left 
ear  without  any  preceding  pain,  but  followed  by  severe  pain 
extending  down  on  the  left  side  of  the  neck  and  accompanied 
by  high  fever  and  a  pulse  of  140.  An  examination  showed  a 
perforaticm  of  the  membrana  tympani  just  back  of  the  liandle 
of  the  malleus.  The  discharge  from  the  auditory  canal  ceased 
in  four  days,  but  the  perforation  did  not  close  for  nearly  three 
weeks.  From  this  time  there  were  no  adverse  symptoms,  and 
the  patient  was  discharged  at  the  end  of  the  sixth  week.  A 
microscopical  examination  of  the  growth  proved  it  to  be  a 
spindle-cell  sarcoma,  which  had  originated  in  the  ])eriosteuTn. 

The  little  boy  was  carefully  watched,  being  seen  regularly 
once  a  month,  but  there  was  no  return  of  the  growth  until  the 
spring  of  1880.  Its  progress  was  then  very  rapid,  for  in  less 
than  two  months  it  filled  up  the  entire  orbit,  causing  marked 
exophthalmus  and  destruction  of  the  eyeball  by  .sloughing  of  the 
cornea.  The  entire  contents  of  the  orbit  were  then  removed, 
including  the  eyeball  and  the  entire  periosteal  lining  as  far  back 
as  the  apex.  The  orbit  was  then  carefully  washed  out  with  a 
solution  of  mercuric  bichloride  (1  to  1,000),  and  the  lids  closed 
and  dressed  in  the  usual  manner.  The  patient  did  very  well, 
there  being  little  or  no  reaction,  and  he  was  discharged  at  the 
end  of  a  week.  He  was  seen  at  rather  irregular  intervals,  al" 
though  his  parents  had  been  warned  that  the  growth  would 
probably  return.  In  May,  1885,  he  presented  himself  with  a 
swelling  of  the  lower  lid  and  cheek  on  the  left  side,  which  had 
appeared  two  weeks  before.  This  proved  to  be  a  dense  infiltra- 
tion of  the  tissues  of  the  lid  and  cheek  springing  undoubtedly 
from  the  diseased  periosteum  at  the  edge  of  the  orbit.  There 
was  no  return  of  the  growth  in  the  orbit,  and  the  appearance 
of  the  external  infiltration  did  not  suggest  its  having  spread' 
from  any  complication  in  the  maxillary  sinus.  The  parents  de- 
clined to  permit  any  further  operative  interference,  but  allowed 
me  to  kee[)  the  boy  under  observation.  The  orbit  gradually 
filled  up  with  the  growth,  while  the  external  infiltration  steadilj^ 
advanced  into  the  temporal  fossa,  over  toward  the  nose  and 
upward  upon  the  forehead,  and  the  patient  finally  died  from 
exhaustion,  without  any  head  symptoms,  a  little  more  than  ten 
years  after  the  first  appearance  of  the  tumoi-. 

Case  II.  Small  cell  Sarcoma  of  Orbit,  Maxillary  Antrum, 
Nasal  Meatus,  and  Ethmoid  Cells. — Mrs.  A.  II.,  aged  twenty- 
nine,  came  to  me  on  June  12,  1876,  with  the  following  history: 
Twelve  years  before  a  small  growth  appeared  at  the  external 
angle  of  the  left  orbit,  just  beneath  the  sni)erior  orbital  mar- 
gin. It  W!is  the  size  of  a  largo  pe.i,  and  for  a  number  of  years 
occasioned  no  discomfort  and  showed  no  tendency  to  increase 
iu  size.    After  about  six  years  of  (juiescence  it  began  .slowly  to 


40  BTTLL:  TUMORS  OF  THE  ORBIT 

grow  until  it  reached  the  size  of  .1  walnut  and  caused  a  protru- 
sion of  tlie  upper  lid  and  external  cantlius,  and  a  slifjlit  displace- 
ment ot  the  eye  inward.  It  tlicn  ceased  jsrrowing  until  about 
four  months  before  1  saw  her,  when  it  suddenly  began  to  in- 
crease in  size  and  became  very  painfid.  On  examination,  I 
found  the  following  condition  of  the  parts:  The  upper  lid  was 
pushed  forward  and  drooped  considerably  over  the  eye,  but 
could  be  elevated,  and  the  skin  was  of  a  marked  d\isky-red 
color.  The  eyeball  was  pushed  downward  and  inwai'd,  and 
protruded  nearly  half  an  inch  beyond  the  plane  of  the  fellow- 
eye,  and  its  motility  was  limited  in  all  directions.  The  con- 
junctiva was  injected,  and  the  palpebral  veins  were  engorged 
and  prominent.  The  media  wei'e  clear,  and  tlie  retinal  veins 
were  e'stremely  engorged  and  tortuous.  The  patient  coin]daiiied 
of  a  constant  pain  over  the  anterior  surface  of  the  superior 
maxilla  and  at  the  infra-orbital  foramen,  and  said  that  during 
the  last  four  months  the  vision  of  the  left  eye  had  materially 
f  ,iiled.  She  could  not  read,  but  could  count  fingers  at  twenty 
feet.  The  other  eye  was  normal.  The  tumor  could  be  seen 
and  felt  through  tlie  lid,  and  by  careful  pal[)ation  the  growth 
could  be  felt  along  the  floor  and  outer  wall  of  the  orbit.  Khino- 
scopic  examination  revealed  a  displacement  of  the  sseptum  nasi 
toward  the  right  side,  and  a  nearly  complete  obliteration  of  the 
left  nasal  meatus  by  wliat  appeared  to  be  a  moderately  hard 
mass  coming  from  the  middle  meatus.  Nothing  could  be  felt 
witii  the  finger  posteriorly.  The  patient  stated  that  for  some 
months  slie  had  not  been  able  to  breathe  through  her  nose. 
With  tills  history  and  the  digital  examination,  it  seemed  proba- 
ble that  the  tumor  had  begun  in  the  maxillary  antrum  or  nasal 
meatus,  and  had  involved  the  orbit  secondarily.  Assuming  this 
to  be  a  correct  diagnosis,  the  patient  was  told  that  the  only 
means  of  relief  was  an  operation,  but  that,  owing  to  the  deep- 
seated  nature  of  the  growth  and  its  probable  origin,  its  removal 
would  probably  not  be  complete,  and  that  it  would  be  likely  to 
return.  She  was  also  told  that  in  all  probability  the  eye  could 
not  be  saved,  but  that  an  attempt  would  be  made  to  preserve 
it.  The  vision  by  this  time  had  sunk  to  counting  fingeis  at  two 
feet,  and  the  optic  disc  was  beginning  to  assume  a  dirty-white 
color.  She  consented  to  an  operation,  which  was  done  on  the 
following  day.  The  external  canthus  was  split,  and  the  upper 
lid  turned  up  over  the  forehead  and  held  there.  A  further  ex- 
amination with  the  finger  and  large  probe  showed  that  the  en- 
tire orbit  was  filled  with  the  growth,  and  that  any  attempt  to 
save  the  eye  would  prove  a  failure.  Enucleation  was  imme- 
diately done,  and  then  the  entire  contents  of  the  orbit  were 
carefully  removed.  After  this  was  done  the  tumor  could  be 
seen  projecting  through  a  large  opening  in  the  orbital  plate  of 
the  ethmoid  and  also  through  the  sphenoidal  fissure.  It  evi- 
dently filled  the  ethmoidal  cells,  extending  to  them  from  the 
superior  and  middle  nasal  meatus,  and  was  of  much  greater  ex- 
tent than  had  been  at  first  recognized.  The  orbital  plate  of  the 
ethmoid  wa>  then  removed,  and  all  the  growth  that  could  be 
reached  was  dissected  out.  The  floor  of  the  orbit  had  not  been 
perforated,  and  the  possibility  of  the  antrum  not  being  in- 
volved was  recognized.  The  lacrymal  bone  was  next  removed, 
and  a  free  opening  made  into  the  nasal  meatus.  This  was 
found  filled  with  the  growth,  which  was  removed  by  forcei)s 
and  fingers  as  far  down  as  possible.  It  was  necessary  to  break 
down  and  remove  the  entire  inner  wall  of  the  orbit,  and  even 
then  the  growth  could  not  be  reached  without  great  difii- 
culty.  The  meatus  was  cleaned  entirely  of  the  growth  by  work- 
ing from  below  through  the  nostril  as  well  as  from  above,  and 
then  the  orbit,  ethmoid  cavity,  and  nasal  meatus  were  thor- 
oughly washed  out  with  a  solution  of  carbolic  acid.  A  carefu] 
examination  of  the  o[)eniiig  from  the  niaxillary  antrum  into 
the  nasal  meatus  was  made,  but  no  jtrotrusion  of  the  growth  or 


AND  NEIGHBORING  CAVITIES.      [N.  Y.  Med  Jook  , 

enlargement  of  the  opening  was  discovered.  The  orbit  was 
then  tamponed,  the  upper  lid  replaced  and  the  canthus  sutured, 
and  the  ordinary  bandage  a|)plied.  The  ])atient  did  very  well, 
having  but  little  local  reaction  and  but  slight  rise  in  tempera- 
ture. She  was  discharged  on  the  eighth  day,  with  directions  to 
report  once  a  week  until  further  orders.  There  was  no  return 
of  the  growth  for  eight  months,  when  a  stiiall  nodule  was  no- 
ticed in  the  left  temporal  fossa.  The  left  nostril  remained  still 
free,  and  the  orbit  was  healthy  and  normal  in  appearance.  The 
patient  was  urged  to  allow  the  removal  of  this  nodule,  but  de- 
clined to  have  it  done.  It  grew  slowly  to  the  size  of  a  walnut, 
and  then  remained  quiescent  for  several  months.  It  then  sud- 
denly began  to  increase,  and  at  the  same  time  a  nodule  was  felt 
at  the  apex  of  the  orbit,  and  another  on  the  inner  side  in  the 
cavity  of  the  ethmoid  bone.  All  these  nodules  grew  rapidly, 
and  the  one  in  the  temporal  fossa  soon  extended  from  the  lower 
margin  of  the  zygoma  upward  and  forward  upon  the  forehead 
and  backward  to  the  auricle.  The  lower  portion  was  moder- 
ately hard,  but  the  portion  which  extended  upon  the  forehead 
was  soft,  fluctuating,  and  very  sensitive  to  the  touch.  I  de- 
clined all  further  operative  interference,  as  it  would  undoubted- 
ly have  hastened  the  patient's  death,  which  occurred,  after  great 
suffering,  four  months  later,  and  about  thirteen  years  after  the 
first  appearance  of  the  growth.  Before  tlie  patient's  death  the 
orbit  and  nasal  meatus  bad  become  entirely  filled  by  the  growth, 
which  had  also  extended  back  into  the  pharynx.  The  tumor 
removed  from  the  orbit  and  neighboring  cavities  was  sarcoma- 
tous in  nature,  of  the  small-cell  variety,  but  in  places  was  dis- 
tinctly myxo-sarcomatous.  After  the  patient's  death  I  was  per- 
mitted to  examine  the  orbit,  and  found  that  the  neighboring 
cavities,  including  the  maxillary  sinus,  were  entirely  filled  by 
the  growth,  though  the  floor  of  the  orbit  was  still  intact. 

Case  III.  Spindle-cell  Sarcoma  of  Orbit  and  Adjacent  Cavi- 
ties.— J.  H.,  a  young  gentleman,  aged  twenty-two,  consulted 
me  in  December,  1879.  The  left  eye  had  been  defective  in  vi- 
sion since  childhood,  and  occasionally  squinted.  For  the  past 
two  weeks  there  had  been  a  constant  dull  pain  in  the  orbit, 
with  ptosis  and  some  protrusion  of  the  eye.  Examination 
showed  limitation  of  motility  in  all  directions,  chemosis  of  the 
ocular  conjunctiva  on  the  temporal  side,  some  ptosis  and  slight 
exophthalmus,  media  clear,  fundus  normal,  and  V.  =  -fg^.  On 
the  floor  of  the  orbit,  reaching  from  the  infra-orbital  notch  to 
the  external  canthus,  was  a  hard,  resisting  growth,  which 
pressed  the  lower  lid  forward,  and  which  could  be  traced  for 
some  distance  backward  into  the  orbit.  It  was  very  sensitive 
to  pressure.    The  patienf  refused  all  operative  treatment. 

By  February  16th  the  exophthalmia  was  very  marked,  and 
the  patient  coni])lained  of  severe  occipital  headache,  and  at  times 
staggered  when  he  walked.  The  lower  lid  was  everted  and  the 
orbital  growth  was  very  prominent  at  the  external  angle.  There 
was  dense  infiltration  of  the  palpebral  and  ocular  conjunctiva, 
the  eye  was  immovable,  the  cornea  was  hazy,  and  vision  was 
reduced  to  perception  of  light.  The  patient  complained  also  of 
constant  pain  in  the  region  of  distribution  of  the  infra-orbital 
nerve.  He  consented  to  an  operation,  and  two  days  later  the 
eye  was  enucleated  and  the  tumor  removed  with  comparative 
ease.  The  latter  was  attached  very  firmly  to  the  sheath  of  the 
optic  nerve  and  only  loosely  to  the  orbital  tissue  ;  but  the  latter 
was  densely  infiltrated,  especially  along  tlie  floor  of  the  orbit, 
and  on  this  account  the  entire  contents  of  the  orbit  were  re- 
moved down  to  the  periosteum,  which  latter  seemed  perfectly 
healthy.  The  infiltration  of  the  orbital  tissue  and  the  pain  over 
the  infra-orbital  nerve  led  me  to  make  another  careful  rhino- 
scopic  examination,  but  nothing  abnormal  was  found.  The  tu- 
mor, on  being  examined,  proved  to  be  a  spindle-cell  sarcoma, 
and  the  orbital  tissue  was  infiltrated  with  small  round  cells.  By 


Jan.  14.  18VI3.] 


BULL:   TUMORS  OF  THE  ORBIT  AND  NEIOEBORINQ  CAVITIES. 


41 


tbo  middle  of  April,  or  two  months  after  the  first  operation, 
there  were  well-marked  signs  of  a  recurrence  of  the  tumor  in 
tlic  periosteum  on  the  floor  of  the  orbit.  A  second  operation 
was  itnmodiatoly  done,  the  periosteum,  which  was  very  nuicli 
thickened,  being  stripped  upon  all  sides  from  the  orbital  inar;;iu 
to  the  aite.x.  It  was  very  vasrular,  and  the  hajmorrhage  was 
|)i'ofuse.  The  orbit  was  then  washed  out  with  a  strong  solution 
ot  carbolic  acid,  and  a  careful  examination  with  the  finuer  was 
made  of  the  floor,  inner  wall,  sphenoidal  fissure,  and  optic  fora- 
men, but  no  trace  of  abnormal  growth  could  be  discovered. 
The  hajmorrhage  still  continued,  and  it  became  necessary  to 
plug  the  orbital  cavity.  Violent  reaction  followed  in  the  skin 
of  the  lids,  cheek,  and  temple,  and  the  plugging  was  removed 
the  next  morning.  The  skin  of  the  left  side  of  the  face  became 
decidedly  erysipelatous.  The  reaction  slowly  subsided,  but  left 
both  lids  retracted  and  adherent  to  the  external  angle  of  the 
orbit,  and  the  lower  lid  adherent  to  the  inferior  orbital  margin 
for  its  outer  third,  and  the  cavity  of  the  orbit  was  much  con- 
tracted.   The  floor  of  the  orbit  was  found  intact. 

Two  months  later,  on  June  25,  1880,  a  firm  nodule,  as  large 
as  a  filbert,  appeared  over  the  left  malar  prominence.  It  was 
firmly  adherent  to  the  periosteum,  but  the  skin  was  freely  mov- 
able over  it.  In  a  month  this  nodule  had  increased  threefold  in 
size;  it  was  elastic  and  sensitive  to  the  touch.  Another  nodule, 
much  smaller,  was  discovered  along  the  lower  margin  of  the 
orbit.  On  July  30th  these  two  external  nodules  were  thoroughly 
removed,  the  bone  was  carefully  scraped  and  then  cauterized 
witii  the  actual  cautery.  By  the  first  week  in  September,  an 
external  tumor  over  the  malar  bone  had  returned  and  had 
reached  the  size  of  a  small  pear,  but  it  was  very  irregular  and 
nodulated.  The  skin  was  drawn  tightly  over  it  and  was  but 
slightly  movable.  This  external  growth  was  found  to  be  con- 
tinuous with  an  orbital  growth,  which  involved  the  floor,  inner 
and  outer  walls  of  the  orbit,  while  the  external  growth  extended 
down  upon  the  superior  maxilla,  and  over  into  the  temporal 
fossa.  The  patient  urged  a  fourth  operation,  which  was  done 
in  the  following  way  :  An  incision  was  made  along  the  lower- 
lid  margin  as  in  the  Arlt-Jaesche  operation  for  entropion,  and 
was  extended  an  inch  and  a  half  from  the  external  canthus  to. 
ward  the  ear  Another  incision  was  made  from  the  inner  end 
of  the  first  incision  down  along  the  nasal  furrow  to  the  ala  of 
the  nose.  This  skin  flap  was  carefully  dissected  up  and  reflected 
from  the  growth.  The  hjemorrhage  was  profuse  and  it  was 
necessary  to  ligate  several  vessels.  The  extra-orbital  portion  of 
the  growth  was  then  thoroughly  removed,  and  there  was  then 
revealed  a  ragged  opening  through  the  anterior  wall  of  the  su- 
perior maxilla  into  the  antrum,  through  which  the  growth  pro- 
truded. The  growth  was  then  removed  from  the  orbit  and  here 
a  large  ragged  hole  was  discovered  through  the  floor  of  the  orbit. 
The  tumor  filled  the  antrum,  nasal  meatus,  ethmoid  cavity,  and 
sphenoidal  fissure,  and  as  much  of  it  as  could  be  reached  was 
removed,  the  antrum  and  nasal  meatus  being  thoroughly  evacu- 
ated. The  parts  and  cavities  were  then  thoroughly  washed  out 
with  a  solution  of  mercuric  bichloride  (1  to  1,000)  and  the  wound 
closed.  No  great  reaction  followed,  though  the  temperature 
went  up  to  103°,  and  there  was  not  much  suppuration.  The 
external  wound  healed,  but  in  less  than  sis  weeks  the  growth 
again  appeared  in  the  orbit  and  externally  over  the  malar  bone. 
The  case  had  long  been  regarded  as  hopeless,  but  the  patient 
lingered  in  great  suffering  till  the  latter  part  of  January,  1881, 
and  died  from  exhaustion. 

Case  IV.  Epithelioma  of  the  Lid  and  Sarcoma  of  the  Orhit. 
— In  the  latter  part  of  September,  1880,  a  woman,  aged  forty- 
two,  from  whom  I  had  previously  removed  a  small  growth,  ap- 
parently epitheliomatous  in  character,  from  the  inner  angle  of 
the  left  lower  lid  three  years  before,  presented  herself  with  the 


following  history  :  There  had  been  no  trouble  with  the  eye  or 
lids  for  nearly  two  years.  The  eye  then  began  to  be  limited  in 
motion  outward  and  to  slightly  protrude.  These  symptoms 
slowly  increased,  the  upper  lid  became  swollen,  and  a  constant 
dull  ache  in  tiie  orbit  began.  Finally  the  sight  of  the  left  eye 
began  to  fail,  and  this  frightened  her  and  brought  her  to  me. 
An  examination  showed  the  right  eye  to  be  normal  in  every  re- 
spect. In  the  left  eye  the  vision  was  |^  -|-  unimproved  ;  the 
media  were  clear  ;  there  was  a  grayish  discoloration  of  the  tem- 
poral half  of  the  disc  and  a  narrowing  of  the  arteries.  The  |)erim- 
eter  showed  a  contraction  of  the  nasal  half  of  the  field.  The 
left  upper  lid  was  decidedly  cedematous  and  somewhat  reddened. 
The  eyeball  was  pushed  inward  and  protruded  very  perceptibly 
in  advance  of  the  plane  of  the  other  eye.  The  e  was  a  decided 
infiltration  of  the  tissue  on  the  temple  and  on  the  cheek  just 
below  the  inferior  orbital  margin.  The  patient  was  told  that 
she  probably  had  a  tumor  of  the  orbit,  and  that  it  must  be  re- 
moved, but  that  I  would  attempt  to  save  the  eye,  and  she  con- 
sented to  the  operation.  As  the  exopbthalmia  was  decidedly 
forward  and  the  limitation  of  motility  was  outward,  the  con- 
junctiva was  divided  at  the  outer  canthus  and  the  wound  then 
enlarged  upward  and  downward  with  the  scissors  and  handle  of 
a  scalpel.  Almost  immediately  a  growth  was  felt  extending 
along  the  outer  wall  of  the  orbit  and  filling  the  entire  apex. 
The  external  rectus  muscle  was  then  divided  at  its  insertion  and 
the  eyeball  turned  far  inward.  The  dissection  of  the  tumor  was 
then  continued,  but  it  was  found  so  intimately  connected  witli 
the  sheaths  of  the  muscles  and  of  the  optic  nerve,  as  well  as 
with  the  periosteum,  that  I  cut  through  the  nerve  and  the  mus- 
cles near  the  apex  of  the  orbit,  as  a  necessary  preliminary  to 
the  removal  of  the  tumor  from  its  orbital  attachments.  The 
growth  extended  on  the  inner  side  of  the  eye  as  well  as  on  the 
outer  side,  and  after  considerable  trouble  was  removed,  leaving 
the  eye  in  place.  About  three  quarters  of  an  inch  of  the  optic 
nerve  was  removed  with  the  tumor.  The  floor  of  the  orbit  ap- 
peared healthy  and  there  was  no  demonstrable  connection  be- 
tween the  growth  in  the  orbit  and  the  infiltration  in  the  cheek 
and  temple.  There  was  no  reaction,  and  the  patient  was  dis- 
charged at  the  end  of  ten  days.  The  eyeball  became  slowly 
atrophic  and  the  cornea  cloudy.  This  case  was  watched  very 
carefully,  being  seen  every  week  or  two,  as  the  history  of  the 
case  pointed  to  a  recurrence  of  the  tumor.  The  infiltration  of 
the  cheek  and  temple  slowly  subsided,  and  at  the  end  of  three 
months  there  was  nothing  abnormal  in  the  patient's  appearance 
except  the  phthisical  eyeball.  Nearly  ten  months  after  the  op- 
eration, however,  there  appeared  a  well-marked  nodule  on  the 
external  surface  of  the  superior  maxilla  on  the  left  side,  just  be- 
low the  orbital  margin  and  external  to  the  infra-orbital  foramen, 
and  the  diffuse  infiltration  reappeared  on  the  temple.  The  eye- 
ball, which  had  previously  receded  into  the  orbit,  began  again 
to  protrude.  Another  careful  examination  was  made  of  the 
naso  pharynx,  but  nothing  abnormal  was  discovered.  As  the 
microscopical  examination  of  the  first  tumor  had  shown  it  to  be 
a  small-cell  sarcoma,  I  advised  an  immediate  operation  including 
the  removal  of  the  atrophied  eye,  but  the  patient  refused  her 
consent  till  November,  1881,  nearly  four  months  after  the  reap- 
pearance of  the  growth.  She  was  then  sufl'ering  severe  pain  at 
times  in  the  orbit  and  temple.  The  eye  was  again  jtrotruded 
beyond  the  orbital  margin  and  the  growth  on  the  cheek  had  be- 
come as  large  as  a  horse-chestnut  and  was  very  sensitive.  The 
skin  was  movable  over  this  growth,  which  was  firmly  adherent 
to  the  bone.  The  eyeball  and  entire  contents  of  the  orbit  were 
first  removed.  After  the  hiemorrhage  had  been  checked  a  care- 
ful examination  showed  a  defect  in  the  orbital  plate  of  the  eth- 
moid, rather  far  back,  and  another  in  the  floor  of  the  orbit.  A 
probe  passed  through  these  openings  into  the  ethmoid  cells  and 


4:2 


BULL:   TUMORS  OF  TEE  ORBTT  AND  NEIOnBORIKO  CAVITIES.      [N.  Y.  Med.  Joitb., 


maxillary  antrum  discovered  a  gelatinous  mass  of  considerable 
consistence  in  both.  This  was  sufficient  evidence  that  both  these 
cavities  were  filled  with  tlie  growth.  The  large  nodule  was  then 
removed  from  the  superior  maxilla  and  the  external  surface  of 
the  hone  carefully  examined,  but  no  opening  into  the  antrum 
was  found.  No  further  attempt  was  made  to  remove  the  growth 
from  the  cavity  of  the  etbmoid  or  the  antrum,  both  on  account 
of  the  severity  of  the  operation  and  the  hopelessness  of  any  suc- 
cessful removal  of  the  diseased  bones.  The  patient  made  a  good 
recovery,  and  there  was  no  return  of  the  external  tumor  on  the 
surface  of  the  superior  maxilla.  The  disease,  however,  soon  ex- 
tended from  the  neighboring  cavities  to  the  orbit,  and  also  in- 
vaded the  nasal  meatus  and  made  rapid  progress.  The  patient 
suffered  considerable  pain  and  the  nasal  cavity  soon  became  so 
completely  blocked  that  she  breathed  almost  entirely  through 
her  mouth.  In  three  months  the  growth  filled  the  orbit  and 
protruded  between  the  lids  and  could  be  seen  at  the  entrance  of 
the  left  nostril.  About  four  months  after  the  last  operation  she 
began  to  complain  of  intense  frontal  headache,  which  at  times 
rendered  her  delirious,  and  in  one  of  these  severe  paroxysms  she 
had  a  violent  convulsion.  This  was  general  in  character  and 
ended  in  coma  from  which  she  never  rallied.  An  autopsy  could 
not  be  obtained. 

Case  V.  Myxosarcoma  of  Oriit  and  all  Adjacent  Cavities. — 
On  January  12,  1881,  a  gentleman,  R.  M.,  aged  thirty-eight, 
presented  himself  at  my  office  with  the  following  history:  The 
first  symptom  which  he  had  noticed  had  been  a  protrusion  of 
the  right  eye,  which  began  five  years  ago,  and  five  months  later 
the  left  eye  also  began  to  protrude.  During  these  five  years 
there  had  been  a  steady  increase  in  the  exophthalmia  and  in  the 
limitation  of  motility  in  both  eyes  in  all  directions.  There  had 
been  some  pain  of  late,  which  was  located  at  the  root  of  the  nose 
and  just  above  both  eyes.  For  a  long  time — but  just  how  long 
he  does  not  know — there  had  been  difficulty  in  breathing 
through  the  left  nostril,  and  for  more  than  a  year  respiration 
was  entirely  abolished  through  both  nostrils,  and  he  had  be- 
come an  absolute  mouth-breather.  He  had  had  several  polypi 
removed  from  the  right  nostril  at  dili'erent  times,  with  a  tem- 
porary improvement  in  breathing. 

An  examination  showed  a  marked  protrusion  forward  and 
outward  of  both  eyes,  so  that  the  lids  could  with  difficulty  be 
closed  over  them,  and  the  axes  were  widely  divergent.  At  one 
period  of  the  disease  there  had  been  crossed  diplopia,  which  sub- 
sequently disappeared.  The  eyes  were  almost  immovable,  and 
the  ocular  conjunctiva  was  deeply  injected.  The  irides  re- 
sponded to  light,  the  media  were  clear,  and  the  ophthalmoscopic 
examination  showed  nothing  but  engorged  and  pulsating  veins. 
R.  E.  V.  =  ^l-^.  L.  E.  V.  =  perception  of  light.  The  sight 
had  begun  to  fail  one  year  ago  in  both  eyes  and  had  slowly 
grown  worse.  There  was  pain  on  pressure  backward  of  the 
eyeballs.  The  posterior  nares  on  both  sides  were  blocked  by  a 
growth  extending  across  the  anterior  pharyngeal  space.  The 
left  nostril  was  impervious.  The  right  nostril  was  blocked  by 
a  polypus,  which  apparently  grew  from  the  left  wall  of  the 
meatus,  entirely  filled  it,  and  pushed  the  inferior  turlinated 
bone  and  sieptum  nasi  over  to  the  left  side.  It  was  soft  and 
bled  easily.  The  growth  behind,  which  filled  the  posterior 
nares  and  extended  into  the  pharynx,  was  hard  and  resistant, 
and  apparently  was  attached  to  the  body  of  the  sphenoid. 
Nothing  was  discernible  on  the  floor  or  inner  wall  of  the  right 
orbit,  but  in  the  left  orbit  the  floor  was  pushed  upward  and  tlie 
orbital  plate  of  the  ethmoid  pushed  outward,  and  I  thought  1 
could  detect  a  tumor  in  the  orbit.  The  external  surface  of 
both  cheeks  and  temples  was  smooth  and  normal  in  appear- 
ance. The  desperate  character  of  the  case  was  at  once  recog- 
nized, and  the  i)atient  was  told  that  a  complete  removal  of  the 


growth  was  hopeless,  but  that  the  growth  could  be  removed 
from  the  nostrils  and  his  respiration  made  more  comfortable. 
To  this  he  consented,  and  this  was  done  both  anteriorly  and 
posteriorly.  A  large,  gelatinous,  i)olypoid  mass,  attached  to 
the  outer  wall  high  up,  was  removed  from  the  right  nostril. 
By  means  of  a  guarded  bistoury,  blunt  scissors,  and  polypus  for- 
ceps, the  entire  mass  was  removed  from  the  posterior  nares,  in- 
cluding with  it  a  large  i)ortion  of  the  inferior  turbinated  bones. 
The  hemorrhage  at  first  was  profuse,  but  was  soon  checked, 
and  a  careful  examination  of  the  parts  made.  The  whole  mid- 
dle and  superior  nasal  meatus  were  filled  with  the  tumor,  which 
could  also  be  felt  protruding  from  the  opening  into  the  left 
maxillary  antrum.  After  the  first  week  1  did  not  see  this  pa- 
tient again  until  five  months  had  elapsed,  when  he  came  again 
for  relief  of  his  respiration.  His  condition  was  then  deplor- 
able. The  left  eye  was  sightless,  the  cornea  cloudy  and  ulcer- 
ated, and  the  lids  could  not  be  closed.  The  growth  had  ap- 
peared as  a  large  protuberance  at  the  left  inner  canthus,  pro- 
jecting through  the  lids,  and  had  also  appeared  at  the  inferior 
margin  of  tlie  orbit  and  tilled  up  the  temporal  fossa.  He  had 
perception  of  light  still  in  the  right  eye,  in  which  the  optic  disc 
was  found  in  a  condition  of  gray  atrophy.  Both  nostrils  had 
again  filled  up  with  a  solid,  somewhat  resistant  mass.  I  re- 
peated the  same  operation,  removing  as  much  of  the  growth  as 
could  be  reached,  and  again  rendering  the  nostrils  free.  The 
mass  was  not  polypoid,  but  on  both  occasions  proved,  on  micro- 
scopical examination,  to  be  myxo-sarcomatous  in  character.  In 
two  months  the  nasal  meatus  had  filled  up  again,  while  the 
growth  in  the  right  orbit  had  increased  very  rapidly.  He  suf- 
fered greatly  from  pain  deep  in  the  orbits  and  frontal  headaches, 
but  lived  for  nearly  four  months  longer  without  any  additional 
head  symptoms,  and  finally  died  from  exhaustion.  In  this  case, 
although  all  the  deep  bones  of  the  face  and  skull  had  become 
involved,  the  tendency  of  the  growth  had  been  outward.  In 
spite  of  all  urging  an  autopsy  was  positively  refused.  Before 
death  the  tumor  had  perforated  the  conjunctiva  at  the  inner 
angle  of  the  left  eye,  and  extended  over  the  side  of  the  nose 
and  down  upon  the  cheek. 

Case  VI.  Melano-sarco7na  of  Conjunctica  and  Orbit. — Early 
in  August,  1881,  a  woman,  F.  A.,  aged  forty-five,  consulted 
me  and  gave  the  following  history:  About  two  months  before 
a  small,  dark  nodule  had  appeared  at  the  supero-temporal  mar- 
gin of  the  left  cornea,  seated  mainly  in  the  conjunctiva.  It  was 
slightly  movable,  and  slowly  increased  to  the  size  of  a  small 
Lima  bean.  When  I  saw  her  the  growth  had  encroached  some- 
what upon  the  cornea  and  was  painless  to  the  touch.  On  Au- 
gust 8th  I  removed  the  tumor,  which  was  found  to  be  adherent 
to  the  sclera,  and  extended  somewhat  along  the  infero-temporal 
margin  of  the  cornea.  Ij;  was  friable  and  bled  easily.  It  was 
thoroughly  removed,  and  the  surface  of  the  sclera  was  then 
scraped  and  cauterized,  and  the  edges  of  the  conjunctiva  brought 
together  loosely  over  the  wound.  I  did  not  see  the  patient 
again  until  November 4:th,  when  the  growth  had  returned.  The 
tumor  occupied  the  upper,  outer,  and  lower  quadrants  of  the 
ocular  conjunctiva  and  sclera,  and  covered  the  temporal  third 
of  the  cornea.  It  was  irregularly  lobulated  and  somewhat 
flattened,  dark  in  color,  quite  vascular,  and  non-sensitive.  It 
extended  above  the  eyeball  into  the  orbit  as  far  as  the  equa- 
torial region ;  the  eye  was  displaced  somewhat  toward  the  nose, 
and  its  motility  upward  and  inward  was  Umited.  The  field  of 
vision  was  limited  on  the  temporal  side,  but  central  vision  was 
still  H  +  ,  and  the  fundus  was  normal.  The  patient  was  told 
that  the  eye  must  be  enucleated  at  once,  and  on  November  21st 
the  entire  contents  of  the  orbit,  including  tumor,  eyeball,  and 
ocular  conjunctiva,  were  removed.  The  optic  nerve  was  divided 
far  back  and  looked  perfectly  healthy,  and  the  periosteum  of 


Jan.  14,  1893.J  BULL:   TUMORS  OF  THE  ORBLT  AND  NEIGEBORLNG  CAVITIES. 


43 


the  orbit  also  appeared  normal.  The  case  did  well,  and  there 
was  nothing  abnormal  noticed  until  the  following  June,  1882, 
when  a  small,  dark  nodule  was  found  on  the  outer  wall  of  the 
orbit  about  lialfv\'ay  back.  The  patient  declined  another  opera- 
tion, and  I  did  not  see  her  till  the  last  of  October,  when  the 
growth  tilled  the  orbit  and  protruded  between  the  lids.  It 
seemed  as  yet  to  be  confined  to  the  orbit,  for  the  naso-pharynx 
was  clear  and  there  was  no  evidence  of  any  trouble  in  the  maxil- 
lary antrutn.  The  patient  now  consented  to  an  operation,  and 
on  November  2,  1882,  the  entire  contents  of  the  orbit  were  re- 
moved with  ease,  though  the  haemorrhage  was  profuse.  The 
periosteum  was  then  cut  through  all  round  the  orbital  margin, 
and  was  stripped  up  on  all  sides  as  far  as  tlie  apex  of  the  orbit 
and  removed.  After  fhe  haamorrhage  had  ceased,  the  bone 
was  thoroughly  scraped,  and  then  the  orbit  was  washed  out 
with  a  sublimate  solution  (1  to  1,000).  There  was  little  or  no 
suppuration  and  the  raw  surface  soon  healed.  I  saw  this  pa- 
tient at  intervals  until  the  autumn  of  1886,  a  period  of  four 
years,  and  there  was  no  return  of  the  tumor  in  that  interval. 
She  then  disappeared  from  observation,  and  I  have  heard  nothing 
of  her  since.  All  the  specimens  removed  at  different  times  and 
examined  proved  to  be  true  melano-sarcoma.  The  eyeball  on 
examination  proved  a  very  interesting  specimen.  The  tumor 
was  almost  entirely  superficial  and  extrinsic.  None  of  the  tis- 
sues of  the  eye  were  invaded  by  the  growth  except  the  sclera, 
and  even  here  only  the  superficial  layers  were  infiltrated  by  the 
sarcoma  cells.  The  region  of  the  lymphatic  channels  around 
the  openings  of  the  vasa  vorticosa  was  entirely  free  from  any 
infiltration,  as  were  also  the  sheath  of  the  optic  nerve  and  the 
nerve  itself. 

Case  VII.  Fibrosarcoma  of  the  Orbit. — A  gentleman,  II. 
A.,  aged  twenty-two,  first  seen  on  June  12,  1882,  gave  the  fol- 
lowing history:  Has  always  been  perfectly  well,  and  has  never 
noticed  anything  abnormal  about  his  eyes  until  five  months  ago, 
when  the  right  eye  began  to  protrude.  Since  then  the  exoph- 
thalmus  has  slowly  but  steadily  increased,  but  there  has  never 
been  any  pain.  The  vision  of  the  right  eye  remained  good 
until  ten  days  ago,  when  it  suddenly  and  rapidly  became  im- 
paired, and  now  he  says  it  is  entirely  blind.  An  examination 
showed  that  vision  was  reduced  to  perception  of  light.  The 
protrusion  of  the  eye  was  forward  and  slightly  outward,  and 
motility  outward  and  inward  was  decidedly  impaired.  The  iris 
reacted,  the  media  were  clear,  and  the  fundus  showed  a  well- 
marked  condition  of  papillitis  with  haamorrhages.  At  the  inner 
side  of  the  orbit  a  tumor  could  be  felt,  apparently  springing 
from  the  inner  wall  of  the  orbit,  and  sen.sitive  on  pressure.  The 
left  eye  was  normal  in  every  respect.  The  patient  was  told  the 
probable  nature  of  the  trouble  and  consented  to  an  operation, 
which  was  done  on  June  14th.  The  external  canthus  was  in- 
cised for  the  distance  of  an  inch  outward  and  the  upper  lid 
turned  up  on  the  eyebrow.  The  ocular  conjunctiva  was  divided 
in  the  horizontal  meridian  from  the  internal  canthus  to  the  cor- 
neal margin.  The  tendon  of  the  internal  rectus  muscle  was 
divided  and  the  eye  turned  strongly  to  the  temple.  The  tumor 
could  then  be  plainly  seen  on  the  inner  wall  of  the  orbit,  its 
anterior  aspect  being  flattened.  By  means  of  blunt  hook  and 
blunt-pomted  scissors  it  was  readily  dissected  from  its  periosteal 
adhesions  and  removed  entire,  with  but  trifling  haemorrhage. 
It  proved  to  be  a  long,  flattened  growth,  the  size  of  a  large 
Lima  bean,  and  was  apparently  entirely  inclosed  in  a  capsule.  A 
careful  examination  of  the  orbit  discovered  no  trace  of  any  fur- 
ther growth,  and  the  muscles  and  optic  nerve  seemed  to  be  in- 
tact, though  the  latter  was  somewhat  flattened.  The  cavity 
was  then  carefully  washed  out  with  a  sublimate  solution  (1  to 
2,000),  the  tendon  ot  the  internal  rectus  was  stitched  in  place 
to  the  sclera,  the  conjunctiva  brought  together  and  closed  over 


the  opening  with  sutures,  and  the  slight  wound  in  the  can- 
thus  closed  in  the  same  way.  The  eye  was  then  bandaged 
in  the  usual  way.  Not  a  drop  of  suppuration  occurred, 
and  the  patient  was  discharged  at  the  end  of  a  week.  The 
tumor  was  hardened  and  sections  were  carefully  made  in  all 
directions.  It  proved  to  be  entirely  inclosed  in  a  fibrous  cap- 
sule, and  was  divided  into  several  ])arts  by  fibrous  trabeculae, 
which  seemed  to  be  prolongations  inward  of  the  fibrous 
capsule.  The  spaces  between  the  trabeciilse  were  filled  with 
large  and  small  round  cells,  with  nucleus  and  granular  contents. 
Regarded  as  a  whole,  the  growth  would  be  classed  as  a  sar- 
coma, or  possibly  a  fibro-sarcoma,  as  there  were  a  few  fusiform 
cells  between  the  fibers  of  the  trabeculfe.  The  superior  oblique 
muscle  was  not  injured.  The  patient's  vision  slowly  improved, 
so  that  at  the  end  of  a  month  he  could  count  fingers  at  three 
feet  from  the  eye,  but  beyond  this  it  did  not  improve,  and 
eventually  the  optic  disc  took  on  the  appearance  of  gray  atrophy. 
The  patient  was  last  seen  in  the  autumn  of  1884,  a  period  of 
more  than  two  years,  during  which  there  had  been  no  return 
of  the  growth,  and  from  the  encapsulated  condition  of  the  tu- 
mor it  is  probably  safe  to  conclude  that  it  has  not  reap[)eared. 

Case  VIII.  Fibrosarcoma  of  the  Sheath  of  the  Optic  Nerve 
and  Orbit. — Fanny  S.,  aged  seventeen,  was  first  seen  on  Sep- 
tember 24,  1884.  Two  years  before  she  had  suffered  from  an 
attack  of  meningitis,  during  which  the  vision  of  both  eyes  be" 
came  affected,  and  has  since  grown  slowly  but  steadily  worse. 
She  has  been  deaf  in  both  ears  for  eight  years,  the  cause  being 
catarrhal  inflammation  of  the  middle  ear  extending  from  the 
naso-pharynx.  The  right  eye  began  to  protrude  about  a  year 
ago,  and  the  exophthalmus  has  slowly  increased,  but  without  any 
pain.  When  I  saw  her,  the  right  eye  j)rotruded  forward  and 
outward  and  was  limited  in  motion  in  all  directions.  The  iris 
was  moderately  dilated  and  immovable.  The  fundus  showed  a 
gray,  atrophic  disc.  Vision  was  ,^^"5.  There  was  marked  en- 
gorgement of  the  subconjunctival  and  episcleral  veins.  The 
cornea  was  slightly  cloudy  from  old  keratitis.  In  the  left  eye 
the  cornea  was  still  more  cloudy,  and  the  iiis  was  dilated  above 
the  normal  and  very  sluggish.  The  optic  disc  was  discolored  on 
the  temporal  side  and  the  retinal  veins  looked  engorged.  A'ision 
was  1*0"^.  There  was  no  cxophthalmia  and  no  limitation  of  mo- 
tility. An  examination  of  the  naso-pharynx  showed  nothing 
abnormal  beyond  a  general  hypertrophy  of  the  mucous  mem- 
brane. There  was  no  trace  of  any  growth.  When  the  right; 
eye  was  pressed  backward,  a  hard  resisting  mass  was  felt  at  the 
bottom  of  the  orbit.  A  diagnosis  of  orbital  tumor  on  the  right 
side  was  somewhat  hypothetical,  and  the  patient  was  told  that 
she  must  await  developments.  The  cxophthalmia  slowly  in- 
creased and  vision  slowly  grew  worse,  but  nothing  absolutely 
certain  was  discovered  until  eight  months  had  elapsed,  when  a 
growth  was  for  the  first  time  felt  on  the  nasal  side  of  the  orbit. 
The  patient  was  then  told  that  an  operation  was  necessary  and 
that  the  eye  must  be  enucleated,  to  which  she  consented.  The 
eyeball  was  first  removed  in  the  ordinary  way,  great  difiiculty 
being  met  with  in  cutting  the  optic  nerve;  and,  on  examining 
the  eye  after  removal,  the  whole  nerve  was  found  to  be  envel- 
oped in  a  dense  fibrous  mass,  showing  that  the  tumor  had  been 
cut  through.  The  entire  contents  of  the  orbit,  including  the 
conjunctiva,  were  then  removed,  considerable  dissection  being 
necessary  around  the  optic  foramen.  The  periosteum  was  ap- 
parently healthy  except  at  the  apex  of  the  orbit,  where  it  was 
much  roughened  from  the  adhesions  to  the  growth.  The  latter 
measured  about  three  quarters  of  an  inch  in  length  and  was 
roughly  molded  to  the  shape  of  the  orbit.  The  optic  nerve 
l)assed  nearly  through  its  center  and  was  decidedly  flattened. 
The  orbit  was  then  washed  out  antiseptically  and  bandaged  in 
the  usual  way.    There  was  no  defect  in  the  orbital  walls,  and. 


44 


BATES:  A  CASE  OF  OTITIS  MEDIA. 


[N.  Y.  Med.  Jour., 


no  apparent  prolongation  of  the  tumor  into  any  of  the  neigh- 
borinu'  cavities.  A  careful  examination  of  the  growth,  after 
hardening,  showed  that  it  mainly  involved  the  sheath  of  the 
optic  nerve,  the  nerve  itself  being  but  slightly  encroached  upon. 
It  could  not  positively  be  decided  whether  the  tumor  had  origi- 
nated in  the  sheath  or  in  the  periosteum  of  the  orbit.  It  ex- 
tended forward  upon  the  sclerotic  for  a  short  distance,  this 
membrane  being  intimately  involved  in  the  pathological  i)ro- 
cess.  Sections  through  the  tumor,  both  longitudinally  and 
transversely,  showed  it  to  be  composed  almost  entirely  of  con- 
nective tissue  bundles,  the  fibers  being  densely  pressed  together. 
In  some  places  between  the  fibers  were  a  few  fusiform  cells. 
Tiie  nearer  the  optic  nerve  was  approached  the  denser  became 
the  fibers.  The  cells  in  the  perineural  lymphatic  space  were  in- 
creased in  number  and  size.  The  optic  nerve  behind  the  eye 
and  within  the  tumor  was  flattened  and  showed  signs  of  inter- 
stitial neuritis.  The  optic  disc  and  the  immediately  surround 
ing  zone  of  the  retina  showed  the  traces  of  neuro-retiintis,  but 
the  rest  of  the  eyeball,  with  the  exception  of  the  cornea,  was 
normal. 

The  patient  rapidly  recovered  and  has  been  carefully  watched 
since,  but  no  return  of  the  tumor  has  been  observed.  An  in- 
teresting feature  in  the  case  is  the  possible,  I  might  almost  say 
the  probable,  connection  between  the  preceding  meningitis  as  a 
cause  and  the  development  of  the  orbital  tumor  as  the  effect. 
We  know  that  complications  on  the  side  of  the  eye  are  by  no 
means  infrequent  during  or  after  the  meningeal  disease.  The 
ocular  complication  is  sometimes  a  purulent  chorioiditis,  but 
more  often  it  is  a  neuro-retinitis,  with  or  without  papillitis.  It 
is  by  no  means  an  improbable  supposition  that,  in  the  case  just 
described,  the  intracranial  inflammation  extended  along  the 
membranes  of  the  brain,  involved  the  dural  sheatli  of  the  optic 
nerve,  and  set  up  a  hypertrophic  vaginitis,  which  subsequently 
took  on  the  form  of  a  tumor  of  the  optic  nerve,  or  more  properly 
of  the  nerve  sheath,  compressing  the  optic  nerve  and  producing 
the  exo[)hthalmus. 

O'ASE  IX.  Cyst  of  the  Orbit  and  Ethmoid  Cells.  —On  Octo- 
ber 6, 1884,  a  young  child,  Jennie  S.,  aged  two  years  and  a  half, 
was  brought  to  me  by  the  mother,  who  gave  the  following  his- 
tory :  About  a  year  before,  after  an  attack  of  bronchitis,  the 
mother  noticed  a  small  swelling  at  the  inner  angle  of  the  left 
orbit  beneath  the  upper  lid  which  caused  the  lid  to  protrude. 
This  was  much  less  marked  when  the  child  was  lying  down  than 
when  she  was  in  an  erect  position.  It  had  grown  somewhat  in 
size  during  the  year.  There  had  been  no  other  symptom.  When 
I  saw  the  child  there  was  a  small  circumscribed  orbital  growth 
at  the  upper  and  inner  angle  of  the  left  orbit,  beneath  the  upper 
lid  and  outside  the  periosteum.  When  the  child  sat  or  stood 
the  protrusion  occupied  the  region  of  the  inner  canthus  above 
the  lacrymal  sac,  but  when  she  lay  down  it  receded  almost  en- 
tirely from  view.  It  felt  elastic  and  I  concluded  it  was  an  ex- 
ample of  a  i-etention  cyst  of  the  orbit.  The  tumor  was  punctured 
through  the  cul-de-sac  beneath  the  lid,  and  a  quantity  of  clear, 
straw-colored  fluid  escaped,  and  the  cyst  at  once  collapsed.  I 
told  the  mother  that  the  little  tumor  might  return,  but  that  the 
child  was  so  young  it  might  be  better  to  wait  and  see  whether 
any  more  serious  operation  would  be  necessary.  For  nearly 
three  months  there  was  no  return  of  the  cyst.  Then  it  began 
to  fill  u[)  again  and  soon  regained  its  former  dimensions.  The 
mother  also  noticed  that  when  the  head  was  bent  forward  the 
swelling  became  much  more  prominent  than  ever  before.  I 
then  determined  to  attempt  the  removal  of  the  entire  cyst,  still 
regarding  it  as  a  retention  cyst  developed  in  the  orbital  tissue. 
The  njjper  lid  was  strongly  everted  and  the  eyeball  turned  to 
the  outer  canthus  and  held  there  by  a  strong  suture  passed 
through  the  conjunctiva  on  the  nasal  side  of  the  cornea,  cross- 


ing the  cornea  and  passing  through  the  skin  of  the  extei-nal 
canthus.  The  cul-de-sac  was  then  opened  at  tiie  inner  canthus 
and  the  cyst  at  once  presented.  It  extended  well  up  under  the 
arch  of  the  orbit  and  far  back  into  the  orbit,  but  seemed  to  hug 
the  inner  wall.  Its  attachments  to  the  orbital  tissue  were  very 
slight  and  easily  broken,  hut  on  the  side  of  the  bone  they  were 
more  firm,  and  in  endeavoring  to  separate  the  cyst  wall  from 
one  of  these  adhesions  the  sac  ruptured  and  a  large  quantity  of 
cloudy  yellowish  fluid  escaped.  The  cyst  collapsed  and  my  fin- 
ger passed  into  a  large  cavity.  An  examination  showed  that 
the  orbital  plate  of  the  ethmoid  bone  and  most  of  the  lacrymal 
bone  were  absent  and  that  tbe  ethmoid  cells  formed  one  large 
cavity  which  comtnunicated  with  the  superior  nasal  meatus. 
This  was  proved  by  the  fluid  used  in  washing  out  the  orbit  and 
cavity  in  the  bone  passing  down  and  out  through  the  nostril.  A 
drainage-tube  was  then  inserted.  The  little  patient  did  very 
well.  There  was  hardly  any  suppuration,  the  draiuiige  tube 
was  removed  on  the  third  day,  and  the  child  was  discharged  on 
the  eighth  day.  There  has  been  no  return  of  the  disease,  but 
there  was  rather  a  marked  sinking  in  of  the  tissues  at  the  inner 
canthus  and  beneath  the  inner  end  of  the  orbit,  so  that  there  is 
a  decided  difference  in  the  appearance  of  the  two  eyes. 

If  there  had  been  a  carious  process  in  the  bone  which  led  to 
the  disappearance  of  the  inner  wall  of  the  orbit,  there  would 
almost  certainly  have  been  some  general  as  well  as  local  symp- 
toms in  the  child  during  the  process.  For  this  reason  I  am  more 
inclined  to  regard  the  case  as  one  of  congenital  absence  or  arrest 
of  development  of  the  inner  wall  of  the  orbit,  and  the  cystoid 
develoi)ment  in  the  cavity  of  the  ethmoid  and  orbit  as  the  result 
of  a  chronic  catarrhal  irritation  of  the  nasal  passages,  perhaps 
connected  with  the  bronchitis  from  which  the  child  had  suf- 
fered. 

(To  be  concluded.) 


A  CASE  OF  OTITIS  MEDIA 

DEVELOPING  GRAVE  SYMPTOMS  OF  BRAIN"  PRESSURE 
AND  ENDING  IN  RECOVERY  WITHOUT  OPERATION. 

By  H.  ELLIOTT  BATES,  M.  D., 

POnGHKBBPSIE,  N.  T. 

Inflammation  of  the  middle  ear — otitis  media — is  of 
interest  not  only  to  the  otologist  but  also  to  the  surgeon 
and  general  practitioner,  from  the  fact  that  in  a  small  but 
important  proportion  of  cases  it  leads  to  results  which 
render  the  diagnosis  as  important  as  it  is  often  difficult 
and  calls  for  prompt  and  usually  operative  treatment. 

Cases  of  cerebral  abscess  occurring  with  or  following 
otitis  media  are  to  be  found  in  every  standard  medical  jour- 
nal. Mayo  {Northwestern  Lancet,  February  15th),  Pritch- 
ard  [Revue  de  laryngologie  et  otologie,  Paris,  August  15th), 
S.  Paget  {British  Medical  Journal,  May  16th),  Gluck 
{Archiv  fur  Kinder heilkunde,  Stuttgart),  have  reported  cases 
in  which  recovery  took  place  after  operation  in  all  save  the 
last.  But  a  case  which  some  time  ago  came  under  obser- 
vation of  the  writer  is  unique,  from  the  fact  that  although 
symptoms  of  so  grave  a  nature  as  to  lead  to  an  unfavorable 
prognosis  existed,  yet  the  recovery  took  place  without  the 
aid  of  operative  treatment. 

The  patient,  a  boy  of  fourteen,  had  always  been  strong  and 
healthy,  active  and  intelligent,  with  the  exception  of  a  dis- 
charge from  the  left  ear  which  had  existed  for  a  long  time. 

Naturally  good-tempered  and  obliging,  lie  had  been  noticed 


Jan.  14,  1893.1 


LEADING  ARTICLES— MINOR  PARAGRAPHS. 


45 


to  have  become  peevish,  (retfiil,  and  subject  to  fits  of  drowsi- 
ness, during  whicli  he  would  fall  asleep  even  at  the  dinner- 
table.  At  sucli  times  it  was  seen  that  tlie  discharge  ceased. 
Several  times  lie  had  flown  into  a  passion  upon  a  trivial  irrita- 
tion, complained  of  headache,  ringing  sounds  in  liis  head,  and 
"spots  before  his  eyes."  This  continued  for  over  a  month, 
when  one  day,  wliile  at  school,  upon  being  reproved  by  the 
teacher  for  some  sliglit  misdemeanor,  he  became  furious,  tlirevv 
school-books  al)out,  and  was  only  by  force  restrained  from  in- 
juring his  companions.  A  carriage  was  obtained  and  he  was 
taken  home.  On  the  way  lie  became  comatose,  with  stertorous 
breatliing  and  contracted  pupils.  A  physician  was  called,  who 
pronounced  it  a  "rush  of  blood  to  the  head,"  and  prescribed 
rest  and  a  small  dose  of  calomel. 

The  boy  slowly  regained  consciousness,  but  when  seen  by 
the  writer  was  unable  to  move  the  right  arm  and  leg.  The 
skin  was  insensible  to  puncture  with  a  needle;  the  contact  of 
the  needle  with  the  skin  was  appreciated,  but  referred  to  the 
opposite  side  of  the  limb.  Total  motor  paralysis  existed.  Tlie 
face  was  tlattened  upon  the  right  side,  the  eyelid  drooped  and 
could  not  be  raised.  Vision  in  the  right  eye  was  slightly  im- 
paired, the  tongue  deviated  to  the  side,  and  taste  upon  the  right 
half  was  dulled.  There  was  evidence  of  incontinence  of  the 
sphincter.  As  the  case  was  in  charge  of  another  physician,  no 
treatment  was  prescribed  except  that  the  patient  was  placed 
upon  his  left  side.  Two  days  later  he  was  found  in  a  comatose 
condition,  and  only  the  prolonged  use  of  a  strong  electric  cur- 
rent restored  him  to  consciousness.  Soon  after  a  sudden  and 
profuse  discharge  of  purulent  fluid  took  place  from  the  ear,  the 
paralysis  of  the  face  and  arm  disappeared,  and  the  boy  began  to 
get  about  on  crutches.  Slow  but  steady  improvement  followed, 
and  when  last  seen  by  the  writer  he  was  engaged  in  "mowing 
away  "  a  load  of  hay. 

The  symptoms  were  so  grave  as  to  give  rise  to  an  un- 
favorable prognosis  by  one  of  the  physicians  who  saw  it. 
An  operation  was  declined  by  the  family. 
102  Market  Street. 


The  Alamni  Association  of  the  Woman's  Hospital  will  hold  its  an- 
nual meeting  at  the  New  York  Academy  of  Medicine  on  Tuesday  and 
Wednesday,  the  17th  and  18th  inst.  The  custom  of  reading  papers 
has  been  superseded  by  a  plan  of  assigning  topics  for  discussion.  Three 
topics  have  been  chosen  for  the  coming  meeting :  Pelvic  Adhesions, 
The  Treatment  of  Extra-uterine  Pregnancy,  and  When  should  the 
Parturient  Woman  be  allowed  to  assume  the  Upright  Posture  ?  Dr. 
Thomas  Addis  Emmet  will  read  a  paper  in  which  he  will  give  reminis- 
ences  of  the  consulting  board  of  the  Woman's  Hospital.  Dr.  E.  C. 
Dudley,  of  Chicago,  will  present  a  new  operation  for  the  cure  of  proci- 
dentia uteri.  A  new  feature  in  the  programme  is  the  practical  recog- 
nition of  the  fact  that  it  is  impossible  to  get  a  good  attendance  of 
New  York  men  at  a  morning  session.  A  number  of  prominent  general 
surgeons  have  promised  to  make  special  efforts  to  have  operations  on 
the  abdominal  viscera  to  occupy  the  morning  hours.  This  will  be  of 
the  greatest  interest  and  profit  to  those  alumni  who  may  not  frequently 
see  these  gentlemen  operate. 

The  Columbian  University  in  Washington. — This  institution  is  said 
to  have  withdrawn  from  the  co-educational  ranks  for  the  alleged  reason 
that  the  presence  of  women  in  the  medical  department  had  had  the 
effect  of  keeping  male  students  away.  The  university  could  not  afford 
to  become  gradually  transposed  into  a  female  seminary. 

The  New  York  Ophthalmological  Society. — At  the  annual  meeting, 
held  on  Monday,  January  9th,  tlie  following  officers  were  elected :  Presi- 
dent, Dr.  W.  r.  Mittendorf  ;  vice-president,  Dr.  W.  S.  Dennett ;  secre- 
tary and  treasurer.  Dr.  Frank  N.  Lewis  ;  committee  on  adudssions,  Dr. 
U.  D.  Noyes,  Dr.  C.  E.  llackley,  and  Dr.  David  Webster. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekhj  Review  of  Medicine. 

Published  by  Edited  by 

0.  Applbton  &  Co.  Frank  P.  Poster,  M.  D 


NEW  YORK,  SATURDAY,  JANUARY  14,  1893. 


THE  EMPLOYMENT  OF  EPILEPTICS. 

In  an  editorial  paragraph,  the  Lancet  remarks  upon  the  es- 
tablishment in  England  of  a  home  for  patients  affected  with  epi- 
lepsy and  similar  disorders.  Quite  recently  there  has  been 
opened  at  Godalming  an  institution  called  Lady  Meath's  Home 
of  Comfort  for  Epileptics,  and  a  benevolent  organization  to  be 
known  as  the  National  Society  for  the  Employment  of  Epilep- 
tics has  been  formed  for  the  purpose  of  providing  for  needy  epi- 
leptics who  are  able  and  willing  to  work,  a  part  of  the  time  at 
least,  but  are  practically  debarred  from  obtaining  situations  on 
account  of  their  infirmities.  A  series  of  cottages,  it  is  expected, 
will  be  occupied,  each  of  which  will  accommodate  from  ten  to 
twenty  epileptics.  The  sexes  will  be  separated,  and  children 
and  adults  will  be  kept  apart.  The  institution  will  be  con- 
ducted on  a  system  similar  to  what  has  been  so  successful  at 
the  Bielefeld  Epileptic  Colony,  and  a  beginning  is  soon  to  be 
made  with  a  few  male  patients.  Market-gardening  and  spade- 
and-barrow  labor  will  be  among  the  initial  industries,  but  as 
the  colony  extends,  other  pursuits  and  even  some  of  the  me- 
chanical arts  will  develop.  It  is  hoped  that  in  this  way  there 
will  be  a  prospect  of  self-support,  partial  at  first,  growing  with 
the  growth  of  the  institution.  The  colony  or  home  will  from 
the  first  be  under  medical  supervision  and  without  sectarian 
limitations.  While  it  will  be  primarily  for  the  benefit  of  the 
poor,  the  home  will  extend  its  advantages  to  patients  with 
financial  means,  who  will  be  received  as  boarders. 


MINOR    PA  RA  OR  A  PUS. 

THE  OUTLOOK  AS  TO  INFLUENZA. 

There  have  been  some  cases  of  influenza  in  New  York  since 
the  middle  of  autumn,  and  the  Lancet  for  December  31st  an- 
nounces that  a  number  of  persons  have  been  attacked  with  the 
disease  in  Shefltteld,  that  isolated  cases  have  been  reported  from 
other  places  in  England,  and  that  London  is  not  wholly  free 
from  it.  The  news  of  its  recurrence  in  epidemic  form  in  KiefF, 
Odessa,  Kherson,  NicolaieS',  and  other  places  in  southern  Rus- 
sia and  of  attacks  in  the  more  northerly  parts  of  that  country 
the  Lancet  takes  as  an  unmistakable  sign  that  the  disease  will 
prevail  again  in  Great  Britain  this  winter,  although  it  regards  it 
as  highly  improbable  that  it  will  attain  to  anything  like  the 
dimensions  of  its  previous  outbreaks.  It  is  well  to  bear  these 
considerations  in  mind  with  reference  to  the  chances  of  recur- 
rent epidemics  in  America. 


QUACKERY  PUNISHED  IN  GREAT  BRITAIN. 

An  American  quack  professing  to  be  a  graduate  of  the  Cin- 
cinnati Eclectic  Medical  College,  and  advertising  himself  as  a 
"  great  American  physician  "in  certain  Irish  and  Scottish  cities, 


46 


MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Med.  Joub., 


has  been  convicted  and  sentenced  to  a  term  of  eifjliteen  months 
at  hard  labor.  The  charge  was  not  made  under  the  Medical 
Act,  but  simply  for  obtaining  money  under  false  pretenses. 
The  quack  was  known  as  "Dr.  Hale,"  and  commonly  had  an 
associate  or  accomplice  in  the  ditferent  cities  that  he  visited. 
The  man  was  brought  to  justice  through  the  instrumentality  of 
a  medical  practitioner  of  Dublin,  who  played  the  part  of  volun- 
teer detective. 


THE  ADMINISTRATION  OF  QUININE  TO  NURSING 
WOMEN. 

In  the  Revue  generale  de  clinique  et  de  therapeutique  for 
December  7,  1892,  there  is  an  article  by  M.  Oui,  who  has  ex- 
perimented upon  the  influence  of  quinine  on  sucklings  when  it 
is  given  to  the  mother  or  wet-nurse.  From  an  abstract  of  M. 
Oui's  article  given  in  Lyon  medical  fur  December  25th  it  ap- 
pears that  that  observer  has  satisfied  himself  that  only  a  minute 
proportion  of  the  quinine  administered  passes  into  the  milk — a 
proportion  far  too  small  to  affect  the  child  injuriously. 


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  week.s  ending  January  10,  1893: 


DISEASES. 


Typhus  

Typhoid  fever  

Scarlet  fever  

Cerebro-spinal  meningitis 

Measles  

Diphtheria  

Small-pox  


Week  ending  Jan.  1. 


Cases.  Deaths. 


63 
16 
112 
1 
86 
132 
2 


1 

12 
6 
2 
10 
63 
1 


Weekending  Jan.  10. 


Cases.  Deaths. 


56 
17 
143 
4 
117 
154 
1 


9 
1 
8 
42 
1 


Columbia  College. — In  the  department  of  biology  of  the  school  of 
pure  science,  Mr.  Edmund  B.  Wilson,  Ph.  D.,  adjunct  professor  of 
biology,  will  continue  liis  course  of  lectures  on  The  Cellular  Basis  of 
Heredity  and  Development  as  follows  : 

Thursday,  January  19ih,  Cell  Genesis  and  Division. 

TJiumday,  January  26th,  Egg  and  Spermatozoon.  The  Preparation 
for  Development. 

TTmrsday,  February  Sd,  Physiology  of  the  Individual  Cell. 

Thursday,  February  9th,  Intercellular  Dynamics.  Theories  of 
Heredity. 

Mr.  Bashford  Dean,  Ph.  D.,  instructor  in  biology,  will  give  a  course 
on  The  Origin  and  Evolution  of  the  Fishes  as  follows : 

Thursday,  February  IGtli,  The  General  Structure  of  Fishes. 
Thursday,  February  23d,  Sharks  and  Rays — fossil  and  recent. 
Thursday,  March  2d,  The  Teleosts. 
Tliursday,  March  9th,  The  (Janoids. 

TliuTsday,  March.  IGlh,  Chimaera  and  the  Lung-fishes.  The  New- 
bury collection  of  Giant  Placoderms. 

Thursday,  March  23d,  The  Embryology  of  Fishes. 

Mr.  Arthur  Willey,  B.  Sc.,  tutor  in  biology,  will  give  a  course  on 
Amphioxus  and  other  Ancestors  of  the  Vertebrates  as  follows : 

Thursday,  March  30th,  Introduction,  History,  Mode  of  Life,  and 
Distribution. 

Thursday,  Ajyril  6th,  General  Structure. 

Thursday,  April  13th,  Nervous,  Vascular,  and  Excretory  Systems. 

llvursday,  April  20th,  Reproduction  and  Development. 

Thursday,  April  27th,  Larval  Growth  and  Metamorphosis.  Rela- 
tionships of  Amphioxus  to  other  Types. 

These  courses  follow  the  lectures  given  by  Professor  Henry  F. 
Osborn  on  The  History  of  the  Theory  of  Evolution,  and,  especially  Mr. 
Wilson's,  will  be  of  special  intercut  to  physicians. 


The  Proposed  Colony  for  Epileptics  in  New  York  State. — In  ac- 
cordance with  the  ])r()visions  of  (Ihaptcr  ''M'-',  of  the  Laws  of  1892  mak- 
ing the  State  Board  of  Charities  a  commission  to  select  a  site  and  pre- 
pare plans  for  a  colony  for  epileptics  in  the  State  of  New  York,  tins 
body  on  Wednesday,  the  11th  inst.,  made  its  report.  The  tract  of  land 
selected  is  the  Shaker  Colony  near  Geneseo,  in  Livingston  County.  We 
quote  the  following  from  the  board's  printed  report : 

"  Soiiyea  Property. — This  property,  situated  in  the  (ienesee  Valley, 
about  three  miles  from  Mount  Morris,  in  Livingston  County,  is  owned 
by  the  Sonyea  Society  of  United  Christian  Believers,  the  members  of 
which  have  within  a  few  weeks  joined  the  similar  society  near  Water- 
vliet,  N.  Y.  One  of  the  original  purposes  of  the  society,  many  years 
ago,  was  to  take  and  train  children,  some  of  whom  would  take  the  places 
of  deceased  members ;  but  as  the  multiplication  of  orphan  asylums  in 
the  regions  round  about  has  interfered  with  tlie  supply  of  recruits  to 
the  society,  of  which  one  of  the  practices  is  celibacy,  its  present  mem- 
bers are  generally  advanced  in  years  and  unable  to  continue  its  exist- 
ence. Their  expressed  wish  is  to  have  the  Sonyea  property  dedicated 
to  some  public  work  of  a  charitable  nature. 

"The  land  is  in  one  tract  comprising  over  eighteen  hundred  acres, 
traversed  by  two  streams,  one  spring,  brook,  or  creek  issuing  from 
springs  which  are  situate  principally  on  the  prendses,  and  the  other, 
the  Cashauque  Creek,  rising  about  thirty  miles  above,  and  flowing 
through  the  land  in  question,  in  a  deep  gorge  with  a  fall  of  one  hundred 
and  six  feet  on  the  premises,  dividing  them  into  nearly  etjual  parts. 
This  gorge  with  creek  is  of  immense  advantage  for  the  complete  sepa- 
ration of  the  sexes  in  free  colony  life. 

"A  report  from  George  J.  Metzger,  of  Buffalo,  a  competent  archi- 
tect, showing  general  design  and  ground  plans  for  new  buildings  and 
improvements  to  accommodate  a  population  of  six  hundred,  with  future 
increase  as  indicated  by  the  statute,  is  also  filed  in  the  office  of  the 
board. 

"  This  report  has  been  made  by  the  architect  under  the  supervision 
and  approval  of  Commissioner  Letchworth,  of  the  committee,  and  Dr. 
Frederick  Peterson,  of  New  York  city,  who  has  on  several  occasions 
visited  the  site  for  inspection,  and  Albany  and  Buffalo  for  consultation, 
refusing  all  compensation  for  his  time  or  services.  Dr.  Peterson  is  a 
specialist  skilled  in  the  treatment  of  epilepsy  and  nervous  diseases,  and 
acquainted  with  the  colony  for  epileptics  at  Bielefeld,  Westphalia,  who 
has  lately  been  consulted  in  the  establishment  of  an  institution  for  epi- 
leptics in  the  State  of  Ohio.  His  advice  and  co-operation  with  the  board, 
from  the  beginning,  have  been  of  great  benefit,  and  have  been  as  freely 
accepted  as  given,  inasmuch  as  Dr.  Peterson  would  not  suffer  himself  to 
be  included  in  any  list  of  possible  candidates  for  the  office  of  superin- 
tendent of  the  colony  or  any  position  of  emolument  relating  to  it. 

"  His  written  memorandum  of  his  first  inspection  of  the  site,  made 
at  the  request  of  the  committee,  with  his  conclusions,  is  in  the  form  of 
a  letter  to  the  president  of  the  board,  dated  November  1,  1892,  and  on 
file  in  its  office. 

"  The  soil  is  very  fertile  and  easily  tilled,  inviting  the  light  labors  of 
invalid  patients,  for  their  own  physical  and  mental  benefit,  as  well  as  for 
their  maintenance.  It  is  of  various  qualities  adapted  respectively  to 
grains,  vegetables,  and  fruits.  Mr.  Alexander,  one  of  the  elders  of 
United  Society  of  Christian  Believers,  and  a  trustee  of  its  property, 
states  that  in  one  year  the  society  sold  ten  thousand  dollars'  worth  of 
crops  from  the  land,  besides  those  consumed  thereon  by  the  community. 
On  tile  in  the  office  of  the  board  is  a  written  memorandum  of  statements 
made  by  Mr.  Alexander.  .  .  .  This  memorandum  relates  to  the  soil  and 
crops  considered  in  the  foregoing,  and  to  the  stables  and  barns.  These 
stables  and  barns  are  of  magnificent  proportions,  and  are  substantially 
built  upon  api)roved  plans.  The  other  buildings  are  also  on  good  foun- 
dations and  are  well  built  of  good  materials.  They  are  of  sufficient  ca- 
pacity, in  the  opinion  of  the  committee  and  the  board,  to  accommodate 
))ctween  three  and  four  hundred  patients  at  the  present  time. 

"  The  buildings,  which  as  represented  cost  about  eighty  thousand 
dollars,  present  two  essential  features — viz.  :  First.  They  are  plain  and 


Jan.  14,  1893.] 


ITEMS. 


47 


economical,  though  substantial  and  attractive,  and  afford  an  assured  ba- 
sis for  future  expenditures  in  buildinjis  and  improveruents  with  due  re- 
gard to  economy,  of  which  many  State  institutions  have  not  been  duly 
regardful.  Second.  The  buildings  include  a  chapel,  or  church,  a  school- 
house,  a  structure  ailapted  to  an  infirmary  or  hospital  for  cases  coming 
directly  and  constantly  under  medical  treatment  or  care,  a  laundry,  a 
dining  hall,  and  numerous  cottages  for  dwellings,  and  shops  for  the 
teaching  and  profitable  prosecution  of  trades,  with  the  complete  and  ex- 
tensive barns  and  stables  already  alluded  to  ;  and  all  the  said  structures 
and  improvements  are  on  the  said  statutory  plan — namely,  that  of  a 
colony. 

"  The  healthfulness  of  the  site  and  general  sanitary  conditions  are 
attested  by  four  affidavits,  respectively  of  three  physicians  of  high 
staniling  in  the  county  and  a  member  of  the  .-society,  w  hich  are  tiled  in 
the  office  of  the  board. 

"  The  only  disadvantage  of  the  situation  is  its  distance  from  the 
center  of  population.  But  this  is  more  apparent  than  real  on  accoimt 
of  the  excellent  railway  accommodations  already  mentioned;  and,  in 
the  judgment  of  the  committee  and  board,  is  overruled  by  the  forego- 
ing considerations,  which  make  the  site  in  all  other  respects  not  only 
relatively  but  absolutely  good.  The  Sonyea  property  in  its  entirety  far 
surpasses  any  of  the  other  proposed  sites ;  and  from  the  nature  of  the 
case  it  must  be  unrivaled  in  any  part  of  the  State,  and,  except  as  to  its 
relation  to  center  of  population,  fulfills  ideal  conditions. 

"  Recommendations  and  Conclusions. — From  the  foregoing  consider- 
ations and  on  general  principles,  and  in  pursuance  of  the  provisions  of 
chapter  503  of  the  Laws  of  18112,  the  State  Board  of  Charities  respect- 
fully submits  to  the  Legislature  the  following  recommendations  and 
conclusions : 

"  I.  There  should  be  established  in  Livingston  County  in  this  State 
a  colony  for  epileptics,  to  be  known  as  the  Sonyea  Colony. 

"  II.  There  should  be  excluded  from  the  colony,  at  least  in  its  be- 
ginnings and  formative  stages,  all  insane  epileptics,  for  two  reasons — 
viz.,  First.  Their  presence  would  throw  a  cloud  over  the  brightness  and 
joyousness  that  should  prevail  so  far  as  possible  ;  and  would  set  limits 
to  the  free  life  of  the  colony ;  and  would  tend  to  restrict  commitments 
and  intrustments  of  non-insane  patients.  Second.  Proper  buildings  and 
accommodations  for  msane  epileptics  would  cost  more  than  due  provis- 
ion for  the  insane  at  the  existmg  State  hospitals,  inasmuch  as  there 
buildings  and  appointments  for  administration  are  already  provided  ; 
and  any  saving  to  the  State  at  the  said  hospitals  by  transfers  of  patients 
from  them  to  the  colony  would  be  more  than  offset  by  increased  expend- 
iture at  the  colony. 

"  III.  The  objects  should  be  to  secure  a  community  for  the  humane, 
curative,  scientific,  and  economical  treatment  and  care  of  epileptics, 
exclusive  of  insane  epileptics ;  to  frlfill  which  design  there  should  be 
provided,  among  other  things,  a  tract  of  fertile  and  productive  laud,  in 
a  healthful  situation,  with  an  abundant  supply  of  wholesome  water, 
sufficient  means  for  drainage  and  disposal  of  sewage,  and  sanitary  con- 
ditions ;  and  there  should  be  furnished,  among  other  necessary  struc- 
tures, cottages  for  dormitoiy  and  domiciliary  uses,  buildings  for  an  in- 
firmary, a  schoolhouse,  and  a  chapel,  workshops  for  the  proper  teach- 
ing and  productive  prosecution  of  trades  and  industries — all  of  which 
structures  should  be  substantial  and  attractive,  but  plain,  and  moderate 
in  cost,  and  arranged  on  the  colony  or  village  plan. 

"  IV.  There  should  be  a  board  of  nine  managers  of  the  Sonyea 
Colony,  appointed  by  the  Governor,  by  and  with  the  advice  and  consent 
of  the  Senate.  The  full  term  of  office  of  each  appointed  manager 
should  be  eight  years,  after  the  first  appointments ;  and  the  terra  of 
office  of  one  of  such  managers  should  expire  annually.  To  effect  such 
order  of  expiration  of  terms  of  managers,  the  first  appointments  should 
be  made  for  the  respective  terms  of  eight,  seven,  six,  five,  four,  three, 
two,  and  one  years.  Appointments  of  successors,  and  of  persons  to 
fill  vacancies  occurring  by  death,  resignation,  or  failure  in  attendance 
at  meetings,  should  be  made  without  delay.  Failure  of  any  manager 
to  attend  the  whole  of  two  consecutive  stated  meetings  of  the  board 
should,  at  its  election,  cause  a  vacancy  in  his  office.  The  qualifica- 
tions of  such  managers  should  be  as  follows :  Two  of  said  managers 
should  be  well-educated  physicians ;  one  or  two  of  the  managers  should 


be  women  ;  and  all  of  said  managers  should  be  citizens  of  the  State 
and  residents  respectively  as  follows :  One  in  each  of  the  eight  judicial 
districts  of  the  State,  with  one  additional  manager  for  the  city  and 
county  of  New  York ;  but  no  manager  should  reside  in  the  town  where 
said  colony  is  located  or  in  Livingston  County,  the  object  of  such  re- 
striction being  to  prevent  local  influence  for  local  expenditures  of  State 
monev  beyond  general  requirements  or  necessary  uses.  The  managers 
should  receive  no  compensation  for  their  services,  V)ut  should  be  allowed 
their  reasonable  traveling  and  official  expenses,  when  duly  verified  and 
approved  by  an  auditing  committee  of  the  board,  and  duly  presented  to 
the  treasurer  of  the  colony  for  payment. 

"  V.  The  board  of  managers,  within  sixty  days  from  their  appoint- 
ment, should  submit  to  the  Attorney-General  the  land  contract  with 
option  in  the  State,  reported  to  the  Legislature  by  the  State  Board  of 
Charities  at  this  session,  and  an  official  search  and  abstract  of  the  title 
of  the  tract  of  land  described  in  said  contract,  containing  eighteen 
hundred  acres  more  or  less,  lately  occupied  and  owned  by  the  United 
Society  of  Christian  Believers,  situate  in  Groveland,  in  Livingston 
County ;  and  if  such  title  shall  be  approved  by  the  Attorney-General 
and  certified  by  him  to  be  good  and  free  from  incumbrance,  the  board 
of  managers  should,  within  thirty  days  thereafter,  accept  a  good  and 
sufficient  deed  of  conveyance  of  said  tract  of  land  to  the  State,  to 
be  approved  by  the  Attorney-General ;  and  thereupon  the  treas\irer  of 
the  State,  on  the  warrant  of  the  comptroller,  should  pay  therefor,  in 
manner  to  be  provided,  the  consideration  of  $125,000,  with  proportion- 
ate reduction  for  deficiency,  if  any,  in  the  quantity  of  land,  which  is 
assumed  in  said  contract  to  be  at  least  eighteen  hundred  acres  for  said 
purchase  price.  Provided  that  if  such  title  shall  not  be  approved,  or 
such  deed  w  ith  a  good  title  free  from  incumbrance  can  not  be  secured, 
the  board  of  managers  should  so  soon  as  practicable  report  the  facts 
to  the  Legislature. 

"  YI.  Upon  securing  the  conveyance  of  said  tract  of  land  to  the 
State,  with  the  approval  of  the  Attorney-General  as  aforesaid,  the 
board  of  managers  should  immediately  put  the  premises  thus  conveyed 
into  proper  condition  for  reception  of  patients,  and  should  receive  them 
gradually  and  as  rapidly  as  practicable,  and  for  such  uses  and  purposes 
shall  utilize  the  present  buildings  and  improvements  upon  said  prem- 
ises, and  adopt  a  general  design  including  the  same  and  the  recommen- 
dations in  this  report. 

"  VII.  The  act  establishing  the  colony  should  contain,  among  other 
things,  provisions  prescribing  the  duties  and  powers  of  the  managers, 
and  of  the  officers,  including  a  medical  superintendent  and  a  treasurer, 
neither  of  which  two  officers  should  be  a  manager ;  regulating  the  desig- 
nation, commitment,  reception,  discharge,  and  support  of  public  and 
private  patients;  apportioning  State  patients,  and  governing  all  the 
officers,  assistants,  inmates,  and  inhabitants  of  the  colony.  Such  pro- 
visions are  formulated  in  a  bill  which  will  be  offered  by  the  State 
Charities  Aid  Association  and  approved  by  the  State  Board  of  Charities. 

"  VIII.  The  act  establishing  the  colony  should  appropriate  the  sum 
of  one  hundred  and  fifty  thousand  dollars  or  upward  out  of  any  moneys 
in  the  treasury  not  otherwise  appropriated,  and  should  provide  that  the 
treasurer  of  the  State  shall,  on  the  warrant  of  the  comptroller,  pay  to 
the  treasurer  of  the  board  of  managers  of  said  colony  such  sums  as  may, 
from  time  to  time,  be  required  for  the  purchase  of  land,  improvements 
and  betterments,  erection  of  buildings  and  furnishing  the  same,  heat- 
ing, lighting,  and  ventilating  the  same,  and  putting  the  lands  and  build- 
ings into  proper  condition  for  the  reception  of  patients  and  beneficiaries, 
not  to  exceed  one  hundred  and  twenty-five  thousand  dollars  for  the  pur- 
chase of  the  land  as  hereinbefore  stated,  and  not  to  exceed  twenty-five 
thousand  dollars  for  such  other  purposes ;  provided  that  such  i)urposes 
and  all  requirements  upon  which  such  payments  may  be  made  should 
be  certified  to  the  comptroller  by  said  board  of  managers  in  writing, 
specifying  its  items,  the  purposes  for  which  the  said  sums  are  required, 
and  should  be  verified  by  the  affidavit  of  the  sui)erinten(lent  and  treas- 
urer of  the  colony,  and  of  the  president  and  secretary  and  majority  of 
the  said  board  of  managers,  while  other  necessary  sums  for  mainte- 
nance in  the  next  fiscal  year  and  during  the  residue  of  the  present  fiscal 
year,  and  for  waterworks  and  sewers,  and  for  extensions  to  meet  the 
immediate  capacity  of  six  hundred  patients  as  required  in  the  act  under 


48 


ITEMS. 


[N.  Y.  Med.  Jode., 


which  this  report  is  made,  and  future  increase  of  population,  as  therein 
also  directed,  should  be  provided  in  the  appropriation  and  supply  IjiHs 
of  this  and  succeeding  sessions  of  the  Legislature. 

"  IX.  The  direct  effect  of  the  establishment  of  the  colony  would 
be  the  relief  of  a  numerous  class  of  sufferers,  of  which  there  are  over 
five  hundred  in  the  almshouses  of  the  State,  and  as  many  thousands  in 
its  families  of  the  relatively  poor  and  indigent ;  to  promote  which  bene, 
fits.  New  York  should  be  quick  to  follow  where  Ohio  has  taken  the 
lead  and  precedence  in  this  work  of  humanity. 

"X.  The  indirect  results  of  proper  provisions  for  the  medical  treat- 
ment and  education  of  epileptics,  and  their  employment  in  the  profita- 
ble prosecution  of  trades  and  industries  and  agricultural  labors  in  colony 
life,  would  be  to  remove  from  the  almshouses  duties  which  they  can 
not  discharge ;  and  to  release  poor  and  indigent  families  from  their 
tendencies  to  become  dependent  upon  charity,  on  account  of  their  in- 
firm members ;  and  thus  to  promote  a  wise  and  true  economy  and  pub. 
lie  policy  in  the  prevention  of  pauperism." 

The  American  Gynaecological  Society. — The  secretary,  Dr.  Henry 
C.  Coe,  of  No.  27  East  Sixty-fourth  Street,  New  York,  has  issued  a 
circular  stating  that  the  next  meeting  of  the  society  will  be  held  in 
Philadelphia  on  Tuesday,  May  16th,  and  it  is  hoped,  he  says,  that  the 
occasion  may  be  a  memorable  one.  The  number  of  papers  will  be 
limited,  so  that  those  who  propose  to  contribute  are  requested  to  an- 
nounce the  titles  as  early  as  possible,  and  to  mention  the  day  on  which 
they  prefer  to  read.  Attention  is  called  to  the  recent  change  in  the  by- 
laws permitting  fellows  to  publish  their  papers  in  medical  journals, 
provided  that  such  papers  also  appear  in  the  Transactiom.  As  unneces- 
sary delay  in  the  printing  of  the  Transactions  has  been  caused  every  year 
by  the  failure  of  the  secretary  to  receive  papers  promptly,  he  again  re- 
minds fellows  of  the  rule  that  all  contributions  must  be  placed  in  his 
hands  before  the  close  of  the  mcelinfj.  There  are  now  ten  vacancies  in 
the  list  of  fellows. 

The  New  Haven,  Conn.,  Medical  Association. — At  the  annual  meet^ 
ing,  which  was  held  at  the  residence  of  Dr.  Francis  Bacon  on  Monday 
evening,  January  4th,  the  following  officers  were  elected  :  President,  Dr. 
Gustavus  Eliot ;  first  vice-president,  Dr.  H.  L.  Swain  ;  second  vice-presi- 
dent. Dr.  0.  T.  Osborne ;  secretary  and  treasurer.  Dr.  Joseph  H.  Town- 
send  ;  presidential  committee.  Dr.  W.  G.  Daggett  and  Dr.  W.  W.  Hawkes ; 
finance  committee.  Dr.  C.  A.  Lindsley  and  Dr.  W.  H.  Carmalt.  Since 
the  last  annual  meeting  one  member,  Dr.  Henry  Pierpont,  has  died,  and 
eight  new  members  have  been  added.  The  present  membership  is 
sixty-six.  Meetings  are  held  on  the  first  Wednesday  evening  of  each 
month.  The  average  attendance  during  the  past  year  was  nearly  six- 
teen. The  building  fund  amounts  to  between  twenty-two  and  twenty- 
three  hundred  dollars. 

The  Medical  Society  of  the  County  of  Otsego,  N.  Y. — At  the  semi- 
annual meeting,  to  be  held  at  Schenevus  on  Tuesday,  the  17th  inst., 
under  the  presidency  of  Dr.  C.  H.  Chesebro,  an  address  will  be  deliv- 
ered by  the  vice-president,  Dr.  George  F.  Entler,  and  papers  will  be 
read  as  follows :  Hypnotics,  by  Dr.  C.  E.  Parish ;  Cholera,  its  Home 
and  its  Visits  to  the  United  States,  by  Dr.  0.  W.  Peck ;  The  Old  and 
the  New,  by  Dr.  E.  W.  Spafford ;  Physiological  Culture,  by  Dr.  H. 
Lathrop ;  and  Brain  Surgery,  by  Dr.  B.  A.  Church. 

The  Society  of  Medical  Jiu'isprudence. — The  special  order  for  the 
meeting  of  Monday  evening,  the  0th  inst.,  was  the  annual  address  by  the 
president.  Dr.  N.  E.  Brill,  on  The  Return  of  Cholera  and  Federal 
Quarantine. 

The  New  York  Academy  of  Medicine. — At  the  annual  meeting, 
held  on  Thursday  evening  of  last  week.  Dr.  D.  B.  St.  John  Roosa  was 
elected  president. 

The  British  Laryngological  and  Rhinological  Association. — Dr. 

Francke  H.  liosworth,  of  New  York,  and  Dr.  von  Schrotter,  of  Vienna, 
have  Ijcen  elected  hcmorary  fellows. 

Changes  of  Address. — Dr.  Albert  C.  Stanard,  to  No.  lo8  West 
Thirty-fourth  Street ;  Dr.  Reynold  W.  Wilcox,  to  No.  38  East  Sixtieth 
Street. 


The  City  Hospital. — Dr.  W.  ('.  .Jarvis  has  resigned  from  the  attend- 
ing staff,  and  Dr.  J.  K.  Hayden  has  been  appointed  to  succeed  him. 

The  Death  of  Dr.  Joseph  Creamer,  of  Brookljm,  occurred  on  the  fith 
inst.,  in  tlie  sixty-tliiid  year  of  his  age.  He  was  a  native  of  Nova  Scotia, 
but  came  to  New  York  while  he  was  yet  a  youth.  He  had  Ijcen  a  sur- 
geon of  the  police,  county  physician,  and  autopsy  physician  to  the  board 
of  coroners.  He  was  a  man  of  wide  experience  in  medico-legal  conten- 
tions and  a  good  witness  at  public  inquests  and  trials.  Flis  son.  Dr. 
Joseph  M.  Creamer,  was  elected  a  coroner  of  Kings  County  at  the  last 
general  election.  The  deceased  was  for  several  years  a  visiting  surgeon 
to  the  Eastern  Hospital.  His  final  illness  was  a  broncho-pneumouia  of 
only  a  few  days'  duration. 

The  Death  of  Dr.  Francis  J.  Young,  of  Bridgeport,  Conn.,  president 
of  the  Fairfield  County  Medical  Society,  took  place  suddenly  on  the  5th 
inst.  He  was  taken  sick  while  attending  as  a  gue.st  the  annual  banquet 
of  the  Danbury  Medical  Society,  and  died  soon  afterward.  He  was  an 
esteemed  practitioner  of  Bridgeport,  and  president  of  the  city  board  of 
health.  He  was  fifty-seven  years  old,  and  had  been  a  resident  of  Bridge- 
port for  the  greater  part  of  his  professional  life,  since  1866  when  he 
took  his  medical  degree  at  Yale. 

Army  Intelligence. — Official  List  of  Changes  in  the  Staiiom  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army,  from  December  £5,  1892,  to  January  7,  1893 : 
Ten  Eyck,  Ben.iamin  L.,  First  Lieutenant  and  Assistant  Surgeon,  is  re- 
lieved from  duty  at  Fort  Leavenworth,  Kansas,  and  will  proceed  at 
once  to  San  Antonio,  Texas,  and  report  to  the  commanding  general. 
Department  of  Texas,  for  duty  with  the  troops  now  in  the  field. 
Meriwether,  Frank  T.,  First  Lieutenant  and  Assistant  Surgeon.  The 
leave  of  absence  granted  for  seven  days  is  hereby  extended  ten 
days. 

Glennan,  James  D.,  First  Lieutenant  and  Assistant  Surgeon,  will,  upon 
his  arrival  at  his  station  (Fort  Sill,  Oklahoma  Territory)  from  leave 
of  absence,  proceed  immediately  to  San  Antonio,  Texas,  and  report 
in  person  to  the  commanding  general,  Department  of  Texas,  for 
temporary  duty  in  the  field  with  troops  operating  on  the  Mexican 
border. 

Taylor,  Marcus  E.,  Captain  and  Assistant  Surgeon.  By  direction  of 
the  Secretary  of  War,  two  months'  ordinary  leave  of  absence  is 
granted,  to  take  effect  upon  the  expiration  of  his  present  sick  leave. 

Crampton,  Louis  W.,  Captain  and  Assistant  Surgeon.  The  leave  of  ab- 
sence granted  is  extended  three  months. 

Meriwether,  Frank  T.,  First  Lieutenant  and  Assistant  Surgeon,  is  re- 
lieved from  further  duty  at  Fort  Adams,  Rhode  Island,  and  assigned 
to  duty  at  Madison  Barracks,  New  York. 

Ware,  Isaac  P.,  First  Lieutenant  and  Assistant  Surgeon,  is  assigned  to 
duty  at  Fort  Sill,  Oklahoma  Territory,  until  further  orders. 

PoLHEMUS,  Adrian  S.,  Captain  and  A.ssistant  Surgeon.  The  leave  of 
absence  granted  for  two  weeks,  on  surgeon's  certificate  of  disability, 
is  hereby  extended  fourteen  days,  from  December  30,  1892,  on  sur- 
geon's certificate  of  disability. 

Promotions. 

Alden,  Charles  H.,  Lieutenant-Colonel  and  Deputy  Surgeon-General, 
to  be  Assistant  Surgeon-General,  with  the  rank  of  Colonel,  Decem- 
ber 4,  1892,  vice  Heger,  retired. 

Hartsuff,  Albert,  Major  and  Surgeon,  to  be  Deputy  Surgeon-General, 
with  the  rank  of  Lieutenant-Colonel,  December  4,  1892,  vice  Alden, 
promoted. 

Maus,  Louis  M.,  Captain  and  Assistant  Surgeon,  to  be  Surgeon,  with 
the  rank  of  Major,  December  4,  1892,  vice  Hartsuif,  promoted. 

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  7,  1893 : 
PuRViANCE,  George,  Surgeon.    Detailed  as  chairman  of  Board  for 
Physical  Examination  of  Passed  Assistant  Surgeon  S.  C.  Devan.  De- 
cember 21,  1892. 

Gassaway,  J.  M.,  Surgeon.  To  proceed  to  Gulf  (Quarantine  on  special 
duty.    January  4,  1893. 


Jan.  14,  1893.] 


ITEMS.— LETTERS  TO  THE  EDITOR. 


49 


Devan,  S.  C,  Passed  Assistant  Surgeon.  To  report  for  physical  ex- 
amination, December  21,  18!i2;  detailed  for  special  duty  at  Phila- 
delphia, Pa.,  December  28,  1892  ;  granted  leave  of  absence  for  two 
months  on  surgeon's  certificate  of  disability.    January  7,  1893. 

Kai.loch,  p.  C,  Passed  Assistant  Surgeon.  To  assume  command  of 
the  service  at  Cincinnati,  Ohio,  when  relieved  at  Boston,  Mass.  De- 
cember 21,  1892. 

Glennan,  a.  H.,  Passed  Assistant  Surgeon.  Leave  of  absence  ex- 
tended sixteen  days  on  account  of  sickness.  December  13,  1892. 
To  proceed  to  New  York  for  special  temporary  duty.  January  3, 
1893. 

Williams,  L.  L.,  Passed  Assistant  Surgeon.  To  proceed  to  Helena, 
Ark.,  on  special  duty.    January  3,  1893. 

McI.NTOSH,  W.  P.,  Passed  Assistant  Surgeon.  When  relieved,  to  pro- 
ceed to  Boston,  Mass.,  for  duty.    December  21,  1892. 

Magkcder,  G.  M.,  Passed  Assistant  Surgeon.  When  relieved,  to  pro- 
ceed to  San  Diego,  Cal.,  on  special  duty ;  thence  to  New  Orleans,  La., 
for  duty.    December  16,  1892. 

Cobb,  J.  0,,  Passed  Assistant  Surgeon.  Upon  expiration  of  leave  of 
absence,  to  proceed  to  Port  Townsend,  Wash.,  for  duty.  December 
21,  1892. 

Stimpson,  W.  G.,  Assistant  Surgeon.    To  proceed  to  Detroit,  Mich.,  for 

duty.    December  20,  1892. 
Brown,  B.  W.,  Assistant  Surgeon.    To  proceed  to  Port  Townsend, 

Wash.,  for  temporary  dut)'.    December  16,  1892. 

Society  Meetings  for  the  Coming  Week : 

Monday,  January  16th :  New  York  County  Medical  Association  ;  New 
York  Academy  of  Medicine  (Section  in  Ophthalmology  and  Otolo- 
gy); Hartford,  Conn.,  Medical  Society;  Chicago  Medical  Society. 

Tuesday,  January  17th :  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 — Schenevus),  and  Westchester,  N.  Y. ;  Ogdens- 
burgh,  N.  Y.,  Medical  Association  ;  Connecticut  River  Valley  Medical 
Association  (Bellows  Falls,  Vt.) ;  Baltimore  Academy  of  Medicine. 

Wednesday,  January  18th:  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  York ;  Medico-legal  Society,  New  York;  New  Jersey 
Academy  of  Medicine  (Newark) ;  Philadelphia  County  Medical  So- 
ciety. 

Thursday,  January  19th :  New  York  Academy  of  Medicine  ;  Brooklyn 
Surgical  Society  ;  New  Bedford,  Mass.,  Society  for  Medical  Improve- 
ment (private). 

Friday,  January  20lh :  New  York  Academy  of  Medicine  (Section  in 
Orthoptedic  Surgery);  Baltimore  Clinical  Society;  Chicago  Gynae- 
cological Society. 

Saturday,  January  21sl :  Clinical  Society  of  the  New  York  Post-gradu- 
ate Medical  School  and  Hos])ital. 


f  cttfrs  to  tbc  (gbitor. 

THE  OPHTHALMOMETER. 

New  York,  December  30,  1S92. 
To  the  Editor  of  the  New  Yorl:  Medical  Journal  : 

Sir:  It  would  ;ii)i)ear  from  a  letter  under  the  title  Ophthal- 
mometry in  America,  by  Dr.  A.  E.  Davis,  of  this  city,  in  the 
issue  of  the  Journal  for  December  24,  1892,  that  the  ophthal- 
mometer of  Javfil  ami  Schiutz  was  an  instrument  "forgotten  " 
and  "consigned  to  the  limbo  of  oliscui-ity  "  until  rescued  from 
oblivion  by  Dr.  Koosa  about  three  years  ago.  That  Dr.  Roosa 
has  been  au  enthusiastic  advocate  of  the  ophthalmomelerduring 
tiie  last  two  or  three  years  is  well  known  ;  but  he  is  a  comjjar.a- 
tively  recent  convert,  and  his  conversion  is  but  the  natural  fruit 


of  the  early  missionary  work  of  Dr.  Noye.s  and  Dr.  Burnett.  So 
recently  as  1890,  in  an  article  entitled  The  Relation  of  Errors 
of  Refraction  and  Insufficiency  of  the  Ocular  Muscles  to  Func- 
tional Diseases  of  the  Nervous  System  {Medical  Record,  April 
19,  1890) — an  article  in  which  great  stress  is  laid  on  refractive 
errors — the  oj)hthalmometer  is  only  once  casually  referred  to  by 
Dr.  Roosa. 

Dr.  Burnett  was  the  pioneer  in  the  use  of  the  ophthalmome- 
ter in  this  country  and  is  rightly  characterized  as  its  champion 
in  the  article  of  Dr.  de  Schweinitz  referred  to  hy  Dr.  Davis,  and, 
if  Dr.  Davis  will  take  the  trouble  to  inform  himself  of  the  recent 
utterances  of  Di'.  Burnett,  he  will  find  that  he  has  by  no  means 
relegated  his  instrument  to  the  "  lumber  room." 

The  instrument,  however,  has  for  the  last  seven  years  had 
no  firmer  friend  or  more  stanch  and  persistent  advocate  and 
defender  than  Dr.  Noyes,  in  whose  ofl^ice  it  has  been  in  constant 
use  since  1885,  and  where  the  ophthalmometric  examination  is 
as  much  a  part  of  the  regular  routine  examination  as  the  oph- 
thalmoscopic. 

In  the  winter  of  1885-'86  Dr.  Noyes  exhibited  the  ophthal- 
mometer at  a  largely  attended  meeting  of  the  New  York  Acad- 
emy of  Medicine,  and  from  that  time  to  the  present  he  has  con- 
tinued to  sound  its  praises  and  to  commend  it  to  scores  of  his 
fellow-practitioners,  who  have  visited  his  office  from  all  parts 
of  the  country,  as  an  invaluable  aid  in  the  diagnosis  of  errors 
of  refraction.  Again,  at  the  twenty-fourth  annual  meeting  of 
the  American  Ophthalmological  Society,  in  New  London,  July, 
1888,  in  the  discussion  of  Dr.  Burnett's  paper,  An  Analysis  of 
the  Refraction  of  Five  Hundred  and  Seventy- six  Healthy  Hu- 
man Corneae  examined  with  the  Ophthalmometer  of  Javal  and 
Schiotz,  Dr.  Noyes  said:  "It  has  been  my  habit  to  employ  the 
ophthalmometer  in  every  case  where  it  was  necessary  to  inquire 
into  the  state  of  the  refraction.  In  a  general  way,  I  may  say 
as  follows:  That  the  evidence  of  the  ophthalmometer,  without 
the  use  of  atropine,  has,  in  the  immense  majority  of  cases,  cor- 
responded with  the  evidence  of  the  trial  case.  .  .  .  This  is  an 
extremely  practical  and  valuable  instrument.  It  saves  an  im- 
mense amount  of  time,  and,  when  one  has  learned  to  use  it, 
gives  very  little  trouble.  I  now  scarcely  know  how  to  do 
without  it.  The  examination  with  it  is  much  more  rapid  and 
satisfactory  than  under  former  methods."  Dr.  Noyes  has  up- 
held the  instrument  before  his  classes  at  Bellevue  Hospital 
Medical  College  and  the  New  York  Eye  and  Ear  Infirmary,  and 
from  his  hook,  Diseases  of  the  Eye,  1890,  I  quote  the  following: 
"A  little  experience  soon  makes  this  method  of  working  the 
most  expeditious  and  the  most  satisfactory.  The  whole  prob- 
lem may  often  be  solved  a  ta  single  sitting  and  without  atropine. 
For  rapid  work,  and  especially  in  public  institutions,  this  in- 
strument is  invaluable." 

This  quotation  is  taken  from  a  description  of  the  ophthal- 
mometer and  its  use  in  the  work  just  referred  to,  pp.  121-124, 
and  certainly  its  English  is  not  so  poor  or  its  meaning  so  ob- 
scure or  involved  as  to  warrant  the  following  passage  in  Dr. 
Davis's  article:  "That  the  new  modeled  instrument  could  have 
been  popularized  from  a  dt-scriptioti  of  the  old  is  out  of  the 
question.  I  doubt  very  much  if  the  new  instrument  could  be 
used  at  all  from  the  description  of  the  old,  and  I  am  >ure  it 
could  not  be  correctly  employed." 

If  Dr.  Davis  takes  exception  to  Dr.  Noyes's  description  on 
the  ground  that  it  applies  to  the  old  model  instead  of  the  now, 
it  needs  only  to  be  said  that  the  new  model  differs  in  no  essen- 
tial particular  from  the  old,  and  that  a  description  of  one  is  per- 
fectly ai.plicable  to  the  other.  The  only  decided  advantage  of 
the  large  disc  of  the  new  model  is  that  it  terms  a  shield  to  pro- 
tect the  eye<  i>f  the  observei-  from  the  light  ;  but  its  place  is 
just  as  effectually,  if  not  better,  sujjphed  by  a  disc  twelve  inches 


50 


LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES.         [N.  Y.  Med.  Joub., 


in  diameter  covered  with  black  velvet,  which  Dr.  Noyes  has 
added  to  his  (old  model)  instrument,  and  this,  besides  being  less 
cumbersome,  does  away  with  the  multiplicity  of  corneal  reflexes, 
which  are  more  or  less  confusing. 

D.  W.  Hunter,  M.  D. 
NATIONAL  QUARANTINE. 

January  3,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sik:  Referring  to  your  editorial  on  The  Question  of  a  Na- 
tion Quarantine,  in  the  Journal  of  December  24th  last,  I  beg  to 
remark  that  the  desirability  of  a  uniform  system  of  national 
maritime  quarantine  in  our  country  is  hardly  a  debatable  mat- 
ter— it  is  conceded  by  all. 

You  think  "  there  is  no  reason  for  establishing,  as  some 
have  proposed,  a  national  board  of  health,  and  still  less  a  new 
department  to  be  called  the  Department  of  Public  Health  under 
the  charge  of  a  secretary."  But  you  think  "  the  Treasury  De- 
partment has  already  the  frame  upon  which  to  Jjuild  a  quaran- 
tine corps  of  trained  men  iu  the  Marine-Hospital  Service."' 

In  other  words,  the  proposition  seems  to  be  practically  to 
abolish  the  Marine-Hospital  Service  by  transmuting  it  into  a 
"Quarantine  Corps,"  «Z/as  a  United  States  sanitary  scavenger 
service.  The  name,  however,  is  not  to  be  changed,  for,  if  it 
were,  certain  statutes  must  be  examined  and  perhaps  repealed) 
which  might  not  be  agreeable  to  all. 

As  one  of  the  older  members  of  the  endangered  organiza- 
tion, your  correspondent  feels  it  to  be  his  right  and  duty 
strongly  to  protest  against  this  retrograde  metamorphosis  and 
proposed  destruction  of  a  time-honored  and  beneficent  service. 

If  "  an  increased  force  and  more  money  "be  necessary  to 
enable  the  executive  officer  of  the  Marine- Hospital  Service  to 
cause  to  be  performed  the  "  additional  duties"  you  allude  to, 
and  this  "increased  force"  is  not  to  consist  of  medical  officers 
of  the  Marine-Hospital  Service— the  frame  on  which  the  pro- 
posed new  "  corps  "  is  to  be  built — then  why  not  change  the 
name  of  the  chief  officer  and  have  a  Secretary  of  Hygiene? 

This  would  not  "  complicate  the  machinery  of  Government," 
but  would  simplify  it,  by  continuing  the  Marine-Hospital  Serv- 
ice in  its  legitimate  role.,  with  its  "supervising  surgeon,"  as 
now  provided  by  statute ;  whilst  the  Secretary  of  Hygiene,  be- 
ing a  person  learned  in  all  the  arts  and  sciences  pertaining  to 
public  sanitation,  could  intelligently  and  properly  direct,  under 
existing  laws  slightly  modified,  the  new  "force"  in  its  highly 
necessary  but  exceedingly  disagreeable  labors. 

Medical  officers  of  the  Marine- Hospital  Service  are  not  espe- 
cially trained  in  sanitary  affairs  more  than  similar  officers  of 
other  brandies  of  the  public  service,  and  a  large  number  of  them 
are  no  more  anxious  or  willing  to  lay  aside  their  purely  profes- 
sional duties  for  those  of  sanitary  policemen  than  are  medical 
officers  of  the  navy  or  army,  or  most  physicians  in  private 
practice. 

Omitting  details,»i)n)bably  the  best  system  of  national  quar- 
antine would  be  to  put  the  entire  seaboard  and  land  frontier 
quarantine  service  under  the  direction  of  a  Government  bureau 
specially  organized  for  that  jmrpose,  under  new  and  uniform 
laws  and  rules,  with  a  new,  thoroughly  competent,  and  experi- 
enced chief,  and  newly  appointed  officers  for  this  particular 
duty,  leaving  all  interior  and  inter-State  sanitary  and  quaran- 
tine matters  to  the  inanagement  of  the  State  and  local  boards  of 
health,  witiiout  interference  by  Federal  officials. 

Some  remedies  are  worse  than  the  disease,  and  the  liberties 
and  best  interests  of  the  people  at  large  should  be  ever  kept  in 
view  and  not  allowed  to  be  jeopardized  l)y  personal  ambitions. 

SUKQKON,  M.-II.  S. 


IJrofcfbmgs  of  ^odeties. 


NEW  YORK  STATE  MEDICAL  ASSOCIATION. 

Ninth  Annual  Meeting,  held  in  New  TorTc  on  Tuesday,  Wednes- 
day, and  Thursday,  November  15,  16,  and  17,  1892. 

The  President,  Dr.  Judson  B.  Andrews,  of  Buffalo,  in  the  Chair. 

{Concluded  from  page  22.) 

Acute  Pleurisy.— Dr.  Frank  S.  Parsons,  of  Northampton, 
Mass.,  read  a  paper  on  this  subject.  Reviewing  the  opinions  of 
such  French  teachers  as  Gu6rin  and  Germain  86e,  the  author 
found  that  they  looked  upon  inflammation  as  a  physiological 
process  to  develop  phagocytes  against  microbes,  and  considered 
pleurisy  to  be  nothing  more  than  a  lymphangeitis.  Personally, 
he  saw  no  reason  for  considering  every  pleurisy  as  dependent 
upon  lesions  of  pre-existing  maladies,  especially  of  tuberculosis. 
Acute  pleurisy  was  probably  caused  by  microbes,  and  secondary 
jjleurisies  occurred  for  the  most  part  in  connection  with  dis- 
eases of  microbic  origin.  Acute  pleurisy  was  a  well-defined 
cyclical  malady,  and  might  be  divided  into  three  periods  of  evo- 
lution of  seven  days  each.  The  first  period  represented  the 
time  occupied  in  the  increase  of  the  pathological  lesions,  and  at 
the  end  of  that  time  the  effusion  reached  its  limit  of  advance. 
The  next  seven  days  represented  the  time  during  which  the 
pathological  lesions  appeared  to  remain  stationary,  and  the  effu- 
sion underwent  no  perceptible  alteration  in  quantity.  From  the 
fifteenth  to  the  twenty-first  day  of  the  disease  there  was  an  ab- 
sorption of  the  inflammatory  products,  including  the  eff"usion. 
In  the  modern  treatment  of  acute  pleurisy,  three  classes  of  agents 
were  used — antiseptics,  antipyretics,  and  evacuants.  Diuretics 
were  the  most  useful,  while  purgatives  not  only  failed  to  reduce 
the  quantity  of  fluid,  but  were  often  dangerous.  The  indications 
for  treatment  were  to  relieve  the  pain,  reduce  the  fever,  and 
arrest  the  effusion.  Antiphlogistic  treatment  was  indicated  just 
as  much  now  as  formerly,  for  revulsives  removed  the  congestion 
at  the  same  time  that  they  relieved  the  pain,  while  opium  merely 
deadened  the  sensibility  to  pain.  M.  Peter  believed  that  early 
resort  to  revulsive  methods  often  prevented  or  arrested  the  se- 
rous effusion,  and  called  attention  to  the  toleration  of  the  system 
to  free  venesection  and  the  rapidity  with  which  it  relieved  pain 
and  caused  a  diminution  in  the  severity  of  the  local  symptoms 
of  pleurisy.  The  author  thought  a  lesson  might  be  learned  from 
Nature  on  this  point,  for  she  seemed  to  bleed  the  patient  in 
acute  pleurisy  by  causing  an  effusion  of  fluid  which  closely  re- 
sembled the  plasma  of  the  blood.  In  sero-fibrinous  pleurisy, 
aspirtition  should  not  be  performed  until  after  the  third  week, 
and  then  only  if  there  was  no  indicatinn  of  absorption.  The 
only  exception  to  this  rule  was  where  there  was  urgent  dysp- 
noea or  other  indication  that  life  was  in  danger.  The  physical 
signs  of  the  presence  of  fluid  at  the  level  of  the  second  rib  fur- 
nished the  best  guide.  In  purulent  pleurisies  in  children  aspi- 
ration should  be  performed  several  times  before  resorting  to  se- 
verer surgical  measures,  but  in  adults  one  trial  of  aspiration  was 
sufficient.  In  conclusion,  the  author  suggested  endeavoring  to 
secure  the  absorption  of  pleuritic  effusions  by  electrolysis.  An 
electro-puncture  needle  connected  with  the  positive  pole  was  to 
be  inserted  so  as  to  just  reach  the  effusion,  and,  the  negative 
pole  being  connected  with  a  large  clay  electrode  placed  on  the 
chest  walls,  a  current  of  from  thirty  to  fifty  iisilliamperes  was  to 
be  passed  through  the  effused  fluid.  We  might  reasonably  ex- 
I)ect  from  such  an  application  more  or  less  coagulation  of  the 
fibrinous  matter  and  absorption  of  the  fluid  portions  of  the  effu- 
sion.   Such  a  method  of  treatment  would  be  specially  applica- 


Jan.  14,  1893.] 


PROCEEDINGS  OF  SOCIETIES. 


51 


ble  where  for  any  reason  tlioracentesis  could  not  be  performed, 
or  where  there  had  been  repeated  accuiniihitions  of  fluid,  or  in 
secondary  pleurisies  of  a  tuberculous  nature. 

Dr.  F.  \V.  IIioGiNS,  of  Cortland  County,  said  the  practice  of 
venesection  was  theoretically  good,  but  he  had  never  happened 
to  meet  with  a  case  of  pleurisy  in  which  he  had  thought  this 
treatment  was  indicated. 

Dr.  n.  D.  DiDAMA  said  that  by  early  and  complete  aspira- 
tion the  lung  was  permitted  to  expand  immediately.  Tonic 
treatment  was  proper  from  the  very  beginning,  and  Anstie, 
who  had  recommended  the  administration  of  tincture  of  chlo- 
ride of  iron  in  all  cases,  had  obtained  better  results  from  this 
traetment  than  from  the  use  of  antiphlogistic?. 

Dr.  John  Cronyn,  of  Erie  (\)unty,  said  that  in  the  early 
years  of  his  practice,  when  he  had  bled  fi-eely  and  administered 
large  doses  of  opium  with  calomel,  his  cases  of  pleurisy  had 
given  him  very  little  trouble.    He  also  favored  early  aspiration. 

Dr.  Nelson  B.  Sizer,  of  Kings  County,  recalled  a  case  of 
acute  pleurisy  with  violent  initial  symptoms  in  which  the  dis- 
ease had  been  aborted  by  prompt  venesection. 

The  .Etiology  of  Gastric  Ulcer.— Dr.  Charles  G.  Stock- 
ton, of  Erie  County,  read  a  paper  in  which  he  said  that,  while 
undoubtedly  the  stomach  became  ulcerated  from  a  variety  of 
causes,  such  as  traumatism,  syphilis,  scurvy,  serious  blood 
changes,  extensive  burns,  and  continued  pressure,  the  simple 
round  ulcer  of  Cruveilhier,  which  occurred  oftenest  in  young 
women,  must  have  a  more  precise  and  definite  fetiology.  There 
had  been  a  very  general  acceptance  of  the  view  expressed  long 
since  by  Vircho  w,  that  ulceration  followed  hfemorrhagic  erosions 
resulting  from  disturbance  of  the  circulation,  due  for  the  most 
part  to  morbid  conditions  of  the  gastric  vessels,  and  particu- 
larly to  a  hcemorrhagic  necrosis  of  the  mucous  membrane. 
This  mode  of  formation  was  substantiated  by  clinical  and  patho- 
logical observations  and  by  laboratory  experiments.  Duodenal 
nicer  not  infrequently  followed  external  scalds  and  burns,  and 
severe  injuries  inflicted  experimentally  on  animals  had  been 
followed  by  ulcers  in  the  stomach,  so  that  Niemeyer  had  sug- 
gested that  the  nervous  system  might  possibly  take  part  in  the 
process.  The  experiments  of  Schiti'  and  Ebstein  seemed  to 
show  that  certain  parts  of  the  nervous  system  were  competent 
to  establish  ulcus  ventriculi.  Although  a  large  proportion  of 
cases  of  gastric  ulcer  were  associated  with  diminished  alkalinity 
of  the  bk)od  and  hyperacidity  of  the  gastric  juice,  there  were 
cases  on  record  in  which  theacidity  of  the  gastric  juice  had  even 
been  below  the  normal.  These  facts  showed  that  there  must  still 
be  some  other  cause  as  yet  unknown,  which  in  a  certain  group  of 
cases  led  to  local  necrosis,  for  the  affection  showed  itself  par- 
ticularly in  adolescence,  when  there  was  the  least  probability 
of  vasi;ular  changes ;  it  occurred  most  frequently  in  women,  who 
were  less  often  subjects  of  arterial  disease  than  men,  and  the 
ulcer  very  frequently  selected  for  its  site  the  lesser  curvature 
and  posterior  wall  of  the  stomach,  near  the  pylorus,  a  portion 
of  the  economy  not  often  invaded  by  embola,  and  a  region  of 
the  stomach  which  was  especially  rich  in  anastomosing  vessels. 
It  seemed  not  at  all  improbable  that  this  form  of  ulcer  might 
take  its  origin  in  some  unknown  but  definite  neuropathic 
change — trophic,  vaso-motor,  or  both — for  analogous  processes 
might  be  observed  in  other  parts  of  the  body.  For  instance,  it 
was  well  known  that  herpetic  eruptions  were  very  prone  to 
occur  at  particular  points  under  special  conditions,  and  that 
strange  disease  known  as  "  idiopathic  linomatoma  auris,"  accord- 
ing to  recent  investigation,  was  of  neuropathic  origin.  In  con- 
clusion, the  author  said  that  the  object  of  his  paper  was  to  sug- 
gest that  by  the  influence  of  some  process  analogous  to  herpes, 
or  to  idiopathic  hsematoma  auris,  or  to  Raynaud's  disease,  or  to 
herpetic  gangrene,  we  might  best  explain  the  recognized  but 


unaccounted-for  feature  of  the  clinical  history  as  regarded  loca- 
tion, age,  and  sex. 

The  Examination  and  Commitment  of  the  Insane  in 
New  York  County.— Dr.  Matthew  D.  Field,  of  New  York 
County,  read  a  paper  thus  entitled.  The  present  reception 
pavilion  for  the  insane  was  erected  at  Bellevue  Hospital  in 
1879.  When  he  was  first  appointed  Examiner  in  Lunacy,  in 
1882,  the  percentage  of  disciiarges  was  over  thirty-three,  but, 
owing  to  the  exercise  of  more  care  in  excluding  improper  cases, 
this  had  been  greatly  reduced.  Only  three  times  within  these 
ten  years  had  a  case  been  registered  at  the  asylum  as  "not  in- 
sane," and  never  to  his  knowledge  had  a  discharged  patient 
during  this  time  committed  any  outrage  against  the  commu- 
nity. There  was  no  reason  to  look  with  suspicion  on  every 
case,  and  therefore,  as  Nellie  Bly  had  come  to  them  after  due 
commitment  by  a  police  justice,  and  during  the  whole  time  of 
her  stay  in  the  pavilion  had  acted  irrationally  and  would  give 
no  information  concerning  herself  or  friends,  she  could  not  be 
discharged. 

The  President  said  that  he  could  fully  appreciate  the  difH- 
culties  met  with  in  regard  to  communicating  with  the  many 
foreigners  who  came  up  for  examination  as  to  their  sanity,  and 
then,  again,  many  of  these  people  acted  so  strangely,  even  when 
sane,  that  it  was  no  easy  task  to  know  just  where  to  draw  the 
line,  or,  if  they  had  been  insane,  to  tell  when  they  had  recov- 
ered. The  statistics  presented  by  Dr.  Field  showed  a  degree  of 
skill  in  diagnosis  far  superior  to  that  seen  in  ordinary  medical 
practice. 

Dr.  Field  said  that  such  a  reception  pavilion  not  only  took 
these  unfortunates  from  the  unpleasant  surroundings  of  jails, 
but  it  materially  assisted  the  work  of  the  examiners,  as  during 
the  intervals  of  their  visits  the  conduct  of  the  patients  was 
carefully  observed  by  skilled  attendants. 

Mitral  Stenosis  in  Pregnancy.— Dr.  Zera  J.  Lusk,  of 
Wyoming  County,  reported  two  cases  in  which  mitral  stenosis 
had  seriously  complicated  pregnancy.  In  his  opinion,  the  physi- 
cian should  make  it  an  invariable  rule  to  examine  the  heart  in 
every  case  of  pregnancy  coming  under  his  care,  and,  where 
mitral  stenosis  was  present,  the  only  safe  treatment  prior  to  the 
fifth  month  was  the  production  of  abortion.  It  was  about  the 
sixth  month  that  the  heart  showed  marked  signs  of  weakness, 
and  if  the  pregnancy  was  allowed  to  proceed,  it  was  probable 
that  the  foetus  would  not  survive  the  last  two  months.  It  must 
be  remembered  that  children  whose  mothers  were  the  victims 
of  cardiac  disease  were  often  imperfectly  developed  and  were 
predisposed  to  an  untimely  death.  If  the  patient  was  not  seen 
before  the  sixth  month,  she  must  be  kept  absolutely  at  rest  and 
under  the  constant  care  of  a  physician.  When  collapse  oc- 
curred in  the  cases  reported,  chloroform  was  cautiously  admin- 
istered until  its  stimulating  effect  was  produced,  and  this  meas- 
ure not  only  resulted  in  immediate  improvement  of  the  symp- 
toms, but  it  gave  an  opportunity  for  other  medication. 

Dr.  F.  W.  Ross  said  there  was  fully  as  much  danger  in  abor- 
tion as  in  allowing  a  woman  to  go  to  full  term.  These  cases 
did  well,  as  a  rule,  even  though  to  all  appearances  quite  un- 
favorable. 

Dr.  John  Cronvn  .said  that  the  cases  reported  were  instances 
of  collapse  occurring  with  an  irritable  heart,  and  the  chloro- 
form had  acted  favorably  because  it  had  allayed  this  irritability. 
He  could  indorse  the  whole  treatment  except  the  use  of  digi- 
talis. 

Dr.  F.  W.  HiGGiNS  thought  that,  as  the  latter  months  of 
pregnancy  were  the  more  dangerous,  if  labor  could  be  induced 
while  the  patient  was  still  strong,  the  result  would  probably  be 
more  favorable. 

Dr.  S.  T.  Armstrong,  of  New  York  County,  said  that  he 


52 


PROCEEDINGS 


OF  SOCIETIES. 


[N.  Y.  Med.  Joub.» 


tarl  had  under  observntion  for  the  past  ten  years  a  lady  who, 
altljoii^'h  Laving  a  mitral  stenosis  before  her  first  pregnancy, 
had  been  pregnant  five  times,  and  yet  there  had  been  but  very 
little  increase  in  the  stenosis.  Her  last  child  was  a  healthy 
boy  of  sixteen  months.  He  agreed  with  Dr.  Cronyn  in  con- 
demning the  use  of  digitalis. 

The  Use  of  Electricity  in  Midwifery.— Dr.  Oguen  C. 
LcDLOw,  of  New  York  County,  read  a  paper  thus  entiileti.  The 
term  "electricity"  was  used  in  this  paper  as  synonymous  with 
the  faradaic  current,  and  the  more  important  uses  of  this  form 
of  electricity  were  considered  under  tliree  heads—  viz.,  (1)  its  sed- 
ative action,  (2)  its  oxytocic  action,  and  (3)  its  power  to  prevent 
and  to  control  uterine  hiemorrhage.  It  was  useful  wliere  chlo- 
ral or  morphine  was  contraindicated,  on  account  of  idiosyncrasy 
■or  debility,  or  where  it  was  not  considered  prudent  to  push  the 
nse  of  these  drugs  further.  It  was  also  available  where  the 
stomach  was  too  irritable  to  retain  medicine,  and,  unlike  mor- 
phine or  chloroform,  it  did  not  interfere  with  the  progress  of 
labor,  but,  on  the  contrary,  excited  more  powerful  and  eflicient 
uterine  contractions,  at  the  same  time  that  it  quieted  the  gen- 
eral nervous  irritability.  As  it  did  not  favor  uterine  relaxation, 
its  administration  did  not  complicate  subsequent  operative  pro- 
cedures under  anfesthesia.  When  this  sedative  action  of  the 
current  was  desired  its  strength  was  carefully  adjusted  so  as  to 
be  distinctly  perceptible  to  the  patient,  but  not  painful.  It  was 
im[)ortant  that  the  vil>rations  of  the  contact-breaker  should  he 
smooth  and  rapid,  and  that  the  current  should  be  continuously 
applied  for  ten  or  fifteen  minutes.  Its  power  to  excite  and  to 
stimulate  uterine  contractions  was  one  of  its  most  certain  ac- 
tions, and  hence  it  was  indicated  in  every  case  of  tedious  lal>or 
in  which  the  delay  was  due  to  feeble  or  infrequent  contractions, 
or  where,  owing  to  a  slight  disproportion  between  the  foetal  and 
maternal  parts,  unusual  muscular  exertion  was  required  to  ex- 
pel the  child.  It  produced  a  "steadying  effect"  on  the  uterine 
contractions  when  they  were  severe  and  almost  incessant,  mak- 
ing them  less  frequent  and  at  the  same  time  more  efficient.  The 
action  of  ergot  was  slow  and  uncertain  in  degree  ;  faradizati<m 
produced  its  effect  instantaneously,  and  the  amount  could  be 
accurately  gauged.  Ergot  exerts  its  influence  for  a  variable 
length  of  time,  which  was  entirely  beyond  control ;  faradization 
acted  upon  the  uterus  for  just  so  long  a  period  as  the  operator 
desired.  Ergot  produced  a  tonic  cramp  of  the  uterine  muscle, 
which  necessarily  exhausted  the  mother  and  was  dangerous  to 
both  mother  and  child  ;  faradization  produced  a  steady,  rhyth- 
mical contraction,  which  allowed  a  proper  interval  of  rest  to 
the  uterine  muscle  and  closely  imitated  Nature's  method.  By 
virtue  of  its  power  to  excite  uterine  contraction,  the  faradaic 
current  was  also  of  service  where  there  was  moderate  post- 
partum hffimorrh.age.  The  current  was  best  applied  to  the  pa- 
tient in  all  cases  with  the  positive  pole  over  the  sacro-lumbar 
region  and  the  negative  on  the  abdomen,  the  only  precaution 
being  to  avoid  pa-^sing  the  current  directly  through  the  head  of 
the  child.  The  positive  pole  was  a  small  copper  plate  covered 
with  wet  absorbent  cotton  and  fastened  to  the  body  by  a  belt  or 
bandage.  The  negative  pole  was  a  flat  sponge  backed  with 
rubber,  or,  preferably,  the  operator's  hand.  The  author  then 
cited  several  cases  showing  where  this  agent  had  succeeded,  and 
where  it  had  failed  to  give  assistance. 

The  Role  of  Microbes  in  Disease  was  the  title  of  a  paper 
by  Dr.  Nki.son  B.  Sizeh,  of  Kings  ("ounty.  It  was  devoted  to 
a  consideration  of  our  recent  knowledge  concerning  some  of  the 
Jiiore  imiiortant  bacliliiry  diseases. 

Some  Personal  Observations  upon  the  Treatment  of  Al- 
coholism, and  the  Known  Effects  of  Alcoholic  Abuse  upon 

Posterity. — Dr.  H.  Ehnkt  Sohmid,  of  Westciiester  ('oiinty,  in  a 
paper  thus  entitled,  said  that  alcoiiol,  when  prescribed  lor  chil- 


dren, not  infrequently  caused  convulsions;  its  effect  was  tran- 
sient, and,  even  when  given  in  small  doses,  was  soon  followed  by 
relaxation.  Medicinally,  it  was  only  indicated  in  conditions  ap- 
proaching collapse.  Tea  and  coffee,  particularly  the  former, 
were  the  agents  par  excellence  to  sustain  strength  in  muscular 
and  mental  labor.  Tea  had  been  the  chief  beverage  of  those 
who  had  gone  on  Lieutenant  Peary's  [lolar  expedition,  and  now 
alcohol  was  entirely  exclinKd  from  the  (luartcrtnaster's  supplies 
for  such  expeditions.  Physicians  objecttd  to  children  being  fed 
on  milk  from  swill  fed  cows,  but  they  very  frequently  advised 
nursing  women  to  drink  beer  to  increase  their  supply  of  milk. 
Careful  and  competent  observers  had  noticed  a  relation  between 
this  i)ractice  and  the  development  of  true  imbecility  or  even 
idiocy  in  children.  He  considered  heredity  an  important  ele- 
ment, and  narrated  many  instances  exemplifying  this.  For  ex- 
ample, in  the  case  of  a  man  who  became  a  drunkard  after  mid- 
dle life,  the  chiklren  born  to  him  before  his  degradation  re- 
mained free  from  drunkenness,  while  those  born  at'tei'ward  in 
turn  became  drunkards.  A  well-known  specialist  in  diseases  of 
children  had  observed  ten  families  of  drunkards  and  ten  of  tem- 
perate persons  for  a  period  of  twelve  jears,  and  found  that  dur- 
ing this  time  the  drunkards  had  fifty  seven  children,  only  ten 
of  whom  showed  during  their  youth  a  normal  disposition  and 
development  of  body  and  mind;  while  sixty-one  children  were 
born  to  the  temperate  parents,  fifty  of  wliom  developed  nor- 
mally. The  author  closed  his  paper  with  an  earnest  appeal  for 
the  co-operation  of  the  association  in  endeavoring  to  induce  the 
Legislature  to  legalize  the  commitment  of  drunkards  and  to  pro- 
vide a  special  institution  for  them. 

Climatology  in  its  Relation  to  Disease.— Dr.  S.  J.  Mur- 
ray, of  New  York  County,  read  a  pai)er  in  which  he  said  he 
considered  the  health  resorts  of  our  own  land  preferable  to 
those  abroad,  because  the  invalid  could  readily  find  congenial 
company  with  less  change  of  customs  and  habits  of  life.  The 
Adirondack  region  possessed  qualities  which  should  make  it  the 
most  famous  health  resort  in  the  world.  Among  the  desirable 
places  in  southern  California,  none  was  better  than  San  Diego, 
as  the  temperature  was  equable  and  the  air  dry.  Where  a 
greater  altitude  was  desired,  this  could  be  best  found  in  the 
Rocky  Mountains  of  Colorado.  In  the  Southern  States  there 
was  perhaps  no  better  all-the-year-round  place  than  Asheville, 
N.  C,  which  combined  a  healthful  climate,  beautiful  scenery, 
and  excellent  hotel  accommodations.  On  the  Cumberland 
plateau  of  Tennessee  was  to  be  found  one  of  the  most  remark- 
able climates  for  phthisical  patients.  Notwithstanding  that  the 
natives  of  this  region  lived  on  corn-bread,  bacon,  coffee,  and 
tobacco,  careful  investigation  by  the  ])hysicians  who  had  prac- 
ticed there  for  years  showed  that  pulmonary  consumption  did 
not  exist  among  them.  For  the  majority  of  phthisical  patients, 
the  writer  thought,  a  pure  and  dry  atmosphere  with  plenty  of 
sunshine  was  most  desirable.  The  climate  of  southern  Cali- 
fornia was  the  best  adapted  for  the  relief  and  even  for  the  cure 
of  hay  fever ;  those  suffering  from  nervous  debility  required  the 
invigorating  aii'  of  the  mountains  and  seas,  while  for  rheumat- 
ics and  those  afflicted  with  Bright's  disease  a  climate  should  be 
selected  which  was  as  near  as  possible  a  perpetual  spring. 

Some  Recent  Experience  in  Renal  Surgery  was  the 

title  of  a  paper  by  Dr.  E.  D.  Ferguson,  of  Ren.sselaer  County. 
From  the  three  cases  whicdi  he  reported,  he  concluded  that  it 
was  not  always  best  to  follow  the  rule  generally  laid  down  to 
perform  nephrectomy  as  a  secondary  operation.  Nephrotomy 
was  a  simple  procedure,  and  would  usually  prolong  life,  but, 
if  the  renal  tissue  was  extensively  destroyed,  and  if  the  patient's 
condition  was  such  as  to  admit  of  ne])hrectomy,  this  should  be 
the  iirimiirj'  operation. 

In  addition  to  the  papers  already  mentioned,  the  following 


Jan.  14,  1893.] 


BOOK  NOTICES. 


53 


were  read,  most  of  them  bv  title :  Musoular  Traction  for  Ilip- 
joint  Disease,  by  Dr.  T.  M.  Liullovv  Olirystie,  of  New  York 
County  ;  A  Review  of  some  of  tlie  Injuries  of  the  Upper  Ex- 
tremities, by  Dr.  E.  M.  Moore,  of  Monroe  County;  Fractures 
of  the  Patella  treated  by  Continuous  Extension,  Patients  not 
Confined  to  Bed,  by  Dr.  Joseph  D.  Bryant,  of  New  York 
County ;  Antiseptic  Vaginal  and  Intra-uterine  Injections  Un- 
necessary, if  not  Injurious,  in  the  Daily  Practice  of  Midwifery, 
by  Dr.  Darwin  Colvin,  of  Wayne  County;  Abdominal  Hyster- 
ectomy for  Myoma,  by  Dr.  Frederick  A.  Baldwin,  of  New 
York  County;  Tumors  of  the  Orbit  and  Adjacent  Cavities,  by 
Dr.  Charles  Stedraan  Bull,  of  New  York  County;  Winter 
Cholera  in  Pouglikeepsie,  by  Dr.  James  G.  Porteous,  of  Dutch- 
ess County ;  The  Limit  of  Responsibility  in  the  Insane,  by  Dr. 
John  Shrady,  of  New  York  County;  Shall  we  treat  Fever?  by 
Dr.  S.  T.  Armstrong,  of  New  York  County  ;  Dermic  and  Hypo- 
dermic Therapeutics,  by  Dr.  S.  F.  Rogers,  of  Rensselaer  County ; 
and  A  Memorial  of  Abram  Dn  Bois,  M.  D.,  by  Dr.  S.  S.  Purple. 

Dr.  S.  B.  W.  McLeod,  of  New  York  County,  was  elected 
president  for  the  ensuing  year. 


Text-hoolc  of  Nervous  Diseases,  being  a  Compendium  for  the  Use 
of  Students  and  Practitioners  of  Medicine.  By  Charles  L. 
Dana.,  A.M.,  M.  D.,  Professor  of  Nervous  and  Mental  Dis- 
eases in  the  New  York  Post-graduate  Medical  School  and  in 
Dartmouth  Medical  College.  With  Two  Hundred  and  Ten 
Illustrations.  New  York:  William  Wood  &  Co.,  1892.  Pp. 
xii  to  524. 

This  is  one  of  the  useful  and  important  books  of  the  year, 
designed  to  present  the  science  of  neurology  in  a  concise  yet,  as 
far  as  possible,  com|)lete  form.  Between  its  covers  an  almost 
incredible  amount  of  information  is  compactly  arranged  by 
means  of  condensed  tables  and  notes,  and  by  a  critical  descrip- 
tion of  each  morbid  condition  and  its  treatment,  together  with 
distinct  chapters  on  anatomy  and  cranio-cerebral  topography, 
and  over  two  hundred  illustrations. 

Part  first  contains  a  general  description  of  the  nervous  sys- 
tem, its  anatomy  and  diseases,  and  the  method  of  studying  neu- 
rology ;  the  general  symptomatology  and  technical  terms;  the 
physiognomy  and  stigmata ;  and  the  causes,  pathology,  treat- 
ment, and  prophylaxis  of  nervous  disorders.  The  second  part 
treats  of  diseases  of  the  cerebro-spinal  nerves,  of  those  of  the 
cranial  nerves,  and  of  those  of  the  spinal  nerves.  Part  third 
deals  with  the  anatomy,  the  physiology,  and  the  diseases  of  the 
spinal  cord,  its  inflammations,  degenerations,  and  functional 
disorders,  with  tumors  and  cavities  of  the  cord,  and  with  pro- 
gressive mu<cular  atrophies  and  dystrophies  that  pathologically 
belong  to  the  cord.  Part  fourth  is  a  survey  of  cerebral  anato- 
my, physiology,  and  localization ;  of  malformations,  degenera- 
tions, scleroses,  and  tumors  of  the  brain  ;  and  of  cerebral  syphi- 
lis. Part  fifth  is  a  condensed  exposition  of  functional  nervous 
diseases  and  their  treatment.  This  is  of  special  value  to  the 
general  practitioner,  who  is  so  often  called  upon  to  treat  func- 
tional nervous  disease.  It  considers  the  degenerative  neuroses, 
such  as  epilepsy,  hysteria  major,  general  spasmodic  tics,  etc.; 
the  acquired  neuroses,  such  as  neurasthenia  and  exophthalmic 
goitre;  the  acquired  degenerative  neuroses,  such  as  paralysis 
agitans  and  tic  douloureux;  the  trophic  and  vaso  motor  neu- 
roses, such  a«  progressive  facial  hemiatrophy,  acromegaly,  and 
angeioneurotic  ooderna  ;  and  the  disorders  of  sleep. 


The  definitions  in  the  first  part  of  the  book  are  invaluable 
to  the  student  and  to  the  general  reader  of  medicine,  notably 
for  clearness,  brevity,  and  directnt-ss.  Methods  of  examination 
are  carefully  explained,  without  excess  of  minute  detail.  In 
the  chapter  on  hygiene,  pro[)hylaxis,  and  treatment,  very  sensi- 
ble directions  are  given  concerning  the  best  uses  of  water,  food, 
massage,  exercise,  electricity,  and  climate.  The  introduction 
to  each  special  section  of  the  book  presents  the  subject  at  large 
in  its  most  modern  aspect,  and  gives  a  clear  outline  that  is 
easily  remembered.  The  definitions  of  the  di-enses  themselves 
are  felicitous  in  form  and  as  brief  as  circumstances  permitted. 
Each  division  of  every  subject  is  arranged  according  to  a  regu- 
lar order  that  prevents  the  possibility  of  any  confusion.  The 
chapters  on  the  anatomy  and  physiology  of  the  brain  and  spinal 
cord  are  marvels  of  multum  in  parvo.  Directions  for  treatment 
are  the  results  of  close  observation  and  personal  experience,  to- 
gether with  careful  study  and  a  knowledge  of  the  fact  that  the 
physician  is  the  doctor  of  the  soul  as  well  as  of  the  body. 

In  certain  directions  the  author  does  himself  injustice,  nota- 
bly in  regard  to  the  index.  It  is  disappointing  and  inadequate. 
This  impairs  the  usefulness  of  the  book  to  the  general  reader 
and  impedes  the  student's  progress.  The  ordinary  mind  soon 
wearies  of  forcing  itself  through  any  mass  of  information  upon 
a  serious  subject,  and  requires  a  guide  to  point  out  regions  best 
suited  to  its  nature  and  its  needs.  Such  a  guide  is  a  good  index, 
and  this  book  has  it  not.  Until  this  deficiency  is  made  good,  it 
is  unreasonable  to  expect  that  the  author's  work  and  power  will 
meet  with  the  general  recognition  that  they  both  deserve,  and 
which  is  their  manifest  destiny.  The  publisher  is  also  unkind 
to  himself.  With  the  exception  of  the  bright  and  attractive 
binding,  nearly  all  that  pertains  to  the  making  of  the  book  fails 
in  dignity  worthy  of  the  subject.  The  illustrations  are  for  the 
most  part  coarsely  reproduced,  and  many  are  indistinct.  The 
paper  is  indifferent  and  the  print  poor.  It  seems  inexcusable  to 
present  sentences  that  begin  with  fair  type  and  run  into  smaller 
and  irregular  print  before  a  period  is  reached.  Such  inequali- 
ties add  materially  to  the  fatigue  of  study.  But  these  short- 
comings are  easy  to  remedy  in  a  second  edition. 

As  the  book  stands,  it  contains  about  all  the  information 
that  human  ingenuity  could  possibly  condense  into  the  same 
space.  The  author  is  of  wide  mind  and  willing  to  learn  of  the 
humble  as  well  as  the  great,  and  gives  due  credit  to  both  alike. 
Nowhere  has  anything  been  taken  bodily  from  the  German  and 
foisted  upon  the  English-speaking  public.  Each  division  has 
grown  organically,  and  is  the  result  of  careful  clinical  observa- 
tion, painstaking  research,  cautious  judgment,  and  logical  de- 
duction. The  book  is  clear,  concise,  and  modern,  yet  sufficient- 
ly conservative,  and  merits  gratitude  and  praise. 

BOOKS,  ETC.,  RECEIVED. 

The  Diseases  and  Deformities  of  the  Foetus  :  an  Attempt  to- 
ward a  System  of  Ante-natal  Pathology.  By  J.  W.  Ballantyne, 
M.  D.,  F.  R.  C.  P.  E.,  F.  R.  S.  E.,  Lecturer  on  Diseases  of  In- 
fancy and  Childhood,  Minto  House  School  of  Medicine,  Edin- 
burgh, etc.  With  Plate  and  other  Illustrations.  Volume  I. 
Edinburgh:  Oliver  and  Boyd,  1892.  Pp.  xiii-252.  [Price, 
10.*.  &d.] 

A  Manual  of  Clinical  Ophthalmology.  By  Howard  F.  Han- 
sell,  M.  D.,  Lecturer  on  Ophthalmology  in  the  Jefferson  Medical 
College,  and  James  H.  Bell,  M.  D.,  lately  Demonstrator  of 
Anatomy  in  Jefferson  Medical  College.  With  One  Hundred 
and  Twenty  Illustrations.  Philadelphia :  P.  Blakiston,  Son,  & 
Co.,  1892.    Pp.  xiv-9  to  231.    [Price,  $1.Y5.] 

Fermentation,  Infection,  and  Immunity.  A  Now  Theory  of 
these  Processes,  which  unifies  their  Primary  Causation  and 


54 


MISCELLANY. 


[N.  Y.  Meu.  Joub  » 


places  the  Explanation  of  their  Phenomena  in  Clieinistry,  Biolo- 
gy, and  the  Dynamics  of  Molecular  Physics.  By  J.  W.  Mc- 
Laughlin, M.  D.,  Austin,  Texas.  Austin:  Eugene  vou  Boeck- 
niann,  1892.    Pp.  8-9  to  240.    [Price,  $2.50.] 

Etudes  de  clinique  chirurgicale.  Ann6e  scolaire  1890-1891. 
Par  A.  Le  Dentu,  professeur  de  clinique  chirurgicale  il  la  Faculte 
de  ni6decine  de  Paris.  Avee  trente-six  figures  dans  le  texte. 
Paris:  G.  Masson.  1892.    Pp.  si-302. 

Human  Embryology.  By  Charles  Sedgwick  Minot,  Profes- 
sor of  Histology  and  Human  Embryology,  Harvard  Medical 
School,  Boston.  Four  Hundred  and  Sixty-three  Hlustrations. 
New  York  :  William  Wood  and  Company,  1892.  Pp.  xxiii-815. 

The  Modern  Antipyretics ;  their  Action  in  Health  and  Dis- 
ease. By  Isaac  Ott,  M.  D.,  Easton,  Pa.  Second  Edition,  re- 
vised and  enlarged.    Easton  :  E.  D.  Vogel,  1892.    Pp.  5  to  124. 

A  Report  of  Five  Cases  of  Ciironic  Mercurial  Poisoning.  By 
Lewis  H.  Adler,  Jr.,  M.  D,,  Philadelphia.  [Reprinted  from  the 
Medical  A'ews.] 

Two  Cases  (jf  Fracture  of  the  Body  of  the  Scapula.  By  Lewis 
H.  Adler,  Jr.,  M.  D.,  Philadelphia.  [lieprinted  from  the  Ameri- 
can Lancet.^ 

Fistula  in  Ano — General  Considerations — j32tiology — Symp- 
tomatology— Diagnosis— Prognosis.  By  Lewis  H.  Adler,  Jr., 
M.  D.,  Philadelphia.  [Reprinted  from  the  Medical  and  Surgical 
Seporier.] 

The  Treatment  of  Anal  Fissure,  or  Irritable  Ulcer  of  the  Rec- 
tum. By  Lewis  H.  Adler,  Jr.,  M.  D.,  Philadelphia.  [Reprinted 
from  the  Medical  yews  ] 

The  Operative  Treatment  of  Fistula  in  Ano.  By  Lewis  H. 
Adler,  Jr.,  M.  D.,  Philadelphia.  [Reprinted  from  the  Interna- 
tional  Medical  Mafjasine.] 

Conclusions  regarding  the  Use  of  Drainage-tubes  and  Liga- 
tures, and  the  Possibilities  of  Skin  Disinfection  based  upon  Bac- 
teriological Investigations.  By  Hunter  Robb,  M.  D.,  Baltimore. 
[Reprinted  from  the  American  Journal  of  Ohstetrics.] 

Chancre  of  the  Mouth,  with  Statistics  and  a  Report  of  Twelve 
Cases,  Three  occurring  in  Children  in  One  Family.  By  E.  Har- 
rison Griffin,  M.  D.    [lieprinted  from  the  Medical  Record.] 

Congenital  Chorea.  Two  Cases.  By  John  Dunn,  M.  D., 
Richmond,  Va.  [Reprinted  from  the  Virginia  Medical  A/onthli/.] 

A  Case  of  Metastatic  Abscess  of  the  Brain.  Operation — 
Death.  By  G.  L.  Walton,  M.  D.,  Boston.  [Reprinted  from  the 
Boston  Medical  and  Surgical  Journal.'] 

The  Weight  of  the  Body  in  its  Relation  to  the  Pathology  and 
Treatment  of  Clubfoot.  By  A.  B.  Judson,  M.  D.  [Reprinted 
from  the  Boston  Medical  and  Surgical  Journal.] 

The  Results  of  Expectant  Treatment  in  Three  Hundred  and 
Twenty-three  Cases  of  Typhoid  Fever.  By  Arnot  Spence,  M.  D. 
[Reprinted  from  the  Medical  Record.] 

The  Palliative  and  Operative  Treatment  of  the  Enlarged 
Prostate.  By  W.  N".  Wishard,  M.  D.,  Indianapolis.  (Read  be- 
fore the  Indiana  State  Medical  Society,  June  12,  1892.) 

Perineal  Operations  on  the  Prostate,  with  a  Brief  Report  of 
a  New  Method  of  removing  tlie  Lateral  Lobes.  By  W.  N.  Wish- 
ard, M.  D.,  Indianapolis.  [Reprinted  from  the  Journal  of  Cu- 
taneous and  Geaito-urinary  Diseases.] 

The  Use  of  Menthol  through  the  Stomach  Tube.  By  A.  L. 
Benedict,  M.  D.  [Reprinted  from  the  International  Medical 
Magazine.] 

Transactions  of  the  Medical  Society  of  the  State  of  North 
Carolina.  Thirty-ninth  Annual  Session,  held  at  Wilmington, 
N.  C,  May  17,  18,  and  19,  1892. 

Les  formes  cliniques  du  cliolera  pernicieux  dans  l'6pid6mie 
juxta-Parisienne  et  Parisienne  de  1892.  Par  le  Dr.  L.  Galliard, 
m6decin  des  l]6[)itaux.  [Extrait  des  Bulletins  et  memoires  de  la 
Societe  medicale  des  hojntaux  de  Paris.] 


Gynaecolog'ical  Teclinique  as  carried  oat  at  the  Gynecean  Hospi- 
tal, Philadelphia.- — ^At  a  meeting  of  the  Phihul('li)hia  County  Medical 
Society  held  on  December  28,  1802,  Dr.  J.  M.  Baldy  read  a  paper  sub- 
stantially as  follows : 

It  is  no  uncommon  thing  to  have  physicians  from  all  over  the  coun- 
try, who  are  making  a  temporary  stay  in  Philadelphia  and  who  are 
visiting  the  hospital  with  the  object  of  seeing  operations,  question 
minutely  as  to  the  different  points  in  the  preparation,  and  not  infre- 
quently express  surprise  at  the  simplicity  of  these.  In  fact,  it  has  often 
occurred  to  me  that  many  of  our  visitors  are  more  interested  in  the 
preparation  than  in  the  operation  itself.  To  one  who  has  the  success 
of  this  class  of  work  at  heart,  this  seems  to  be  a  step  in  the  right  direc- 
tion, as  it  has  long  since  been  recognized  by  the  successful  operators  of 
the  world  that  more  good  results  are  obtained  by  mediocre  operators 
whose  preparations  have  been  most  careful  and  systematic,  than  by 
their  more  brilliant  colleagues  who  have  been  inclined  to  scoff  at  minu- 
tia;  and  to  depend  upon  their  mechanical  skill. 

From  time  to  time  articles  on  this  subject  have  appeared  in  medical 
print  giving  the  most  elaborate  description  of  the  preparation  and  the 
apparatus  used,  most  of  which  are  undoubtedly  excellent  and  well  fitted 
for  the  operating-room  of  a  hospital,  but  which  are  unnecessarily  cum- 
brous when  one  comes  to  apply  them  to  private  work.  For  this  reason 
I  have  been  encouraged  to  enter  upon  a  detailed  description  of  our 
work  at  the  Gynecean  Hospital,  the  application  of  which  can  readily  be 
carried  into  private  practice.  The  watchwords  from  the  beginning  to 
the  end  of  an  operation  are  thoroughness  and  simplici/y. 

The  aim  of  all  successful  operators  is  the  same — namely,  the  pre- 
vention of  any  septic  matter  entering  into  the  field  of  operation.  Dif- 
ferent operators  adopt  different  methods  of  accomplishing  this  object, 
but  for  success,  the  object  and  result  must  be  the  same,  whatever  the 
method  adopted  may  be. 

Antisepsin  or  asepsis,  as  fancy  may  dictate,  the  principle  is  the  same. 
To  be  successful  one  must  be  surgically  clean.  For  the  proper  accom- 
plishment of  this  one  must  consider  and  treat:  1.  The  patient.  2.  The 
operating-room  and  its  paraphernalia,  including  tables,  basins,  pitchers, 
buckets,  instruments,  ligatures,  sponges,  dressings.  3.  The  operator, 
assistants,  and  nurses. 

The  preparation  of  the  patient  should  begin,  when  possible,  at 
least  twenty-four  hours  before  the  operation.  The  first  steps  are  to 
regulate  the  diet  and  empty  the  gastro-intestinal  tract.  Free  purga- 
tion is  begun  at  once,  preferably  by  the  use  of  some  saline.  This  is 
usually  administered  in  the  dose  of  a  drachm  of  sulphate  of  magnesium, 
dissolved  in  watei',  each  hour  until  the  bowels  begin  to  move.  Usually 
five  or  six  doses  are  sufficient  to  accomplish  the  object.  The  purga- 
tives should  be  so  administered  that  the  action  of  the  bowels  ceases 
five  or  six  hours  before  the  time  set  for  the  operation.  After  begin- 
ning the  administration  of  the  purgative,  the  diet  should  be  light  and 
concentrated.  If  the  operation  is  to  be  performed  in  the  afternoon, 
the  patient's  supper  on  the  day  before  consists  of  the  ordinary  house 
diet.  From  this  time  on  nothing  passes  her  lips,  unless  it  be  a  glass 
of  milk  or  a  cup  of  bouillon  at  breakfast-time.  Even  water,  except  in 
small  quantities,  is  withheld.  These  steps  in  the  preparation  can  be 
carried  out  in  the  case  of  most  patients,  but  in  dealing  with  an  unu- 
sually weak  woman  considerable  judgment  must  be  used  in  their  ap- 
plication. A  hot  bath  is  given,  both  the  day  before  and  the  morning 
of  the  operation.  If  the  patient  is  unable  to  be  moved  to  the  bath- 
tub, the  baths  are  given  in  bed.  Prior  to  the  final  bath  an  enema  of 
soapsuds  and  water  and  a  vaginal  douche  of  bichloride  of  mccury 
(1  to  3,000)  are  given.  Immediately  on  coming  from  the  bath  a  fresh 
night-gown  is  put  upon  the  patient  and  she  is  placed  in  a  bed  which 
has  been  specially  prepared  for  her  reception.  After  her  return  to  bed 
the  abdomen — the  seat  of  the  operation — is  especially  prepared.  A 
nail-brush,  soap,  and  hot  water  are  used  freely  and  vigorously,  special 
attention  being  paid  to  the  umbilicus  and  pubic  hairs.  In  but  excep- 
tional cases  is  the  jjuhes  shaved.    The  abdomen  is  then  bathed  with 


Jan.  14,  189S.] 


MISCELLANY. 


55 


alcohol  and  turpentine,  and  is  finally  protected  until  the  time  of  the 
operation  with  a  towel  w  rung  out  of  bichloride  solution. 

When  the  patient  is  placed  on  the  operating-table  the  abdomen  is 
well  rubbed  with  ether  and  bathed  with  alcohol  by  the  operator  as  the 
final  preparation,  special  attention  being  paid  to  the  pubic  hairs  and 
the  umbilicus.  The  legs  are  wrapped  in  a  blanket,  which  extends 
f loni  the  feet  to  the  pubes  ;  a  second  blanket  is  placed  over  the  chest. 
All  blankets,  clothing,  table,  etc.,  about  the  patient  from  her  chest  to 
her  feet  are  now  covered  with  towels  prepared  for  the  purpose,  the 
abdomen  being  left  bare  from  the  epigastrium  to  the  pubes.  Over  all 
this  is  placed  a  piece  of  bichloride  gauze  with  a  slit  in  it  at  the  point 
of  the  incision. 

All  tables  used  in  the  operating-room,  with  the  exception  of  the 
Krug  frame  for  Trendelenburg's  posture,  which  Is  of  galvanized  iron, 
are  made  of  wood,  perfectly  plain,  and  shellacked.  The  reason  for  this 
is  twofold — first,  because  it  is  desirable  in  the  preparation  of  the  roqpi 
that  it  should  be  emptied ;  this  is  rendered  possible  in  the  case  of 
everything  except  the  gas  fixture  and  the  sink.  Secondly,  as  there  is 
an  operating-ropm  on  each  floor,  it  becomes  necessary  to  frequently 
move  the  tables  from  one  room  to  the  other.  When  not  in  use,  the 
windows  in  these  rooms  are  always  open.  The  walls  of  the  room  from 
floor  to  ceiling  are  of  white  tile,  the  window  trimmings  are  of  white 
marble,  the  floors  are  asphalt,  the  ceilings  are  plastered  and  heavily 
painted.  In  the  preparation,  the  room  is  first  stripped  of  all  its  furni- 
ture. The  walls,  ceiling,  and  floor  are  washed  down  with  a  hose,  and 
then  mopped  off  with  a  cloth  dipped  in  bichloride  solution.  As  each 
article  is  brought  into  the  room  it  is  scrubbed  with  soap  and  water, 
rinsed  off,  mopped  with  bichloride  solution,  and  placed  in  its  proper 
position ;  the  tables  and  benches  are  covered  with  sheets  or  towels  spe- 
cially prepared  for  this  purpose.  A  glance  at  the  accompanying  cut 
will  more  clearly  demonstrate  this.  All  linen  used  in  the  operating- 
room  has  been  laundried  by  itself.  Distilled  water  is  used  throughout 
the  operation. 


After  an  operation  the  instruments  are  thoroughly  scrubbed  with 
soap  and  water,  and  are  then  passed  through  scalding  water  before  be- 
ing returned  to  the  case.  Prior  to  the  operation  they  are  boiled  for 
twenty  minutes  in  a  weak  soda  solution.  As  few  instruments  as  possi- 
ble are  used.  In  an  ordinary  operation,  two  needles,  two  ligature  staffs, 
four  hsemostatic  forceps,  a  knife,  a  needle-liolder,  and  a  pair  of  scissors 
are  amply  sufficient.  These  are  taken,  together  with  the  tray  on  which 
they  are  placed  for  boiling,  directly  from  the  sterilizer,  and  put  upon 
the  table  as  the  patient  is  brought  into  the  room.  In  this  way  they  are 
not  handled  from  the  time  they  are  taken  out  of  the  sterilizer  until 
they  are  to  be  used. 

Three  varieties  of  ligatures  are  employed — silk,  silkworm-gut,  and 
catgut.  A  half-hour  before  the  operation  the  silk  is  immersed  in  a  bi- 
chloride solution  (1  to  100) ;  prior  to  being  used  it  is  washed  in  boiling 
water.  The  silkworm-gut  is  boiled  with  the  instruments.  The  catgut 
is  prepared  by  being  immersed  in  ether  for  forty-eight  hours,  soaked  for 
the  same  length  of  time  in  a  l-to-lOO  alcoholic  solution  of  bichloride  of 


mercury,  after  which  it  is  put  into  a  solution  of  two  parts  of  oil  of  juni- 
per and  one  part  of  alcohol.  It  is  taken  directly  from  the  latter  solu- 
tion for  use  at  the  o])eration. 

All  sutures  and  ligatures  used  within  the  abdominal  cavity  are  of 
silk  (Chinese  twist).  Silkworm-gut  is  invariably  used  for  closing  the 
abdominal  wound.  Catgut  is  used  principally  in  vaginal  hysterectomy 
and  plastic  work. 

New  sponges  are  prepared  by  being  thoroughly  beaten  and  soaked 
for  twenty-four  hours  in  a  weak  solution  (three  per  cent.)  of  hydro- 
chloric acid,  after  which  they  are  soaked  for  twenty-four  hours  in  a 
strong  soda  solution,  and  finally  placed  in  alcohol.  Immediately  after 
being  used  in  an  operation  they  are  thoroughly  washed  in  cold  water, 
placed  in  a  strong  soda  solution  (practically  a  saturated  solution)  for 
twenty-four  hours,  at  the  end  of  which  time  they  are  removed,  washed 
under  the  cold-water  spigot  until  all  the  soda  is  washed  away,  and  then 
immersed  in  a  solution  of  sulphurous  acid  for  twenty-four  hours.  They 
are  taken  directly  from  the  acid  solution,  washed,  and  placed  in  com- 
mercial alcohol  until  used.  Four  sponges  only  are  used  at  each  opera- 
tion. 

The  dressing  of  the  abdominal  wound  consists  in  placing  several 
strips  of  dry  bichloride  gauze  over  the  incision  and  a  cotton  pad  covered 
with  gauze  placed  over  this.  The  whole  is  held  in  place  by  a  six-tailed 
bandage.  Dressings  are  not  disturbed  for  eight  days.  No  iodoform  or 
other  powder  is  used.    Stitch-hole  abscesses  are  the  rare  exception. 

After  being  used,  the  glass  drainage-tubes  are  soaked  in  strong  soda 
sohition  for  twenty-four  hours,  rinsed  under  the  spigot,  washed  with 
turpentine  and  ether,  and  then  boiled  for  twenty  minutes,  after  which 
they  are  kept  in  commercial  alcohol. 

Rubber  drainage-tube,  whenever  used,  is  soaked  in  bichloride  solu- 
tion, and  washed  in  boiling  water. 

After  an  operation  the  drainage-tube  is  cleaned  by  the  nurse  every 
fifteen  minutes  or  half-hour,  as  occasion  requires.  As  the  fluid  dis- 
charged from  the  tube  lessens  in  quantity,  the  intervals  of  cleaning  are 
lengthened.  Each  time  the  tube  is  cleaned  the  nurse's 
hands  are  carefully  prepared  with  soap  and  water  and 
bichloride  solution. 

At  and  after  each  cleaning  the  syringe  used  to 
withdraw  the  tube  contents  is  cleansed  inside  and  out- 
side with  hot  water  and  bichloride  solution,  as  are 
also  the  mouth  of  the  tube  and  the  rubber  protecting 
it.  Fresh  bichloride  cotton  is  placed  over  the  en- 
trance of  the  tube  at  each  cleaning.  The  tube  is  re- 
moved as  soon  as  the  contents  become  clear  and  small 
in  quantity.  The  edges  of  the  opening  left  by  the  tube 
are  drawn  together  by  a  strip  of  adhesive  plaster,  and 
the  dressings  replaced  by  fresh  ones. 

Everybody  who  takes  part  in  an  operation,  and  may 
during  its  performance  handle  any  of  the  instruments  or 
materials,  is  required  to  go  through  the  same  preparation. 
All  assistance  is  rendered  by  three  nurses  ;  the  chief  nurse 
assisting  the  operator  directly,  a  second  nurse  attending  to 
the  sponges,  and  a  third  nurse  changing  the  waters.  The 
preparation  of  operator  and  nurses  is  as  follows :  A  hot  soap  bath,  and 
clean  linen  clothing  direct  from  the  wash.  The  hands  and  arms  are 
prepared  by  first  carefully  cleansing  the  nails  with  a  penknife,  a  free  use  of 
hot  water,  soap,  and  nail-brush  for  twenty  minutes,  and  rinsing  in  fresh 
water.  They  are  then  bathed  in  commercial  alcohol,  and  are  finally 
soaked  in  a  bichloride  solution  (1  to  2,0()0)  for  five  minutes.  The 
greatest  danger-point  of  infection  is,  of  course,  under  the  nails,  and 
time  used  in  a  most  careful  hand  toilet  is  never  mis.-jpent — is,  in  fact, 
absolutely  essential  to  success. 

A  careful  study  of  the  cut,  which  represents  one  of  the  operating- 
rooms  as  it  appears  prior  to  the  introductiim  of  the  patient,  will 
demonstrate  the  .simphcity  and  thoroughness  of  all  the  preparations. 
There  is  not  an  article  in  the  room  which  can  not  be  duplicated  or 
easily  replaced  in  almost  any  well-ordered  household.  Soap,  water, 
nail-brush,  and  bichloride-of-mercury  tablets  are  easily  obtained,  and 
as  for  the  remainder,  it  rests  entirely  with  the  surgeon  and  his  nurse. 
With  a  little  more  time  and  trouble  the  poorest  hovel  can  be  turned 


56 


MISCELLANY. 


[N.  Y.  Med.  Joub. 


into  a  good  and  safe  opeiating-rooru  by  adopting  these  rules,  as  I  have 
been  able  to  demonstrate  time  after  time  in  my  work  in  tiie  shuns  of 
this  great  city.  Of  course  it  means  plenty  of  hard  labor  for  both  nurse 
and  surgeon  ;  but  what  nurse  or  surgeon  who  has  once  passed  through 
the  horrors  of  attendance  at  a  death  from  septic  peritonitis  would  not 
feel  that  the  work  before  the  operation  was  as  nothing  in  comparison 
to  that  afterward  ? 

The  number  of  instruments,  sponges,  etc.,  may  seem  to  many  to  be 
entirely  inadequate  for  the  purpose,  but  in  many  hundreds  of  operations 
we  have  found  them  amply  sufficient ;  it  is  the  rare  exception  that  re- 
course to  the  instrument-case  is  necessary.  The  fewer  articles  used,  the 
fewer  sources  of  possible  infection  and  accident.  A  large  number  of 
instruments  lying  about  arc,  in  addition,  a  source  of  endless  confusion 
and  annoyance,  and  they  require  an  extra  assistant. 

The  Necessity  of  the  Restriction  of  Immigration. — In  its  issue  for 
January  Vth  the  Philadelphia  Medical  News  says  editorially: 

"  If  the  press  is  to  be  taken  as  the  exponent  of  popular  sentiment, 
it  would  seem  to  be  settled  that  immigration  will  be  interdicted  for  the 
next  twelve  months.  This  sentiment  is,  in  a  measure,  founded  upon  the 
expression  of  medical  opinion,  which  is  based  on  the  belief  that  the 
greatest  danger  of  importation  of  Asiatic  cholera  is  through  the  immi- 
grant class  an<i  their  baggage  and  personal  effects.  There  are  other 
reasons,  practical  and  non-medical,  why  immigration  should  be  re- 
stricted, and  there  are  opposing  arguments  against  restriction,  but  with 
these  we  have  nothing  to  do  in  considering  the  subject  from  a  medical 
and  precautionary  standpoint. 

"  Judging  from  the  history  of  epidemics  of  cholera  in  Europe  and 
the  numerous  scattered  places  on  the  Continent  at  which  cholera  still 
exists  and  has  existed  with  a  tendency  even  now  to  recrudescence,  it 
is  extremely  probable  that,  under  favorable  conditions,  later  in  the  year 
the  disease  will  become  more  widespread  and  epidemic,  and  finally 
reach  the  United  States.  There  seems  to  be  a  parallel  between  the 
conditions  and  the  course  of  the  disease  in  the  years  1865  and  1866, 
and  those  of  1892  and  1893.  Extraordinary  measures  will  be  required 
to  protect  the  United  States  from  the  introduction  of  the  disease  during 
the  coming  spring  and  summer. 

"  It  is  a  fact  substantiated  by  past  experience  that  the  greatest  dan- 
ger springs  from  the  inflow  of  the  immigrant  class  and  the  fomites  of 
disease  concealed  in  their  baggage  and  personal  effects ;  and  it  stands 
to  reason  that  if  immigration  were  temporarily  suspended  the  problem 
of  preventing  a  visitation  of  cholera  would  be  greatly  lessened,  if  not 
solved.  It  is  a  question  whether  the  same  end  might  not  be  accom- 
plished without  resort  to  so  radical  a  measure.  The  English  practice, 
which  has  yielded  such  favorable  results,  might  be  cited  as  a  reason 
for  hesitating  before  adopting  so  unusual  and  stringent  a  measure  as 
exclusion ;  but  the  conditions  in  England  and  in  the  United  States  are 
quite  dissimilar.  In  England,  under  the  Local  Government  Board,  sani- 
tary law  and  sanitary  administration  are  made  applicable  to  every  part  of 
the  realm,  and  local  sanitation  is  brought  to  a  high  degree  of  efficiency. 
Therefore,  on  account  of  this  comprehensive  system  of  local  sanitation 
and  the  state  of  preparedness  to  meet  and  cope  with  disease,  quarantine 
is  limited  to  inspection  and  the  isolation  of  the  sick,  with  httle  inter- 
ference with  commerce  and  without  the  necessity  of  restricting  immi- 
gration. 

"It  is  far  different  in  this  country.  We  are  not  yet  prepared  to 
throw  down  the  barriers  of  quarantine,  because  our  internal  sanitary 
administration  is  only  exceptionally  adapted  to  meet  the  emergency,  in 
the  vast  majority  of  places  being  neglected  or  only  in  its  developmental 
stage.  We  are,  however,  making  rapid  strides  in  matters  of  sanita- 
tion, and  may,  at  no  distant  day,  catch  up  with  England  ;  but  for  the 
present,  at  least,  it  would  be  foolhardy  to  imitate  England's  practices 
without  the  facilities  to  carry  out  her  sanitary  methods. 

"  If  our  quarantine  defenses  were  uniform,  complete,  and  in  the 
highest  stage  of  efficiency  there  would  be  less  justification  for  a  tem- 
porary Buspensi<m  of  immigration  ;  but  such,  unfor  tunately,  is  not  the 
case.  Quarantine  is  in  the  transition  stage  of  adiniuistration.  It  is  by 
no  means  certain  what  will  be  the  issue  of  the  discussion  of  the  vari- 
ous proposed  systems  now  before  Congress;  but  this  much  is  certain, 
that  whether  a  national  quarantine  system  shall  be  adopted  or  the  local 


quarantines  be  continued  and  supplemented  by  Government  aid  and 
supervision,  a  considerable  period  will  elapse  before  organization  and 
equipment  will  be  completed.  This  very  unceitainty  impedes  the 
activity  of  preparation.  Consequently,  if  the  suspension  of  immigra- 
tion as  a  temporary  expedient  will  help  materially  to  prevent  our  land 
from  the  threatened  danger — and  of  this  there  can  be  little  doubt — by 
all  means  let  the  Government  resort  to  this  expedient. 

"  There  is  another  consideration  of  great  weight.  This  is  the  year 
of  the  Columbian  Exposition,  and  it  would  be  particularly  disastrous  if, 
by  neglect  to  lessen  the  chances  of  the  entrance  of  cholera,  this  disease 
should  be  introduced  the  coming  spring  or  summer ;  but,  laying  aside 
this  view  of  the  question,  if,  with  the  great  number  of  visitors  attracted 
to  our  shores  by  the  Exposition,  immigration  remains  unrestricted,  the 
immense  passenger  traffic  would  greatly  enhance  the  risk  of  the  impor- 
tation of  disease  and  seriously  tax  the  ability  of  the  quarantine  au- 
thorities to  meet  the  emergencies  should  cholera  unfortunately  break 
out. 

"For  the  protection  of  the  public  health  and  for  the  best  advantage 
of  the  whole  country,  there  seems  to  be  no  alternative  but  to  suspend 
immigration  as  a  temporary  expedient,  made  necessary  by  the  existing 
conditions  abroad." 


To  ContribtitorB  and  Correspondents. —  The  attention  of  all  who  jnirpost 
favoring  us  with  communications  is  respectfully  called  to  the  follow- 
ing  : 

Authors  of  articles  intended  for  publication  under  the  Ivead  of  "  originai 
contributions  "  are  respectfully  informed  tliat,  m  accepting  switch  arli 
ales,  we  always  do  so  with  tlie  uriderstanxling  that  the  following  condi 
lions  are  to  be  observed:  (I)  ivhen  a  rnainiscripd  is  sent  to  this  jour- 
nal, a  similar  manuscript  or  any  abstract  tliercof  must  not  be  or 
have  been  sent  to  any  oilier  periodical,  unless  we  are  specially  notified 
of  tJie  fact  at  the  time  the  article  is  sent  to  us  ;  (S)  accepted  articlet 
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THE  JN-EW  YORK  MEDICAL 


JOURNAL,  Januaey  2 1 ,  1893. 


Original  Communications. 


DISINFECTION  AT  QUARANTINE  STATIONS, 
ESPECIALLY  AGAINST  CHOLERA* 
By  GEORGE  M.  STERNBERG,  M.  D., 

DEPUTY  snRGBON-GENEBAL,  U.  8.  ARMT. 

During  the  recent  prevalence  of  cholera  on  the  Ham- 
burg steamships,  anchored  in  the  "  lower  bay  "  of  New 
York,  the  writer,  in  liis  capacity  as  "  consulting  bacteriolo- 
gist "  to  the  health  officer  of  the  port,  gave  considerable  at- 
tention to  questions  relating  to  the  practical  measures  of 
disinfection  required  under  such  circumstances  as  then  ex- 
isted. 

The  practical  questions  which  confront  the  sanitary  offi- 
cial charged  with  the  exclusion  of  a  pestilential  exotic  dis- 
ease may  be  included  in  two  categories  :  First,  What  arti- 
cles require  disinfection  ?  Second,  How  can  th'ese  articles 
be  disinfected  most  expeditiously  and  economically  ? 

An  intelligent  answer  to  these  questions  requires  an  ex- 
act knowledge  as  regards  the  biological  characters  of  the 
infectious  agent  which  is  to  be  destroyed,  and  also  with  ref- 
erence to  the  cost,  practical  availability,  etc.,  of  various  dis- 
infecting agents. 

The  principal  biological  characters  of  the  cholera  spiril- 
lum had  been  ascertained  by  bacteriologists  before  the  re- 
cent outbreak  of  cholera  in  Europe.  But,  before  giving  a 
positive  opinion  with  reference  to  certain  questions  which 
presented  themselves  upon  the  arrival  of  cholera-infected 
ships  in  the  port  of  New  York,  the  writer  considered  it 
necessary  to  make  some  additional  experiments,  the  results 
of  which  will  be  given  in  the  present  paper. 

These  experiments  v/ere  made  at  the  Hoagland  Labo- 
ratory, Brooklyn,  by  myself  and  Dr.  E.  H.  Wilson,  associate 
in  bacteriology  in  this  laboratory. 

There  is  a  general  agreement  among  bacteriologists  and 
sanitary  officials  as  to  the  necessity  for  disinfecting  the  ex- 
creta of  cholera  patients  and  all  articles  which  may  by  any 
possibility  have  been  recently  soiled  by  such  excreta.  But 
there  is  no  general  agreement  as  to  the  length  of  time  dur- 
ing which  soiled  articles  may  remain  dangerous,  and  opin- 
ions dilfer  greatly  with  reference  to  the  necessity  for  disin- 
fecting merchandise  brought  in  ships  from  infected  ports. 

The  so-called  "  practical  sanitarians  "  are,  as  a  rule,  far 
more  exacting  than  the  bacteriologists,  and  some  of  them 
demand  the  disinfection  of  everything  that  has  come 
through  an  infected  port,  and  of  every  portion  of  a  ship 
upon  which  a  case  of  cholera  has  occurred.  In  the  interest 
of  the  public  health  it  is  no  doubt  best  to  err  on  the  side  of 
safety  and  to  demand  too  much  rather  than  too  little.  But, 
on  the  other  hand,  extravagant  and  unnecessary  restrictions 
upon  commerce  bring  our  "  sanitary  science  "  into  disre- 
pute, and  we  must  be  prepared  to  support  the  measures 
recommended  by  exact  experimental  data. 

At  the  last  International  Sanitary  Conference,  held  in 

*  Read  before  the  Section  in  Public  Health  of  the  New  York  Acad- 
emy of  Medicine,  January  18,  1893. 


Rome  in  1885,  upon  the  writer's  motion  a  committee  on 
disinfectants  was  appointed  by  the  president  of  the  "tech- 
nical commission  "  of  the  conference  (Dr.  Moleschott,  of 
Rome). 

This  committee  consisted  of  Koch,  of  Germany  ;  Stern- 
berg, of  the  United  States  ;  Proust,  of  France  ;  Thorne 
Thorne,  of  England  ;  Eck,  of  Russia  ;  Hotlmann,  of  Aus- 
tria ;  and  Semmola,  of  Italy. 

One  of  the  conclusions  reached  by  this  committee  and 
unanimously  adopted  by  the  conference  was  the  following : 

"  V.  Disinfection  of  merchandise  and  of  the  mails  is 
unnecessary  (steam  under  pressure  is  the  only  reliable  agent 
for  the  disinfection  of  rags — les  chiffons  en  gros).^^ 

No  doubt  the  other  members  of  the  committee  were 
largely  influenced  by  Dr.  Koch's  opinion  in  adopting  this 
conclusion,  and  no  doubt  Dr.  Koch's  opinion  was  founded 
upon  his  own  recent  experiments  relating  to  the  biological 
characters  of  the  cholera  spirillum,  and  especially  upon  the 
fact  that  it  is  quickly  destroyed  by  desiccation.  He  had 
ascertained  that  when  freely  exposed  to  the  air  in  a  thin 
film  upon  a  cover-glass,  its  vitality  was  destroyed  in  two  or 
three  hours.  If,  therefore,  merchandise  or  the  mails  should 
be  soiled  by  material  containing  this  spirillum,  while  being 
handled  upon  the  docks  at  an  infected  seaport,  it  would  be 
quickly  destroyed  by  desiccation,  unless  the  infected  articles 
were  in  a  moist  condition — in  a  moist  condition  the  cholera 
spirillum  may  retain  its  vitality  for  several  months. 

In  the  experiments  recently  made  by  Dr.  Wilson  and 
myself  I  have  endeavored  to  determine  whether  desiccation 
can  be  relied  upon  for  the  destruction  of  the  spirillum  when 
attached  to  absorbent  materials,  such  as  raw  cotton  or  woolen 
goods.  And  at  the  same  time  I  have  tested  the  germicidal 
action  of  direct  sunlight,  which  had  previously  been  shown 
to  be  considerable  in  the  case  of  certain  other  pathogenic 
bacteria. 

The  cultures  used  in  these  experiments  came  originally 
from  a  case  of  cholera  in  New  York  city  (spirillum  isolated 
by  Dr.  Dunham),  and  from  a  case  taken  to  Swinburne  Isl- 
and from  one  of  the  Hamburg  steamers  (isolated  by  myself 
from  a  "rice-water"  discharge  collected  by  Dr.  Byron). 
The  cultures  from  the  first-mentioned  source  I  have  marked 
"  cholera  D,"  those  from  the  second  "  cholera  S." 

In  a  first  experiment  (September  26th)  Dr.  Wilson,  at 
my  request,  placed  small  squares  (about  an  inch  square)  of 
a  sterilized  woolen  blanket  in  sterilized  Petri  dishes.  Each 
piece  of  blanket  was  moistened  with  one  or  two  minims  of 
a  bouillon  culture,  twenty-four  hours  old,  of  "  cholera  D." 
Some  of  the  pieces  were  exposed  to  the  direct  sunlight 
upon  a  balcony  having  a  southern  exposure,  and  others  in  a 
dark  closet  in  the  laboratory. 

After  a  given  time  of  exposure  the  piece  of  blanket  was 
transferred  from  the  Petri  dish  to  a  test-tube  containing 
sterile  bouillon,  and  this  was  placed  in  tlic  incubating  oven 
at  37°  C.  The  same  method  has  been  followed  in  the  other 
experiments  to  be  referred  to  later. 

In  this  first  experiment  it  was  found  that  development 
occurred  after  two  hours'  exposure  in  the  sunlight  (tem- 
perature, 82°  F.),  but  not  after  four  hours;  and  that  no  de- 


1 


58 


STERNBERG:  DISINFECTION  AT  QUARANTINE  STATIONS. 


|N.  Y.  Med.  Jour., 


Telopment  occurred  from  the  pieces  which  had  Lean  kept 
in  the  dark  closet  for  forty-eight  hours.  In  experiments 
made  subsequently  by  myself  with  "  cholera  S  "  the  same 
result  was  obtained. 

The  experiment  was  varied  by  putting  the  square  of 
blanket  in  a  sterilized  glass  tube,  three  quarters  of  an  inch 
in  diameter,  closed  at  each  end  with  a  plug  of  cotton.  In 
every  instance  there  was  a  failure  to  grow  after  four  hours' 
exposure  to  direct  sunlight,  or  forty-eight  hours'  exposure 
in  the  dark  closet.  Dr.  Wilson  varied  the  experiment  by 
moistening  pieces  of  sterilized  white  filtering  paper  with  a 
drop  or  two  of  a  bouillon  culture,  and  found  that  no  de- 
Telopraent  occurred  when  these  were  subsequently  trans- 
ferred to  bouillon  after  two  hours'  exposure  to  sunlight. 

That  the  result  does  not  depend  directly  upon  the  heat 
of  the  sun  is  shown  by  the  fact  that  a  thermometer  exposed 
at  the  same  time  did  not  show  a  temperature  above  82°  F. 
in  Dr.  Wilson's  experiments,  made  in  September  and  Octo- 
ber, or  above  60°  F.  in  my  experiments  made  in  December. 

The  failure  to  grow  after  forty- eight  hours'  exposure  in 
a  dark  closet  can  only  be  ascribed  to  desiccation. 

In  another  series  of  experiments  I  saturated  pledgets  of 
sterilized  cotton,  half  an  inch  in  diameter,  with  a  bouillon 
culture  of  the  cholera  spirillum  and  placed  them  in  glass 
tubes  closed  at  each  end  with  a  plug  of  dry  cotton.  These 
tubes  were  exposed  upon  the  balcony  and  also  in  the  dark 
closet.  The  sun  was  obscured  by  clouds  most  of  the  time 
while  this  experiment  was  going  on,  and  desiccation  oc- 
curred slowly.  The  cotton  pledgets  exposed  upon  the  bal- 
cony were  still  moist  at  the  end  of  four  days,  and  still  gave 
a  culture  of  the  spirillum  when  transferred  to  bouillon. 
The  cotton  pledgets  exposed  in  a  dark  closet  (temperature, 
70°  to  75°  F.)  remained  moist  and  gave  a  culture  at  the 
end  of  eight  days,  but  at  the  end  of  ten  days  were  com- 
pletely dry,  and  no  longer  gave  a  culture  of  the  spirillum. 
Similar  cotton  pledgets  placed  in  Petri  dishes  between  four 
thicknesses  of  sterilized  blanket  (four  inches  square),  and 
placed  in  a  dark  closet,  were  dry  at  the  end  of  forty- eight 
hours,  and  failed  to  give  a  culture  when  transferred  to 
bouillon  and  placed  in  the  incubating  oven.  In  this  case 
the  cotton  pledgets  were  more  quickly  dried  because  the 
moisture  was  absorbed  by  the  layers  of  blanket  between 
which  they  were  placed. 

Sunlight. — With  reference  to  the  experiments  in  which 
squares  of  blanket  and  of  blotting  paper  were  exposed  to 
the  direct  rays  of  the  sun,  the  question  arises  as  to  the 
germicidal  action  of  the  sunlight  per  se.  This  is  a  question 
which  has  already  engaged  the  attention  of  bacteriologists, 
and  I  propose  to  give  a  brief  account  of  some  of  the  results 
obtained  before  referring  to  some  additional  experiments 
recently  made  by  myself. 

Downes  and  Blunt*  ascertained  in  1877  that  certain 
non-pathogenic  bacteria,  in  liquid  media,  fail  to  develop 
when  exposed  to  direct  sunlight,  and  are  restricted  in  their 
development  when  exposed  to  diffused  light.     Arloing  f 

*  Downes  and  Blunt.  Proc.  of  tlu  Roy.  Soc,  London,  vol.  xxvi, 
1877,  p.  488;  also  vol.  xxviii,  1878,  p.  199. 

I  Arloiiig.  Compt.  rend,  de  I' Acad,  dcs  sci.,  t.  c  et  ci.  Also  Archives 
■de  phynol.,  188G,  p.  2152. 


(1885)  reported,  as  the  result  of  experiments  made  by  him, 
that  anthrax  spores,  in  liquid  media,  after  two  hours'  ex- 
posure to  direct  sunlight,  failed  to  develop.  Roux*  (1887) 
confirmed  Arloing  as  to  the  action  of  sunlight  on  anthrax 
spores  when  they  are  suspended  in  bouillon  and  there  is 
free  access  of  atmospheric  oxygen.  In  the  experiments  of 
Mormontf  (1892)  dry  anthrax  spores  were  found  to  resist 
the  action  of  sunlight  for  a  long  time,  but  moist  spores, 
freely  exposed  to  the  air,  failed  to  grow  after  forty-four 
hours'  exposure  to  sunliglit.  In  the  absence  of  spores  th« 
anthrax  bacillus  in  a  moist  condition,  when  freely  exposed 
to  the  air,  failed  to  grow  after  exposure  to  the  direct  rays 
of  the  sun  for  two  hours  ;  but  in  the  absence  of  atmos- 
pheric oxygen,  the  same  bacilli  were  not  destroyed  at  the 
end  of  fifty  hours'  exposure. 

GaillardJ  (1888)  found  that  four  hours'  exposure  to 
direct  sunlight  was  fatal  to  the  typhoid  bacillus  when  freely 
exposed  to  the  air  in  culture  media.  Pansini*  (1889)  ex- 
perimented upon  a  variety  of  pathogenic  and  non  patho- 
genic  bacteria,  and  arrived  at  the  conclusion  that  diffused 
daylight  exercises  a  decided  restraining  influence,  and  that 
direct  sunliglit  destroys  the  vitality  of  these  micro-organ- 
isms. In  a  liquid  medium,  all  of  the  bacteria  tested  were 
destroyed  in  two  hours  and  a  half.  Geisler  ||  (1892)  has 
tested  both  sunlight  and  the  electric  light,  and  reports,  as 
the  result  of  his  experiments,  that  all  of  the  rays  exercise  a 
restraining  influence  upon  the  development  of  the  typhoid 
bacillus,  with  the  exception  of  the  red  rays,  and  that  the 
effect  is  greatest  at  the  violet  end  of  the  spectrum.  He 
concludes  that  the  germicidal  action  is  not  due  alone  to  the 
direct  effect  of  sunlight  upon  the  bacilli  exposed  to  it,  but 
also,  and  probably  chiefly,  to  changes  induced  in  the  culture 
medium — a  conclusion  previously  reached  by  Roux  and 
others. 

The  fact  that  the  germicidal  action  of  sunlight  depends 
largely  upon  the  presence  of  atmospheric  air  and  moisture 
makes  it  appear  probable  that  it  is  due  to  the  production  of 
ozone  rather  than  to  the  direct  action  of  sunlight  upon  the 
micro-organisms  exposed  to  it.  This  conclusion  is  in  ac- 
cord with  the  results  of  my  own  experiments  upon  the 
cholera  spirillum  suspended  in  a  liquid  medium. 

In  my  experiments,  test-tubes  containing  sterile  bouil- 
lon, inoculated  with  two  or  three  ose  of  a  recent  bouil- 
lon culture  of  the  cholera  spirillum  ("  cholera  S  "),  were  ex- 
posed to  direct  sunlight  (in  December)  upon  a  balcony  of 
the  Iloagland  Laboratory  having  a  southern  exposure.  After 
such  exposure  the  lubes  were  placed  in  an  incubating  oven 
at  37°  C.  No  development  occurred  in  the  tubes  exposed 
for  two  hours  or  more.  But  when  a  larger  number  of  spi- 
rilla were  added  to  the  bouillon,  by  carrying  over  with  the 

*  Roux.    Ann.  de  Vlnstitut  Pasteur,  vol.  i,  p.  445. 

f  Monnont.  Action  de  la  desiccation  de  I'air  et  de  la  lumifere  sur  la 
bacteridie  cliaibonneusc  lilamenteuse.  Ann.  de  Vlnstitut  Pasteur,  toL 
vi,  1892,  p.  21. 

\  Gaillard.  De  I'injlucnce  de  In  lumicre  sur  les  micro-organismet. 
Lyon,  1888. 

*  Pansini.  Rivista  d'ir/iene,  1889.  Review  in  Ann.  de  Vlnstitut 
Pasteur,  vol.  iii,  p.  686. 

II  Geisler.  Zur  Frage  iiber  die  Wirkung  des  Licbtes  auf  Bakterien 
Ctrlbl.fiir  Bakteriol.,  Bd.  xi,  1892,  p.  191. 


Jan.  21,  1893.] 


STERNBERG:  DISINFECTION 


AT  QUARANTINE  STATIONS. 


platimiin  I()0[)  a  purtion  of  tlie  pellicle  from  the  surface  of 
the  culture,  a  longer  exposure  was  required — development 
occurred  in  such  tubes  after  four  hours'  exposure,  but  not 
after  five  hours. 

The  question  arises  whether  exposure  to  sunlight  effects 
some  change  in  the  bouillon  which  renders  it  unfit  for  the 
development  of  the  cholera  spirillum.  This  is  answered  in 
the  negative  by  the  following  experiment :  The  tubes  con- 
taining bouillon  inoculated  with  the  spirillum  and  exposed 
to  direct  sunlight,  having  been  left  in  the  incubating  oven 
for  forty-eight  hours  and  remaining  perfectly  transparent, 
were  reinoculated  from  a  recent  bouillon  culture  and  re- 
turned to  the  incubating  oven.  In  every  instance  a  char- 
acteristic development  occurred  within  twenty-four  hours. 

In  a  single  experiment  in  which  flesh-pei)tone-gelatin 
was  inoculated  by  puncture  and  exposed  to  the  sunlight 
for  six  hours,  development  occurred  after  such  exposure — 
experiment  made  in  December,  when  the  temperature  was 
too  low  to  melt  the  gelatin  culture  medium  during  ex- 
posure. 

We  conclude,  from  the  experimental  data  given,  that 
desiccation  is  a  reliable  method  of  destroying  tbe  cholera 
spirillum,  and  that  the  International  Sanitary  Conference 
of  Rome  was  justified  in  the  conclusion  that  "  disinfection 
of  merchandise  and  of  the  mails  is  unnecessary,"  if  the 
merchandise  was  clean  and  dry  when  received  on  shipboard 
for  transportation,  and  if  it  arrives  at  our  ports  in  the  same 
condition. 

Also  that  free  exposure  to  fresh  air  and  sunshine  is  one 
of  the  most  reliable  methods  of  disinfecting  articles  which 
have  attached  to  them  the  cholera  spirillum. 

The  washing  of  the  exterior  of  packages  of  merchan- 
dise with  a  solution  of  mercuric  chloride,  and  the  fumiga- 
tion of  the  mails  with  sulphur  dioxide,  which  has  been  in- 
sisted upon  by  some  sanitarians  in  this  country,  appears  to 
us  to  be  an  unnecessary  procedure,  unless  the  merchandise 
has  been  exposed  to  infection  by  the  dejecta  of  cholera  pa- 
tients during  the  voyage,  or  after  its  arrival  at  our  ports. 
But  certain  kinds  of  merchandise  are  more  or  less  moist 
when  loaded  for  transportation,  and  the  question  arises  as 
to  the  possible  danger  of  receiving  sucli  merchandise  when 
shipped  from  an  infected  port  or  brought  upon  a  vessel 
upon  which  cases  of  cholera  have  developed  during  the 
voyage.  In  this  class  of  merchandise  beet  sugar  occupies 
the  most  prominent  place,  because  a  very  large  amount  of 
it  is  shipped  from  Hamburg  and  other  German  ports. 

As  "  consulting  bacteriologist "  to  the  health  officer  of 
the  port  of  New  York  the  writer  was  called  upon  to  give  an 
opinion  as  to  the  possible  danger  from  this  source  during 
the  recent  prevalence  of  cholera  in  Hamburg.  In  the  ab- 
sence of  any  exact  experimental  data  the  opinion  given  was 
necessarily  guarded,  and  it  was  thought  advisable  to  insist 
upon  the  disinfection  in  quarantine  of  the  sacks  in  which 
sugar  is  transported,  as  there  was  a  possibility  of  their  be- 
ing infected  upon  the  Hamburg  docks ;  and,  being  moist, 
the  cholera  spirillum  might  retain  its  vitality  or  even  mul- 
tiply during  transit.  In  order  to  satisfy  myself  as  to  the 
possible  danger  from  this  kind  of  merchandise,  I  made  a 
number  of  experiments  with  the  following  results : 


Extract  from  a  letter  addressed  to  Dr.  William  T.  Jen- 
kins, health  officer,  dated  October  24,  1892  : 

"  My  experiments  show  that  the  spirillum  of  Asiatic 
cholera  does  not  grow  in  an  acpieous  solution  of  beet  sugar 
in  the  absence  of  any  nitrogenous  pabulum  ;  but  tbat  in 
such  pabulum,  as  found  in  the  '  flesh-peptone  solution,' 
commonly  used  in  bacteriological  laboratories,  it  grows 
even  when  a  considerable  amount  of  beet  sugar  is  held  in 
solution.  In  my  experiments  it  has  not  grown  in  bouillon 
containing  fifty  per  cent,  of  beet  sugar,  but  there  bas  been 
a  more  or  less  abundant  development  when  the  amount  was 
less  than  twenty-five  per  cent. 

"  I  infer  from  these  experiments  that  beet  sugar  alone 
will  not  serve  as  a  pabulum  for  the  growth  of  this  spirillum, 
and  that  a  fifty-per-cent.  solution  would  prevent  its  devel- 
opment. 

"  I  have  made  the  following  practical  experiment  to  de- 
termine how  long  the  spirillum  would  be  likely  to  survive 
if  by  accident  the  exterior  of  sacks  containing  beet  sugar 
should  be  contaminated  by  cholera  dejecta : 

"  Pledgets  of  cotton  were  soaked  in  a  recent  bouillon 
culture  of  the  spirillum  and  were  then  placed  between  sacks 
containing  beet  sugar  in  a  closed  receptacle — a  tin  wash- 
boiler.  After  a  period  varying  from  two  to  eight  days 
these  pledgets  were  removed  and  placed  in  test-tubes  con- 
taining sterile  bouillon.  In  my  experiments  I  have  not 
succeeded  in  recovering  the  cholera  spirillum  in  such  cul- 
tures after  the  pledgets  of  cotton  had  been  left  between  the 
sugar  sacks  for  four  days  or  more.  But  other  saprophytic 
bacteria  have  always  developed  in  these  cultures. 

"  It  may  be  that  failure  to  develop  in  these  cultures 
was  due  to  the  presence  of  the  saprophytic  bacteria,  which 
multiplied  rapidly  and  caused  a  fermentation  of  the  sugar 
carried  over  with  the  pledgets  of  cotton  to  the  culture 
medium ;  or  it  may  be  that  it  was  due  simply  to  desicca- 
tion." 

Since  writing  the  foregoing  I  have  made  additional  ex- 
periments, which  show  that  exposure  to  a  fifty-per-cent. 
solution  of  beet  sugar  for  forty-eight  hours  destroys  the 
vitality  of  the  cholera  spirillum  ;  also  that  pledgets  of  cot- 
ton, thoroughly  wet  with  a  bouillon  culture  and  placed  in 
contact  with  beet  sugar,  in  a  glass  jar  in  which  the  moist 
sugar  was  above  and  below  the  cotton  pledgets  for  a  depth 
of  three  or  four  inches,  when  subsequently  transferred  to 
sterile  bouillon  do  not  give  a  culture  of  the  cholera  spiril- 
lum after  forty-eight  hours'  contact  with  the  sugar. 

In  view  of  the  results  of  these  experiments,  I  see  no 
good  reason  for  making  an  exception  of  this  kind  of  mer- 
chandise. 

Another  question  which  confronts  the  quarantine  ofli- 
cial  relates  to  the  danger  from  green  hides,  salted  fish,  and 
various  food  products  imported  into  this  country  from  Eu- 
rope. I  have  no  evidence  with  reference  to  hides.  If  they 
are  perfectly  dry,  I  see  no  reason  for  making  an  exception 
with  reference  to  them  ;  but  I  should  be  disposed  to  regard 
wet  hides  or  skins  of  any  kind  as  possibly  dangerous,  and 
I  would  be  governed  by  the  same  rule  in  deciding  with  ref- 
erence to  the  admission  of  packages  of  wool,  furs,  etc. 
Such  articles  may  be  infected  with  anthrax  spores,  and  the 


60 


STERNBERG:  DISINFECTION  AT  QUARANTINE  STATIONS.         [N,  Y.  Med.  Jouh., 


infection  of  small-pox  could  no  doubt  cling  to  them  a  long 
time  ;  but,  in  view  of  the  fact  that  a  piece  of  blanket  moist- 
ened with  a  pure  culture  of  the  cholera  spirillum  and  placed 
in  a  dark  closet  is  no  longer  infected  at  the  end  of  forty- 
eight  hours,  it  is  evident  that  we  have  nothing  to  fear  from 
dry  packages  of  wool  from  Russia  which  have  been  in  tran- 
sit for  several  weeks,  even  if  the  sheep  were  sheared  by 
persons  suffering  from  cholera  (?). 

The  Imperial  Board  of  Health  of  Germany  has  recently 
published  the  results  of  an  extended  series  of  experiments 
made  to  determine  the  length  (^f  time  the  cholera  spirillum 
will  survive  upon  the  pulp  of  various  kinds  of  fruit  and 
upon  the  surface  of  fresh  or  salted  fish,  etc.* 

I  give  below  a  brief  summary  of  the  results  reported : 

Upon  fresh  flounder,  carp,  and  shell-fish  the  spirillum 
had  died  out  in  two  days ;  upon  smoked  or  salted  herring, 
in  twenty-four  hours.  Upon  confectionery  of  sugar,  choco- 
late, or  almonds  no  development  occurred  after  twenty- four 
hours.  At  the  room  temperature,  upon  sweet  cherries  the 
spirillum  survived  from  three  to  seven  days ;  upon  sour 
cherries,  three  hours  ;  strawberries,  one  day  ;  pears,  two  to 
five  days ;  cucumbers,  five  to  seven  days.  At  a  tempera- 
ture of  37°  C,  the  time  during  which  the  spirillum  retained 
its  vitality  was,  as  a  rule,  somewhat  less.  Upon  the  sur- 
face of  dried  fruits — cherries,  apricots,  peaches,  plums — the 
spirillum  could  not  be  recovered  after  one  or  two  days. 
When  the  dried  fruit  was  moistened  the  time  was  longer — 
one  day  on  apricots,  two  days  on  peaches,  five  days  on  cher- 
ries, six  days  on  cucumbers. 

The  writer  has  recently  made  a  few  experiments  of  the 
same  kind  with  sweet  Florida  oranges  and  bananas.  In- 
oculations were  made  upon  the  freshly-cut  surface  of  the 
fruit  from  a  recent  bouillon  culture.  The  fruit,  in  a 
glass-covered  dish,  was  placed  in  the  incubating  oven 
at  37°  C.  No  development  occurred  in  bouillon  inocu- 
lated from  the  surface  of  the  fruit  at  the  end  of  twenty- 
four  hours. 

In  the  report  from  which  we  have  already  quoted,  the 
survival  of  the  cholera  spirillum  in  various  drinks  is  also 
given,  as  follows  :  Pilsener  beer,  three  hours  ;  Munich  beer, 
three  hours ;  white  wine,  five  minutes ;  red  wine,  fifteen 
minutes  ;  cider,  twenty  minutes ;  cold  coffee  (six-per-cent. 
infusion),  two  hours  ;  milk,  not  sterilized,  twenty-four 
hours  ;  milk,  sterilized,  still  living  at  the  end  of  nine  days ; 
tea,  two-per  cent,  infusion,  four  days  ;  three-per-cent.  in- 
fusion, one  day;  four-per-cent.  infusion,  one  hour;  cacao, 
one-per-cent.  or  two-per-cent.,  still  living  at  the  end  of  seven 
days. 

Uffelmann,f  in  a  recently  published  article,  gives  some 
additional  data  of  interest  in  this  connection.  In  his  ex- 
periments the  cholera  spirillum  was  found  to  survive  upon 
the  surface  of  slices  of  rye  bread,  freely  exposed  to  the  air, 
for  twenty-four  hours ;  when  the  bread  was  wrapped  in 
paper,  for  three  days ;  and  when  it  was  placed  under  a 
bell-jar,  for  seven  days.  Upon  slightly  acid  butter  the 
spirillum  survived  for  from  four  to  six  days.    On  roasted 


*  Abstract  in  Ctrlbl.  fiXr  Bakteriol.,  Bd.  xii,  1892,  p.  755. 
•j-  Berl.  klin.  Wochenschr.,  1892,  No.  48,  p.  1209. 


meat  which  was  protected  from  drying  by  a  bell-jar,  devel- 
opment still  occurred  at  the  end  of  a  week,  and  upon  smoked 
fish  on  the  fourth  day. 

According  to  Uffelmann,  the  spirillum  may  survive  upon 
the  printed  pages  of  a  book  for  seventeen  hours,  and  upon 
writing-paper  inclosed  in  an  envelope  for  twenty -three  hours 
and  a  half ;  upon  silver  and  copper  coins  it  only  survives 
for  half  an  hour ;  upon  the  dry  hand  for  an  hour,  but  not 
for  two  hour.s. 

In  Uifelmann's  experiments  the  time  of  survival  upon 
textile  fabrics  which  were  apparently  dry  is  stated  to  have 
been  four  days ;  upon  moist  goods  the  spirillum  was  found 
to  be  still  living  at  the  end  of  twelve  days. 

Before  concluding  this  paper  I  desire  to  make  some  re- 
marks upon  practical  disinfection  by  heat.  The  low  ther- 
mal death-point  of  the  cholera  spirillum  justifies  us  in  giv- 
ing heat  the  first  place  as  an  agent  for  the  destruction  of 
this  pathogenic  micro-organism.  And  most  authorities  have 
recommended  the  use  of  steam  for  the  disinfection  of  cloth- 
ing, blankets,  etc. 

At  the  request  of  the  health  officer  of  the  poyt  of  New 
York,  I  made  (in  September)  some  experiments  to  determine 
the  reliability  of  the  method  of  disinfecting  the  clothing, 
etc.,  of  immigrants  sent  to  Hoffman's  Island  from  the 
cholera-infected  ships  in  the  lower  bay.  This  is  effected  in 
a  steam  disinfecting  chamber,  constructed  under  the  direc- 
tion of  the  predecessor  of  the  present  health  officer.  I 
quote  from  my  report  to  Dr.  Jenkins,. dated  September  25, 
1892,  as  follows:  • 

"  Sir  :  In  compliance  with  your  written  request,  dated 
September  17,  1892,  I  have  made  'a  practical  test  of  the 
method  of  disinfection  now  employed  at  Hoffman's  Island,' 
with  the  following  results  : 

"On  the  21st  inst.,  at  10  a.  m.,  I  found  that  the  wire 
baskets  in  the  disinfecting  chambei'  had  been  filled  in  the 
usual  manner  with  articles  to  be  disinfected  from  the  bag- 
gage of  immigrants  from  the  steamship  Scandia.  I  placed 
in  five  of  these  baskets,  in  different  parts  of  the  disinfect- 
ing chamber,  the  following  test  organisms  :  Cholera  spiril- 
lum, typhoid  bacillus,  Sarcina  lutea.  The  thermal  death- 
point  of  these  micro-organisms,  as  determined  by  my  own 
experiments  (1887),  is  for  the  cholera  spirillum,  52°  C.  ; 
for  the  bacillus  of  typhoid  fever,  56°  C. ;  for  Sarcina  lutea, 
64°  C.  These  determinations  all  relate  to  moist  heat;  in 
dry  air  the  thermal  death-point  is  very  much  higher.  Small 
pledgets  of  the  cotton  were  soaked  in  a  bouillon  culture  of 
each  of  the  test  organisms,  and  each  of  these  pledgets  was 
placed  between  two  jjieces  of  sterilized  woolen  blanket  two 
inches  and  a  half  square. 

"  In  making  the  test  the  cholera  spirillum  was  placed 
in  the  middle  and  one  of  the  other  test  organisms  above 
and  below  it,  so  that  three  layers  of  sterilized  blanket  cov- 
ered the  spirillum,  while  but  one  layer  covered  externally 
the  pledgets  of  cotton  containing  the  other  test  organisms. 
These  packets,  each  containing  the  three  test  organisms  on 
pledgets  of  cotton  between  pieces  of  blanket,  were  placed 
in  five  baskets  beneath  the  clothing  to  be  disinfected,  and, 
so  far  as  possible,  in  the  middle  of  the  loosely  piled  articles. 
The  doors  of  the  disinfecting  chamber  were  closed,  and  Mr. 


Jan.  21,  1893.] 


STERNBERG:  DISINFECTION 


AT  QUARANTINE  STATIONS. 


61 


Crawford  was  instructed  to  follow  his  usual  method  with 
reference  to  the  admission  of  steam,  etc. 

"...  The  test  organisms  were  taken  to  the  Hoagland 
Laboratory,  and  each  pledget  of  cotton  was  washed  off  in 
ten  cubic  centimetres  of  sterile  bouillon  in  a  test-tube. 
From  each  of  these  test  tubes  a  small  quantity  was  trans- 
ferred by  means  of  a  platinum  loop  (three  ose)  to  liquefied 
gelatin  in  other  test-tubes,  and  ilsraarch  roll-tubes  were 
made.  The  tubes  containing  bouillon  were  placed  in  an  in- 
cubating oven  at  35°  C,  and  the  Esmarch  roll-tubes  were 
kept  at  the  room  temperature.  At  the  end  of  four  days  no 
development  had  occurred  in  any  of  the  tubes  inoculated 
with  the  cholera  spirillum  or  the  typhoid  bacillus  ;  but  two 
of  the  bouillon  cultures  contained  Sarcina  lutea,  and  the 
corresponding  roll-tubes  contained  colonies  of  this  micro- 
organism, showing  that  there  was  a  failure  to  destroy  the 
sarcina  in  two  out  of  five  of  the  exposures  made.  .  .  ." 

Now,  there  is  a  fact  connected  with  my  experiment 
which  I  failed  to  mention  in  this  report  to  Dr.  Jenkins. 
My  "  controls  "  of  the  cholera  spirillum  upon  pledgets  of 
cotton  between  squares  of  blanket,  which  were  kept  at  the 
laboratory,  when  placed  in  bouillon  in  the  incubating  oven, 
at  the  same  time  with  those  exposed  in  the  disinfecting 
chamber  at  Hoffman's  Island,  also  failed  to  grow.  The 
spirillum  had  been  destroyed  by  desiccation  during  the  forty- 
eight  hours  that  the  pledgets  of  cotton  were  kept  between 
squares  of  sterilized  blanket.  In  view  of  this  fact  and  of 
the  experimental  evidence  heretofore  recorded,  the  question 
arises  as  to  whether  the  exactions  made  by  bacteriologists 
and  sanitarians  with  reference  to  the  use  of  steam  as  a  dis- 
infecting agent  are  not  extravagant,  and  whether  there  is 
not  some  better  way  of  disinfecting  clothing,  etc.,  in 
cholera. 

After  disinfection  by  steam  in  an  apparatus  such  as  is 
used  at  Hoffman's  Island,  the  articles  exposed  in  the  cham- 
ber are  quite  wet,  and  some  method  of  drying  them  before 
repacking  in  trunks,  etc.,  is  necessary  for  two  reasons:  1. 
If  by  any  chance  cholera  germs  should  escape  destruction, 
they  would  be  preserved  for  a  longer  time  in  the  moist 
clothing  than  in  the  same  articles  if  dry  before  they  were 
placed  in  the  disinfecting  chamber.  2.  The  clothing  would 
soon  be  injured  if  packed  away  wet. 

As  already  stated,  the  thermal  death-point  of  the  chol- 
era spirillum  in  a  moist  condition  (bouillon  culture),  as  de- 
termined by  the  writer,  is  52°  C.  (125-G^  F.),  the  time  of 
exposure  being  ten  minutes.  It  is  with  certainty  destroyed 
in  a  very  brief  time  by  a  temperature  of  60°  C.  (140°  F.). 
The  demand,  therefore,  that  it  shall  be  subjected  for  half 
an  hour  or  more  to  a  tempei'ature  of  100°  C,  or  to  steam 
under  pressure  at  a  higher  temperature,  would  certainly  be 
extravagant  if  the  only  question  related  to  the  destruction 
of  the  spirillum  by  the  disinfecting  agent.  It  is  something 
like  asking  for  a  sledge  hammer  for  the  purpose  of  killing 
a  mosquito.  Such  an  instrument  would  be  certain  death 
to  the  insect,  but  it  seems  a  waste  of  energy  to  use  it.  We 
do  not  need  such  a  tremendous  blow,  but  we  must  be  very 
sure  that  the  blow  is  struck  in  the  right  place,  otherwise 
the  insect  will  escape  uninjured,  while  serious  damage  may 
be  done  in  the  ineffectual  effort  to  kill  it. 


In  practical  disinfection  the  question  of  the  penetration 
of  the  objects  to  be  disinfected  by  the  disinfecting  agent 
is  quite  as  important  as  that  relating  to  the  germicidal 
power  of  this  agent.  And  it  has  been  shown  by  carefully 
conducted  experiments  that  neither  steam  nor  hot  air  readi- 
ly penetrate  bundles  or  piled-up  heaps  of  clothing,  blankets, 
etc.  The  free  exposure  of  such  articles  in  the  disinfection 
chamber  is  therefore  a  matter  of  prime  importance.  As  it 
is  extremely  desirable  that  the  articles  to  be  disinfected 
should  come  from  the  disinfecting  chamber  in  a  dry  condi- 
tion, and  as  the  cholera  spirillum  is  quickly  destroyed  by 
desiccation,  the  question  at  once  arises.  Why  not  use  dry 
heat  instead  of  steam  in  cholera  disinfection  ?  The  use  of 
dry  heat  as  a  disinfecting  agent  has  generally  been  given 
up  since  Koch  and  Wolffhiigel  (1881)  showed  that  the  de- 
struction of  various  micro-organisms  tested  by  them  re- 
quires a  temperature  of  120°  to  128°  C,  and  that  the  de- 
struction of  dry  spores  requires  a  temperature  of  140°  C, 
maintained  for  three  hours. 

But  at  the  time  these  experiments  were  made  the  chol- 
era spirillum  had  not  been  discovered,  and  the  bacteria 
tested  by  Koch  and  Wolffhiigel  were  not,  like  it,  quickly 
destroyed  by  desiccation. 

Desiring  to  ascertain  the  effect  of  dry  heat  upon  the 
cholera  spirillum,  I  requested  Dr.  Wilson  to  make  some  ex- 
periments in  an  ordinary  incubating  oven  maintained  at  a 
temperature  of  60°  C.  As  a  preliminary  experiment,  small 
pieces  of  sterilized  blanket  were  moistened  with  a  drop  of 
a  twenty-four-hours-old  bouillon  culture  of  the  cholera 
spirillum.  These  were  kept  in  sterilized  Petri  dishes  for 
twenty -four  hours  so  that  they  might  be  partly  dry.  They 
could  not  be  kept  much  longer  without  killing  the  spirillum 
by  desiccation.  At  the  end  of  the  time  mentioned  they 
were  placed  in  the  incubating  oven  (at  60°  C.)  and  left  for 
periods  varying  from  three  quarters  of  an  hour  to  four 
hours.  Upon  transferring  the  little  squares  of  blanket  to 
sterile  bouillon,  it  turned  out  that  no  development  occurred 
from  any  one  of  them,  while  the  controls  gave  a  pure  cul- 
ture of  the  cholera  spirillum. 

Upon  considering  this  result  in  connection  with  our 
other  experiments,  heretofore  reported,  it  was  apparent  that 
it  was  not  worth  while  to  carry  the  experiment  any  further. 
For,  if  the  spirillum  was  still  moist  when  placed  in  the 
incubating  oven,  a  short  exposure  would  certainly  kill  it, 
inasmuch  as  its  thermal  death-point,  when  in  a  moist  con- 
dition, is  several  degrees  below  00°  C. ;  and  if  it  were 
completely  dry  when  placed  in  the  incubating  oven,  its  vi- 
tality would  already  have  been  destroyed  by  desiccation. 

It  is  evident  that,  having  an  exact  knowledge  of  the 
biological  characters  of  this  spirillum,  we  need  no  longer 
be  controlled  in  making  recommendations  relating  to  its 
destruction  by  data  relating  to  anthrax  spores  or  pathogenic 
bacteria  which  resist  desiccation — e.  g.,  the  pus  cocci,  the 
typhoid  bacillus,  the  diphtheria  bacillus. 

To  the  writer  it  appears  that  disinfection  would  be  ac- 
complished quite  as  effectually  by  the  free  exposure  of 
woolen  garments,  blankets,  etc.,  in  a  hot-air  drying  oven  or 
chamber  to  a  temperature  of  80°  to  100°  C.  for  half  an 
hour  or  more,  being  careful  that  no  two  articles  were  piled 


62 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Joue., 


one  upon  another,  for  the  penetrating  power  of  dry  heat  is 
very  slight.  If  the  hot-air  oven  were  provided  with  an 
exhaust  pump,  the  drying  process  could  be  effected  more 
promptly.  Or  it  might  be  so  arranged  that  a  current  of 
hot  dry  air  should  pass  over  and  through  the  articles  to  be 
disinfected. 

In  the  absence  of  such  a  disinfecting  chamber,  and  in 
favorable  weather,  such  articles  could  be  exposed  to  the 
sun  and  air  upon  clothes  lines  or  spread  out  upon  an  as- 
phalt pavement  like  that  at  Hoffman's  Island,  for  example. 

Soiled  underclothing  and  all  articles  that  are  commonly 
sent  to  a  laundry  can  be  most  expeditiously  disinfected  by 
immersion  in  boiling  water.  To  pile  up  such  things  in 
baskets  in  a  steam  disinfecting  chamber  appears  to  the 
writer  to  be  bad  practice  and  possibly  dangerous.  Mat- 
tresses, feather  pillows,  etc.,  should  either  be  destroyed  or 
thoroughly  dried  in  a  hot-air  oven — preferably  in  one  pro- 
vided with  an  exhaust  pump,  or  by  long  exposure  to  a  cur- 
rent of  hot  air. 

For  the  disinfection  of  paper  rags  (in  cholera),  thorough 
desiccation  appears  to  the  writer  to  be  a  safer  method  than 
exposure  to  steam ;  but  neither  method  can  be  safely  ap- 
plied to  baled  rags.  If  rags  are  thoroughly  dried  when 
baled  and  not  exposed  to  infection  subsequently,  I  see  no 
good  reason  for  making  an  exception  with  reference  to 
them.  But  rags  collected  in  an  infected  area  are  justly 
regarded  with  suspicion  by  sanitarians,  and  should  be  ex- 
cluded from  our  ports. 

In  disinfection  on  shipboard  the  germicidal  action  of 
sunlight  and  dry  air  should  be  kept  in  view.  Solutions 
of  chemical  disinfectants  are  chiefly  required  for  excreta, 
for  soiled  clothing,  and  for  washing  surfaces  exposed  to 
contamination  by  the  excreta  of  the  sick.  It  is  prudent 
also  to  apply  them  to  the  walls  and  ceiling  of  apartments 
which  have  been  occupied  by  cholera  patients.  But  it 
hardly  appears  necessary  to  deluge  a  whole  ship  with  a 
solution  of  corrosive  sublimate  because  one  or  more  cases 
of  cholera  have  occurred  in  the  steerage,  in  view  of  the  fact 
that  the  cholera  spirillum  only  survives  a  few  hours  when 
freely  exposed  to  light  and  dry  air. 

If  there  is  a  compartment  on  shipboard  which  can  be 
used  as  a  steam  disinfecting  chamber,  woolen  clothing, 
blankets,  etc.,  had  better  be  disinfected  by  steam  or  burned 
if  of  little  value.  But  it  hardly  seems  necessary  to  blister 
the  paint  in  the  cabins  and  injure  the  dry  and  clean  cur- 
tains, stuffed  furniture,  etc.,  when  no  cases  have  occurred 
in  tliis  part  of  the  ship. 

The  rubbing  down  of  walls  with  moist  bread  may  be  a 
useful  and  necessary  measure  for  the  disinfection  of  apart- 
ments occupied  by  patients  with  diphtheria  or  erysipelas, 
for  the  speciflc  infectious  agent  in  these  diseases  resists 
desiccation.  In  the  case  of  cholera  it  appears  to  be  super- 
fluous, if  by  artificial  heat  or  exposure  to  fresh  air  such 
walls  and  surfaces  can  be  thoroughly  dried. 

The  writer  earnestly  hopes  that  what  has  here  been 
written  will  not  be  used  as  a  pretext  for  the  neglect  of 
those  necessary  measures  of  disinfection  upon  which  we 
must  depend  for  the  exclusion  of  the  pestilence  which  was 
knocking  at  our  doors  in  the  autumn  and  will  probably 


make  a  renewed  attempt  to  effect  an  entrance  in  the  spring. 
We  fully  believe  that  such  an  entrance  may  be  prevented 
by  the  intelligent  application  of  methods  based  upon  the 
experimental  data  obtained  by  exact  scientific  research. 

In  the  absence  of  such  knowledge  the  efforts  of  sani- 
tarians to  exclude  an  exotic  pestilential  malady  have  not 
infrequently  been  attended  with  unnecessary  exactions  upon 
commerce,  and  an  unjustifiable  interference  with  the  rights 
of  individuals  who  have  been  so  unfortunate  as  to  embark 
upon  a  suspected  or  infected  ship. 


A  CLINICO-PATHOLOGICAL  STUDY  OF 
INJURIES  OF  THE  HEAD, 

WITH  SPECIAL  REFERENCE  TO 
LESIONS  OF  THE  BRAIN  SUBSTANCE. 
By  CHARLES  PHELPS,  M.  D., 

SURGEON  TO  BELLEVtTE  AND  ST.  VINCENT'S  HOBPITAI.8. 

{Continued  from  page  39.) 
FRACTURES  OF  THE  VERTEX. 

Case  LXXI. — Male,  aged  fifty-two ;  fell  backward  and  struck 
back  of  liis  head,  at  tlie  same  time  fracturing  his  left  patella. 
At  the  hospital  to  which  Le  was  taken  his  head  injury  did  not 
attract  attention.  He  was  delirious  on  the  second  day  and  had 
a  convulsion  on  the  fifteenth,  and  his  condition  was  attributed 
to  the  alcoholic  habit.  Six  months  later  the  yiatella  was  wired 
for  non-union.  His  muscular  rigidity  under  the  anaesthetic  was 
notable.  His  temperature  the  day  following  the  operation  was 
99°  till  one  o'clock  p.  m.  Half  an  hour  later  and  without  pre- 
monition he  iiad  an  epileptiform  convulsion  which  began  in  the 
face  and  became  general,  and  was  followed  by  wild  delirium. 
He  had  two  other  sinnlar  convulsions,  also  followed  by  wild 
delirium,  and  the  last  by  a  temperature  of  103°.  The  kidneys 
acted  freely  and  the  urine  was  normal.  The  wound  of  opera- 
tion was  the  seat  of  primary  union.  The  temperature  was  nor- 
mal on  tb^next  day  and  so  remained  for  fifteen  days.  At  that 
tinjc  an  attempt  was  made  to  coapt  the  fragments  of  the  patella, 
which  he  had  torn  assunder  in  his  convulsions  and  delirium. 
This  failed  and  there  was  some  subsequent  suppuration  which 
elevated  the  temperature  for  the  next  ten  or  twelve  days  to  99° -f 
to  102°.  The  wound  was  then  healed  and  the  temperature 
again  became  normal.  At  each  dressing  great  muscular  rigidity 
and  tonic  spasm  had  been  noted  in  the  affected  limb  (left).  Just 
one  month  from  the  previous  attack  convulsions  recurred  and 
were  frequently  repeated  for  thirty-six  hours.  They  were  all 
marked  by  the  same  characteristics.  Each  one  was  preceded 
by  great  restlessness.  In  about  fifteen  seconds  this  was  followed 
by  wide  dilatation  of  both  pupils.  The  muscles  of  the  left  side 
of  the  face  began  to  twitch  and  the  eyes  deviated  to  the  left. 
The  muscular  spasm  extended  to  the  other  side  of  the  face,  then 
to  the  left  arm  and  leg,  and  fiually  became  general.  The  whole 
convulsion  lasted  about  thirty  seconds.  During  the  day  the  de- 
viation of  the  left  eye  became  permanent.  The  tendon  reflexes 
were  markedly  increased.  After  the  convulsions  ceased  he  be- 
came delirious  and  died  nine  hours  later.  At  the  tinie  of  the 
seizure  his  temperature  was  100"1°,  in  twelve  hours  it  became 
102°,  in  twenty  hours  10i°,  in  twenty-four  hours  104'8°,  and 
afterward  fell  to  104°. 

Necropsy. — The  knee  joint  of  operation  was  found  to  be  free 
from  inflammatory  complication,  and  the  wound  practically 
healed.  A  depression  was  discovered  in  the  skull  just  above 
the  external  occipital  protuberance  in  the  median  line.  This 


Jan.  21.  1893.] 


PHELPS:  INJURIES  OF  THE  HEAD. 


63 


was  confined  to  the  external  table  and  no  lesion  of  the  brain  ex- 
isted beneath  it.  At  the  oppofite  extremity,  however,  of  the 
antero-[)osteri()r  diameter  there  was  a  circular  laceration  upon 
the  anterior  border  of  the  rijjht  frontal  lobe,  and  another  lacera- 
tion existed  upon  the  under  surface  of  the  left  frontal  lobe,  upon 
the  middle  of  the  second  and  third  orbital  convolutions,  an  inch 
and  a  half  by  an  inch  in  diameter.  A  still  larger  laceration  of 
the  base,  at  least  three  inches  and  a  half  by  an  inch  and  a  half 
in  diameter,  existed  upon  the  right  temporo-sphenoidal  lobe,  in- 
volving a  little  of  the  first,  and  almost  the  whole  of  the  second 
and  third  convolutions.  All  these  lacerations  were  distinctly 
limited,  softened,  and  of  a  brownish  color,  showing  the  consid- 
erable time  which  had  elapsed  since  they  were  inflicted.  The 
whole  right  temporo-sphenoidal  lobe  was  greatly  atrophied,  in- 
durated, and  pigmented.  The  pia  was  thickened  over  each 
laceration. 

Case  LXXII. — Male,  aged  forty  ;  cause  of  injury  unknown; 
found  unconscious  in  bed  ;  contusion  of  forehead  and  left  upper 
eyelid;  pupils  regular  and  fixed;  right  facial  paralysis;  both 
arms  and  right  leg  rigid;  pulse,  96;  respiration,  36.  Twenty- 
four  hours  later,  right  arm  paralyzed,  but  still  rigid  ;  could  not 
determine  whether  right  leg  was  paralyzed  ;  pulseless  ;  died  in 
thirty  hours;  temperature  at  admission,  102"6°;  twenty-four 
hours  later,  105°. 

Necropsy. — Hgematoma  over  whole  left  jjarietal  region.  Lin- 
ear fracture  across  whole  length  of  parietal  bone  just  above  tem- 
poral ridge,  recurving  upon  itself  posteriorly  for  a  little  distance. 
Large  epidural  clot  beneath  the  fracture  compressing  and  tiatten- 
ing  the  whole  left  hemisphere  and  forming  an  oblique  plane. 
General  contusion  of  the  whole  brain,  which  was  byperEemic  and 
studded  with  minute  extravasations. 

Case  LXXIIL — Male,  aged  twenty-eight;  received  a  blow 
upon  the  head  from  a  falling  elevator  (lift);  compound  commi- 
nuted fracture  of  right  frontal  bone;  wound  filled  with  clot  and 
brain  tissue  ;  opening  in  the  skull  an  inch  and  a  half  by  half  an 
inch  in  diameter.  After  cleansing  the  wound  a  cavity  was  left 
in  the  frontal  lobe  as  large  as  a  Mandarin  orange.  The  patient 
was  semi-conscious,  but  mental  condition  soon  became  normal. 
Pulse,  68;  temperature,  100-2°.  Vomited  frequently.  At  the 
end  of  twenty- four  hours  he  was  rather  heavy  and  somnolent, 
but  could  be  easily  roused,  and  was  rational.  Two  hours  later 
he  was  found  in  a  comatose  condition,  with  a  temperature  of 
105 -4",  and  died  soon  afterward,  twenty-seven  hours  from  the 
time  he  received  the  injury. 

Necropsy. — Two  large  fissures  ran  backward  on  either  side 
of  the  skull,  one  terminating  in  the  paiietal  and  the  other  in  the 
occipital  bone.  There  was  no  epidural  haemorrhage.  An  irregu. 
larly  shaped  piece  of  the  internal  table  was  detached  and  rested 
upon  the  brain  just  above  the  cavity  noted,  but  nearer  the  me- 
dian line,  and  a  subdural  clot  three  inches  in  diameter  and  half 
an  inch  thick  was  situated  just  posterior  to  it  upon  the  right 
frontal  lobe.  There  Wiis  slight  cortical  hfemorrliagc  in  the  left 
occipital  region.  There  was  no  lesion  at  the  base.  The  cavity 
made  by  laceration  of  the  frontal  lobe  extended  nearly  to  the 
lateral  ventricle.  The  whole  brain,  including  the  pons,  optic 
thalami,  and  corpora  striata  upon  both  sides,  and  the  cerebel- 
lum, was  streaked  with  minute  coaguia,  some  of  which,  an  inch 
in  length,  could  be  teased  from  the  vessels. 

Case  LXXIV. — Male,  aged  thirty-two;  fell  thirty  feet  into 
the  hold  of  a  vessel,  striking  upon  his  back.  Unconscious;  pulse 
and  respiration  slow  ;  stertor  ;  no  other  symptoms.  Condition 
resembled  that  of  alcoholic  coma.  Next  morning  the  tempera- 
ture was  101'()°;  evening,  10r8°.  On  the  second  d.'iy,  a.m., 
103-8°;  M.,  104-2°;  p.m.,  105-4°.  Right  hemiplegia  and  both 
eyes  turned  to  the  left.  Pupils  normal.  Pulse  feeble  and  rapid. 
Respiration  inadequate  from  pulmonary  oedema.    Still  uncon- 


scious. On  the  third  day  temperature,  a.m.,  106  4°.  Death  in 
sixty  hours. 

Necropstj. — Separation  of  coronary  suture  from  right  frontal 
eminence  to  its  left  external  extremity.  Not  much  epidural 
haemorrhage.  Laceration  of  posterior  extremity  of  left  temporo- 
sphenoidal  extending  into  occipital  lobe.  Consequent  subdural 
haemorrhage  of  moderate  amount,  involving  left  motor  area  and 
occipital  lobe  to  the  base.  Another  laceration  existed  on  the 
posterior  border  of  the  left  cerebellum.    General  contusion. 

Case  LXXV. — Male,  aged  thirty-two;  fell  from  his  truck. 
Contusion  of  left  parietal  region  ;  unconscious;  irritable  when 
disturbed  ;  temperatofe,  99°  ;  pulse,  60  and  full ;  coma  con- 
tinued for  about  a  week  with  temperature  from  99°  to  100°, 
then  a  period  of  irritability  and  mild  delirium  which  lasted  two 
weeks  longer.  Mental  condition  after  the  first  two  weeks  apa- 
thetic and  weak.  lie  answered  questions  rationally  when 
spoken  to,  but  rambled  in  his  speech.  lie  recognized  his  friends, 
but  spoke  only  when  spoken  to  and  had  some  delusions.  At  the 
end  of  a  month  he  was  transferred  to  Mount  Sinai  Hospital  and 
died  there. 

Necropsy. — Fracture  found  in  left  occipito-parietal  region. 
Laceration. 

Case  LXXVI. — Female,  aged  twenty-three;  suicidal  gun- 
shot wound  through  right  temporal  fossa;  median  line  of  ver- 
tex presented  a  conical  elevntion ;  hemorrhage  considerable ; 
patient  unconscious  with  stertor;  coma  became  more  profound; 
temperature  fell  to  95° ;  pulse  rapid  ;  death  in  four  hours. 

Necropsy. — Scalp  infiltrated  with  blood.  Bullet  entered 
frontal  bone  a  little  above  and  external  to  right  eye,  penetrated 
the  brain,  passed  inward,  upward,  and  backward,  and  impinged 
upon  the  inner  surface  of  the  skull,  a  little  to  the  left  of  the 
median  line  in  the  middle  parietal  region.  It  elevated  two  little 
triangular  pieces  of  bone  which  remained  attached  to  the  peri- 
cranium. The  bullet  then  fell  back  into  the  brain.  It  had  en- 
tered at  the  anterior  extremity  of  the  fissure  of  Sylvius,  trav- 
ersed the  right  frontal  lobe,  just  below  the  cortex  and  parallel 
to  its  curve,  and  then  passed  a  little  backward  and  across  the 
longitudinal  fissure  below  the  longitudinal  sinus,  into  the  left 
j)arietal  lobe  ;  after  fracturing  the  left  parietal  bone  and  falling 
back  into  its  cerebral  track  as  noted,  it  rested  about  half  an  inch 
below  the  surface.  The  skull  was  very  thick  and  fissured  from 
the  point  where  tlie  bullet  entered.  There  was  little  intracranial 
hiemorrhage. 

Case  LXXVII. — Male,  ageil  twenty-six  ;  homicidal  gunshot 
wound  in  right  temporal  fossa ;  patient  unconscious ;  pupils 
normal;  general  muscular  twitching ;  coma  became  profound, 
and  death  followed  in  twelve  hours. 

Necropsy. — Bullet  entered  just  behind  external  angular  pro- 
cess of  right  frontal  bone,  traversed  tWe  right  hemisphere  nearly 
in  its  antero-posterior  diameter,  just  above  cor|)us  callosum,  im- 
pinged upon  inner  surface  of  the  occipital  bone,  and,  rebounding 
through  the  opening  in  the  dura,  fell  into  the  inferior  occipital 
fossa.    Consi<lerable  subdural  ha;morrhage. 

Case  LXXVIII. — Male,  aged  fortv-tvvo;  suicidal  gunshot 
wound  in  right  temporal  fossa;  patient  unconsciouss ;  pulse, 
70;  no  other  symptoms.  lie  soon  regained  consciousness  and 
was  rational,  but  his  mental  processes  were  .sluggish.  He  had 
syphilitic  laryngitis  and  aphonia.  Temperature,  99°.  An  at- 
tempt was  made  to  remove  the  ball  next  day,  the  opening  in 
the  bone  at  about  the  right  temporo-frontal  junction  having 
been  enlarged  by  the  trephine.  The  track  of  the  ball  could  bo 
traced  about  two  inches  and  a  half  forward,  downward,  and  in- 
ward, at  which  distance  a  i)iecc  of  bone,  carried  inward  by  the 
ball,  circular  and  comprising  both  tables,  was  discovered  and 
removed.  Considerable  brain  matter  oozed  out  during  this  ex- 
ploration.   The  ball  was  not  found.    No  reaction  followed  the 


61 

opet-ation.  The  patient  lived  thirty  days.  His  urine  and  lacces 
were  voided  freely,  but  witiioiit  attracting  his  attention.  The 
discharge  of  brain  matter  from  the  wound  gradually  diminished. 
At  the  time  of  his  death  the  external  wound  had  almost  en- 
tirely healed.  The  most  notable  symptom  in  his  condition  was 
hebetude.  He  remained  rational  but  quiet,  listless,  and  taking 
no  notice  of  people  or  things,  and  without  interest  in  what 
went  on  about  him,  with  occasional  intervals  in  which  his 
mind  seemed  brighter.  The  temperature  ranged  from  100°  + 
to  103-6°,  and  was  usually  above  101°. 

JSecropsu. — The  ball  entered  the  brain  about  the  middle  of 
the  third  right  frontal  convolution,  and  passed  nearly  trans- 
versely through  the  center  of  both  fnmtal  lobes,  and  lodged 
just  behind  the  ascending  arm  of  the  fissure  of  Sylvius  on  the 
left  side  in  the  upper  portion  of  the  island  of  Reil.  Its  track 
passed  just  above  the  anterior  horn  of  both  lateral  ventricles, 
and  above  the  corpus  callosum,  just  involving  the  calloso- margi- 
nal convolutions.  On  the  left  side  the  track  was  8hari)ly  de- 
fined, and  formed  a  cavity  Kve  eighths  by  seven  eighths  of  an 
inch  in  diameter  containing  the  ball  surrounded  by  clot  and 
brain  detritus.  This  was  separated  by  the  median  fissure  from 
the  cavity  on  the  right  side  from  which  the  bone  was  extracted 
during  life.  Between  the  two  cavities  was  a  minute  piece  of 
bone. 

Case  LXXIX. — Female,  aged  eight,  fell  three  stories;  con- 
scious; shock;  compound  comminuted  de()res9ed  fracture  of 
left  frontal  bone,  with  laceration  of  brain  and  meninges;  rest- 
less and  delirious ;  died  on  the  third  day;  temperature  on  ad- 
mission, 100-2°;  rose  to  104  6°. 

Necropny. — Cavity  in  left  prefontal  lobe  filled  with  clot  and 
bi'ain  detritus.  No  considerable  intracranial  haemorrhage. 
General  contusion  of  brain  substance  with  coagula  in  minute 
vessels. 

Case  LXXX. — Male,  aged  fifty;  cause  of  injury  unknown; 
nnconscimis;  pulse  and  respiration  rapid;  temperature,  100°; 
both  pupils  dilated;  died  in  four  hours. 

]Secro}i8y. — Simple  fracture  of  left  temporal  bone,  squamous 
portion.  Deep  laceration  of  right  temporo-sphenoidal  lobe, 
also  of  anterior  border  of  left  temporo-sphenoidal,  smaller  and 
shallower.  Whole  su;ierior  surfaces  of  both  hemispheres  cov- 
ered by  cortical  haemorrhage. 

Case  LXXXI. —  Male,  aged  sixteen;  struck  on  the  head  by 
an  iron  wrench ;  scalp  wound ;  depressed  fracture  at  right 
parieto  occipital  junction ;  trephined  and  elevated ;  no  general 
symptoms;  walking  case;  no  injury  of  dura;  no  subsequent 
symptoms. 

Case  LXXXH. — Male,  aged  thirty;  struck  on  the  head; 
compound  depressed  fracture  of  left  temporal  bone  at  parietal 
junction;  temporarily  unconscious;  afterward  dazed;  agraj'hia; 
tre[)bined  and  bone  elevated  next  day ;  agraphia  continued  eight 
days;  sensory  apha-ia  on  the  third  day;  temperature  on  ad- 
mission. 99°;  next  day,  103°;  second  day,  103-8°;  became  nor- 
mal on  eighth  day;  wfterward  varied  from  99°  to  102°  for 
twenty  days;  did  not  again  become  normal  till  thirtieth  day. 

Case  LXXXIII. — Male,  aged  thirty-three ;  blow  from  a 
deliver;  fragment  of  outer  table  of  left  frontal  cut  off  and  left 
hanging  by  the  periosteum,  including  the  frontal  eminence; 
condition  irritable ;  wound  healed  in  four  days;  no  subsequent 
symptoms. 

C-^sE  LXXXIV. — Female,  nged  two  years  and  a  half;  fell 
down  stairs;  compound  depressed  fracture  of  left  parietal  bone 
just  posterior  and  external  to  frontal  eminence;  wound  lacer- 
ated and  contused.  Three  days  later,  convulsion  occurred  and 
admitted  to  hospital.  Wound  snpjiurating  and  sloughy.  No 
general  symptoms.  Bone  elevated.  Highest  temperature,  102°. 
Discharged  in  twenty-eight  days;  readmitted  fourteen  days 


[N.  Y.  Med.  Jodk., 

later:  subdural  abscess;  hernia  cerebii ;  abscess  in  brain  evacu- 
ated ;  hernia  subsided  and  patient  discharged. 

Case  LXXXV. — Female,  aged  forty-two;  struck  with  a 
hammer  weighing  eight  pounds;  several  lacerated  and  con- 
tused wounds  of  the  scalp,  and  a  depres^ed  fracture  of  the  pos- 
terior inferior  part  of  the  right  parietal  bone  one  half  by  three 
fourths  of  an  inch  In  diameter,  with  a  fissure  running  forward ; 
hajmatoma  over  right  malar  bone  and  a  contusion  of  the  back 
of  the  neck;  patient  conscious,  rational,  and  restless;  pulse, 
120  and  full;  temperature,  99°;  third  day,  100°;  fourth  day, 
104°;  trephined  and  elevated;  some  epidural  clot  removed; 
dura  tense  and  not  pulsa'ing,  and  was  incised;  small  amount 
of  blood  and  serum  escaped;  wound  healed  at  once  and  tem- 
perature fell  gradually  to  99"  in  four  days  ensuing.  Six  months 
later,  I  was  told  by  Dr.  G.  Douglass  that  he  had  seen  her  at 
about  that  time.  She  was  very  nervous,  excitable,  and  com- 
plained that  she  was  confused  and  "wrong  in  her  head"  ever 
since  her  discharge. 

Case  LXXX VI. — Male,  aged  thirty-eight;  was  struck  by  a 
bottle  in  middle  of  forehead;  he  was  dazed,  but  able  to  walk; 
compound  depressed  fracture  of  right  frontal  bone  extending 
into  orbital  plate,  and  frontal  sinus  opened ;  trephined  and  a 
piece  of  bone,  an  inch  and  a  half  square,  with  a  sharp  edge, 
which  had  i)eiietrated  the  cerebral  substance,  was  removed. 
The  superior  longitudinal  sinus  was  torn,  and  hasmorrhage  was 
controlled  by  pressure  against  the  bone  with  one  blade  of  a 
Langenbeck's  forceps.  Sutured  in  position  till  the  third  day. 
The  patient  for  a  time  was  irritable  and  delirious,  requiring  me- 
clianical  restraint.  The  temperature  was  very  uniform,  vary- 
ing only  from  99°  to  100°,  when  it  became  normal. 

Case  LXXXVII. — Male,  aged  forty;  knocked  down  by  a 
blow  upon  the  head.  When  he  recovered  consciousness  he 
walked  into  the  hospital.  Compound  depressed  fracture  posterior 
to  left  frontal  eminence,  and  piece  of  inner  table  driven  in.  Dura 
uninjured.  No  general  symptoms.  Temperature,  101°  to  102° 
for  six  ditys,  when  it  suddenly  dropped  from  101°  to  normal. 

Case  LXXXVllI. — Male,  aged  fourteen;  fell  two  stories; 
temjjorarily  delirious  from  fright  and  excitement,  and  then  re- 
covered and  walked  home:  depressed  fracture  in  right  frontal 
bone  near  coronal  suture;  elevated;  no  subsequent  symptoms. 

Case  LXXXIX. — Male,  aged  thirty;  gunshot  fracture  of 
right  frontal  one  inch  above  the  zygoma;  considerable  haemor- 
rhage from  wound  and  beneath  the  conjunctiva;  right  eye  pro- 
truded so  much  that  the  lids  could  not  be  closed ;  no  mental 
symptoms;  temperature,  99-5°  to  104-.5°;  next  day  tempera- 
ture 104°.  The  bullet-opening  in  the  skull  was  enlarged  by  the 
trephine,  several  loose  pieces  of  bone  removed,  and  the  bullet 
felt  near  the  optic  foramen.  The  eye  was  then  removed  and 
the  bullet  extracted  througli  the  orbit,  the  dura  having  been 
first  incised.  The  roof  of  the  orbit  was  found  to  be  much  com- 
minuted. Temperature  remained  high,  and  delirium  and  illu- 
sions continued  for  three  days.  The  wound  supi)urated  rather 
freely  for  the  first  month,  and  the  patient  often  suffered  from 
headache,  which  was  always  relieved  by  changing  the  dress- 
ings. He  remained  in  the  hospital  for  two  months  and  was 
then  discharged  entirely  well.  The  temperature  for  the  first 
ten  days  was  102°  to  103°  ;  for  the  next  twenty  days,  100°  to 
101°;  for  the  next  ten  days,  100°;  and  the  next  ten  days,  99° 
to  99°  4-. 

Case  XC. — Male,  aged  eighteen  ;  blow  upon  the  head  from 
a  hammer;  conscious;  compound  fissured  fracture  in  left  parietal 
region;  no  depression ;  no  symptoms. 

Case  XCI. — Male,  aged  twelve;  ran  into  an  iron  post;  com- 
pound depressed  fracture  of  right  frontal  bone,  encroaching 
ui)on  coronal  suture  in  temporal  region;  slight  esca|)e  of  brain- 
substance  ;  elevated  piece  of  bone  three  quarters  of  an  inch  in 


PHELPS:  INJURIES  OF  THE  HEAD. 


Jan.  21,  1893.] 


PHELPS:  INJURIES  OF  THE  HEAD. 


65 


diameter;  no  general  symptoms  of  cerebral  injury.  Had  no 
subsequent  symptoms,  except  for  a  single  day  following  the  oper- 
ation, when  he  responded  slowly  to  questions. 

Case  XCII. — Male,  aged  thirty-five;  blow  upon  the  head 
from  an  earthen  mug;  compound  fissured  fracture  of  external 
table  of  posterior  part  of  left  parietal  bone ;  no  general  symp- 
toms. 

Case  XCIII. — Female,  aged  thirty-seven;  struck  by  a  brick 
falling  from  a  roof;  compound  depressed  fracture  of  right  parie- 
tal bone,  three  quarters  of  an  inch  from  median  line,  double 
comminuted.  One  fragment  removed  and  the  other  elevated. 
No  general  symptoms  either  before  or  after  the  operation. 

Case  XCIV. — Male,  aged  sixteen;  tiirown  from  a  horse; 
compound  depressed  fracture  of  left  frontal  bone,  just  above 
suiierciliary  ridge;  conscious  and  irritable;  temperature,  99'8°; 
pulse,  60,  full.  A  piece  of  bone,  an  inch  and  a  quarter  by  half 
an  inch,  completely  separated  and  driven  in  upon  the  dura,  ele- 
vated and  removed  under  ether.  Had  no  subsequent  general 
8ym[)toms  except  temperature,  which  for  ten  days  was  usually 
from  99°  to  100°,  and  a  somewhat  irritable  mental  condition. 

Case  XCV. — Female,  aged  seven ;  fell  one  flight  of  stairs  over 
the  banisters;  struck  her  head  ;  unconscious;  vomited.  Became 
dull  and  stupid  on  the  second  day  ;  next  day  admitted  to  hos])i- 
tal.  Hiematoma  in  left  parietal  region,  and  linear  fracture,  dis- 
covered by  incision,  confined  to  left  parietal  bone.  Tempera- 
ture, 99°.    No  subsequent  symptoms. 

Casc  XCVI. — Male,  aged  thirty-two ;  stabbed  in  the  forehead 
with  a  pocket  knife.  Tiiree  days  later  no  general  symptoms. 
Temperature,  99°  to  100°;  pulse,  76.  After  incision,  the  knife 
blade  could  be  seen  broken  off  at  the  level  of  the  surface  of  the 
bone,  an  inch  and  three  quarters  above  left  supra-orbital  ridge, 
and  an  inch  and  a  half  to  left  of  median  line.  A  button  of 
bone,  which  included  the  knife  point  in  the  center,  was  removed 
by  the  trephine.  The  point  had  penetrated  the  brain  a  quarter 
of  an  inch.  Dura  incised  and  closed  by  suture.  No  subsequent 
symptoms. 

Case  XCVII. — Male,  aged  twenty  ;  knocked  down  by  a  blow 
from  a  heavy  stick ;  unconscious ;  linear  fracture  from  just  above 
left  superciliary  ridge,  extending  mto  parietal  bone,  and  incised 
wound.    No  general  symptoms. 

Case  XCVIII. — Male,  aged  thirtv-one;  struck  by  a  shower 
of  bricks  ;  compound  depressed  fracture  of  right  parietal  bone. 
Trephined,  and  loose  fragment  of  inner  table,  half  an  inch  square, 
removed.    No  general  symptoms. 

Case  XCIX  — Male,  aged  twenty-six  ;  fell  thirty-five  feet 
from  a  scaffold ;  had  been  temporaiily  unconscious.  A  frag- 
ment of  the  right  parietal  bone,  near  its  upper  posterior  angle, 
including  both  tables,  had  been  torn  out  and  was  missing,  two 
inches  by  one  inch  and  three  quarters  in  diameter.  The  inner 
table  was  comminuted,  and  fragments  pressing  upon  the  dura 
were  removed.  No  fissures.  Dura  uninjured.  No  disorders 
of  sensation  or  other  general  symptoms.  Temperature,  99°  to 
100° -f-. 

Case  C. — Female,  aged  forty-five  ;  fell  down  stairway  at  ele- 
vated railroad  station  ;  unconscious.  Admitted  after  five  days. 
Iltematoma  over  left  eye,  which  had  been  incised ;  fissure,  ex- 
tending into  frontal  sinus,  could  be  detected  through  the  incis- 
ion. The  only  general  symptom  was  occipital  headache  for 
some  days  after  the  injury  was  received. 

Cask  CI. — Male,  aged  eight;  kicked  by  a  horse;  compound 
depressed  fracture  of  right  frontal  bone,  just  above  frontal  sinus 
and  near  the  median  line.  Elevated  on  the  fourth  day.  Dura 
uninjured.  Opening  in  the  skull  which  remained  was  three 
quarters  of  an  inch  in  diameter.  Had  no  previous  general 
symptoms.  Temperature,  from  99°  to  99'8° ;  after  the  opera- 
tion, rose  in  twenty-four  hours  to  103°,  and  in  forty-eight  hours 


to  104°.  In  the  next  five  days  it  fell  gradually  to  99°,  and  re- 
mained 99° -f-  for  ten  days  following.  Once  during  this  time — 
on  the  fifteenth  day — some  serum  escaped  from  the  wound  at 
the  time  of  dressing.  On  the  twentieth  day  some  laudable  pus 
escaped,  also  at  the  time  of  dressing,  and  a  probe  was  carried 
two  inches  and  a  half  into  the  frontal  lobe  parallel  to  theorhital 
plate.  The  next  day  the  dura  was  incised  to  the  extent  of  the 
cranial  opening,  and  from  two  to  three  otmces  of  laudable  pus 
evacuated.  The  probe  could  be  carried  backward  two  inches 
and  a  half  parallel  to  the  cranial  wall  on  the  external  aspect  of 
the  hemis|)here,  as  well  as  two  inches  and  a  half  ])arallel  to  the 
orbital  plate.  The  temperature  at  this  time  was  99'2°  and  pulse 
96.  There  were  no  general  symptoms,  except,  a  little  mental 
dullness  or  apathy  and  slight  right  lower  facial  paralysis.  His 
general  condition  was  also  becoming  asthenic.  The  cavity  was 
irrigated  and  drained  by  tube.  Temperature  rose  next  day  to 
102° -f;  became  normal  in  a  week.  Facial  paralysis  entirely 
disappeared  in  ten  days.  Discharge  ceased  during  the  third 
week.  Mental  cnndition  became  normal,  and  nutrition  rapidly 
improved  after  the  first  few  days.  There  was  a  fungus,  not 
larger  than  a  hazel-nut,  which  spontaneously  disappeared.  The 
external  wonnd  was  entirely  healed  in  little  more  than  a  month, 
and  no  symjitoms  of  any  kind  remained. 

injcries  of  tue  encepoalon.  • 

Case  Clf. — Male,  aged  forty-one;  fell  upon  his  face  ;  contu- 
sions most  marked  on  left  side  of  face  and  eyes;  violent  deliri- 
um for  two  days.  Temperature,  103°  to  104°.  On  the  sixth 
day  again  became  delirious,  and  later  unconscious  and  violently 
responsive  to  irritations.  Temperature  was  at  no  lime  below 
100°,  and  was  103°  just  previous  to  death,  which  occurred  at 
the  end  of  six  days. 

Necroyi^y. — Hsematoma  and  small  scal[)  wound  in  right  parie- 
tal region.  Thin  cortical  coagulum  over  left  occipital  lobe,  ex- 
tending into  median  fissure.    Subarachnoid  serous  effusion. 

Case  Clll. — Male,  aged  sixty  ;  pushed  down  three  steps  of  a 
stairway,  and  sustained  minor  superficial  injuries.  No  head 
symj)toms  till  the  fourth  day,  when  he  had  four  convulsions. 
There  was  one  the  next  day,  and  afterward  they  occui-red  with 
increasing  frequency  till  his  death  on  the  eighth  day.  Each  one 
began  by  tvvitching  of  the  muscles  of  the  face,  with  the  head  and 
eyes  turned  to  the  left,  and  these  extended  to  the  left  arm  and 
finally  to  the  left  hand.  The  right  side  was  not  involved  at  all. 
Temperature  on  admission,  100°;  in  twelve  hours,  103°.  From 
this  time  it  varied  from  103°  to  104°  till  six  hours  before  his 
death,  when  it  became  and  continued  105°. 

Necrojjsy. — No  lesion  of  scalp  or  skull.  Subdural  haemor- 
rhage over  whole  right  cerebrum,  and  extensive  laceration  of 
right  temporo-sphenoidal  lobe. 

Case  CIV. — Male,  aged  thirty-two;  fell  upon  the  sidewalk; 
scalp  wound  in  left  occii)ito-parietal  region.  Admitted  to  hos- 
pital ten  hours  later.  Conscious  and  rational,  but  dazt  d,  and 
with  extreme  muscular  tremor.  Two  liours  afterward  the  pa- 
tient had  a  general  convulsion.  From  this  time,  during  periods 
of  about  six  hours,  there  would  be  a  succession  of  convulsions, 
with  intervals  of  unconsciousness  or  delirium,  followed  by  an 
equal  period  during  which  he  would  remain  ([iiiet  and  rational. 
The  convulsions  were  all  general  from  beginning  to  end,  without 
recognizable  initial  symptom.    Died  in  two  days. 

Necropsy. — Scalp  wound,  as  previously  nott-d.  No  lesion  ol 
skull.  Cortical  hajmorrhage  on  the  right  side  of  the  vertex, 
from  anterior  border  of  frontal  lobe  to  posterior  fissure  of  Ro- 
lando, and  covering  the  tcmi)oro  sphenoidal  lobe  laterally  and 
at  the  base.  Deep  laceration  of  right  fi  ontal  lobe,  through  the 
cortex,  upon  anterior  and  lateral  borders,  and  extending  well 
into  the  parietal  region. 


66 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Joub., 


Case  CV. — An  unknown  man  was  found  in  the  street,  lean- 
ing against  a  fence  in  an  upright  position,  dead. 

Necrcpny. — HfBinatoiua  over  right  side  of  the  vertex;  no 
lesion  of  the  skull ;  blood  fluid  and  viscera  generally  much  con- 
gested ;  area  of  contu>ion  and  laceration  over  greater  part  of 
lefr  frontal  and  temporo-sphenoidal  lobes;  subdural  hasuior- 
rhage  over  whole  left  hemisphere. 

Case  CVI. —  Male,  aged  thirtj  ;  found  unconscious  and  sup- 
posed to  have  jumped  or  fallen  from  a  second-story  window. 
Wound  over  right  eye  and  fracture  of  the  nasal  bones;  coma 
profound;  stertor ;  pupils  contracted.  On  the  two  following 
days  the  temperature  rose  progressively  from  101° 4-  on  admis 
sion  to  104'5° ;  pulse  full,  res|)iration  rapid.  Patient  could  he 
roused  by  pressure  on  supraorbital  nerve.  On  the  third  day 
still  deeper  coma,  dysphagia,  continued  irritability,  and  rest- 
lessness, and  temperature  still  104"o°.  Death  at  end  of  four 
days;  temperature,  107"4°. 

Necropsy. — No  lesion  of  skull;  no  meningeal  lesions;  small 
cortical  hemorrhage  over  posterior  part  of  left  parietal  lobe, 
and  sujall  laceration  of  brain  at  parieto  occipital  junction ;  both 
cerebra  bypersemic. 

Case  CVII. — Male,  aged  forty ;  fell  down  stairs.  Admitted 
to  alcoholic  ward  and  transferred  to  surgical  service  next  day. 
Slight  scalp  wound  above  right  ear;  comatose,  but  later  could 
be  roused  sufficiently  to  tell  his  name;  temperature,  103"4°; 
restless;  hypei'a'sthetic ;  pneumonia  discovered;  died  next 
day. 

Necropsy. — Left  lung  pneumonic ;  lower  lobe  in  second 
stage,  upper  lobe  in  first  stage;  no  lesion  of  tlie  skull ;  duia 
mater  adherent  to  the  calvarium ;  the  left  hemisphere  on  its 
upper  surface  was  completely  covered  by  an  organized  false 
membrane,  which  also  dipped  into  the  median  fissure  and  cov- 
ered its  internal  surface.  This  membrane  was  divisible  ])oste- 
riorly  into  two  layers;  it  was  thin  anteriorly,  but  fully  an  eighth 
of  an  inch  in  thickness  in  its  posterior  part;  its  upper  surface 
was  smooth,  non-adherent,  and  comparable  in  appearance  to  a 
section  of  raw  beef ;  its  inferior  or  cerebral  surface  was  smooth, 
velvety,  non-adherent,  and  could  be  raised  without  injuring  the 
arachnoid;  it  did  not  dip  into  the  sulci;  it  was  traversed  by 
minute  vessels  and  studded  with  some  fifteen  or  twenty  gray- 
ish, caseous,  and  partially  calcareous  nodules,  varying  in  size 
from  that  of  a  robin-shot  to  that  of  a  buckshot.  Similar  nod- 
ules were  found  in  the  basilar  vessel-^,  which  were  generally 
atheromatous.  No  recent  lesion  of  the  br;iin  was  discovered, 
except  general  contusion  indicated  by  moderate  bypersemia  and 
some  c;ipillary  extravasations. 

His  wife  subsequently  stated  that  he  had  never  lost  a  day's 
work  by  reason  of  sickness,  and  that  he  had  never  had  even 
temporary  loss  of  consciousness  or  paralysis. 

Case  CVIII. — Male,  aged  tifty-seven;  fell  from  bis  cab; 
unconscious:  large  beematoma  over  left  parietal  region;  respira- 
tion slow  and  stertorous  double  facial  paralysis  and  cheeks 
flapping;  complete  right  hemiplegia  and  anasthesia ;  tempera- 
ture, 99°.  Trephined  over  left  motor  area;  dura  pale,  tense, 
and  bloodless ;  no  brain  pulsation.  After  incision  of  dura, 
serum  escaped  freely  and  the  quantity  increased  when  the  head 
was  so  turned  as  to  drain  from  the  base.  No  blood  clot  found. 
Temperature  at  time  of  operation  bad  risen  to  103'4° ;  six  hours 
later  it  bad  fallen  to  98-C°.  The  patient  had  regained  con- 
sciousness and  could  articulate,  and  gave  his  name  and  address. 
Hemiplegia  not  relieved.  After  twelve  hours,  pulsation  in  the 
brain  returned  and  he  could  speak  rationally  and  intelligently, 
though  with  difliculty.  Two  hours  later  still  he  had  a  sliglit 
•convulsion  and  death  followed  in  four  hours.  The  temperature 
Temained  at  98'0°  after  the  operation  for  fourteen  hours,  and 
it  then  rose  steadily  to  104'G°  just  previous  to  death.  The  lower 


face  continued  paralyzed  and  the  resi>iration  became  frequent 
and  insufficient. 

Necropny. — No  lesion  of  skull;  laceration  of  external  bor- 
der of  right  cerebellum  anteriorly,  from  Which  clot  bad  formed 
about  circle  of  Willis  upon  anterior  part  of  pons  and  in  trans- 
verse fissure  in  front  of  left  cerebellum  ;  the  vessels  were 
atheromatous;  tlie  interior  of  the  left  occipital  lobe  was  filled 
with  clot  which  had  completely  broken  down  its  structure;  the 
left  lateral  ventricle  was  tilled  with  blood  which  had  broken 
through  the  saaptum  into  the  right  lateral  ventricle  and  also 
communicated  with  the  blood  cavity  in  the  occii)ital  lobe. 

Case  CIX. — Male,  aged  sixty-three;  struck  by  some  part 
of  the  machinery  of  his  engine ;  no  general  symptoms ;  tem- 
perature, 100°;  wound  in  posterior  parietal  region  in  median 
line  and  curving  to  the  right;  contusion  over  left  parietal  emi- 
nence; temperature  second  day,  103  2°;  delirious  in  the  night; 
temperature  third  day,  lOl-S"  to  101°;  headache;  fourth  and 
fifth  days,  temperature,  103'4°  to  103°;  no  genei-al  symptonis ; 
sixth  day,  temperature,  106'4°,  pulse,  140;  restless  and  irrita- 
ble, but  rational;  weaker;  died  on  the  eighth  day;  tempera- 
ture last  two  days  from  105°  to  105'2° ;  post-mortem  tempera- 
ture, 104°.  A  few  hours  previous  to  death  there  wa''  muscular 
rigidity  of  all  the  extremities,  most  marked  on  right  side  and 
esjjecially  in  right  arm.  There  was  perforating  ulcer  of  the 
cornea. 

Necropsy. — No  lesion  of  skull  or  meninges;  no  hsemorrhage; 
no  lacerations;  cortex  of  brain  and  meninges hypersemic ;  brain 
substance  moderately  cedematous  and  minute  vessels  filled  with 
coagula ;  this  condition  involved  corpora  striata,  optic  thalami? 
pons,  and  cerebellun),  and  was  most  pronounced  on  left  side 
and  at  the  base ;  no  minute  extravasations;  both  lateral  and 
both  inferior  petrosal  sinuses  were  filled  w|th  decolorized 
thrombus,  extending  into  jugular  vein  on  the  rigbt  side;  the 
thrombus  was  colored  only  near  the  torcular  Herophili. 

Case  CX. — Male,  aged  sixty ;  fell  two  stories  to  the  side- 
walk. Contusion  of  left  eye  and  sliuht  contusion  just  above  it ; 
temperature,  101 '4  ;  delirium;  pupils  and  respiration  normal; 
pulse,  1 14.  Later  symptoms :  patient  very  irritable ;  cried  out  and 
tried  to  get  away  when  touched,  but  replied  rationally  to  ques- 
tions;  incontinence  of  urine  and  fiEces;  delirium  continued; 
died  on  the  fifteenth  day ;  temperature  rose  to  103'2°  on  the 
fifth  day  and  then  fell  very  gradually  to  100°.  The  day  before 
death  it  was  108"4°,  was  103*8°  five  hours  ante  mortem,  and 
104"2°  one  hour  post  mortem.  General  symptoms  remained 
unchanged. 

Necropsy. — No  fracture ;  subarachnoid  li&jmorrhage  over 
both  hemispheres,  forming  a  sheet  which  was  thickest  about 
occipitoparietal  junction  on  both  sides;  some  subarachnoid 
serous  effusion  in  left,  frontal  region;  general  contusion,  which 
was  most  marked  on  left  side  ;  bypersemia  and  punctate  hfcmor- 
rhages. 

Case  CXI. — Male,  ased  forty-five;  cause  of  injury  un- 
known ;  found  unconscious  in  the  street  and  admitted  to  hospi- 
tal after  forty-eight  hours;  contused  wound  in  right  parietal 
region;  muttering  stupor;  rigidity  of  left  arm ;  right  hemiple- 
gia, which  was  incomplete,  but  most  marked  in  right  arm ; 
pulse,  60;  temperature,  101°.  On  the  third  day  the  rigidity  of 
the  left  arm  was  increased,  and  the  paralysis  of  right  arm  was 
complete;  paralysis  of  right  leg  was  nearly  so;  coma  absolute  ; 
pulse,  128;  temperature,  105°.  Trephined  over  motor  area 
and  incised  the  dura.  Pulsation  of  brain  absint  at  first,  but 
soon  returned  in  some  degree.  His  movements  became  freer, 
and  he  began  to  utter  articulate  sounds.  Signs  of  sensibility 
increased;  pulse,  108;  temperature  still  105°.    Died  next  day. 

Necropsy. — Moderate  subacute  arachnitis  over  anterior  two 
thirds  of  upper  surface  of  right  cerebrum ;  laceration  of  left 


Jan.  21,  1893.] 


PHELPS:  INJURIES  OF  THE  HEAD. 


67 


temporo-sphenoidal  lobe,  excavating  and  filling  with  clot  its 
whole  interior  structure.  The  haeraorrhage  extended  down- 
ward around  the  circle  of  "Willis  and  upward  upon  the  cere- 
brum, mainly  upon  the  occipital,  but  also  in  patches  upon  the 
frontal  and  parietal  lobes. 

Case  CXII. — Male,  aged  sixty;  found  unconscious  in  bed  ; 
seemed  to  be  in  perfect  health  when  he  retired  to  his  room  on 
the  previous  evening.  He  was  heard  moaning;  no  evidence 
of  injury  could  be  discovered  ;  stertor ;  pupils  normal ;  rigid- 
ity of  right  side;  pulse  120  and  weak;  temperature,  100°.  On 
the  next  day  the  right  side  was  less  rigid ;  the  second  day  he 
was  comatose  ;  temperature,  103"2°,  and  he  died. 

J^ecropsy. — No  lesion  of  scalp  or  skull ;  lai-ge  amount  of 
serum  under  the  arachnoid.  Tliere  was  a  very  soft  elliptical 
area  of  disintegrated  brain  tissue  an  inch  and  a  half  by  three 
quarters  of  an  inch  in  diameter  upon  the  anterior  part  of  the 
left  occipital  lobe,  near  the  median  fissure.  There  was  a  simi- 
lar area,  smaller  in  size,  on  the  under  surface  of  the  same  lobe, 
but  with  disintegration  less  advanced,  and  containing  a  clot  not 
yet  decolorized.  There  was  a  red,  firm  clot  beneath  the  latter 
and  deep  in  the  substance  of  the  cerebellum  of  more  recent 
formation.  The  temporal  artery  was  atheromatous,  but  none 
of  the  basilar  arteries  were  diseased. 

Case  CXIII. — Male,  aged  thirty;  fell  down  stairs;  con- 
sciousness was  lost,  and  only  partially  restored.  He  fell  out  of 
bed  that  night,  and  again  the  next  day,  striking  each  time  upon 
his  right  side.  Admitted  to  hospital  that  evening.  No  exter- 
nal evidence  of  injury  except  slight  contusion  over  crest  of  right 
ilium.  Rational,  but  slow  to  respond  to  questions;  left  pupil 
slightly  dilated;  temperature,  99°.  The  following  day  he  again 
fell  out  of  bed,  and  again  the  day  after,  always  on  the  right 
side,  and  there  was  a  constant  tendency  to  move  to  the  right 
side  of  the  bed,  which  was  quite  level.  Some  left  paresis  and 
some  difficulty  in  swallowing,  which  he  referred  to  tiie  left  side 
of  the  throat ;  transient  facial  paresis.  The  amount  of  paresis 
and  the  condition  of  the  left  pupil  varied  from  day  to  day.  His 
mental  condition  deteriorated  ;  he  was  stupid,  rambling  in  talk, 
delirious,  apathetic,  and  had  delusions.  At  first  urine,  and 
later  faeces,  were  voided  unconsciously.  His  temperature  for 
ten  days  was  99° -f  ;  it  then  began  to  rise  and  was  ]00°-|-  to 
101°;  pulse  usually  from  8i  to  96,  and  respiration  nearly  nor- 
mal. On  the  fifteenth  day  he  was  trephined  over  the  right 
motor  leg  area,  and  a  small  subcortical  cavity  discovered,  from 
which  half  a  drachm  of  yellowish  fluid  was  removed.  This 
fluid  was  subsequently  found  to  contain  numerous  leucocytes. 
There  was  no  marked  ciiange  in  his  s^ymptoms  after  the  opera- 
tion. Temperature  was  a  trifle  lower — 99°  to  100° — till  the 
eleventh  day,  when  it  rose  to  104°,  fell  the  next  day  to  100°, 
and  rose  again  to  104°,  when  he  died  from  asthenia  on  the 
twenty-eighth  day  after  his  admission. 

Necropsy. — Large  subarachnoid  serous  effusion  compressing 
frcuital  lobes.  General  cerebral  hyperaemia  and  many  minute 
vessels  filled  with  coagula.  The  brain  substance  around  the 
small  cavity  discovered  during  life  was  soitened,  stained  a  red- 
disli  gray  color,  and  it  contained  minute  extravasations. 

Case  CXIV. — Male,  aged  twenty-nine;  was  found  uncon- 
scious in  Central  Park.  He  was  taken  to  a  hospital,  sent  to 
court  charged  with  intoxication,  and  afterward  admitted  to 
Bellevue,  still  unconscious.  Small  contused  wound  in  right 
frontal  region;  pupils  slightly  dilated;  complete  left  hemiple- 
gia and  hemiantesthesia ;  slight  left  facial  paralysis;  tempera- 
ture, 106°;  pulse,  140;  respiration  accelerated;  convulsions 
shortly  after  admission,  which  wei'e  repeated  at  frequent  inter- 
vals; initial  symptom  in  the  mouth  and  face;  arms  and  legs 
gradually  involved  ;  trephined  over  junction  of  right  arm  and 
leg  areas  by  house  surgeon;  result  negative;  temperature  two 


hours  later,  107'4°,  and  three  hours  later  still  he  died  in  a  con- 
vulsion. The  ventricle  was  aspirated  in  the  operation ;  tem- 
perature forty-five  minutes  post  mortem,  was  109'4°. 

Necropsy. — Brain  and  meninges  excessively  hypersBmic;  a 
small  tumor  as  large  as  a  pea  was  found  in  right  lower  face 
area;  the  surrounding  brain  tissue  was  disintegrated,  forming 
a  small  cavity ;  no  hfemorrhages;  the  viscera  were  generally  soft 
and  congested. 

Case  CXV. — Male,  aged  thirty-seven ;  was  found  at  the 
bottom  of  a  stairway  with  his  feet  uppermost;  unconscious; 
pupils  contracted  ;  muscular  rigidity,  especially  marked  in  the 
legs;  pulse  rapid;  stertor;  died  in  two  days  without  having 
regained  consciousness. 

Case  CXVI. — Male,  aged  twenty-six ;  thrown  out  of  a 
wagon  and  struck  his  head;  unconscious,  but  conscious  on  ad- 
mission ;  contusion  in  left  parietal  region ;  became  irritable, 
and  later  comatose;  died  suddenly  five  hours  afterward. 

Case  CXVIl. — Male;  struck  by  a  cleat  failing  from  aloft 
aboard  ship;  large  hajmatoma  covering  whole  right  side  of  the 
head;  unconscious;  slight  rigidity  of  left  side;  pulse  full  and 
slow ;  died  in  fifteen  minutes  after  admission. 

Case  CX  VIII. — Male,  aged  thirty-two ;  struck  with  a  shovel ; 
contusion  of  the  right  posterior  parietal  region  ;  pulse  full  and 
slow;  temperature,  100°:  pain  in  back  of  the  head ;  dilatation 
of  left  pupil ;  rigidity  of  flexor  muscles  of  the  arms;  somno- 
lence and  restlessness.  After  twenty-four  hours  patient  be- 
came stupid  and  mildly  delirious;  left  pupil  widely  dilated; 
urinated  unconsciously ;  left  arm  only  moved  when  irritated ; 
sensation  slightly  more  acute  on  right  side;  dysphagia  marked  ; 
left  pupil  irresponsive  to  light.  His  condition  varied  from 
time  to  time  for  the  first  two  weeks;  left  pupil  more  or  less 
dilated  and  more  or  less  irresponsive  to  light ;  mind  obscured 
and  apathetic ;  some  ptosis  of  left  eye.  After  that  time  his 
mind  became  clear,  and  he  could  intelligently  describe  the 
manner  in  which  he  received  his  injury.  Paralysis  of  the  left 
external  rectus ;  optic  nerve  and  retina  normal;  pertbr<(tion  of 
left  tympanum  and  purit'orm  discharge;  some  left  facial  paraly- 
sis. He  was  discharged  at  the  end  of  two  months.  His  ptosis 
and  external  strabismus  had  disappeared,  and  there  was  only  a 
perceptible  trace  of  the  paralysis  of  the  lower  face.  His  left 
hemiparesis  and  anajsthesia  were  no  longer  noticeable.  He 
was  dull  and  stupid,  which  his  family  said  was  his  normal  con- 
dition. 

Case  CXIX. — Male,  aged  twenty-five;  fell  from  a  truck, 
striking  his  forehead;  unconscious  for  twenty-four  hours; 
slightly  delirious  for  two  days;  pain  in  frontal  legion  after  that 
time;  temperature,  100°,  followed  by  mild  dementia,  which 
continued  till  his  discharge. 

Case  CXX. — Male,  aged  twenty-one;  fell  sixty  feet  down  an 
embankment;  unconscious;  afterward,  violent  dehrium  lasting 
a  week;  then  admitted  to  the  hospital,  still  delirious,  but  more 
(]uiet;  suppurating  scalp  wound  external  to  right  frontal  emi- 
nence; heme  exposed;  also  double  fracture  of  right  inferior 
maxilla.  The  following  day  he  had  eleven  epileptiform  con- 
vulsions within  two  hours.  Each  one  hegan  with  twitching  in 
right  hand  and  arm,  extending  to  left  arm  and  then  to  both 
legs,  and  finally  a  general  convulsion  was  established.  Face  not 
much  involved,  but  eyes  deviated  to  the  right.  After  these  at- 
tacks he  remained  unconscious  for  one  hour;  the  right  arm 
was  then  found  to  be  anesthetic,  and  with  the  right  leg  paretic. 
The  next  day  he  had  one  similar  attack,  but  he  was  more 
rational  afterward  and  recognized  his  paretic  condition.  On 
the  next  day  he  had  six  convulsions  within  a  little  more  than 
two  hours,  each  one  beginning  on  right  side  of  the  face  and  ex- 
tending to  right  side  of  the  body  before  becoming  general,  and 
the  right  arm  was  paralyzed  for  five  minutes  afterward.   In  the 


G8 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Jodb. 


next  few  hours  he  had  six  others,  one  of  which  was  confined  to 
right  side  of  tlje  face. 

He  was  then  trephined  over  left  face  area  and  the  opening 
freely  enlarged.  Dura  tense  and  incised,  but  no  lesion  discov- 
ered. He  was  then  trephined  through  the  exposed  bone  on  the 
right  side  witliout  result.  No  further  convulsions  occurred- 
The  next  day  he  was  entirely  rational,  and  it  was  discovered 
that  he  was  aphasic.  Some  difficulty  in  articulation  [>revious 
to  the  operation  was  ascribed  to  the  fractures  of  the  Jaw.  He 
Lad  both  motor  and  sensory  aphasia.  Called  his  own  name 
McNannold.  He  was  discharged  at  the  end  of  a  month.  His 
wounds  were  entirely  healed,  right  arm  still  paretic,  and  mind 
clear,  fie  had  some  hesitancy  in  speech,  and  the  selection  of 
Words  required  a  little  time.  His  temperature  ranged  from 
99°+  to  101°  during  his  whole  convalescence. 

Case  CXXI. — Male,  aged  twenty;  cause  of  injury  un- 
known; unconscious  for  a  short  time;  scalp  wound  in  left 
parietal  region  near  the  median  line,  and  a  large  htematoma 
just  behind  it  in  posterior  parietal  region.  He  had  no  general 
symptom,  except  nearly  complete  paraplegia  with  flaccid  mus- 
cles and  somewhat  increased  reflexes.  There  was  no  evidence 
of  specific  disease,  and  it  was  possible  to  verify  the  fact  that  no 
paralysis  had  existed  previous  to  this  recent  injury.  He  was 
discharged  at  the  end  of  six  weeks  and  could  w^dk  fairly 
well.  The  diagnosis  was  cortical  hsemorrhage  from  direct 
contusion  of  the  brain,  extending  from  left  motor  leg  area 
across  the  median  line  into  tlie  corresponding  area  on  the 
right  side. 

Case  CXXII. — Male,  aged  twenty-one;  cause  of  injury 
unknown;  found  unconscious.  Committed  as  drunk  and  dis- 
orderly, and  sent  to  Bellevue  as  a  case  of  alcoholism.  He  again 
became  unconscious  and  was  constantly  crying  out,  but  always  a 
single  phrase.  He  was  restless  and  hypera?sthetic,  and  the 
muscles  of  both  sides  were  generally  rigid.  There  was  a  slight 
scalp  wound  in  right  temporal  region;  incision  disclosed  no 
fracture.  The  day  following  he  was  more  quiet  and  the  muscles 
were  less  rigid.  Partial  paralysis  of  the  lower  left  face  was 
developed.  He  became  rational,  but  a[)athetic.  Then  there 
were  two  days  more  of  active  delirium,  afier  which  he  again 
became  quiet,  but  had  delusions.  He  was  coherent  in  speech, 
though  voluble,  loquacious,  and  silly.  He  had  sensory  aphakia 
and  agraphia,  and  his  memory  of  recent  events  returned  ;  he 
thought,  however,  he  was  born  in  September,  1891  —two  months 
before.  In  notation  at  dictation  he  interpolated  figures,  as  in 
writing  495  he  wrote  49000.5.  He  could  write  two  figures  cor- 
rectly, but  not  more.  After  his  discharge  he  returned  to  the 
hospital  some  months  later,  and  was  noisy  and  excitable.  Sub- 
sequent inquiry  at  the  station-house  made  it  probable  that  he 
was  not  intoxicated  at  the  time  of  his  arrest.  He  remained  un- 
conscious from  early  evening  all  night.  When  he  was  finally 
roused  he  made  strenuous  efforts  to  speak.  He  was  only  able 
to  say  "  Peter,"  his  first  name,  which  he  repeated  again  and 
again,  and  evidently  strove  to  give  his  last  name.  Tempera- 
ture, 100  2°  on  admission  ;  from  100°  to  101°  for  five  days,  then 
normal.    After  that  time  averaged  98'5°  to  99'5°. 

Case  CXXill. — Male,  aged  twenty-one;  cause  of  injury  un- 
known; found  unconscious  in  the  street;  contusion  of  left  eye 
and  wound  over  superciliary  ridge.  On  admission,  he  looked 
about  with  a  vacant  stare,  but  could  not  be  induced  to  speak. 
Next  day  he  had  delusions  and  failed  to  recognize  his  family. 
His  subsequent  symptoms  were  all  mental.  Memory  of  recent 
events  lapsed.  Never  spoke  except  when  disturbed,  then  an- 
swered questions  intelligently  but  mechanically.  For  three 
nights  he  became  violently  defirious,  and  attacked  his  neighbor 
in  the  next  bed;  then  he  became  quiet  again,  and  began  to 
manifest  some  interest  in  what  passed  about  him.    Two  weeks 


from  the  time  of  his  admission  his  condition  suddenly  improved, 
and  he  began  to  remember  some  things  which  imme<liately  f)re- 
ceded  his  injury.  For  the  ensuing  two  weeks  it  was  mainly 
noticeable  that  he  never  suggested  or  carried  on  any  sustained 
conversation,  and  that  he  laughed  much  and  without  due  cause. 
In  the  next  and  final  two  weeks  of  his  continuance  in  the  hos- 
pital he  ceased  to  laugh  inordinately  or  causelessly,  and  his 
memory  seemed  to  be  restored  in  reference  to  matters  up  to  the 
time  he  was  hurt,  and  since  his  recovery  of  con-iciousness.  The 
only  abnormal  indication  in  his  appearance  was  a  slightly  weak 
expression  in  his  face.  Temperature  on  admission,  99-2° ;  after- 
ward from  99°  to  101  °. 

Case  CXXIV. — Female,  aged  seventeen,  fell  three  stories 
through  a  hatchway;  coutu-<ion  of  left  occcipiial  region;  no 
fissure  found  on  incision.  She  was  unconscious,  with  muscular 
rigidity  of  all  the  extremities,  and  was  irritable  when  disturbed. 
She  moved  the  right  arm  and  left  leg  only.  Temperature, 
100'2°.  Delirious  on  the  fourth  day,  and  noisy  and  excitable 
for  several  days  afterward.  There  was  left  paresis  and  dilata- 
tion of  left  pupil  on  the  tenth  day,  and  at  the  same  time  incon- 
tinence of  urine  and  fieces  which  continued  eight  days.  Tem- 
perature was  100°-1-  for  the  first  five  days,  99°-i-  for  next  five 
days,  and  then  became  normal.  It  rose  on  the  thirteenth  day 
from  99°  to  103*.5°,  and  on  the  next  day  to  104'5°.  For  the  next 
ten  days  it  was  usually  from  102°  to  103°,  at  which  time  she 
was  removed  from  the  hospital.  She  subsequently  recovered. 
Sbe  was  of  bad  constitution,  had  inherited  syphilis,  was  deaf, 
and  had  interstitial  keratitis  in  both  eyes,  with  loss  of  sight  in 
one  from  opacity  of  cornea. 

The  following  cases  of  idiopathic  lesion  are  added  to 
illustrate  simulated  traumatism : 

a.  Male,  aged  fifty  five,  fell  upon  the  sidewalk,  and,  after  rising 
and  walking  a  short  distance,  fell  again.  Upon  admission  he 
had  a  small  wound  in  the  median  line  of  the  frontal  region.  He 
smelled  strongly  of  spirits  and  was  ascertained  to  be  of  intem- 
perate h.abits.  He  was  unconscious  from  the  time  he  fell  until 
he  died,  seven  hours  later.  He  was  restless,  and  upon  irrita- 
tion had  muscular  spasm  of  both  lower  and  upper  extremi- 
ties. He  had  incontinence  of  urine  and  fasces,  dilated  pu])ils, 
and  Cheyne-Stokes  respiration.  No  paralysis.  Temperature, 
103-4°,  104°,  and  105°.  It  was  subsequently  learned  that  the 
scalp  wound  was  received  two  days  previously,  and  that  the 
spirits  of  which  he  smelled  so  strongly  had  been  spilled  upon 
him  in  an  effort  to  restore  him  to  consciousness  before  ad- 
mission. 

Necropsy. — Clironic  meningitis  with  great  arachnoid  opacity 
but  no  serous  effusion.  Basilar  arteries  extremely  atheromatous. 
Both  lateral  ventricles  enormou.sly  distended  with  very  bloody 
serum.  Clot  extended  through  each  posterior  cornu.  The 
right  optic  thalamus  was  swollen  with  clot  which  also  filled  the 
third  ventricle. 

h.  Male,  aged  seventy-one,  said  to  have  accidentally  fallen 
from  a  chair  four  days  previous  to  admission  ;  no  loss  of  con- 
sciousness ;  subsequent  delirium  ;  reijuired  mechanical  restraint 
till  his  deatb,  twenty-four  hours  later  ;  pupils  contracted  ;  pos- 
terior cervical  muscles  rigid;  hy  pertesthesia;  retention  of  urine; 
temperature,  102°,  102°-|-,  103°;  pulse,  90  to  114. 

Necropsy. — Abrasion  of  the  nose.  Dura  mater  adherent  to 
the  calvarium,  and  arachnoid  to  the  brain.  Little  serous  effu- 
sion. Some  oparity  of  the  arachnoid.  Meningeal  and  cerebral 
vessels  hyperajmic.    Cortex  softened. 

The  result  of  an  analysis  of  the  preceding  cases  may  be 
expressed  in  a  brief 


Jan.  21,  189S.] 


PHELPS:  INJUBIES  OF  THE  HEAD. 


69 


SUMMARY. 

I.  Fractures  of  the  Base   70 

Recovered   21 

Died   49 

Number  of  necropsies   35 

II.  Fractures  of  the  Vertex  

Recovered   21 

Died   10 

Number  of  necropsies   10 

III.  Encephalic  Injuries  without  Fracture ...  .  23 

Recovered   7 

Died   16 

Number  of  necropsies   13 

Total  number  of  recoveries   49 

"        "      "  deaths   75 

124 

"         "       "   necropsies   58 

NECROPSIES. 

I.  Fracture  of  the  Base. 

Involving  posterior  fosste   7 

"       middle  fossae   6 

"       middle  and  anterior  foss.c ....  9 

"       middle  and  posterior  fossae.  .  .  11 

"        anterior  and  posterior  fossae. .  .  1 

"       all  fossae   1 

35 

Total  number  involving  middle  fossae.  .  .  27 
"        "  "        posterior  fossae. .  20 

"        "  "       anterior  fossae. .  .  11 

Complications. 

Laceration  and  resulting  haemorrhages   9 

"         "  general  contusion   6 

"         "  meningeal  contusion   6 

"  "   thrombi,  haemorrhages   2 

"  "   epidural  haemorrhages   6 

"         "  meningeal    contusion,  epi- 
dural haemorrhages   1 

"  '*   general  contusion,  epidural 

haemorrhages   1 

Contusion  and  abscess   1 

General  contusion  and  epidural  haemorrhage.  2 
Meningeal  contusion   1 

35 

From  direct  violence   31 

"     contre-coup   4 

II.  Fracture  of  the  Vertex. 

Involving  frontal  bone   4 

"        parietal  bone   1 

"        occipital  bone   1 

"        parietal  and  occipital  bone   1 

"        parietal  and  frontal  bone   1 

"       temporal  bone   1 

9 


Complications. 

Laceration  and  resulting  haemorrhage   5 

"  "    general  contusion   2 

"  "    atrophy   1 

"        meningeal  and  genera!  contusion  .  .  1 

General  contusion  and  epidural  haimorrhage  1 

10 

III.  Injuries  of  the  Encephalon  without  Fracture. 
Varieties. 

Laceration  and  resulting  haemorrhage   5 

"  "  meningeal  contusion   2 

"  "  general  contusion   1 

Meningeal  contusion   1 

General  contusion   2 

"  "        and  thrombi   1 

"       and  meningeal  contusion   1 

13 

In  Fifty-eight  Necropsies. 

Laceration  and  resulting  haemorrhage.  ...  19 

"         "   general  contusion   8 

"          "    meningeal  contusion   8 

"          "    epidural  h;emorrhage   6 

"        thrombi,  and  lueraorrhages ....  2 
"        general,  and  meningeal  contu- 
sion   2 

"        and  atrophy   1 

"        meningeal  contusion,  epidural 

haemorrhage   2 

48 

General  contusion   2 

Meningeal  contusion   2 

General  contusion  and  epidural  hiemor- 

rhage   3 

General  contusion  and  thrombus   1 

"            "         "    meningeal  contu- 
sion  1 

Subcortical  contusion  and  abscess   1 

10 

Total  number  of  cases  in  which  injury  was  received  by 

Contre-covp  alone   31 

Direct  violence  alone   5 

Contre-coup  and  direct  violence   19 

Unknown   2 

Unrecorded   1 

58 

Pseudo-injuries. 

Apoplexy   1 

Arachnitis   1 

2 

In  the  majority  of  instances  the  subjects  were  males  in 
adult  life.  Vocation,  the  blundering  helplessness  of  ine- 
briety, and  the  homicidal  passion  sufficiently  account  for 


70 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Jouh., 


the  influence  of  age  and  sex  in  the  production  of  these  in- 
juries. 

Fractures. — It  is  a  noteworthy  fact  that  so  many  injuries 
of  the  head — nearly  sixty  per  cent. — involve  fracture  at  the 
base.  I  have  ranked  as  basic  fractures  all  those  which  have 
involved  that  region,  even  though  beginning  at  the  vertex, 
because  it  is  upon  the  implication  of  the  base  that  all  the 
so-called  characteristic  symptoms  depend.  In  fact,  frac- 
tures of  the  skull  which  do  not  begin  at  the  vertex  are  ex- 
ceptional. I  have  found  upon  necropsic  examination  but 
four  cases  in  which  fracture  at  the  base  was  not  continuous 
with  a  fissure  extending  from  the  point  upon  the  vertex  at 
which  the  violence  was  inflicted.  These  four,  which  began 
and  ended  in  the  base,  were  evidently  from  contre-coup. 
That  they  were  the  result  of  violence  acting  directly  upon 
the  vertex  was  proved  by  the  history  of  the  injury,  as  well 
as  by  existent  wound,  contusion,  or  fracture.  In  neither 
one  was  there  the  slightest  reason  to  suspect  that  the  force 
was  transmitted  through  the  spinal  column.  The  greater 
frequency  of  fractures  which  extend  to  the  base,  when  com- 
pared with  those  which  are  confined  to  the  vertex,  depends 
simply  upon  the  fact  that,  under  ordinary  circumstances,  the 
physical  properties  of  bone  are  such  that  force,  even  when 
of  crushing  character,  will  not  expend  itself  wholly  upon  the 
point  of  impact,  but  will  extend  to  a  considerable  distance. 
That  the  fissure  extends  from  vertex  to  base,  and  not  from 
base  to  vertex,  is  proved,  even  in  the  absence  of  a  history, 
by  the  mute  evidence  of  the  superficial  injury,  and  by  the 
narrowing  of  the  fissure  as  it  passes  downward.  The  ex- 
planation of  the  fact  that  fracture  through  the  middle  is 
more  frequent  than  through  the  other  fossfe  is  equally  sim- 
ple. The  experiments  of  Aran  have  shown  that  when  any 
part  of  the  vault  is  subjected  to  violence  it  is  the  corre- 
sponding part  of  the  base  which  suffers.  It  follows  that 
the  central  or  parietal  region  is  the  one  most  exposed  to 
violence,  and  it  is  corroborated  by  post-mortem  examination. 

Four  cases,  aside  from  those  produced  by  contre-coup, 
are  of  special  interest  simply  as  fractures.  The  first  is  a 
separation  of  the  temporal  bone  into  its  constituent  parts — 
squamous,  petrous,  and  mastoid — in  an  adult  male,  the  re- 
sult of  an  apparently  inadequate  cause.  The  specimen  was 
shown  to  this  association  two  years  ago.  The  second  was 
a  comminuted  fracture  of  nearly  the  whole  occipital,  the 
posterior  part  of  both  parietal,  and  the  right  temporal  bones, 
in  which  the  fragments  were  completely  detached  from  each 
other.  This,  like  the  first,  was  occasioned  by  a  fall  in  the 
street,  and  was  accompanied  by  extensive  injuries  of  the 
brain,  sinuses,  and  membranes.  The  patient  recovered  par- 
tial consciousness,  and  lived  for  a  week's  time.  The  third 
involved  all  the  fossae  on  both  sides  from  a  fall  from  the 
mast-head,  and  the  patient  survived  two  hours.  This  case 
I  believe  to  be  the  first  on  record  in  which  all  the  fossse 
were  involved  in  fracture.  The  fourth  case  was  a  wide  sepa- 
ration of  the  coronal  suture  on  both  sides,  occurring  in  an 
adult  without  concomitant  fracture. 

The  most  practical  comment  to  be  made  upon  fractures 
of  the  skull  is  that  in  themselves  they  are  absolutely  un- 
important. It  is  only  by  their  complications,  immediate  or 
remote,  that  they  involve  danger  to  life. 


COMPLICATIONS   OF  FRACTURES. 

The  complications  of  fracture  are  haemorrhages,  throm- 
bosis, lacerations,  contusions,  and  paralyses.  Their  deriva- 
tives are  meningitis,  abscess,  and  atrophy.  All  of  these 
may  be  produced  directly  from  injury  to  the  encephalon 
without  fracture,  with  the  exception  of  one  form  of  hajmor- 
rhage.  If  epidural  luemorrhage  ever  occurs  without  the 
intervention  of  fracture,  I  have  never  seen  it  in  necropsies, 
or  had  reason  to  suspect  it  in  recovering  cases. 

Fractures  of  the  skull  without  complication  are  not  only 
without  importance  or  consequences,  but  they  are  devoid  of 
symptoms.  A  simple  fissure  of  the  posterior  fossa  would 
probably  be  unsuspected,  for  symptomatic  cervical  ecchymo- 
sis  is  of  the  rarest  occurrence.  A  simple  fracture  of  the 
vault  is  often  overlooked  in  the  absence  of  pressure  symp- 
toms. In  fracture  at  the  base,  displacement  of  the  frag- 
ment does  not  occur,  or  is  insufficient  to  occasion  trouble, 
and  when  the  patient  survives,  union,  of  course,  is  without 
provisional  callus.  The  very  general  existence  of  compli- 
cations, however,  often  of  the  gravest  character,  has  given 
fracture  of  the  base  vicariously  both  an  importance  and  a 
symptomatology. 

The  encephalic  lesions  which  complicate  fracture  include 
all  those  which  occur  independently,  and  therefore  may  be 
considered  at  once,  from  a  double  point  of  view,  as  compli- 
cations and  as  primary  injuries. 

HEMORRHAGES. 

Epidural  haemorrhage  is  perhaps  the  most  characteristic 
complication  of  fractures.  In  moderate  quantity  from  the 
osseous  or  smaller  meningeal  vessels,  it  is  the  usual  source 
of  the  diagnostic  haemorrhages  from  the  ears,  nose,  or 
mouth,  and  into  the  orbital  and  subconjunctival  tissues. 
In  larger  amount  and  as  a  source  of  danger,  it  is  derived 
from  the  larger  meningeal  vessels,  notably  from  the  middle 
meningeal  artery.  In  at  least  two  and  possibly  four  cases 
it  was  the  immediate  cause  of  death.  In  a  third,  involving 
fracture  at  the  base,  life  was  saved  by  operation,  although 
the  clot  removed  measured  four  ounces  and  a  half  by  vol- 
ume. Such  a  case  is  in  evidence  that  the  brain-tissue  is 
really  susceptible  of  compression. 

Subarachnoid  or  cortical  hajmorrhage  is  ordinarily  de- 
rived from  laceration  of  the  cortical  substance,  and  is  often 
the  direct  cause  of  death,  as  well  as  of  certain  of  the  pre- 
cedent symptoms.  From  a  laceration  at  the  base,  whether 
of  the  frontal  or  temporo- sphenoidal  lobe,  it  may  cover  the 
whole  superior  surface  of  one  or  both  hemispheres,  and  cause 
various  localizing  symptoms  which  accompany  or  precede 
those  of  fatal  pressure.  From  a  laceration  of  the  occipital 
lobe  or  cerebellum,  it  may  cause  immediate  death  from 
compression  of  the  medulla ;  or  the  haemorrhage  from  the 
torn  vessels  of  the  brain,  even  in  extensive  laceration,  may 
be  insuflRcient  to  seriously  modify  symptoms  or  hasten  the 
fatal  termination.  A  moderate  amount  of  cortical  haemor- 
rhage from  rupture  of  the  vessels  of  the  pia  is  also  one  of 
the  results  of  meningeal  contusion. 

Subdural  hoEmorrhagc  I  have  found  most  frequently  to 
depend  upon  rupture  of  the  arachnoid  and  escape  of  blood 


Jan.  21,  1893.J 


RICE:  SPRATS  IN  TEE  TREATMENT  OF  CATARRH. 


71 


from  the  inesbes  of  the  pia  mater  into  the  arachnoid  cavi- 
ty. In  a  smaller  number  of  instances  its  source  has  been  in 
the  meningeal  vessels.  In  a  recent  case  there  was  rupture 
of  the  dura  mater,  and  the  blood  was  of  epidural  origin. 
Cortical  haemorrhage,  however,  is,  of  all  others,  the  one 
most  frequently  encountered.  The  majority  of  lacerations 
reach  the  surface  of  the  cortex,  and  superficial  hajmorrliage 
results. 

( To  be  concluded. ) 


THE  VALUE  OF  SPRAYS  IN 
THE  TREATMENT  OF  CATARRHAL  AFFECTIONS 
OF  THE  UPPER  AIR  PASSAGES.* 
By  clarence  C.  RICE,  M.  D., 

PEOFESSOK  OF  DISEASES  OF  THE  NOSE  AND  THROAT, 
NEW  TORK  POST-GRADUATE  MEDICAl  SCHOOL  AND  HOSPITAL. 

A  TOPIC  so  general  in  character  as  this  would  more 
properly  appear  on  the  programme  as  a  subject  for  dis- 
cussion ratlier  than  as  the  title  of  a  paper.  This  subject  is 
submitted,  however,  chiefly  for  the  purpose  of  obtaining 
the  views  of  the  members  of  this  association.  A  consensus 
of  opinion  gathered  from  a  society  of  physicians  lil^e  tliis, 
who  have  for  years  made  use  of  and  carefully  noted  the  ef- 
fects of  all  the  many  applications  of  atomized  remedies  upon 
mucous  membranes,  would  be  especially  valuable  if  not  in- 
fallible. It  is  perhaps  the  tendency,  as  one  increases  the 
years  of  his  practice,  to  diminish  the  number  of  drugs  em- 
ployed, and  this  is  true  both  in  prescription  writing  and  in 
the  selection  of  remedies  for  local  application  to  mucous 
surfaces.  While  something  may  be  said  in  favor  of  such  a 
habit,  in  that  only  those  remedies  are  used  which  have 
been  tried  and  found  useful,  there  is  danger,  on  the  other 
hand,  that  attachment  to  a  few  pet  drugs  will  prevent  the 
trial  of  newer  and  perhaps  more  useful  medicines.  The 
very  busy  practitioners  of  our  association  are  hardly  in  the 
position  to  experiment  with  new  remedies  locally  applied 
unless  they  continue  their  dispensary  practice,  so  that  the 
young  men  must  be  depended  upon  to  keep  the  materia 
medica  up  to  date.  However  it  may  be  in  other  towns,  in 
New  York  it  may  be  stated  truthfully  that  one  great  ob- 
stacle in  the  way  of  studying  the  effects  of  atomized  medi- 
cines upon  mucous  membranes  is  the  difficulty,  both  in  our 
colleges  and  dispensaries,  of  keeping  the  spray  apparatus 
in  working  order.  In  teaching-institutions  the  instruments 
are  at  the  mercy  of  the  many  working  students,  and  in  the 
dispensaries  the  authorities  rarely  have  money  enough  or 
take  sufficient  interest  to  supply  the  necessary  outfit.  It  is 
well-nigh  impossible  to  keep  apparatus  which  is  used  in 
common  by  many  physicians  in  pi'oper  condition,  conse- 
quently the  treatment  of  catarrhal  diseases  by  nebulized 
fluids  has,  in  some  of  the  dispensaries,  given  way  to  treat 
ment  by  other  methods,  such  as  the  insufflation  of  pow- 
ders, local  applications  by  means  of  brush  or  cotton  appli- 
cator, and  even  surgical  measures  have  been  adopted,  in 
some  instances,  where  the  spray  tube  would  have  been  used 


*  Read  before  the  American  Laryiigological  Association  at  its  four- 
teenth annual  congress. 


if  it  had  been  conveniently  near  and  in  working  order. 
The  wretched  condition  of  the  spraying  apparatus  in  dis- 
pensaries and  teaching-institutions  is  to  be  deplored,  for 
such  a  state  of  affairs  prevents  not  only  the  needful  wash- 
ing of  mucous  surfaces,  but  it  also  seriously  hinders  the 
trial  by  atomization  of  many  drugs  which,  if  not  employed 
in  dispensary  practice,  will  never  be  used.  The  lack  of 
means  of  treating  catarrhal  diseases  by  simple  measures 
encourages  unnecessary  surgical  methods.  Occasionally  we 
find  a  physician  who  deprecates  the  value  of  medication  by 
spraying,  who  apparently  arrives  at  this  conclusion  because 
he  is  unwilling  to  supply  himself  with  air  apparatus  and 
spray  tubes. 

It  is  to  be  regretted  also  that  the  prescription  formu- 
lary employed  in  hospital  and  dispensary  practice  is  so  ab- 
breviated and  out  of  date  that  we  lose  the  benefit  of  the  use 
of  many  valuable  medicaments  which  should  be  employed 
in  varying  strengths  of  solution.  If  it  is  conceded  that  the 
treatment  of  catarrhal  diseases  by  the  application  of  atom- 
ized drugs  is  at  all  efficacious,  we  should  not  allow  such 
pi'actice  to  fall  into  disrepute  because  of  faulty  apparatus. 

It  is  not  intended  in  this  paper  to  speak  of  the  merits 
of  any  particular  line  of  remedies,  or  to  call  attention  to  any 
new  drugs,  or  to  compare  the  efficiency  of  medicines  applied 
by  atomization  with  that  of  the  various  other  methods  of 
making  topical  applications,  but  rather  to  consider  some  of 
the  general  principles  upon  which  sprays  should  be  em- 
ployed in  order  to  make  them  valuable  medicinal  agents. 

It  will  be  of  no  special  interest  to  this  association 
or  of  value  to  this  short  paper  to  relate  the  history  of 
the  development  of  the  principle  of  atomization  or  nebu- 
lization  of  medicated  fluids.  The  very  simple  spray  pro- 
ducers of  the  present  day  were  obtained  only  after  repeated 
failures  and  changes,  and  this  history  is  all  fully  told  by 
Dr.  Cohen  in  his  book  on  Inhalation :  its  Therapeutics  and 
Practice ;  also  by  Sir  Morell  Mackenzie ;  and,  in  a  brief 
way,  by  nearly  every  text  book  relating  to  the  treatment  of 
the  diseases  of  the  nose  and  throat.  When  we  remember 
how  difficult  it  was  to  obtain  the  ordinary  laryngeal  mirror 
and  to  adapt  it  to  its  successful  use,  we  need  not  be  sur- 
prised that  so  simple  an  apparatus  as  the  spray  tube  re- 
quired the  mechanical  ingenuity  of  many  minds  before  it 
was  perfected.  At  one  time  the  temptation  to  resort  only 
to  surgical  methods  was  very  strong,  but  treatment  by 
sprays  has  maintained  a  prominent  position  through  all  the 
vicissitudes  of  practice. 

There  are  a  few  practical  clinical  points  bearing  on  the 
subject  of  treatment  of  catarrhal  diseases  by  the  atomiza- 
tion of  drugs  which  may  not  have  been  recently  considered, 
and  it  is  of  these  I  wish  to  speak.  First,  it  may  be  said 
that  the  various  petroleum  products,  starting  with  solid 
vaseline  and  followed  by  the  semisolids  and  fluids,  called  by 
such  names  as  "  liquid  vaseline,"  "  albolene,"  "  benzoinol," 
"  glymol,"  lanolin,  etc.,  have  crowded  out  of  use  many  of 
the  old  astringent  drugs,  and  the  change  has  been  a  bene- 
ficial one.  Perhaps  the  most  erroneous  principle  upon  M^hich 
atomized  fluids  have  ever  been  used  in  the  treatment  of  the 
nose  was  and  is  the  prevalent  practice  of  spraving  vegeta- 
ble and  mineral  astringents  into  the  anterior  nares  for  the 


72 


RICE:  SPRATS  IN  THE  TREATMENT  OF  CATARRH. 


[N.  Y.  Med.  Jotjh., 


purpose  of  curing  hypertrophic  rhinitis,  attempting  to  as- 
tringe  the  nasal  mucous  membrane,  which  is  an  erectile  struc- 
ture, and  thus  endeavoring  to  diminish  supersecretion.  To 
the  dismal  failure  of  such  practice,  more  than  to  anything 
else,  are  we  indebted  to  the  necessity  which  gave  us  nasal 
surgical  instruments.    I  should  like  to  ask  this  association 
if  there  is  a  single  so-called  astringent  remedy,  of  any 
strength  of  dilution,  which  can  be  with  benefit  atomized 
into  the  anterior  nares  in  cases  of  simple  hypertrophic  ca- 
tarrhal disease.    Are  there  any  useful  solutions  of  silver, 
or  copper,  or  zinc,  or  tannic  acid  for  such  practice  ?  Text 
books  have  been  at  fault  in  printing  such  sprays  for  the 
treatment  of  anterior  nasal  disturbances.    It  required  years 
to  ascertain  that  such  treatment  was  prejudicial.  Solutions 
of  the  mineral  astringents,  of  one  half  the  strength  of  dilu- 
tion usually  printed,  are  capable,  if  thrown  into  the  anterior 
nares  with  much  pressure,  of  producing  acute  coryza,  puru- 
lent disease  of  the  accessory  cavities,  and  intlammation  of 
the  middle  ear.    For  the  treatment  of  simple  and  hyper- 
trophic catarrh  of  the  anterior  nares  it  is  probable  that  no 
drug  should  be  employed  by  atomization  whose  use  is  based 
upon  its  astringency.    Astringency  means  here  only  irrita- 
tion and  inflammation.    The  material  advance  made  when 
the  vaseline  preparations  came  into  use  and  supplanted  the 
old  astringents  was,  first  of  all,  due  to  the  fact  that  the  oily- 
products  were  at  least  harmless — a  simply  negative  value. 
Latterly  they  have  been  used  in  such  ways  and  combina- 
tions as  to  be  of  positive  benefit.    The  physiological  action 
of  the  simple  oily  preparations  is  indefinite.    They  are  cer- 
tainly protective  agents,  both  in  hypertrophic  and  atrophic 
disease,  and  in  this  way  they  may  be  called  sedative.  They 
furnish  a  perfectly  non-irritating  vehicle  for  many  combina- 
tions of  medicine — such  as  cocaine,  iodoform,  aiistol,  oil 
of  pine  needle,  menthol,  thymol,  resorcin,  etc.     The  oil 
decreases  the  action  of  all  these  drugs — that  is,  their  action 
is  less  in  the  oily  vehicle  than  in  watery  solutions,  or  it 
might  be  more  properly  stated  that  the  blandness  of  the 
oil  softens  the  irritation  which  nearly  every  drug  produces 
momentarily  as  it  is  thrown  in  spray  against  the  mucous 
membrane — the  mechanical  concussion.   The  effect  of  men- 
thol and  the  volatile  oils  in  these  oily  vehicles  upon  mucous 
membranes  is  readily  studied.    They  are  at  first  stimulat- 
ing, in  the  sense  of  increasing  capillary  circulation,  and 
later  (and  this  is  their  principal  physiological  action)  they 
are  sedative  or  antiphlogistic,  since  their  evaporation  is 
only  effected  by  and  with  the  rapid  abstraction  of  heat 
from  the  tissues,  a  chilling  of  the  surface,  a  contraction 
of  the  peripheral  circulation.    The  first  or  stimulating  ef- 
fect spoken  of  is  produced  by  the  impact  of  almost  any 
spray  thrown  against  sensitive  mucous  surfaces;  it  might 
be  termed  mechanical  or  traumatic  stimulation.  The  amount 
of  stimulation  is  regulated  by  the  temperature  of  the  fluid 
and  the  force  with  which  it  is  projected.    As  has  been 
said,  the  oily  vehicle  lessens  the  first  shock,  which  has  al- 
ways been  an  objection  to  watery  solutions  when  used  with 
pressure,  and  especially  in  cold  weather.    The  protective, 
sedative  effect  of  [)lairi  oily  sprays  in  the  nasal  chambers, 
in  many  cases  of  simple  and  also  in  those  cases  of  hyper, 
trophic  rhinitis  where  the  turbinated  structures  are  only 


distended,  is  continued  until  what  may  be  termed  a  "  cure  " 
is  effected — that  is,  the  turbinates  become  normally  com- 
pressed and  the  secretions  normal.  I  believe,  however,  that 
too  long  continuation  of  the  use  of  the  oily  sprays  in  the 
nose  tends  to  produce  dryness  of  the  surfaces  and  a  con- 
traction of  the  erectile  tissues,  which  looks  much  like  atro- 
phy. I  have  noted  this  tendency  to  increased  dryness, 
especially  when  these  oily  remedies  have  been  sprayed 
upon  the  middle  and  post  nasal  pharynx.  Iodoform,  iodol, 
and  aristol  seem  to  lose  much  of  their  characteristic  effects 
when  sprayed  in  these  oily  vehicles  ;  they  may  still  possess 
integrity  enough  to  act  as  disinfectants,  but  their  stimulat- 
ing action  in  the  healing  of  ulcerations  can  not  be  thor- 
oughly relied  upon  when  they  are  placed  in  oil.  These 
remedies  are  much  more  effectively  used  when  in  ethereal 
solution,  applied  by  applicators,  or  insuflSated  in  powder. 

One  more  point  about  oily  sprays.  It  is,  I  believe,  wise 
to  employ  them  in  those  cases  of  nasal  obstruction  where 
there  is  a  question  as  to  the  necessity  of  operative  pro- 
cedure— cases  in  which  the  obstruction  is  not  great  and 
congestion  is  a  considerable  factor.  After  the  congestion 
has  been  controlled  by  means  of  the  oily  spray,  there  may 
be  no  demand  for  operation. 

I  spoke  earlier  in  this  paper  of  the  harmful  effect  of 
throwing  watery  astringent  medicaments  into  the  anterior 
nares  when  the  nasal  chambers  were  not  far  advanced  in 
disease.  This  objection  does  not  hold  good  in  atrophic 
rhinitis;  here  there  is  little  sensitive  tissue  to  irritate  ;  but 
even  here  there  is  never  occasion  to  atomize  fluids  of  too 
strong  solution,  or  impel  them  with  pressure  exceeding 
twenty- five  or  thirty  pounds.  I  have  noticed  that  these 
cases  of  atrophic  rhinitis  may  be  fired  up  into  subacute  in- 
flammatory conditions  by  sprays  where  the  middle  turbi- 
nated bones  are  large  and  wedged  down  upon  the  sajptum. 
Disinfecting  medications,  applied  by  spraying,  are  invalua- 
ble in  atrophic  conditions,  in  ozaina,  in  syphilitic  rhinitis, 
in  nasal  polypi,  and  in  purulent  disease  originating  in  the 
accessory  cavities.  Solutions  of  peroxide  of  hydrogen  (from 
ten  per  cent,  to  twenty  per  cent.),  of  mercuric  bichloride 
(1  to  4,000),  of  boric  acid,  of  potassium  permanganate,  and 
of  carbolic  acid — these  are  all  valuable  agents  when  applied 
by  atomization,  and  do  more  oftentimes  than  disinfect ; 
they  stop  purulent  discharges.  The  most  commonly  useful 
method  of  employing  the  spray  is,  in  my  opinion,  with  the 
up-tip  spray  tube  directed  toward  the  back  wall  of  the 
pharynx  and  the  post-nasal  space.  In  the  majority  of  cases 
of  nasal  disease  the  patient  is  not  accomplishing  all  he  can 
for  his  cure  unless  he  has  been  taught  to  use  the  up-tipped 
atomizer  behind  the  soft  palate,  a  task  which  is  correctly 
performed  only  when  he  has  learned  to  breathe  properly 
and  to  relax  the  palatal  muscles.  If  anterior  nasal  spray- 
ing is  useful  in  five  cases,  post- nasal  is  more  useful  in  a 
hundred.  The  vault  of  the  pharynx  and  the  posterior  wall 
can  not  be  washed  by  anterior  nasal  sprays ;  but  the  nasal 
chambers,  except  in  cases  of  atrophic  disease,  can  be 
cleansed  by  atomized  fluids  thrown  in  from  behind  the 
soft  palate.  In  spite  of  the  intelligent  work  which  has 
been  done  by  this  association  in  the  treatment  of  atro- 
phic diseases,  a  mild  alkaline,  stimulating,  disinfecting  so- 


Jan.  21,  18!t3.J 


BULL:   TUMORS  OF  THE  ORBIT  AND  NEIGHBORINa  CAVITIES. 


73 


lution,  sprayed  up  behind  the  nose  tliree  times  daily  by  the 
patient,  is  perhaps  as  effective  treatment  as  we  can  to-day 
command.  The  up  spray,  intelligently  used,  is  a  much  bet- 
ter instrument  than  the  douche,  for,  while  it  can  be  made 
to  cleanse  equally  well,  it  does  not  present  the  same  dan- 
gers of  provoking  inflammations  of  the  ear.  Besides,  I 
believe  that  large  quantities  of  fluid  passed  for  a  long  time 
over  mucous  membranes,  as  is  done  in  douching,  wears  away 
the  healthy  surface  of  a  tissue  and  leaves  it  callous,  com- 
pressed, and  hardened.  In  the  posterior  nares  mild  solu- 
tions (two  or  three  grains  to  the  ounce)  of  the  astringents 
— such  as  silver,  copper,  zinc,  tannic  acid,  or  the  salts  of 
iron — may  be  used  with  mucii  more  safety  and  benefit  than 
in  the  anterior  nares,  for  the  irritation  necessarily  arisincf 
from  the  first  effect  of  these  sprays  is  expended  upon  the 
post-nasal  pharynx,  which  does  not  suffer,  and  enough  of 
the  astringent  medication  reaches  the  nasal  chambers  proper 
to  produce  a  beneficial  effect. 

The  treatment  of  catarrhal  diseases  of  the  upper  air 
passages  has  practically  become  limited  to  such  operative 
measures  as  each  case  demands,  followed  by  the  appli- 
cation of  drugs  in  powder  or  solution.  Ninety  per  cent, 
of  all  topical  remedies  are  applied  in  the  form  of  sprays. 
Sprays  are  beneficial  or  harmful  according  to  the  manner 
in  which  they  are  used.  Nice  judgment  is  required  in 
selecting  not  only  the  drug,  but  the  exact  strength  of  the 
solution  suitable  for  the  particular  portion  of  the  upper 
respiratory  tract.  A  solution  which  might  improve  the 
middle  pharynx  or  larynx  would,  if  directed  into  the  nose, 
cause  an  intense  coryza,  and  possibly  an  acute  inflamma- 
tion of  the  middle  ear.  The  pressure  used  should  be  regu- 
lated to  suit  the  temperament  of  the  patient,  the  local  con- 
dition to  be  treated,  and  the  situation  to  be  reached.  Who 
can  believe  that  a  cold  solution  of  some  harsh  astringent 
sprayed  upon  the  mucous  membrane  of  a  nervous  patient 
will  be  of  benefit  ?  And  we  may  sometimes  add  to  these 
unfavorable  conditions  a  chilly  patient  and  an  underheated 
operating  office.  The  oils,  under  such  circumstances,  are 
much  better  than  the  watery  solutions.  It  is  easy  to  have 
a  water  bath  to  heat  the  solutions  which  are  to  be  used. 
Cocaine  has  been  of  great  service ;  for  a  very  weak  per- 
centage of  this — one  half  of  one  per  cent. — added  to  our 
astringent  sprays  will  to  a  great  extent  nullify  the  first  irri- 
tating effect  of  the  topical  application.  Very  mild  solutions 
of  cocaijje — less  than  one  per  cent. — are,  perhaps,  as  useful 
astringents  as  we  can  employ,  and  none  of  the  uncomfort- 
able reactions  which  sometimes  follow  the  stronger  solu- 
tions are  seen.  Mild  cocaine  solutions  seem  to  clinch  the 
beneficial  effects  of  astringents  when  they  are  used  in  com- 
bination. Cocaine  seems  to  have  justly  supplanted  solu- 
tions of  opium,  morphine,  and  bromide  of  potassium,  and 
I  know  of  no  beneficial  effect  to  be  obtained  from  aconite 
preparations  which  cocaine  does  not  more  surely  afford. 
The  strength  of  the  cocaine  solutions  can  be  more  easily 
regulated  than  those  of  opium  and  aconite.  I  need  not 
speak  of  the  great  value  of  mild  cocaine  sprays  in  the 
nose,  post-nasal  space,  and  larynx,  in  aiding  first  exami- 
nations and  in  making  diagnoses.  Cocaine  sprays  have 
rendered  laryngeal  manipulation  and  operation  easy,  and 


have  saved  life  in  relieving  laryngeal  dyspnoea  until  ob- 
struction could  be  removed.  The  group  of  stimulating  dis- 
infectants represented  by  listerine,  thymol,  menthol,  eu- 
calyptol,  oil  of  wintergreen,  etc.,  cleanse  and  make  com- 
fortable the  dry,  congested  air  passages  from  the  post- nasal 
space  down  as  far  as  they  penetrate.  The  evaporation  of 
their  volatile  elements  diminishes  congestion  for  a  time  at 
least.  I  have  already  said  that  solutions  for  spraying 
should  not  be  cold,  and  should  be  propelled  with  reasonable 
pressure ;  fifteen  pounds  is  sufficient  for  the  anterior  nares, 
twenty-five  for  the  posterior  nares,  and  twenty-five  or 
thirty  for  the  lower  pharynx  and  larynx.  The  treatment 
of  catarrhal  affections  of  the  upper  air  passages  by  the  ap- 
plication of  atomized  fluids  will  not  lapse  into  disuse  in  our 
day,  neither  will  such  treatment  render  nasal  surgery  un- 
necessary. It  is  quite  possible,  however,  that  our  new  com- 
binations of  cocaine,  menthol,  etc.,  applied  in  oily  vehicles, 
will  diminish  the  number  of  nasal  operations  which  to-day 
seem  indicated. 

123  East  Nineteenth  Street. 


TUMORS  OF  THE  ORBIT  AND 
NEIGHBORING  CAVITIES.* 
By  CHARLES  STEDMAN  BULL,  A.  M.,  M.  D., 

PROFESSOR  OP  OrHTnAI.MOLOGT  IN  THE  UNIVERSITT  OP  THE  CITY  OF  NEW  YORK; 
SURGEON  TO  THE  NEW  YORK  EYE  AND  EAR  INFIRMARY. 

( Concluded  from  page  44-) 

Case  X.  Sarcoma  of  the  JVose,  Nasal  Meatus,  and  Orbit. — 
Early  in  November,  1884,  I  was  called  in  consultation  to  see  a 
gentleman,  aged  fifty  two,  and  learned  the  following  history  of 
his  case :  For  many  years  he  had  been  a  sufferer  from  lupus  of  the 
face,  which  had  first  appeared  as  a  small  nodnle  on  the  left  ala 
of  the  nose.  It  slowly  extended  in  several  different  directions, 
healing  as  it  extended,  until  the  cicatrix  and  the  sore  covered  a 
apace  as  large  as  a  silver  half  dollar.  It  then  remained  quiescent 
for  nearly  two  years,  but  subsequently  extended  upon  the  left 
side  of  the  nose  and  orifice  of  the  left  nostril.  During  the  past 
year  its  growth  had  been  rather  more  rapid.  When  [  saw  him 
the  growth  had  entirely  occluded  the  left  nostril,  filled  the  pos- 
teiior nares,  and  extended  overti)echeek  and  malar  prominence 
and  slightly  into  the  orbit  from  the  outside,  pushing  the  eye  up- 
ward, outward,  and  forward.  It  had  also  extended  into  the 
zygomatic  fossa.  The  eyeball  was  still  freely  movable  and  tlie 
axes  of  the  two  eyes  could  be  made  parallel,  when  the  diplopia 
which  ordinarily  existed  disappeared.  Vision  was  normal,  the 
media  were  clear,  and  the  fundus  was  healthy. 

My  opinion  had  been  desired  in  regard  to  the  advisability  and 
feasibility  of  an  operation,  and  I  advised  against  any  attempt  to 
remove  the  external  portion  of  the  growtli,  on  account  of  the 
great  extent  of  diseased  tissue  and  the  impossibility  of  procuring 
a  flap  of  sound  skin  of  sufficient  size  to  close  the  wound.  There 
also  seemed  a  probability  that  the  growth  had  extended  from 
the  nasal  meatus  to  the  maxillary  antrum,  and  any  attempt  to 
remove  this  part  of  the  growth  would  have  necessitated  the  re- 
moval of  the  anterior  bony  wall  of  the  antrum.  The  growth  in 
the  naso-phary  11^ might  be  removed,  and  this  would  render  the 
patient  much  more  comfortable  and  his  respiration  easy,  and 
this  I  advised  should  be  done. 

On  November  13th  the  patient  was  etherized  and  with  some 
difficulty  the  left  nostril  and  naso-pharynx  were  cleared  of  the 
growth,  part  being  removed  through  the  nostril  and  part 


74 


BULL:  TUMORS  OF  THE  ORBIT  AND  NEIGHBORING  CAVITIES.     [N.  Y.  Med.  Jouh. 


through  the  pharynx.  The  sfeptnm  nasi  was  found  driven  over 
to  the  right  side,  and  the  growth  had  extended  far  up  the  nasal 
cavity  on  the  left  side  beyond  the  reach  of  operative  interfer- 
ence. The  immediate  result  was  a  great  improvement  in  the 
patient's  comfort,  whicli  remained  for  nearly  six  months  before 
his  respiration  became  again  obstructed.  I  declined  any  fur- 
ther interference  on  account  of  the  hopelessness  of  the  case. 
The  progress  of  the  disease  was  slow  but  steady.  The  whole 
left  side  of  the  face  became  gradually  involved,  the  disease  ex- 
tending down  to  the  angle  of  the  jaw,  over  on  the  temple,  and 
up  on  the  forehead  and  bridge  of  the  nose.  The  orbit  filled  up, 
apparently  from  tlie  orbital  margin,  and  the  eye  was  pushed 
forward  and  inward  toward  the  nose ;  the  eyelids  became  in- 
volved, the  cornea  ulcerated  and  tlien  perforated,  and  a  large 
staphyloma  developed  and  protruded  between  the  swollen  and 
half-closed  lids.  \The  patient  lived  for  two  years  and  a  half  after 
the  operation,  suffered  greatly,  and  finally  died  from  exhaustion. 
Throughout  the  entire  course  of  the  disease  the  progres^s  had 
been  from  without  inward,  and  the  resulting  disfigurement  was 
unpleasant  in  the  extreme.  No  autopsy  was  permitted,  and 
thus  no  opportunity  was  offered  of  determining  whether  there 
had  been  any  change  in  the  microscopical  character  of  the 
growth.  Before  I  first  saw  the  patient  portions  of  tissue 
had  been  removed  from  the  external  growth  on  the  nose 
and  had  proved  to  be  lupus.  Tlio  portion  removed  from  the 
interior  of  the  nose  had  the  mixed  appearance  of  both  lupus 
and  sarcoma. 

Case  XI.  Caries  and  Aiscess  of  the  Orbital  Walls. — A  little 
boy,  R.  P.,  aged  three,  was  brought  to  me  in  November,  1884, 
with  the  following  history  :  About  two  weeks  before,  the  motlier 
had  noticed  a  staring  appearance  of  the  right  eye,  which  in- 
creased to  a  positive  protrusion  of  the  eye.  "When  I  saw  the 
child  the  lids  were  somewhat  reddened  and  the  exophthalmia 
was  directly  forward.  Pressure  of  the  eye  backward  gave  an 
elastic  sensation  and  caused  some  pain.  Inquiry  developed 
the  fact  that  the  cliild  had  had  some  sym])toms  of  congenital 
syphilis  at  birth  anil  that  the  father  was  undoubtedly  syphilitic. 
The  case  was  watched  for  several  weeks,  but  nothing  abnormal 
was  observed  except  a  slow  increase  in  the  exophlhalmus.  The 
eyeball  was  apparently  normal  in  every  respect.  I  suspected 
the  presence  of  either  a  cyst  or  an  abscess  and  advised  an  ex- 
ploratory puncture.  This  was  done  and  a  small  trocar  was 
passed  into  the  orbital  tissue  on  the  nasal  side  of  the  eye,  but 
with  no  result.  No  trace  of  any  growth  could  be  felt  in  the 
orbit,  and  nothing  was  found  in  the  nasal  meatus  or  naso- 
pharynx. The  exploratory  puncture,  however,  seemed  to  set  up 
a  more  active  process  in  the  orbit,  for  the  exophthalmus  rapidly 
grew  worse  and  the  child  began  to  complain  of  constant  pain. 
A  more  extensive  operation  was  then  proposed  and  consented 
to  by  the  parents.  The  conjunctiva  was  opened  horizontally 
on  the  temporal  side,  the  tendon  of  the  external  rectus  was 
divided,  and  the  eye  turned  strongly  to  the  nose.  The  finger 
was  then  introduced  and  almost  immediately  felt  a  tumor, 
which  seemed  to  occupy  the  apex  of  the  orbit  and  to  be  firmly 
attached  to  the  outer  wall  of  the  orbit  far  back.  It  had  no  at- 
tachments to  the  eyeball,  and  was  easily  detached  from  the 
orbital  tissue  and  sheath  of  the  optic  nerve,  but  was  with  great 
difficulty  separated  from  the  periosteum  on  the  outer  wall  of 
the  orbit.  In  doing  this  the  sac  wall  was  ruptured  far  hack  and 
a  quantity  of  ill-smelling  pus  came  out,  and  the  tumor  collapsed. 
The  sac  wall  was  then  carefully  removed  as  fi#  as  possible,  and 
the  little  finger  being  introduced  discovered  a  small  patch  of 
denuded  bone  far  back  on  the  outer  wall  of  the  orbit.  There 
had  evidently  been  a  focus  of  periostitis  or  perhaps  of  osteitis 
with  caries,  and  an  abscess  had  developed  in  the  orbital  tissue. 
The  dead  bone  was  scraped  as  well  as  possible,  the  cavity  thor- 


oughly washed  out  with  a  solution  of  sublimate  (1  to  2,000), 
and  a  loop  of  carbolized  silk  inserted  for  drainage. 

The  case  did  remarkably  well.  Some  suppuration  occurred 
from  the  orbital  tissue  and  from  the  suture  points  which  united 
the  tendon  of  the  external  rectus,  but  this  ceased  within  the 
first  week.  The  eyeball  gradually  receded  within  the  orbit,  and 
in  two  months  scarcely  a  trace  of  the  operation  wsis  left.  There 
has  been  no  return  of  the  orbital  trouble,  but  the  child  has  had 
a  rather  severe  osteitis  in  the  riglit  ankle  joint,  from  which  he 
eventually  recovered. 

Case  XII.  Myxosarcoma  of  the  Orhit  and  Adjacent  Cavi- 
ties.— A  young  woman,  K.  M.,  aged  twenty-one,  was  brought 
to  me  on  January  12,  1885.  Three  months  before,  she  began  to 
be  troubled  with  epiphora  in  the  left  eye,  and  very  shortly  after 
she  noticed  a  small  tumor  along  the  orbital  margin  just  beneath 
the  lower  lid  and  at  about  its  middle.  It  was  painless  and  oc- 
casioned no  annoyance.  This  lias  increased  in  size  and  now 
begins  to  push  the  lower  lid  forward.  Careful  examination 
proved  tiiat  the  tumor  could  be  jilainly  felt  in  the  orbital  cavity, 
lying  along  the  floor  of  the  orbit  beneath  the  eye  and  extending 
up  slightly  upon  the  inner  wall.  On  being  questioned,  the  pa- 
tient stated  that  for  more  than  a  year  she  had  suffered  from  a 
i  pain  in  the  cheek  just  beneath  the  orbital  margin,  which  was 
dull  in  character  but  never  severe,  and  she  had  considered 
it  neuralgia.  The  teeth  were  examined  and  several  were 
found  badly  decayed,  with  large  cavities.  The  nose  and  nasal 
meatus  were  examined,  but  nothing  specially  abnormal  found. 
A  diagnosis  was  made  of  tumor  of  the  orbit,  with  the  possiltility 
of  its  origin  in  the  maxillary  antrum  and  subsequent  perforation 
of  the  floor  of  the  orbit.  Both  eyes  were  normal  in  every  re- 
spect. The  patient  was  advised  to  have  the  growth  removed 
before  the  vision  of  the  eye  became  affected,  but  declined  all 
interference.  In  two  weeks  she  came  again  and  a  great  change 
in  her  appearance  had  occurred.  The  growth  of  the  tumor 
had  been  very  rapid.  The  eyeball  was  displaced  upward  and  out- 
ward and  vision  was  reduced  to  f  The  lids  were  swollen  and 
protruded  perceptibly.  The  growth  covered  the  entire  floor  of 
the  orbit,  extended  over  the  inner  wall  aud  involved  the  orbital 
plate  of  the  ethmoid,  and  had  spread  over  the  lower  edge  of  the 
orbit  and  down  upon  the  anterior  surface  of  the  superior  maxilla. 
She  was  then  eager  for  an  operation,  although  she  was  told 
that  in  all  probability  the  eye  could  not  be  saved.  The  nose 
and  pharynx  were  again  carefully  examined,  but  nothing  ab- 
normal was  found. 

On  January  30th  I  enucleated  the  eye  and  then  found  that 
nearly  the  whole  orbit  was  filled  with  the  growth.  It  varied 
in  consistence,  being  in  some  places  hard  and  in  others  soft. 
In  examining  the  floor  of  the  orbit,  the  probe  passed  into  a 
cavity,  showing  that  communication  with  the  antrum  existed. 
The  orbit  was  thoroughly  cleaned  out  in  the  usual^ay,  and 
a  large  opening  was  then  discovered  in  the  floor  of  the  orhit, 
which  extended  nearly  to  the  orbital  margin,  and  the  growth 
could  be  seen  and  felt  in  the  antrum.  The  extra-orhital  por- 
tion of  the  growth  was  then  removed  from  the  surface  of  the 
upper  jaw  and  was  found  closely  united  with  the  periosteum. 
The  antrum  was  then  emptied  of  its  contents,  and  an  examina- 
tion showed  that  the  growth  had  not  apparently  extended  into 
the  nose.  The  cavity  of  the  antrum  and  the  orbit  was  care- 
fully washed  out  with  bichloride  solution  (1  to  2,000),  and  the 
surface  of  the  periosteum  thoroughly  scraped  and  cauterized. 
The  patient  recovered  rapidly  and  went  home  at  the  end  of  two 
weeks.  She  was  told  that  the  tumor  would  almost  certainly 
return,  and  that  she  must  be  seen  at  short  intervals.  I  did  not 
see  or  hear  of  her  for  nearly  a  year,  and  then  she  came  with  a 
return  of  the  growth  just  beneath  the  lower  margin  of  the 
orbit,  on  the  superior  maxilla.    There  was  no  sign  of  the  recur 


Jan.  21,  1893.]  BULL:    TUMORS  OF  THE  ORBIT  AND  NEIOHBORINQ  CAVITIES. 


75 


rence  of  the  tumor  in  the  orbit,  and  the  antrum  was  empty  ex- 
cept for  a  considerable  amount  of  thick,  glairy  mucus.  The 
pain  in  the  upper  jaw  had  appeared  at  intervals,  but  did  not 
last  long.  The  external  growth  was  removed  through  the 
lower  eul-de-sac,  the  latter  being  incised  throughout  nearly  its 
entire  length,  and  the  lid  depressed.  After  the  nodule  had 
been  dissected  out,  the  bone  was  thoroughly  scraped  and  then 
cauterized  with  the  actual  cautery.  Considerable  suppuration 
followed  this  operation,  and  the  lid  remained  everted  for  sev- 
eral weeks,  but  eventually  this  defect  entirely  disappeared.  I 
saw  this  patient  at  intervals  for  several  months,  but  she  then 
disappeared  and  I  have  heard  nothing  of  her  since.  The  growth 
in  the  orbit,  on  microscopic  examination,  proved  to  be  of  a 
mixed  nature.  The  denser  portion  of  the  tumor  was  pure  sar- 
coma of  the  small-cell  variety.  The  softer  portion,  together  with 
the  growth  in  the  antrum,  was  myxo-sarcomatous  in  character. 
It  was  impossible  to  decide,  from  an  examination  of  the  tumor 
and  of  the  orbit  and  antrum,  where  the  disease  originated, 
though  the  combined  evidence  was  rather  in  favor  of  tlie 
antrum. 

Case  XIII.  Cyst  of  the  Ethmoid  Cells  and,  OrMt. — Early  in 
March,  1885,  a  man,  C.  K.,  aged  twenty-eight,  came  to  me  with 
a  very  incomplete  and  fragmentary  history  of  trouble  in  the 
orbit  on  the  left  side.  There  had  been  a  dull  pain  in  the  orbit 
and  left  side  of  the  head  for  some  months.  It  was  constant  but 
never  severe.  Lately  there  had  been  some  failure  of  the  vision 
and  some  prominence  of  the  eyeball.  He  had  had  two  decayed 
teeth  removed,  one  from  each  jaw  on  the  left  side,  but  the  pain 
continued.  An  examination  showed  a  very  slight  prominence 
of  the  eyeball,  with  V.  =  clear  media  and  a  normal  fundus. 
On  the  inner  side  of  the  left  orbit,  far  back,  a  slight  elastic 
prominence  could  be  felt.  The  naso-pharynx  was  examined, 
but  beyond  a  chronic  catarrhal  condition,  with  rather  profuse 
secretion,  nothing  abnormal  was  discovered.  The  pain  was  now 
confined  to  the  supra  orbital  region  and  the  root  of  the  nose. 
There  seemed  nothing  to  do  bnt  to  watch  the  patient  and  await 
developments.  One  month  later  there  seemed  a  slight  increase 
in  the  elastic  prominence  on  the  nasal  side  of  the  orbit,  and,  a 
small  trocar  being  introduced,  a  small  quantity  of  yellowish, 
turbid  fluid  was  evacuated.  During  the  next  day  this  continued 
to  dribble  through  the  wound  and  beneath  the  conjunctiva. 
That  night  the  patient  slept  well,  but  toward  morning  he  woke 
up  with  a  feeling  of  a  severe  cold  in  his  head.  In  endeavoring 
to  clear  his  nose  he  made  several  violent  expiratory  efforts,  and 
finally  an  immense  mass  of  fluid  and  gelatinous  discharge  was 
passed  through  the  nostrils,  and  he  felt  as  if  something  had  given 
way  in  his  eye.  He  came  to  see  me  early  in  the  morning.  The 
discharge  was  still  coming  from  the  nose,  and  the  ocular  con- 
junctiva was  swollen  and  distended  all  round  the  cornea,  as  in 
a  case  of  extreme  chemosis.  The  diagnosis  was  now  somewhat 
easier.  As  a  consequence  of  the  chronic  nasal  catarrh,  there 
had  been  an  accumulation  of  fluid  in  the  upper  nasal  meatus, 
ethmoid  cells,  and  probably  the  frontal  sinus.  As  a  result  of 
the  pressure,  either  one  of  the  fissures  in  the  orbital  plate  of  the 
ethmoid  had  been  widened  or  the  bone  itself  had  been  worn 
away,  thus  forming  a  communication  with  the  orbit  and  the 
development  of  an  apparent  cyst  in  the  orbit.  This  was  punc- 
tured and  the  contents  flowed  out  beneath  the  conjunctiva. 
The  violent  expiratory  efforts  had  produced  an  enlargement  of 
this  opening  in  the  ethmoid  pl.ite  and  an  evacuation  of  a  large 
quantity  of  fluid  discharge  into  the  orbital  tissue,  as  well  as 
through  the  nose.  I  punctured  the  conjunctiva  in  several 
places,  and  had  the  eye  and  conjunctival  cul-de-sac  irrigated 
every  two  hours  with  a  sublimate  solution  (1  to  5,000),  while 
the  naso-pharynx  was  frequently  washed  out  with  a  saturated 
solution  of  warm  potassium  chlorate.    The  patient  recovered  ' 


without  an  adverse  symptom,  and  vision  was  gradually  restored 
to  the  normal  standard. 

Cask  XIV.  Disease  of  the  Maxillary  Antrum,  involving  the 
Orbit. — In  the  latter  part  of  September,  1885,  a  gentleman,  Mr. 
W.,  aged  fifty-eight,  came  to  me  with  the  following  complaint: 
In  October,  1884,  be  began  to  have  a  dull  pain  in  the  right  side 
of  the  face,  near  the  external  angle  of  the  right  eye  and  over 
the  malar  prominence,  which  lasted  for  some  months.  Think- 
ing it  might  come  from  the  teeth,  he  consulted  his  dentist,  who 
extracted  the  third  and  fourth  molars  from  the  upper  jaw  on 
the  right  side,  which  were  badly  decayed.  The  fangs  of  the 
fourth  molar  had  penetrated  the  antrum.  For  more  than  a 
month  after  the  removal  of  the  teeth  there  had  been  a  slight 
offensive  discharge  into  the  mouth  from  the  alveolar  opening 
into  the  antrum,  but  this  ceased  and  was  followed  by  a  more  or 
less  profuse  purulent  discharge  through  the  right  nostril  and 
into  the  pharynx.  The  dull  ache  over  the  malar  prominence 
still  continued  and  was  supplemented  by  pain  in  the  region  of 
the  right  frontal  sinus.  In  June,  1885,  the  right  eye  was  noticed 
to  be  on  a  higher  level  than  the  left  eye  and  to  be  somewhat 
more  prominent.  He  consulted  an  oculist  in  a  neighboring  city, 
who  told  him  that  there  was  a  tumor  in  the  orbit  and  that  the 
eye  must  be  removed.  There  was  at  this  time  no  impairment 
of  vision,  but  during  the  summer  he  began  to  have  vertical  di- 
plopia. When  I  saw  him  there  was  a  slight  difference  in  eleva- 
tion of  the  two  eyes  but  no  exophthalmia,  and  the  right  eye 
could  be  moved  freely  in  all  directions.  Shortly  after  his  first 
visit  the  purulent  discharge  from  the  nostril,  which  had  been 
very  slight  for  some  months,  became  again  profuse,  and  the 
right  eye  was  restored  to  its  normal  position  and  the  diplopia 
almost  entirely  disappeared.  This  induced  me  to  believe  that 
the  trouble  was  entirely  in  the  antrum  and  was  of  the  nature  of 
an  abscess,  and  I  urged  an  operation.  To  this  the  patient  ob- 
jected, as  his  condition  was  very  comfortable  and  the  frontal 
pain  had  subsided,  and  I  did  not  see  him  again  until  March, 
1886.  At  that  time  the  discbarge  from  the  nose  had  nearly 
ceased,  the  right  eye  was  displaced  decidedly  upward  and  some- 
what outward,  and  was  distinctly  protruding  from  the  orbit. 
The  diplopia  was  more  marked  than  ever,  and  the  pain  over  the 
malar  bone  and  frontal  sinus  was  at  times  severe.  The  naso- 
pharynx showed  little  abnormal.  A^ision  in  the  right  eye  was 
still  perfect  and  the  opbthahnoscope  gave  a  negative  result.  In- 
fluenced by  my  experience  with  a  former  very  similar  though 
less  severe  case,  which  I  had  transferred  to  the  care  of  a  gen- 
eral surgeon  who  operated  on  the  patient  with  excellent  results, 
I  urged  an  operation  on  the  antrum  through  the  mouth,  and  to 
this  the  patient  consented. 

The  alveolar  opening  at  the  root  of  the  fourth  molar  still 
existed,  though  closed  by  mucous  membrane.  This  I  enlarged 
with  small  bone  forceps,  first  dissecting  away  the  mucous  mem- 
brane and  gum.  There  followed  at  once  the  discharge  of  an 
immense  amount  of  apparently  healthy  pus.  The  antrum  was 
then  irrigated  with  a  warm  saturated  solution  of  boric  acid, 
the  irrigation  being  continued  until  the  fluid  returned  clear. 
The  cavity  was  then  filled  with  a  solution  of  sublimate  (1  to 
5,000)  and  the  opening  temporarily  plugged.  The  nose  and 
orbit  were  then  carefully  examined.  Some  of  the  fluid  escaped 
through  the  nose.  The  floor  of  the  orbit,  which  had  been 
pushed  upward,  had  receded,  and  proved  to  be  excessively  thin 
but  apparently  unperforated.  The  plug  was  then  removed 
from  the  opening  in  the  antrum,  the  sublimate  solution  allowed 
to  run  out,  and  the  antrum  again  irrigated  several  times  with 
the  boric-acid  solution. 

The  result  was  extremely  satisfactory.    There  was  no  re- 
action, and  the  patient  rapidly  recovered.    A  thin  semi-puru- 
'  lent  discharge  continued  for  about  two  weeks,  but  the  cavity 


76 


BULL:   TUMORS  OF  THE  ORBIT 


AND  NEIGHBORim  CAVITIES.     [N.  Y.  Med.  Joub., 


was  washed  out  twice  daily,  and  at  the  end  of  the  second 
month  the  patient  was  discharged  cured. 

Case  XV.  SmalL-cell  Sarcoma  of  the  Orbit  and  Adjacent 
Cavities. — Ahout  the  middle  of  May,  1886,  a  gentleman,  C, 
aged  thirty-two,  consulted  me  in  regard  to  one  of  his  eyes. 
About  six  months  before,  he  h;id  noticed  a  small  tiodule  at  the 
inner  canthns  of  the  left  eye,  which  at  first  looked  like  an  en- 
largement of  the  caruncle.  This  slowly  increased  in  size  until 
it  projected  outside  the  canthus  between  the  edges  of  the  closed 
lids.  While  in  Europe  he  consulted  a  surgeon,  who  removed 
the  growth  together  with  the  caruncle.  It  returned  within  two 
months,  and  increased  rapidly  in  size  and  occasioned  great  dis- 
comfort. When  I  saw  him  the  growth  involved  the  entire  in- 
ner canthns,  including  the  conjunctival  folds,  the  ocular  con- 
junctiva as  far  as  the  corneal  margin  throughout  the  nasal  half, 
both  culs-de-sac,  and  had  extended  deeply  into  the  orbit  along 
the  inner  wall,  being  apparently  closely  connected  with  the 
periosteum  over  the  lacryinal  and  ethmoid  bones.  The  inner 
ends  of  both  lids  were  also  infiltrated.  The  eye  was  limited  in 
motility  in  all  directions,  except  outward.  The  media  were  clear, 
the  fundus  was  healthy,  and  vision  was  normal.  I  advised  a 
very  complete  and  radical  operation — viz.,  ihe  enucleation  of 
the  eye,  the  removal  of  the  entire  contents  of  the  orbit,  includ- 
ing the  periosteum  if  necessary,  and  of  the  inner  halves  of  both 
lids.  To  this  the  patient  would  not  consent  and  went  home, 
but  subsequently  submitted  to  an  operation  by  a  local  surgeon, 
the  exact  nature  of  which  I  do  not  know,  but  it  included  the 
enucleation  of  the  eye.  The  tumor  again  returned  within  two 
months  and  grew  with  great  rapidity,  so  that  le^^s  than  four 
months  after  the  second  operation,  when  he  again  consulted  me, 
the  growth  had  filled  the  orbit,  involving  nearly  the  whole  of 
both  lids,  the  cheek,  side  of  the  nose,  and  temple.  The  left 
nostril  was  also  occluded,  though  by  what  could  not  be  ascer- 
tained definitely,  but  piobably  by  a  prolongation  of  the  growth 
from  above.  Inasmuch  as  nearly  all  the  deep  bones  of  the  face 
were  involved,  as  well  as  the  adjacent  cavities,  I  declined  to 
operate,  but  I  removed  a  piece  of  the  orbital  growth  for  exami- 
nation. The  patient  returned  home  and  a  fourth  operation  was 
done,  but  he  died  within  two  weeks  of  exhaustion.  The  micro- 
scopical examination  of  the  portion  of  orbital  growth  removed 
by  me  proved  it  to  be  a  small-cell  sarcoma.  I  subsequently 
learned  that  the  family  history  of  the  patient  showed  a  dis- 
tinctly cancerous  tendency.  His  mother  had  been  operated 
upon  for  cancer  of  the  breast,  and  had  subsequently  died  of  the 
disease.  A  maternal  aunt  had  died  of  cancer  of  the  uterus, 
and  so  had  his  maternal  grandmother. 

Case  XVI.  Small-cell  Sarcoma  of  the  Arm  and  Orhit. — In 
the  latter  part  of  December,  1887,  a  little  boy,  aged  three, 
was  brought  to  me,  which  proved  to  be  a  case  of  great  inter- 
est. About  fourteen  months  before,  the  child  had  received 
an  injury  to  the  left  arm  from  a  fall.  The  exact  nature  of  this 
injury  1  could  not  ascertain,  but  if  was  not  a  fracture.  From 
this  injury  there  resulted  a  tumor,  which  involved  the  left  up- 
per arm  from  the  elbow  to  the  head  of  the  humerus,  and  the 
glands  in  the  axilla  were  infiltrated.  Some  time  during  the 
summer  of  1887  the  left  arm  was  amputated  at  the  shoulder 
joint  and  the  enlarged  glands  were  removed  from  the  axilla. 
The  mother  said  the  tumor  proved  to  be  a  cancer  on  examina- 
tion with  the  microscope.  Soon  after  the  amputation  of  the  arm 
the  right  eye  was  noticed  to  be  more  prominent  than  the  left 
eye,  and  the  upper  lid  drooped.  When  I  first  saw  the  child  the 
exophthalmus  was  forward,  downward,  and  outward,  and  the 
infiltration  of  the  lid  was  marked.  The  evidence  of  the  pres- 
ence of  an  orbital  tumor  was  unmistakable,  and  the  parents  were 
told  of  the  probable  malignancy  of  the  growth  and  of  its  con- 
nection with  the  tumor  in  the  arm.    The  presence  of  the  same 


trouble  in  the  lid  was  inferred  from  its  swollen,  infiltrated  con- 
dition, and  the  hard  sensation  it  gave  when  compressed  between 
the  fingers.  I  advised  that  the  orbit  be  emptied  of  its  contents, 
including  the  eyeball,  that  the  upper  lid  be  removed,  and  that 
the  orbit  be  closed  up  by  a  plastic  operation.  This  advice  was 
declined,  and  I  heard  nothing  of  the  child  until  four  weeks  later, 
when  the  father  informed  me  that  the  child  was  ill  with  pneu- 
monia. Death  followed  on  the  third  day,  and  I  received  per- 
mission to  remove  the  contents  of  the  orbit,  including  the  eye- 
hall.  The  tumor  had  grown  very  rapidly,  and  was  closely  ad- 
herent 10  the  periosteum  and  to  the  sheath  of  the  optic  nerve, 
.so  that  tlie  eye  and  the  tumor  were  removed  together.  The 
growth  had  also  extended  into  the  sphenoidal  fissure  and  over 
on  the  cheek.  It  proved  to  be  a  small-cell  sarcoma,  very  vas- 
cular, arising  from  the  periosteum,  and  involving  in  its  growth 
the  sheath  of  the  optic  nerve,  the  intravaginal  lymphatic  space 
being  filled  with  small  round  cells,  similar  to  those  in  the  main 
growth.  None  of  the  tissues  of  the  eyeball  itself  were  invaded 
by  the  growth.  I  was  not  permitted  to  mrdce  any  further  ex- 
amination of  the  body. 

Case  XVI  [.  Fibrosarcoma  of  the  Orbit. — I  was  consulted 
in  March,  1889,  by  a  gentleman,  J.  W.,  aged  forty,  who  told  me 
that  the  vision  of  the  right  eye  had  been  defective  frotn  earlj 
childhood,  although  it  could  be  somewhat  improved  by  glasses, 
wliich  he  sometimes  wore.  Three  months  before,  vertical  diplo- 
pia suddenly  appeared,  preceded  by  a  severe  pain  in  the  left  eye, 
and  the  double  vision  had  persisted  ever  since.  He  thought 
also  that  the  left  eye  was  somewhat  more  prominent  than  it  had 
been.  For  the  last  six  weeks  the  upper  lid  on  the  left  side  had 
been  swollen.  When  I  saw  him  the  left  upper  lid  was  swollen 
and  seemed  to  be  pushed  downward.  The  left  eye  protruded 
forward,  downward,  and  outward,  but  the  motility  was  not 
greatly  impaired,  except  upward.  Media  clear  and  fundus  nor- 
mal in  both  eyes.  Diplopia  upward  and  to  the  right  for  all 
large  objects.    R.  E.,  with  cyl.  -D.  2-75,  axis  90°  = 

L.  E.,  with  cyl.  — D.  0  50,  axis  90°  =  f^— .  Just  beneath 
the  superior  orbital  margin  on  the  left  side,  near  the  inner  an- 
gle of  the  orbit,  and  reaching  nearly  to  the  outer  angle  of  the 
orbit,  was  an  elastic,  nodular  mass,  extending  backward  for 
some  distance  and  apparently  closely  connected  with  the  roof 
of  the  orbit.  The  naso  pharynx  was  normal,  as  was  also  the 
orbit  on  the  opposite  side.  The  patient  was  told  that  he  had 
an  orbital  tumor,  and  that,  if  an  operation  were  done  for  its 
removal  at  once,  the  eye  might  he  saved.  He  consented,  and 
the  operation  was  appointed  for  the  nt  xt  day. 

The  hication  of  the  tumor  was  such  that  it  was  necessary  to 
displace  the  eyeball  downward  and  outward  as  far  as  possible, 
and  this  was  done  without  dividing  any  one  of  the  ocular  mus- 
cles. The  conjunctiva  was  divided  through  the  upper  cul-de- 
sac,  the  incision  extending  the  whole  length  of  the  superior  or- 
bital margin.  The  adhesions  between  the  orbital  tissue  and 
eyeball,  and  between  the  latter  and  the  tumor,  were  then  care- 
fully broken  through  with  the  finger  and  a  strabismus  hook, 
which  was  easily  done,  as  none  of  the  adhesions  were  firm.  It 
was  then  found  that  the  tumor  involved  nearly  the  entire  roof 
of  the  orbit,  and  extended  as  far  back  as  the  finger  could  reach. 
It  was  flattened  in  the  center  by  pressure  on  the  eyeball,  but  was 
thicker  on  the  temporal  and  nasal  sides.  It  was  very  firmly 
attached  to  the  periosteum  of  the  roof,  and  its  dissection  was 
extremely  tedious.  Great  care  had  to  be  exercised  to  avoid 
wounding  the  pulley  of  the  superior  oblique,  and,  at  the  apex  of 
the  orbit,  to  avoid  injury  to  the  optic  nerve  and  superior  oblique 
anil  superior  rectus  muscles.  After  its  removal,  as  much  of  the 
periosteum  of  the  roof  as  could  be  reached  was  stripped  off"  and 
removed  and  the  underlying  bono  scraped.  The  hole  was  then 
thoroughly  irrigated  with  sublimate  solution  (1  to  2,000),  the 


Jan.  21,  1893.]  BULL:   TUMORS  OF  TEE  ORBLT  AND  NEIOHBORINQ  CAVITIES. 


77 


wonnd  iu  the  cul-de  sac  carefully  closed  by  a  number  of  sutures, 
and  the  eye  bandaged.  There  was  scarcely  any  reaction,  but 
the  infiltration  in  the  upper  lid  subsided  very  slowly.  At  the 
end  of  a  week  the  eyes  were  tested  for  diplopia,  and  it  was 
found  that  the  superior  oblique  had  been  injured  during  the 
operation,  tlie  relation  of  the  double  images  to  each  other  being 
quite  cliaracteristic.  This  persisted  for  more  than  four  lu'onths, 
but  eventually  nearly  entirely  disappeared.  The  eyeball  re- 
sumed its  normal  position,  but  slowly.  This  patient  still  is  un- 
der observation  at  somewhat  long  intervals,  but  there  has  been 
as  yet  no  trace  of  a  recurrence  of  the  disease,  a  period  of  three 
years  and  a  halt'  since  the  o[)eration.  The  tumor  was  very  care- 
fully examined,  and  proved  to  be  a  fibro-sarcoma,  with  a  very 
large  preponderance  of  dense  fibrous  tissue  and  but  compara- 
tively few  cells,  which  were  of  the  fusiform  variety. 

Case  XVIII.  Spindle  cell  Sarcoma  of  the  Eyelid,  Orhit,  and 
Adjacent  Cavities. — Early  in  April,  1889,  a  man  was  sent  to  my 
office  with  the  following  history :  He  was  twenty-three  years 
of  age,  apparently  in  perfect  health,  with  unusually  fine  muscu- 
lar development.  Five  or  six  weeks  before,  he  had  first  noticed 
a  small  lump  in  the  lower  lid  of  the  left  eye,  near  the  inner 
canthus.  It  was  at  first  movable  and  painless,  but  increased 
rapidly  in  size,  became  painful,  and  led  him  to  seek  advice. 
When  I  saw  him  the  lower  lid  was  swollen,  reddened,  and  par- 
tially everted.  The  growth  ha<l  extended  downward  and  out- 
ward over  the  superior  maxillary  and  malar  bones,  and  back- 
ward into  the  orbit,  along  the  floor  and  inner  wall.  It  was  ir- 
regularly nodulated,  and  the  skin  was  freely  movable  over  it. 
The  left  eye  was  limited  in  motility  inward  and  downward. 
Both  eyes  were  normal  in  every  respect.  The  naso-pharynx 
was  apparently  healthy.  It  was  impossible  to  determine  by  the 
examination  whether  the  growth  had  begun  in  the  orbit  or  in 
the  eyelid.  I  gave  an  unfavorable  prognosis,  and  told  him  that 
the  only  advice  I  could  give  him  was  to  have  an  operation  for 
the  removal  of  the  tumor  done  as  speedily  as  possible,  and  that 
it  would  necessitate  the  loss  of  part  of  the  eyelid  and  possibly  of 
the  eye  itself.  He  agreed  to  do  whatever  I  advised,  and  the 
operation  was  done  on  the  second  day  following  my  examina- 
tion. 

The  internal  canthns  was  split  by  a  horizontal  incision  extend- 
ing to  the  bridge  of  the  nose.  The  lower  lid  was  then  split  into 
an  anterior  lamina  of  skin  and  orbicularis  muscle,  which  seenitd 
to  be  healthy,  and  a  posterior  lamina  containing  the  tarsus, 
conjunctiva,  and  connective  tissue,  as  in  the  old  Arlt-Jaesche 
operation  for  entropion.  The  incision  was  carried  from  the 
outer  end  of  the  first  incision  outward  to  the  middle  of  the  lid, 
and  extended  vertically  downward  to  the  level  of  the  lower 
margin  of  the  orbit.  This  was  done  because  the  skin  of  the  lid 
seemed  healthy.  The  ocular  conjunctiva  was  then  dissected 
free  from  the  nasal  half  of  the  eyeball,  being  cut  entirely  across 
along  the  lower  orbital  margin  and  inner  side  of  the  orbit,  and 
turned  over  on  the  cornea.  It  was  then  seen  that  to  reach  the 
extra-orbital  portion  of  tlie  growth  the  lower  lid  must  be  cut 
in  half  down  to  the  orbital  margin,  which  was  done  and  the 
halves  of  the  lid  turned  as  far  as  possible  out  of  the  way.  The 
growth  was  not  very  adherent  to  the  underlying  bone  outside 
and  was  somewhat  easily  removed  by  the  scissors  and  forceps. 
Inside  the  orbit  it  was  more  flattened  out  and  adherent  to  the 
bone,  especially  along  the  floor  of  the  orbit,  and  here  the  pro- 
cess of  dii-section  was  much  more  slow.  It  extended  about 
two  thirds  of  the  way  back  into  the  orbit,  was  closely  attached 
to  the  periosteum  but  not  at  all  to  the  eyeball,  which  was  read- 
ily pusiied  out  of  the  way.  After  nearly  an  hour's  work  the 
tumor  was  apparently  entirely  removed,  and  a  careful  exam- 
inaticm  was  then  made  of  the  floor  and  inner  wall  of  the  orbit, 
without  discovering  any  remains  of  the  growth.    The  bone  was 


then  scraped  and  the  cavity  in  the  orbit  washed  out  with  a  sub- 
limate solution  (1  to  5,000).  The  inner  half  of  the  lid,  consist- 
ing of  skin  and  muscular  tissue,  was  then  cut  away  and  re- 
moved, and  the  vacancy  filled  by  a  flap  of  skin  taken  from  the 
forehead  and  root  of  the  nose,  twisted  on  its  base,  and  united 
with  the  inner  end  of  the  outer  half  of  the  lid  by  suture  pins 
and  the  necessary  sutures.  There  was  considerable  reaction  on 
the  next  three  days,  but  almost  no  suppuration,  and  the  flap 
healed  well,  so  that  the  patient  was  discharged  from  treatment 
in  about  five  weeks  with  a  very  presentable  lower  lid.  Nothing 
more  was  heard  from  the  patient  for  a  period  of  eight  months, 
when  he  presented  himself  with  an  unmistakable  return  of  the 
growth  in  the  orbit  and  eyelid.  A  very  radical  operation,  in- 
cluding the  removal  of  the  eyeball,  was  the  only  advice  I  could 
give  him,  and  this  he  declined.  Nearly  a  year  later  an  opera- 
tion was  done  in  a  distant  city  for  the  removal  of  the  growth, 
which  had  attained  enormous  proportions.  The  nature  of  the 
operation  was  unknown  to  me,  but  it  involved  the  removal  of 
several  large  pieces  of  bone,  probably  the  superior  maxilla  and 
ethmoid.  lie  recovered  from  this  operation,  but  died  soon 
after  from  some  cerebral  complication,  and  an  autopsy  was  not 
allowed. 

The  tumor  removed  by  me  at  the  first  operation  proved  to 
be  a  sarcoma  of  the  spindle-cell  variety,  with  considerable  fibrous 
tissue  scattered  throughout,  and  contained  but  very  few  blood- 
vessels. 

Case  XIX.  Small-cell  Sarcoma  of  the  Orbit,  Ei/eball,  and 
Adjacent  Cavities. — On  October  4,  1889,  a  woman,  aged  thirty- 
five,  was  brought  to  me  with  the  following  history:  For  about  a 
year  she  had  suffered  from  severe  neuralgia  in  the  right  side  of 
the  head  and  right  orbit.  She  had  had  defective  vision  in  both 
eyes  for  four  or  five  years,  but  had  never  consulted  any  physi- 
cian. Four  days  before  I  saw  her  she  suddenly  discovered  that 
she  was  blind  in  the  right  eye. 

An  examination  showed  the  following  condition  :  The  right 
eye  protruded  straight  forward  and  its  motility  was  limited  in 
all  directions.  It  resisted  any  attempt  at  replacing  it  in  its  nor- 
mal position,  and  the  pain  produced  by  any  such  attempt  re- 
sembled that  present  in  orbital  cellulitis  and  periostitis.  The 
iris  was  dilated  and  immovable.  The  right  eye  was  situated  at 
least  a  quarter  of  an  inch  in  advance  of  the  left  eye,  but  in  the 
same  horizontal  plane.  There  was  an  apparent  infiltration  of 
the  orbital  cellular  tissue,  which  was  mo.st  marked  along  the 
floor  of  the  orbit,  and  upward  and  outward  just  inside  the  su- 
perior orbital  margin.  There  was  a  chain  of  enlarged  glands 
on  the  right  side,  beginning  at  the  pre-auricular  gland  and  ex- 
tending down  along  the  border  of  the  sterno  cleido-mastoid 
muscle  to  the  level  of  the  thyreo-cricoid  region.  The  patient 
had  had  repeated  epistaxis  for  some  months,  together  with  a 
pi-ofuse  purulent  discharge  from  the  right  nostril.  An  exam- 
ination of  the  nose  revealed  a  hypertrophied  and  displaced  in- 
ferior turbinated  bone,  but  no  visible  growth  in  the  naso- 
pharynx. The  patient  complained  of  a  constant  pain  over  the 
malar  and  superior  maxillary  bones. 

A  diagnosis  was  made  of  a  tumor  in  the  nasal  meatus,  orbit, 
and  maxillary  antrum,  with  the  strong  probability  of  its  origin 
in  the  antrum.  Two  weeks  later  the  growth  along  the  floor  of 
the  orbit  a|)peared  at  the  inner  canthus,  where  it  felt  like  a 
hard  though  slightly  yielding  mass,  and  I  urged  an  immediate 
and  radical  operation.  The  right  eye  was  entirely  blind ;  the 
ophthalmoscope  showed  a  neuro-retinitis  or  papillitis  in  the 
stage  of  atrophy.  The  family  consented  to  an  ojjeralion,  which 
was  done  on  October  19th. 

So  far  as  could  be  discovered,  there  was  no  external  growth 
on  the  cheek.  The  eyeball  was  enucleated  in  the  usual  man- 
ner, and  the  posterior  part  of  the  sclera  and  sheath  of  the  optic 


78 


BULL:   TUMORS  OF  THE  ORBIT  AND  NEIGHBORING  CA  VITIES.     [N.  Y.  Med.  Joub., 


nerve,  was  found  to  be  surrounded  and  intimately  connected 
with  the  growth  in  the  orbit.  On  cutting  through  the  optic 
nerve  a  mass  of  the  tumor  was  cut  through  and  came  away  with 
the  eyeball.  The  floor  of  the  orbit  was  found  entirely  absent, 
except  a  narrow  rim  of  bone  along  the  orbital  margin,  and  the 
antrum  was  filled  with  the  growth.  The  conjunctiva  was  then 
cut  through  at  the  cuh-de-sac,  and,  with  the  entire  contents  of 
the  orbit,  was  then  removed.  The  inner  wall,  roof,  and  outer 
wall  of  the  orbit  seemed  to  be  intact  and  the  periosteum  was 
smooth.  There  did  not  appear  to  be  any  extension  of  the 
growth  into  the  optic  foramen  or  sphenoidal  fissure,  and  these 
facts  seemed  to  emphasize  the  probability  that  the  tumor  origi- 
nated in  the  antrum.  The  communication  between  the  antrum 
and  nasal  meatus  was  found  much  enlarged.  The  growth  was- 
removed  from  the  antrum,  and  the  cavity  thoroughly  washed 
out  with  bichloride  solution  (1  to  5,000).  Part  of  the  inner 
wall  of  the  antrum  and  part  of  the  nasal  pi'ocessof  tiie  superior 
maxilla  were  then  removed,  and  the  growth  was  then  talten 
out  from  the  nasal  meatus.  Small  pieces  of  the  tumor  and  bits 
of  the  turbinated  hones  were  removed  in  this  way,  until  it  was 
possible  to  syringe  freely  from  the  antrum  into  the  nose  and 
pharynx.  A  large  amount  of  detritus  was  washed  out  in  this 
way,  until  the  lower  and  middle  meatus  were  entirely  free.  A 
drainnge-tube  was  then  introduced  through  the  nose  and  the 
orbit  dressed  in  the  usual  way.  The  bony  walls  of  the  antrum 
seemed  to  be  intact,  except  that  which  separated  it  from  the 
orbit,  and  this  was  entirely  gone.  In  view  of  this  fact,  I  did  not 
deem  it  wise  to  attempt  the  removal  of  the  maxillary  bone,  as 
the  patient  was  greatly  prostrated  by  the  long  operation.  I 
told  her  family  that  the  tumor  would  probably  return  and  in  a 
comparatively  brief  space  of  time,  but  in  this  I  was  mistaken. 
The  patient  recovered  rapidly  from  the  effects  of  the  opera- 
tion. The  orbit  and  antrum  were  irrigated  twice  daily  for  a 
period  of  tiiree  weeks,  but  there  was  not  at  any  time  much  dis- 
charge, and  it  soon  changed  into  a  slight  mncous  secretion.  At 
the  end  of  two  months  the  periosteum  lining  the  antrum  and 
orbit  looked  "smooth  and  normal,  and  tlie  patient  could  breathe 
through  the  right  nostril.  There  was  no  positive  evidence  of  a 
return  of  the  growth  till  the  November  following,  a  period  ol 
thirteen  months.  It  then  appeared  in  the  nose  from  above, 
extending  downward  into  the  nostril  and  also  through  the  en- 
larged opening  into  the  antrum.  She  began  to  complain  of 
severe  frontal  Iteadache,  which  probably  pointed  to  an  exten. 
sion  of  the  growth  into  the  frontal  sinus  or  ethmoid  or  both 
I  advised  another  operation,  beginning  in  the  nose,  but  did  not 
urge  it  very  strongly,  as  I  regarded  the  case  as  hopeless  from 
the  first,  and  the  patient  herself  did  not  wish  it.  I  attended 
the  case  to  the  end.  The  growth  gradually  filled  the  antrum 
and  orbit,  extended  into  tlie  ethmoid,  broke  through  the  orbita] 
plate  of  the  ethmoid  into  the  orbit,  and  also  filled  the  sphe- 
noidal fissure.  The  growth  in  the  nose  was  so  extensive  as  to 
obliterate  both  nasal  cavities,  and  for  the  last  months  of  her  life 
she  breathed  entirely  through  the  mouth.  She  finally  died 
from  pure  exhaustion  without  any  head  symptoms  nearly  two 
years,  lacking  a  few  days,  after  the  operation.  Her  family 
would  npt  allow  an  autopsy.  The  tumor  on  examination  proved 
to  be  a  small-cell  sarcoma,  very  vascular,  which  had  intimately 
involved  the  sclera  and  sheath  of  the  optic  nerve  as  well  as  all 
the  orbital  tissues. 

Conclusions. 

Tumors  of  the  Sphenoid. — So  long  as  a  pathological 
process,  wlietlier  it  be  inflammatory  or  a  new  growth,  is 
limited  to  the  sphenoidal  antrum,  the  subjective  symp- 
toms are  either  entirely  absent  or  tlicre  may  be  severe  pain 


in  the  head.  If  the  process  extends  to  the  neighboring 
structures,  symptoms  arise  which  point  to  the  probability 
that  the  sphenoid  bone  is  the  seat  of  the  disease — such 
as  blindness  due  to  compression  of  one  or  both  optic  nerves, 
and  the  visible  or  tangible  presence  of  the  growth  in  the 
naso-pharynx,  ethmoid,  orbit,  or  skull.  The  entrance  of  the 
growth  into  the  cranial  cavity  may  occur  without  any  sub- 
jective symptoms,  or  there  may  be  severe  headache.  If 
the  progress  of  the  growth  is  very  rapid,  meningitis  or 
cerebral  abscess  will  result.  The  ophthalmoscopic  symp- 
toms are  either  papillitis  or  atrophy  of  the  optic  nerves,  due 
to  perineuritis  and  pressure  of  the  swollen  nerve  sheath  on 
the  optic  nerve-fibers.  In  some  cases  the  pressure  is  ex- 
erted on  the  optic  nerve  in  the  optic  canal.  Tumors  of  the 
sphenoid  antrum  may  perforate  the  middle  fossa  of  the 
skull  without  causing  blindness,  and  when  blindness  does 
occur  in  these  cases,  it  is  not  necessarily  due  to  pressure  on 
the  optic  chiasm,  for  it  may  be  unilateral.  If  an  orbital 
tumor  rapidly  causes  blindness,  and  the  latter  starts  from 
the  temporal  side  of  the  field  and  leaves  the  region  of  the 
macula  lutea  unaffected  to  the  last,  and  if  at  the  same 
time  a  growth  appears  in  the  naso-pharynx,  it  is  probable 
that  the  tumor  began  in  the  sphenoid  antrum. 

Tumors  of  the  Ethmoid. — A  morbid  growth  confined 
within  the  ethmoid  cells  gives  rise  either  to  no  symptoms 
at  all  or  merely  to  headache,  paroxysmal  in  character.  The 
orbital  symptoms  are  the  same  as  those  of  tiynor  of  the 
orbit.  The  motility  of  the  eyeball  is  limited.  The  vision 
may  be  slightly  affected,  or  there  may  be  complete  blind- 
ness. The  visual  field  may  not  be  involved.  If  the  tumor 
has  entered  the  naso-pharynx,  the  mouth  is  more  or  less 
open  and  the  speech  is  nasal.  Later  there  is  loss  of  the 
sense  of  smell.  There  may  be  more  or  less  continuous 
dropping  of  clear  fluid  from  the  no.se  even  in  .solid  tumors, 
owing  to  a  communication  between  the  upper  wall  or  roof 
of  the  ethmoid  cells  and  fissures  at  the  base  of  the  skull. 
There  may  also  be  orbital  or  palpebral  emphysema  and 
haemorrhage  from  the  nostrils. 

Tumors  of  the  Superior  Maxilla  and  Maxillary  An- 
trum.— Tumors  of  the  maxillary  antrum  may  cause  pain 
in  the  teeth  of  the  upper  jaw,  a  dull  pain  in  the  region  of 
the  antrum,  or  in  the  region  of  distribution  of  the  infra- 
orbital nerve,  but  not  until  they  have  attained  considerable 
size  and  have  more  or  less  completely  filled  the  antrum, 
the  distention  of  the  walls  of  the  cavity  causing  the  pain 
by  pressure  on  the  nerve-twigs.  As  the  tumor  grows,  the 
walls  of  the  antrum  are  gradually  absorbed,  and  a  new 
thin  scale  of  bone  is  developed  from  the  periosteum.  This 
may  occur  in  the  anterior  wall,  or  in  the  orbital  wall,  or  in 
the  alveolar  wall,  and  the  tumor  soon  extends  toward  the 
nose,  and  causes  great  enlargement  of  the  hole  communi- 
cating with  the  nasal  meatus.  These  nasal  growths  extend- 
ing from  the  antrum  are  often  erroneously  mistaken  for 
nasal  polypi.  Subsequently  the  diagnosis  is  rendered  easier, 
either  by  a  projection  forward  of  the  anterior  wall  of  the 
antrum,  or  by  displacement  of  the  eyeball  upward  and  out- 
ward, or  upward  and  inward,  by  the  protrusion  of  the  floor 
of  the  orbit.  A  large  tumor  of  the  antrum  would  probably 
increase  the  breadth  of  the  cheek  and  would  push  the  nose 


Jan.  21,  1893.] 


FLUHRER:  EXTERNAL  PERINEAL  URETHROTOMY. 


toward  the  opposite  side.  If  the  tumor  grows  from  the 
bone  itself,  the  inferior  orbital  margin  is  decidedly  broad- 
ened. Tumors  from  the  antrum  itself  rather  tend  to  break 
through  into  the  nose,  mouth,  or  orbit.  They  early  involve 
the  nasal  meatus,  thence  extend  into  the  spheno-maxillary 
and  palatine  fossa;  and  pharynx,  and  may  finally  perforate 
the  base  of  the  skull.  They  usually  involve  the  orbit  later, 
sometimes  extending  into  it  from  the  ethmoid  cells,  even 
before  the  floor  of  the  orbit  is  perforated.  In  no  case  is  it 
possible  to  diagnosticate  a  tumor  of  the  maxillary  antrum 
early  in  its  development. 

Tmnors  of  the  Naso-pharynx. — Tumors  of  the  nasal  and 
pterygo-palatine  fosste  may  enter  the  orbit  through  the  in- 
fra-orbital fissure.  They  cause  neuralgia  of  the  infra-orbital 
or  posterior  alveolar  nerves.  The  orbital  portion  of  the 
tumor  may  divide  into  two  branches,  one  involving  the  or- 
bit and  the  other  extending  into  the  cranial  cavity  through 
the  supra-orbital  fissure.  They  eventually  extend  into  all 
the  neitrhboring  cavities. 

Finally,  in  the  treatment  of  these  growths,  it  is  abso- 
lutely necessary  that  they  should  be  completely  extirpated 
early  in  their  development,  together  with  all  the  surround- 
ing tissues,  including  the  bony  walls  of  the  cavities  in- 
volved. If  a  malignant  growth  has  already  invaded  the 
deep  bones  of  the  face  and  base  of  the  skull,  including  the 
cavities  contained  within  them,  the  case  may  be  regarded  as 
hopeless,  and  while  an  operation  may  relieve  the  patient 
temporarily,  it  undoubtedly  hastens  the  fatal  termination. 


AN  IMPROVED  TECHNIQUE  IN  THE  OPERATION  OF 
EXTERNAL  PERINEAL  URETHROTOMY. 
By  WILLIAM  F.  FLUHRER,  M.  D., 

VISITING  SUKGBON  TO  BBLLBVUE  AND  MOUNT  SINAI  HOSPITALS. 

For  some  years  I  have  practiced  opening  the  urethra  in 
the  operation  of  external  perineal  urethrotomy  in  a  way 
that  seems  to  me  to  have  advantages  over  the  usual  method 
of  operation.  Recently  I  have  made  further  changes  in 
procedure,  which,  upon  trial  in  two  difficult  cases,  were 
perfectly  satisfactory. 

If  the  operation  is  undertaken  for  urethral  stricture,  a 
whalebone  guide  is,  if  possible,  introduced  into  the  blad- 
der.   In  one  of  my  recent  cases  this  was  impossible,  be- 


The  instrument  is  of  the  form  shown  in  Fig.  1.  It  is  nine 
inches  and  a  half  in  extreme  length,  and  straight  to  within  an 
inch  of  its  distal  end,  where  it  is  slightly  bent  at  an  angle. 
It  is  tunneled,  the  bridge  at  the  end  being  an  eighth  of  an 


Fig.  3. 


inch  long 


cause  the  urethra,  just  behind  the  scrotum,  was  obliterated 
for  three  quarters  of  an  inch.  If  tight  strictures  anteriorly 
interfere  with  the  introduction  of  the  staff  to  be  used,  the 
path  is  opened  by  a  Maisonneuve  urethrotome,  of  a  pattern 
made  for  me  years  ago  by  Tiemann     Co.  for  this  purpose. 


It  is  finished  with  extreme  care  in  the  work- 
manship, and  is  so  constructed  that  the  triangular  blade 
mounted  upon  the  stylet  can  be  made  to  cut  quite  near  the 
distal  end  of  the  slender  stafE.  This  tunneled  straight 
Maisonneuve  is  passed  over  the  guide  down  to  the  perineal 
obstruction  and  intervening  tight  strictures  are  incised. 
A  grooved  tunneled  staff,  No.  19  F.  (Fig.  2),  short  in  length 
of  curve,  is  passed  down  to  the  perineal  obstruction  over 
the  guide,  of  course,  when  that  aid  can  be  used.    Now,  in 

place  of  holding  the  staff  in 
the  usual  position,  its  distal 
end  is,  by  an  appropriate  ma- 
nosuvre,  directed  to  the  surface 
of  the  perinajum  ;  or  the  stafiE 
may  be  directly  passed  to 
this  position,  beginning  its  in- 
troduction from  between  the 
thighs.  The  handle  of  the 
staff  is  then  intrusted  to  an 
assistant,  who  so  holds  the 
instrument  as  to  make  its  distal  end  prominent  in  the 
perina'um,  and  who  always  carefully  maintains  it  at  the 
same  depth  in  the  urethra.  The  operator  then  grasps 
the  promitient  end  of  the  staff  through  the  perineal  tis- 
sues with  the  thumb  and  forefinger  of  the  left  hand, 


80 


FLUHRER:  EXTERNAL  PERINEAL  URETHROTOMY. 


[N.  Y,  Med.  Joce. 


the  inner  edge  of  the  hand  being  directed  upward  and 
retracting  tlie  scrotum  (Fig.  3).  By  tlfie  procedure  the 
operator  himself,  instead  of  the  assistant,  controls  lateral 
displacement  of  the  end  of  the  staff,  and  at  the  same 
time  makes  tense  the  tissues  in  the  line  or  incision.  As 
the  operator  deepens  his  incision,  the  thumb  and  forefinger 
retract  the  tissues  and  thus  control  the  hfemorrhage,  at  the 


Fio.  4. 


same  time  making  more  definite  the  grasp  upon  the  end  of 
the  staff.  The  end  of  the  staff  is  exposed  at  first  by  a  very 
small  cut  into  the  urethra,  so  that  the  staff  shall  not  pro- 
trude through  the  opening,  but  continue  to  push  the  urethral 
wall  before  it.  The  left  hand  being  kept  at  service  in  the 
position  described,  the  operator  now  passes  the  silken- 
thread  retractors  through  the  cut  walls  of  the  urethra.  The 
point  of  the  curved  h;eraostatic  needle,  entering  from  with- 
out, is  passed  inward,  strikes  the  surface  of  the  staff,  along 
which  it  glides,  and  emerges  through  the  little  opening  in  !  ward  into  the  clear  urethra. 


that  purpose  by  means  of  additional  retracting  loops  of 
silk. 

In  case  the  stricture  is  pervious  and  yet  the  operator  is 
foiled  in  his  efforts  to  introduce  a  guide,  he  should  open 
the  urethra  as  described,  and  search  upon  the  anterior  face 
of  the  stricture  for  the  opening  with  a  whalebone  guide  or 
Gouley's  fine  probe-pointed  grooved  director,  and,  having 

found  the  path  to  the  bladder, 
proceed  as  advised  above. 

In  case  the  urethra  is  im- 
pervious, it  is  opened  at  the 
anterior  face  of  the  obstruc- 
tion, and  if  there  is  a  suffi- 
ciently clear  space  of  peri- 
neum behind,  as  in  one  of  my 
last  cases,  the  urethra  is  identified  by  the  touch  and  opened 
behind  the  obstruction.  The  obliterated  portion  between 
the  exposed  two  healthy  portions  of  the  urethra  is  then 
cleanly  incised.  If,  however,  there  is  no  clear  healthy  space 
of  perintcum  in  which  the  urethra  can  be  felt,  then  the 
operator  should  proceed  in  the  usual  approved  manner,  and, 
with  the  forefinger  of  the  left  hand  in  the  rectum  upon  the 
urethra  at  the  apex  of  the  prostate,  with  a  sui-e  hand  and 
keen  knife  cut  throuoh  the  obstruction  from  before  back- 


the  urethra.  This  is  done  first  on  one  side,  then  on  the 
other.    The  opening  into  the  urethra  is  then  enlarged  and  the 


Fig.  5. 

penile  portion  of  the  guide  is  withdrawn  from  the  staff 
through  the  perineal  opening.  Into  the  hole  in  the  end  of 
the  staff  is  then  fitted  the  little  detachable  retractor  (Fig. 
4,  a).  This  is  adjusted  by  holding  the  retracting  hook 
downward  while  the  end  is  fitted  into  the  staff  ;  then,  by 
a  half  turn,  the  retractor  is  brought  upward  into  position, 
where  it  is  firmly  held  by  friction.*  The  grooved  staff  is 
thus  converted  into  a  long- handled  retractor,  by  means  of 
which  the  assistant  commands  the  upper  angle  of  the  peri- 
neal wound,  and  restrains  the  haemorrhage  from  that  spot 
without  getting  in  the  way  in  the  operative  field. 

The  operator  next  threads  the  free  portion  of  the  guide 
through  the  tunneled  Maisonneuve,  and  passes  the  latter 
instrument  into  the  bladder,  its  arrival  there  being  an- 
nounced by  tlie  exit  of  urine.  The  stricture  is  then  cut 
upon  the  fioor  of  the  urethra  and  the  blade  withdrawn. 
Along  the  Maisonneuve  staff  as  a  guide  is  then  passed  into 
the  bladder  the  probe-pointed  grooved  catheter  shown  in 
Fig.  5.  The  fioor  of  the  urethra  is  adequately  incised  by  a 
straight  bistoury,  guided  by  this  director  ;  or,  better  still, 
I  think  this  further  division  of  the  stricture  is  made  partly 
in  the  lower  and  partly  in  the  upper  wall  of  the  urethra, 
the  cut  edges  of  that  organ  being  sufficiently  retracted  for 

*  The  retractor  might  be  fastened  in  place  by  a  bayonet  catch. 


The  last  case  upon  which  I  operated  was  a  very  tight 
stricture  at  the  bulbo- membranous  junction.  Some  diffi- 
culty was  encountered  in  passing  a  guide,  which 
was  tightly  grasped  by  the  stricture,  yet,  uj^on 
the  above-described  technique,  the  steps  of  the 
operation  were  so  simple  and  precise  that  I  am 
confident  the  whole  operation,  except  the  liga- 
tion of  an  artery,  could  have  been  performed 
blindfolded  and  by  the  touch  alone. 

In  case  there  is  no  obstruction,  the  perineal 
urethra  can  be  opened  upon  this  method  with  ease,  speed, 
and  precision,  and  with  lessened  risk  of  wounding  the 
bulb. 

479  Fifth  Avenue. 


The  Death  of  Dr.  Samuel  Logan,  of  New  Orleans,  occurred  by  apo- 
plexy on  the  13th  inst.  He  was  a  veteran  teacher,  surgeon,  and  editor 
in  the  South.  He  was  a  native  of  South  Carolina,  born  in  Colleton  Dis- 
trict in  1831.  Before  the  war  he  practiced  in  Charleston  and  Rich- 
mond, in  both  of  which  cities  he  identified  himself  with  anatomical  in- 
struction in  the  medical  colleges.  During  the  war  he  held  commissions 
in  the  Confederate  service  as  medical  director  and  inspector.  In  1866 
he  took  up  his  residence  in  New  Orleans,  and  very  soon  thereafter  be- 
came professor  of  surgery  in  the  school  of  medicine.  He  was  one  of 
the  compilers  of  the  System  of  Surges-;/  of  Dr.  Eli  Geddings,  a  favorite 
text-book  at  the  Southern  schools  for  many  years.  In  1872  he  became 
professor  of  anatomy  and  clinical  surgery  in  the  University  of  Louisiana) 
and  about  the  same  year  a  member  of  the  editorial  staff  of  the  New  Or- 
leans Jonrwil  o  f  ITcdirine. 

A  Testimonial  Banquet  to  Health  Officer  Jenkins. — The  many 
friends  of  Dr.  W.  T.  Jenkins,  the  health  officer  of  the  port  of  New 
York,  propose  to  tender  him  a  public  reception  and  banquet  on  Satur- 
day evening,  February  llth,  in  recognition  of  "the  very  great  and  effi- 
cient services  that  he  rendered  during  the  past  year  in  saving  this  coim- 
try  from  cholera."  The  reception  will  be  public,  and  tickets  for  the 
banquet  may  be  obtained  from  General  Ferdinand  P.  Earle,  Hotel 
Normandie. 


Jan.  21,  1893.J 


LEADING  ARTICLES. 


81 


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  21,  1893. 


THE  NAVY  AS  A  NATIONAL  QUARANTINE  AGENCY. 

In  a  recent  issue  of  tlie  New  Yorh  Times  it  is  editorially 
stated  that  tiie  performance  of  national  quarantine  service  by 
the  navy  would  be  very  desirable,  the  medical  officers  of  the 
navy  beinfi  accustomed  to  sea  service!  This  is  an  amusinp 
proposition,  as  tlie  Bureau  of  Medicine  and  Surgery  h;is  been 
unable  to  fill  tlie  vacancies  that  have  existed  in  the  medical 
corps  since  the  termination  of  the  civil  war,  and  has  barely 
sufficient  officers  to  attend  to  the  legitimate  duties  of  that 
bureau. 

Unfortunately,  Congress  has  seen  tit  to  ignore  the  repeated 
recommendation  of  the  surgeon-generals  of  the  navy  to  enact 
legislation  that  would  give  to  the  corps  a  similar  status  to  that 
now  held  by  the  medical  corps  of  the  nrmy.  And  those  famil- 
iar with  the  experience  that  many  medical  officers  of  the  navy 
have  had  with  line  officers  who  temporarily  commanded  them 
do  not  wonder  that  the  naval  medical  service  is  the  least  at- 
tractive of  all  the  Government  medical  services. 

While  the  army  and  the  Mai'ine- Hospital  Service  find  it 
possible  to  obtain  all  the  officers  they  need,  the  young  physi- 
cian holds  aloof  from  the  questionable  attraction  of  a  commis- 
sion in  a  corps  in  which  he  is  looked  upon  as  the  inferior  of  a 
lot  of  callow  youths  fresh  from  their  final  examination  at  An- 
napolis. 

We  furthermore  believe  that  the  surgeon-general  of  the 
navy  would  take  the  position  that  the  surgeon-jreneral  of  the 
army  took  some  years  ago,  when  a  similar  proposition  was 
made  relative  to  the  employment  of  medical  officers  of  the 
army  on  quarantine  duty.  He  informed  Congress  that  it  would 
be  impos-^ilile  to  furnish  medical  officers  of  the  army  fur  quar- 
antine duty  "  without  serious  interference  with  their  military 
duties  and  detriment  to  the  interests  of  the  service." 


THE  "CHOLERA"  SCARE  AT  LITTLE  ROCK. 

Our  readers  probably  recall  the  press  dispatches  published 
two  or  three  weeks  ago  to  the  etfect  that  an  apparently  epi- 
demic disease  with  choleraic  symptoms  had  appeared  among 
the  convicts  of  the  Arkansas  penitentiary.  Ac  first  the  disease 
was  supposed  to  he  due  to  poisoning,  but  subsequently  it  was 
imagined  to  be  Asiatic  cholera.  A  request  was  made  that 
Surgeon-General  Wyman  should  detail  an  officer  to  investigate 
the  matter,  and  Passed  Assistant  Surgeon  Henry  D.  Geddings 
was  at  once  ordered  to  do  this.  His  report  is  publislied  in  cx- 
tenso  in  the  Ahatract  of  Sanitary  I\ej)orts  for  January  13th. 

Surgeon  Geddings  states  that  a  i)icked  body  of  a  hundred 


convicts  had  been  sent  from  the  penitentiary  to  a  camp  at 
Helena,  where  they  were  engaged  in  work  upon  a  railroad  near 
the  levee  on  the  banks  of  the  Mississippi  River.  The  food  was 
of  the  coarsest,  commonest  description,  and  the  water  for 
drinking  and  cooking  was  drawn  from  a  stream  that  received 
in  part  the  sewage  of  Helena  and  was  further  contaminated  by 
two  slaughter-houses. 

Shortly  after  the  convicts'  arrival  a  violent  outbreak  of  dis- 
ease occurred  among  tliem.  They  were  quartered  in  five  cars. 
Six  of  them  died,  and  it  was  determined  to  return  the  rest  to 
the  penitentiary.  One  man  died  en  route  and  one  shortly  after 
the  arrival  at  that  institution.  In  all,  eighteen  of  these  men 
died  and  also  three  other  convicts  that  had  not  been  out- 
side the  walls.  This  latter  fact  justified  some  concern  until 
we  read  that  two  of  the  three  had  been  ill  for  some  time, 
while  the  third  h;id  eaten  some  decaying  pickled  beets  found  on 
a  pile  of  decomposing  refuse.  In  a  very  gentle  manner  Dr. 
Geddings  informs  us  of  the  wretched  sanitary  condition  of  the 
penitentiary  itself  and  of  its  immediate  environment. 

Dr.  Geddings  made  a  bacteriological  test  that  failed  to  show 
the  existence  of  the  cholera  spirillum,  and  justly  concludes  that 
the  outbreak  was  due  to  products  of  animal  and  vegetable 
deco!nposition  conveyed  into  the  drinking-water  supply  at 
Helena. 

Passed  Assistant  Surgeon  L.  L.  Williams  was  detailed  to  in- 
spect the  camp  at  Helena,  and  his  report  is  condemnatory  of 
that  establishment  regarding  all  its  sanitary  features.  The  cars 
had  not  been  out  of  the  State  for  some  months. 

It  is  not  unnatural  that  there  should  be  a  disposition  to  as- 
cribe such  seeming  local  epidemics  to  cholera  infection,  and 
Surgeon-General  Wyman  is  to  be  complimented  on  the  effective 
manner  in  which  he  disposed  of  the  rumor  in  this  instance. 


THE  "SCOTCH  DOUCHE"   IN  CHRONIC  ARTICULAR 
RHEUMATISM. 

Dr.  M.  Sciiuller,  of  Berlin,  has  written  in  the  Archiv  fur 
Hinische  Chirurgie  concerning  chronic  joint  trouble  of  rheu- 
matic origin.  He  has  had  better  results  from  the  use  of  the 
" Scotch  douche"  tiian  from  the  other  forms  of  hydrotherapeu- 
tic  application  in  this  difficult  class  of  cases. 

The  Scotch  douche  consists  in  the  quick  alternation  of 
streams  of  hot  and  cold  water,  in  a  stream  of  about  the  size  of 
the  little  finger  and  of  a  constantly  varying  pressure,  delivered 
from  the  same  nozzle.  This  douche  is  not  so  well  known,  says 
Dr.  Schiiller,  as  it  should  be,  and  is  not  found  in  a  number  ot 
bathing  resorts  visited  by  him.  Its  good  effects  are  shown  by 
a  restoration  of  the  thickened  joint  capsule,  and  by  a  strength- 
ening of  the  muscular  apparatus.  The  douche  should  always 
be  used  after  the  warm  baths,  which  are  often  administered  of 
too  high  a  temperature  at  the  bath  establishments. 

The  Scotch  douche  has  other  advantages  in  the  facts  that 
it  can  be  regulated  very  easily  as  to  temperature,  that  it  can  be 
borne  by  weak  jiatients,  and,  above  all,  that  it  conveys  a  dis- 
tinct mechanical  effect,  along  witli  its  thermal  effect,  upon  the 


82 


LEADim  ARTICLES.— MINOR  PARAGRAPHS.— ITEMS. 


[_N.  Y.  Med.  Jode., 


vessels  and  muscles.  This  treatment  is  ordinarily  soon  followed 
by  a  diminution  of  pain  and  an  increased  motility  of  the  joint. 
Many  cases  can  be  kept  for  years  in  an  endurable  condition  by 
this  means  which  would  otherwise  be  attended  by  great  suffer- 
ing. In  cases  that  are  marked  by  a  relative  immobility  due  to 
a  shrinking  and  contraction  of  the  capsule,  but  not  due  to  true 
ankylosis,  the  Scotch  douche,  with  an  especially  delicate  mas- 
sage and  passive  motion,  will  assist  materially  in  the  increase  of 
mobility.  The  author  has  particularly  observed  this  among 
those  of  his  patients  who  have  been  affected  in  the  wrist  and 
ankle  joints.  The  great  susceptibility  to  pain  which  attends 
these  cases  will  not  permit  of  the  most  delicately  applied  mas- 
sage, if  the  latter  is  tried  without  the  douche ;  but  with  the 
combination  these  patients  feel  better,  walk  or  move  the  limbs 
witli  less  difficulty,  and  experience  much  less  pain  so  long  as 
the  treatment  is  continued. 


PUBIC  SYMPHYSEOTOMY. 

The  first  Canadian  case  of  this  operation,  which  is  the 
fourth  American,  is  reported  in  the  Montreal  Medical  Journal 
for  January  as  having  been  performed  in  that  city  on  December 
5th.  The  surgeon  was  Dr.  J.  A.  Sprengle.  The  subject  of  the 
operation  was  a  primipara  of  Irish  parentage.  Both  mother 
and  child  have  done  well.  The  indications  for  the  operation 
were  found  in  a  pelvic  contraction,  as  regarded  the  mother,  and 
in  the  large  head  of  the  infant.  Dilatation  of  the  cervix  uteri 
was  complete  on  the  4th,  the  day  before  delivery,  with  no  de- 
scent of  the  head.  The  forceps,  under  anaasthetics,  failed  to 
bring  relief.  The  "crying  of  the  child  in  utero''"'  is  said  to 
have  been  "  distinctly  heard  by  those  present."  The  surgeon, 
having  the  assistance  of  Dr.  Lockhart  and  Dr.  Kenneth  Cam- 
eron, decided  to  sever  the  symphysis.  Special  care  was  taken 
to  keep  the  urethra  away  from  the  path  of  the  incision,  and  no 
complications  were  encountered.  When  the  symphysis  was 
cut  through  the  two  sides  sprang  apart,  leaving  an  interval  of 
about  an  inch.  Lateral  support  was  given  to  the  pelvis,  the 
forceps  was  again  applied,  and  delivery  was  rapidly  accom- 
plished by  Dr.  Lockhart.  The  infant  was  in  good  condition 
and  not  disfigured  by  the  instrument. 

All  the  operations  thus  far  reported  as  having  been  done  in 
America  have  been  successful  in  saving  the  mother,  and  three 
of  the  infants  have  been  born  alive.  The  fourth  child  might 
have  been  saved,  it  is  believed,  if  the  operation  had  been  per- 
formed a  few  hours  earlier.  It  is  reported  that  a  symphyseoto- 
my performed  at  the  Rotunda  Lying-in  Hospital  in  Dublin,  on 
November  22d,  resulted  successfully  as  to  both  mother  and 
child.  The  operation  had  not  before  been  done  there  since 
1782. 


MINOR  PARA0RAPII8. 

THE  PROPOSED  PENNSYLVANIA  MEDICAL  PRACTICE  ACT. 

We  have  received  a  copy  of  a  bill  prepared  by  the  Medical 
Society  of  the  Stale  of  Pennsylvania,  which  the  society's  legis- 
lative committee  is  making  a  strong  efi'ort  to  have  passed  this 


year.  We  regret  that  we  liave  not  space  for  at  least  a  summary 
of  its  provisions  in  this  issue  of  the  Journal.  From  our  reading 
of  it,  we  believe  it  of  the  first  importance  to  overcome  any  an- 
tagonism that  may  proceed  from  low-grade  schools,  which  fear 
that  a  mixed  board  containing  sectarian  physicians  will  be  dan- 
gerous. The  committee  justly  holds  that  the  only  jjracticable 
test  of  a  physician's  qualifi<;ations  is  his  knowledge  of  the  sci- 
ence of  medicine.  The  bill  leaves  out  of  its  requirements  exami- 
nations in  the  practice  of  medicine  and  in  therapeutics,  because 
it  is  thought  that  these  two  disputed  branches  should  not  be 
touched  upon.  It  is  felt  that  a  physician  who  can  pass  an  ex- 
amination before  an  unprejudiced  board  in  the  other  branches 
of  medicine  stated  is  a  safe  practitioner  so  far  as  the  State  is 
concerned.  A  candidate's  special  belief  in  therapeutics  or  in 
the  doctrine  of  medicine  is  no  more  to  be  interfered  with  than 
his  religion  or  his  politics. 


A  LUMINOUS  FUNGUS. 

The  Union  medicale  for  December  27,  1892,  gives  a  short 
account,  from  the  Revue  iscientifque,  of  the  Pleurotvs  lux,  a 
fungus  that  takes  its  specific  name  from  its  property  of  glowing 
in  the  dark,  even  for  twenty-four  hours  after  it  has  been 
plucked.  It  has  lately  been  carried  to  Europe  from  Tahiti, 
where  the  women  use  it  as  an  adornment  in  bouquets  of  flowers. 


THE  ONTARIO  MEDICAL  JOURNAL. 

The  fifth  number  of  this  new  journal,  for  December,  1892, 
gives  tangible  evidence  that  it  lias  a  decided  raison  detre.  We 
congratulate  the  editors.  Dr.  R.  B.  Orr  and  Dr.  W.  H.  B.  Aikins, 
on  the  value  of  the  matter  contained  in  the  Journal  and  on  the 
attractive  form  in  which  it  appears. 


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  17,  1893  : 


DISEASES. 


Week  ending  Jan.  10. 


Cases. 

Deaths. 

CaBes. 

Deaths. 

56 

16 

19 

18 

17 

5 

8 

4 

143 

9 

138 

18 

Cerebro-spinal  meningitis. . . . 

4 

1 

2 

1 

117 

8 

87 

13 

154 

42 

113 

42 

1 

1 

5 

0 

Week  ending  Jan.  17. 


The  Alumni  Association  of  Bellevue  Hospital  Medical  College. — 

The  annual  meeting  will  be  held  in  room  A  of  the  Hoffman  House  on 
Saturday  evening,  January  21st,  at  S'oO  o'clock. 

The  Society  of  the  Alumni  of  Bellevue  Hospital  will  hold  its  annual 
dinner  at  the  Hotel  Brunswick  on  Wednesday  evening,  February  1st. 

The  New  York  State  Medical  Association. — The  ninth  annual  meet- 
ing of  the  Fifth  District  Branch  will  be  held  in  Brooklyn  on  Tuesday, 
May  23,  1893.  All  fellows  desiring  to  read  papers  will  please  notify 
the  secretary,  Dr.  E.  H.  Squibb,  P.  0.  Box  7G0,  Brooklyn. 

The  New  York  Lying-in  Asylum. — Donations  and  subscriptions  are 
solicited  for  this  institution,  formerly  at  No.  85  Marion  Street,  now  at 
No.  139  Second  Avenue,  where  reputable  married  women  only  are  cared 
for  gratuitously.  The  asylum,  now  in  its  seventieth  year,  has  twenty- 
si.x  free  beds,  and  its  patients  are  of  all  nationalities  and  creeds. 

The  Brooklyn  Surgical  Society. — The  paper  announced  for  the  last 
meeting,  on  Thursday  evening,  the  19th  inst.,  was  On  the  Relation  of 
Food  to  Haimophilia  and  Purpuia  Hasmorrhagica,  by  Dr.  Wunderlich. 


Jan.  21,  1893.] 


ITEMS  —PROGEEDINOS  OF  SOCIETIES. 


83 


JeiFerson  Medical  College,  of  Philadelphia. — Dr.  G.  E.  de  Schweiuitz 
lias  been  elected  cliniciil  professor  of  oplitlialmology.  lie  had  formerly 
held  a  lectureship  on  medical  oplitluilmoscopy  in  the  University  of 
Pennsylvania,  also  a  professorship  in  the  Philadelphia  Polyclinic. 

The  City  (Charity)  Hospital. — Dr.  VV.  C.  Jarvis  has  been  appointed 
consulting  pliysioian  anil  laryngologist. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army,  from  January  S  to  January       1S93 : 

DuNLor,  Samuel  R.,  First  Lieutenant  and  Assistant  Surgeon.  The  leave 
of  absence  granted  is  still  further  extended  to  include  January  31, 
18!t3. 

DuNi.op,  Samuel  R.,  First  Lieutenant  and  Assistant  Surgeon.  His  resig- 
nation has  been  accepted,  to  take  effect  January  31,  1893. 

O'Reilly,  Rohert  M.,  Major  and  Surgeon.  The  order  directing  him  to 
proceed  to  Washington,  D.  C,  and  report  for  duty  as  attending  sur- 
geon, is  suspended  until  further  orders. 

Greenleaf,  Charles  R.,  Lieutenant-Colonel  and  Deputy  Surgeon-Gen- 
eral, is  detailed  as  a  delegate  to  the  Eleventh  International  Medical 
Congress,  to  convene  at  Rome,  Italy,  on  the  24th  of  September, 
1803,  and  will  at  the  proper  time  proceed  to  the  place  designated. 
While  abroad  in  pursuance  of  this  order,  he  will  visit  such  points  in 
Great  Britain,  France,  Germany,  Russia,  Austria,  Italy,  and  else- 
where, as  may  be  deemed  necessary  by  the  Surgeon-General  of  the 
Army,  on  official  business ;  and  on  completion  of  the  duty  contem- 
plated will  return  to  his  station. 

Glennan,  J.  D.,  P'irst  Lieutenant  and  Assistant  Surgeon,  having  reported 
at  Headquarters  Department  of  Texas,  will  proceed  to  Carrizo, 
Texas,  and  report  to  the  commanding  officer  of  the  Seventh  Cavalry 
s(iuadron  at  that  place  for  duty. 

Powell,  J.  L.,  Captain  and  Assistant  Surgeon,  is  hereby  granted  leave 
of  absence  for  one  month,  with  permission  to  apply  for  an  extension 
of  one  month. 

Ten  Eyck,  B.  L.,  First  Lieutenant  and  Assistant  Surgeon,  having  re- 
ported for  duty  at  Headquarters  Department  of  Texas,  will  proceed 
to  Laredo,  Texas,  for  service  in  the  field,  to  relieve  Davis,  W.  B., 
Captain  and  Assistant  Surgeon,  who,  upon  being  thus  relieved,  will 
return  to  his  station,  Fort  Sam  Houston,  Texas. 

Keeper,  Frank  R.,  First  Lieutenant  and  Assistant  Surgeon,  is  relieved 
from  duty  at  Fort  Riley,  Kansas,  and  will  report  in  person  to  the 
commanding  officer.  Fort  Stanton,  New  Mexico,  for  duty  at  that 
post,  relieving  Banister,  John  M.,  Captain  and  Assistant  Surgeon. 
Captain  Banister,  upon  being  relieved  by  Lieutenant  Keefer,  will  re- 
port in  person  to  the  commanding  officer,  Fort  Leavenworth,  Kansas, 
for  duty  at  that  post. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  January  Ij^,  1893 : 
Hessler,  F.  a..  Passed  Assistant  Surgeon.    Ordered  to  Receiving-ship 

Vermont. 

Society  Meetings  for  the  Coming  Week : 

Monday,  Janwiry  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  Medical  Association. 

Tuesday,  January  SJ^lh  :  New  York  Otological  Society  (private) ;  New 
York  Dermatological  Society  (private) ;  Buffalo  Obstetrical  Society ; 
Medical  Society  of  the  County  of  Putnam  (semi-annual),  N.  Y. 

Wednesday,  January  25th :  New  York  Academy  of  Medicin^  (Section 
in  Laryngology  and  Rhinology) ;  New  York  Surgical  Society ;  New 
York  Pathological  Society ;  American  Microscopical  Society  of  the 
City  of  New  York  ;  Metropolitan  Medical  Society  ([irivate) ;  Auburn, 
N.  Y.,  City  Medical  Association ;  Philadelphia  County  Medical  So- 
ciety ;  Middlesex,  Mass.,  North  District  and  Berkshire,  Mass.  (Pitts- 
held),  Medical  Societies  (Lowell) ;  Gloucester,  N.  J.,  County  Medical 
Society  (quarteily). 

Thursday,  January  26th :  New  York  Academy  of  Medicine  (Section 
in  Obstetrics  and  Gyniecology) ;  New  York  Orthopaedic  Society ; 


Brooklyn  Pathological  Society  ;  Roxbury,  Mass.,  Society  for  Medical 
Improvement  (private). 
Frway,  January  27th:  Yorkville  Medical  Association  (private);  New 
York  Society  of  German  Physicians  ;  New  York  Clinical  Society  (pri- 
vate) ;  Philadelphia  Clinical  Society ;  Philadelphia  Laryngological 
Society. 

Saturday,  January  28th :  New  York  Medical  and  Surgical  Society  (pri- 
vate— annual). 


AMERICAN  LARYNGOLOGICAL  ASSOCIATION. 

Fourteenth  Annual  Congress,  held  at  Boston  on  Monday,  Tues- 
day, and  Wednesday,  June  20,  21,  and  22,  1892. 

The  President,  Dr.  S.  W.  Langmaid,  of  Boston,  in  the  Chair. 

(Continued  from  vol.  hi,  page  748.) 

A  Case  of  Tumor  of  the  Larynx.— Dr.  H.  L.  Swain,  of 
New  Haven,  read  a  paper  with  this  title.    (To  be  published.) 

Dr.  C.  C.  Rice:  In  the  removal  of  very  small  laryngeal 
growths  I  have  found  the  laryngeal  loop  guillotine  easier  to  ap- 
ply than  any  variety  of  forceps.  It  can  be  used  in  any  part  of 
the  larynx.  It  is  not  large  enough,  however,  for  growths  of 
the  size  removed  by  Dr.  Swain.  (The  sjieaker  referred  to  a 
case  of  laryngeal  growth  in  which  marked  constitutional  effects 
had  followed  the  use  of  a  four-per-cent.  solution  of  cocaine.) 

Dr.  T.  A.  De  Blots:  I  tliink  Dr.  Swain  has  done  well  in 
calling  attention  to  the  small  amount  of  hfBinorrhage  which 
takes  place  on  removal  of  these  growths.  Whatever  may  be  the 
reason,  whether  natural  contractility  of  the  vessels  or  some- 
thing else,  it  is  true  that  the  removal  of  laryngeal  growtlis  is 
seklotn  followed  by  the  loss  of  more  than  a  few  teaspoonfuls  of 
blood.  In  other  parts  of  the  air  passages  we  meet  with  con- 
siderable hsemorrhage. 

The  Pre.sident  :  I  am  reminded  by  Dr.  Rice's  uncomforta- 
ble experience  with  cocaine  to  say  something  wliich  I  forgot  to 
say  in  connection  with  another  paper.  Having  seen  nicoiine 
recommended  in  a  foreign  Journal  for  operations  upon  the  larynx, 
I  was  induced  to  try  this  narcotic  in  one  case  during  the  past 
winter.  I  procured  a  ten-per-cent.  solution,  and  diluted  that  at 
least  one  quarter,  yet  the  eifect  was  alarming,  and  I  feel  it  my 
duty  to  warn  the  members  of  the  association  not  to  try  it  with- 
out the  greatest  precaution.  It  was  as  severe  a  case  of  nicotine 
poisoning  as  I  could  imagine  short  of  death.  Yet  the  drug  was 
most  carefully  used,  being  applied  on  a  cotton  swab  well  wrung 
out,  so  that  no  dropping  could  have  taken  ])laco.  One  tonsil 
was  rubbed  with  it,  and  in  a  very  few  moments  the  patient  had 
alarming  syncope. 

The  Value  of  Sprays  in  the  Treatment  of  Catarrhal  Af- 
fections of  the  Upper  Air  Passages.— Dr.  C.  C.  Rice,  of  New 
York,  read  a  paper  on  this  subject.    (See  page  71.) 

Dr.  H.  L.  Swain:  One  very  important  point  r.-iised  by  Dr. 
Rice  is  tiie  fact  that  patients  should  be  tauglii  to  do  something 
for  themselves  after  the  operator  has  had  his  say,  and  that 
which  is  required  of  them  should,  if  possible,  be  easy  to  carry 
out.  The  spray  behind  the  palate  is  of  service  in  fifty  cases  to 
every  five  in  which  it  is  of  value  employed  in  the  anterior 
nares.  Yet  it  is  very  hard  for  some  persons  to  become  pro- 
ficient in  spraying  postei'ioriy.  I  have  put  myself  on  record 
in  one  place,  at  least,  as  favoring  a  method  of  gargling.  While 
not  comparing  it  with  sprays  and  the  like,  I  w  ish  to  call  atten- 
tion again  to  the  fact  that  it  is  possible  for  children  and  adults 


84 


PROCEEDINGS 


OF  SOCIETIES. 


[N.  Y.  Med.  Joue., 


to  learn  to  gargle  in  such  a  way  as  to  project  the  Hnid  against 
the  posterior  nares  and  into  the  nasal  passages  themselves.  It 
requires  no  apjiariitus,  and  is  comfortable  to  the  patient  when 
he  acquires  the  practice.  It  is  a  most  uselul  method  for  home 
treatment. 

Dr.  F.  IT.  BoswoRTH :  I  can  not  let  Dr.  Rice's  paper  pass  with- 
ont  saying  that  I  do  not  think  it  represents  the  sentiment  of  the 
members  of  this  assoc'ation.  I  had  supposed  we  were  done 
with  sprays.  I  do  not  believe  they  accomplish  any  practical 
good.  I  have  recently  removed  the  air-punif)  and  s|)ray  appa- 
ratus from  my  office,  and  I  believe  that  I  iiave  done  better  work 
since  then  tlian  wiien  I  placed  much  de[)endence  upon  them.  I 
am  not  a  believer  in  the  value  of  vegetable  or  mineral  astrin- 
gents as  correcting  morbid  processes  in  the  nasal  passages. 
Furthermore,  I  do  not  believe  we  have  to  do  with  a  disease  in 
this  region  where  an  astringent  is  indicated.  There  is  no  such 
disease  as  catarrh,  and  supersccretion  is  a  condition  which  we 
seldom  have  to  meet.  I  am  disposed  to  say  that  in  a  vast  ma- 
jority of  cases  deficient  secretion  exists.  I  except  from  this 
statement  naso-pliaryngitis,  and  really  know  but  little  about 
naso-pharyngitis.  Mackenzie  said  in  his  address  three  or  four 
years  ago  tliat  there  was  a  region  which  afforded  our  most  in- 
teresting field  for  study.  We  do  not  know  even  the  sources  of 
naso  pharyngeal  secretion.  We  only  carry  out  cleansing  indica- 
tions. We  have  to  cleanse  the  pharynx  ;  but  the  best  method  of 
doing  that  is  not  by  the  spray.  Directed  behind  the  palate,  it 
will  not  reach  tiie  parts,  and  the  great  proportion  of  patients 
will  not  tolerate  it. 

Notwithstanding  the  assertion  that  the  post-nasal  douche 
is  injurious,  I  nuhesitatingly  place  it  in  the  hands  of  my  pa- 
tients and  teach  them  to  use  it.  In  the  so-called  post-nasai 
catarrh,  which  is  a  most  obstinate  affection  and  which  occurs 
between  thirty  and  fifty  years  of  age,  we  can  accomplish  the 
best  results  by  training  our  patients  to  use  the  post  nasal 
syringe  two  or  three  times  a  day  for  the  purpose  of  cleanliness. 

I  have  risen  simply  to  enter  a  mild  protest  against  placing 
much  dependence  upon  the  use  of  sprays.  Astringents  are  not 
often  indicated.  Stimulants  are  indi<'ated  in  hypertrophic  rhi- 
nitis, but  we  do  not  cure  these  cases;  the  patients  cure  them 
for  us.  Oily  solutions  we  use  as  adjuvants,  but  I  do  not  believe 
they  correct  any  morbid  condition  which  we  meet  with  in  the 
post-nasal  cavities.  The  petroleum  oils  are  undoubtedly  sooth- 
ing and  grateful  applications  if  more  active  treatment  is  carried 
out  for  the  diseased  condition,  and  they  may  act  as  excellent 
vehicles  under  some  circumstances.  As  to  cocaine,  it  is  not  an 
astringent;  it  does  not  constrict  the  secreting  apparatus.  Its 
effect  is  upon  the  blood-vessels.  As  a  therapeutic  agent  I 
doubt  its  efficacy.  I  was  very  enthusiastic  about  it  at  one 
time,  but  I  have  abandoned  it.  It  simply  produces  a  tempo- 
rary effect  of  which  we  avail  ourselves,  and  it  is  of  immense 
value  to  us  as  a  local  anassthetic.  Without  it  we  could  not 
practice  our  specialty  with  any  great  deuree  of  success.  It 
also  is  of  great  value  in  hay-fever,  but  aside  from  that  disease 
I  doubt  whether  it  possesses  any  therapeutic  value  upon  the 
mucous  membrane. 

Dr.  J.  WRir.nr:  Having  written  a  paper  upon  the  same 
subject  a  few  months  ago,  naturally  I  was  very  much  interested 
in  Dr.  Rice's.  I  agree  witii  Dr.  Boswortb  that  the  dirtiest 
place  in  the  naso-jiharyngeal  tract  is  in  the  vault  of  the  phar- 
ynx, and  that  there  is  the  place  for  carrying  out  the  cleans- 
ing process,  whatever  it  may  be.  But  it  has  not  been  my  ex- 
perience that  in  the  majority  of  cases,  nor  even  in  more  than 
a  small  j)roporti<)n  of  cases,  one  can  educate  the  patient  up  to 
the  point  of  spraying  a  watery  solution  into  his  own  naso-piiar 
ynx.  It  has  been  my  custom  to  use  the  post-nasal  syi-inge 
almost  altogether.    In  operations  upon  the  nose  the  spray  may 


be  used  for  antiseptic  purposes  and  for  cleanliness.  There  is,  I 
think,  a  mistaken  idea  with  regard  to  oily  solutions  in  any  form 
being  suitable  antiseptic  vehicles.  I  do  not  believe  they  have 
the  slightest  antibacterial  effect.  The  moisture  of  each  bacte- 
rium protects  it  from  the  oil.  •  Oily  solutions  have  been  shown 
time  and  again  to  have  very  little  antise[)tic  effect /^er  se. 

I  was  also  interested  in  Dr.  Swain's  remarks  upon  the  nasal 
gargle.  Having  read  his  paper  describing  the  method,  I  tried 
it  long  and  patiently,  but  never  succeeded  in  getting  a  drop  of 
the  fluid  \nU)  my  nose,  nor  have  I  known  any  of  my  patients  to 
succeed  without  choking  and  much  discomfort. 

Dr.  MoKiiis  J.  AsoH :  It  seems  to  me  a  medmm  course  is  the 
one  to  be  taken.  We  should  neither  depend  upon  sprays  al- 
together nor  abidish  them,  as  Dr.  Boswortb  seems  to  have  done. 
I  have  long  since  given  up  sprays  as  a  curative  agent,  whether 
in  watery  or  oily  solution,  but  I  think  they  are  immensely  valu- 
able as  pailiaiive  and  cleansing  means.  I  could  scarcely  get 
along  without  them  for  these  purposes.  While  one  may  be 
able  to  cleanse  the  nose  with  absorbent  cotton,  yet  I  have  found 
nothing  so  valuable  in  the  naso-pharynx  as  the  spray.  I  never 
fail  to  cleanse  the  vault  of  the  pharynx  and  get  rid  of  the  crusty 
secretion  which  may  be  there  by  means  of  the  alkaline  spray. 
In  catarrhal  cases  I  think  astringents  in  spriiy  ai'e  very  valuable. 
In  the  befiinning  of  a  catarrhal  larynfiitis  a  spray  of  about  half  a 
drachm  of  neutral  solution  of  perchloride  of  iron  to  the  ounce 
of  water  will  relieve  the  dryness  and  discomfort  at  once  and 
the  voice  will  be  restored;  the  patient  will  come  back  next 
day  of  his  own  accord  to  have  it  repeated,  and  in  a  few  days 
the  trouble  will  have  passed  away.  I  would,  then,  protest 
against  abolishing  the  spray  entirely,  and  equally  against  de- 
pending upon  it  solely  as  a  curative.  I  agree  with  Dr.  Bos- 
worth  that  the  douche  is  a  very  valuable  cleansing  agent,  but  I 
think  there  can  be  no  question  that  there  is  danger  connected 
with  it.  If  one  depends  u[)on  it  he  wdl  in  time  meet  with 
some  accident.    Accidents  do  occur  and  patients  never  forgive. 

Dr.  Mackenzie:  While  it  must  be  confessed  that  there  is  a 
rivulet  of  common  sense  in  what  Dr.  Boswortb  has  said,  still  it 
meanders  through  a  pretty  big  meadow  of  incautious  observa- 
tion. I  should  be  sorry  to  see  views  such  as  he  entertains  go 
unchallenged  by  members  of  this  body.  Doubtless  the  curative 
value  of  the  spray  has  been  gmssly  overrated,  but  this  is  not 
sufficient  reason  to  banish  this  useful  method  of  topical  appli- 
cation from  our  armamentarium. 

I  would  caution  against  the  use  of  too  much  oily  material, 
especially  in  the  nasal  passages,  and  Dr.  Rice  made  a  center 
shot  when  he  said  that  the  temperament  of  the  patient  should 
determine  to  a  great  extent  the  character  of  the  s|)ray  to  be 
employed.  There  are  a  great  many  patients,  especially  ladies, 
who  object  to  the  oily  medicaments  on  the  ground  that  they  are 
disagreeable.  This  is,  of  course,  of  minor  importance.  The 
chief  objection  to  their  prolonged  use  is  that  they  tend  to  beget 
a  condition  of  dryness  difficult  to  eradicate. 

The  injudicious  use  of  cocaine  in  the  nose  and  larynx  is  great- 
ly to  be  deprecated.  I  have  seen  quite  alarming  cases  of  poi- 
soning from  this  drug,  e\en  when  used  in  very  weak  solution. 
Regarding  the  method  of  gargling  referred  to  by  Dr.  Swain,  I 
am  at  one  with  Dr.  Wright.  It  is  an  unphysiological  act  and  is 
a  roundabout  way  of  accomplishing  a  great  deal  of  possible 
harm  at  considerable  personal  inconvenience. 

I  very  rarely  recommend  the  pust-nasal  syringe,  and  know 
of  cases  in  which  acute  otitis  media  has  resulted  from  its  use. 

Dr.  Swain:  It  is  possible  to  breathe  through  the  noae  with 
the  mouth  open,  and,  that  being  so,  it  is  also  possible  to  cause  a 
gargle  to  enter  the  nose.  I  am  prepared  at  any  time  to  give  a 
personal  demonstration  of  the  practicability  of  the  method. 
The  majority  of  my  patients  who  try  it  succeed. 


Jan.  21,  1893.] 


BOOK  NOTICES. 


85 


Dr.  D.  B.  Delavan:  Dr.  Rice,  I  think,  lias  done  well  to 
brinfX  up  tliis  subject,  and  I  am  very  frlad  that  there  are  at  least 
a  few  here  who  are  ready  to  champion  most  of  the  ideas  lie  has 
pre-ented.  I  think  it  would  bo  a  misrepresentation  of  facts  if 
the  belief  were  to  go  abroad  that  this  society  had  entirely  done 
away  with  the  use  of  the  spray  apparatus;  that  the  nasal  saw 
had  swept  it  from  the  field,  and  that  nasal  surgery  had  totally 
taken  tlio  })lace  of  all  therapeutic  treatment  of  the  nose.  Pnieti- 
cally  the  statement  made  by  Dr.  Bosw  orth,  that  he  had  recently 
caused  his  s[)ray  apparatus  to  be  entirely  removed  from  his  office, 
amounts  to  that.  For  one  I  am  happy  to  say  that  I  still  have 
faith  in  the  treatment  of  certain  niorbi<l  conditions  of  the  nose 
and  tliroat  by  tlierapeutic  means,  and  that  I  still  find  use  for 
the  spiay;  and  I  believe  there  are  few  here  who,  while  fully 
prepared  to  resort  to  surgical  menns  where  necessary,  have  not 
a  s]iray  apparatus  in  their  offices  which  is  called  into  more  or 
less  constant  requisition. 

With  regard  to  the  vaseline  products,  I  think  we  sometimes 
forget  their  limitations.  Vaseline  and  its  products  stand  at  one 
end  of  a  list  of  which  lanolin  stands  at  the  other.  Lanolin  is 
the  most  readily  ab-orbed  of  the  available  fatty  substances,  and 
for  that  reason  api^thecaries  use  it  with  preparations  to  be 
rubbeil  into  tlie  surface  of  tlie  body  an  1  do  not  use  vaseline. 
Vaseline  therapeutically,  therefore,  is  merely  a  mechanical  agent. 
It  prevents  drying  of  the  mucous  membrane,  but  beyond  that 
it  has  comparatively  little  function.  I  believe  the  majority  of 
the  advantages  arising  from  its  use  are  due  to  this  mechanical 
action.  It  is  a  notably  biid  solvent  with  most  substances,  ex- 
cepting the  oils,  anil  particularly  in  the  case  of  iodoform. 

Regarding  the  heating  of  sprays,  if  the  tein|)erature  of  the 
solution  in  the  spray  tube  be  raised  up  to  a  certain  point  and 
then  tlie  atomized  spray  driven  against  the  bulb  of  a  ther- 
mometer, it  will  be  found  that  the  actual  temperature  of  the 
spray  is  considerably  below  that  of  the  solution.  In  other 
words,  the  process  of  atomization  lowers  the  temper.iture. 

I  am  very  filad  there  are  at  least  some  in  this  association 
who  still  have  some  use  for  the  spray,  and  believe  that  if  a  vote 
could  be  taken  ninety-tive  per  cent,  of  our  members  would  re- 
fuse to  ca-t  it  aside. 

Dr.  J.  Weight:  I  wish  to  supplement  my  remarks  by  adding 
that,  like  Dr.  Bosworth,  I  have  seen  no  bad  results  from  the 
use  of  the  post-nasal  syringe.  I  have  never  seen  water  enter 
the  Eustachian  tube  and  so  set  up  trouble.  But  one  precaution 
should  be  observed— natnely,  tell  the  patient  not  to  blow  the 
nose  while  compressing  the  aloa,  for  in  doing  so  one  can  produce 
a  certain  amount  of  pressure  in  the  naso  pharynx  and  drive  an 
excess  ot  fluid  in'o  the  Eustachian  tube.  At  the  same  time, 
although  using  it  at  my  clinic  for  three  or  four  years,  I  have 
never  been  able  to  trace  any  middle-ear  trouble  to  it.  I  do  not 
mean  by  that  statement  that  it  never  does  occur. 

Dr.  BoswoRTu:  I  hope  that  I  may  not  be  misunderstood.  I 
tell  my  patients  to  clean  out  their  noses,  and  the  best  way  for 
them  to  do  it  is  by  means  of  the  spray.  But  what  I  do  say  is 
that  the  spray  does  not  reduce  hyperosmia;  it  does  not  relieve 
hypertrophy;  it  does  not  cure  catarrh,  whatever  that  may  he. 
I  say  there  is  no  such  disease  as  catarrh.  It  does  not  mean  any- 
thing to  us.  I  go  further  and  say  that  most  so-called  catarrhal 
processes  in  the  nose  are  attended  by  deficient  secretion.  The 
nose  secretes  in  twenty-four  hours  sixteen  to  eighteen  ounces  ot 
serum  and  mucus.  Take  away  half  of  the  water  by  a  hyper- 
trophic rhinitis  and  the  thicker  part  will  remain,  give  rise  to 
trouble,  and  lead  to  apparent  excess  of  secretion. 

Dr.  Ason  inquired  of  Dr.  Bosworth  whether  in  the  condi- 
tion in  which  the  patient  wet  five  or  six  handkerchiefs  a  day 
there  was  supersecretion  or  deficient  secretion. 

Dr.  BoswoKTH  :  If  hay  fever  is  meant,  tliere  may  bo  su[)Or- 


secretion,  but  this  consists  largely  of  a  serous  exosmosis,  the 
source  of  which  is  in  the  venous  sinuses,  and  not  of  a  mucous 
secretion.  I  do  not  believe  the  Schneiderian  membrane  is  often 
met  with  in  a  condition  in  which  there  is  supersecretion. 

Dr.  Mackenzie  inquired  of  Dr.  Bosworth  whether  there  were 
not  glands  in  the  Schneiderian  membrane. 

Dr.  BoswoKTH  replied:  Comparatively  few,  if  muciparous 
glands  are  referred  to. 

Dr.  Rice  :  W^hat  more  can  be  said?  My  paper  was  intended 
to  advocate  both  the  use  of  sprays  and  the  necessity  of  con- 
secutive operations  in  the  treatment  of  nasal  and  naso-pharyn- 
geal  diseases.  It  will  be  an  unfortunate  day  when  all  sprays 
are  laid  aside  as  useless.  The  objections  of  Dr.  B.'swor'h  have 
been,  in  my  opinion,  most  admirably  answered  by  Dr.  Macken- 
zie, Dr.  Delavan,  and  others,  and  I  am  quite  willing  to  leave 
the  verdict  as  to  the  value  of  the  spray  to  this  association. 
(To  be  continued.) 


Medical  and  Surgical  Electricity  in  Diseases  of  Women  and 
Obstetrics.  By  Franklin  H.  Martin,  M.  D.,  etc.  Chicago: 
W.  T.  Keener,  1892.    Pp.  xiv-2.52. 

Among  the  enthusiastic  followers  of  Apostoli  there  is  no  one 
who  has  written  more  temperately  and  rationally  than  Dr. 
Martin.  In  his  professional  work  he  has  been  fortunate  in  at 
least  two  respects— in  having  a  mind  without  extreme  bias  in 
favor  of  [ireconceived  theories,  and  in  being  surrounded  by  in- 
fluences that  would  tend  to  check  exclusiveness  or  nariowness. 
He  has  allowed  his  experience  to  mature  before  presenting  it 
in  book  form,  and  therefore  has  fewer  retractions  to  make  than 
most  writers  of  the  past  few  years.  We  confess  that  we  are 
somewhat  disappointed  in  this  book.  Half  of  it  is  occupied 
with  electro-physics,  and  the  other  half  with  the  application 
of  electricity  in  obstetrics  and  gynecology.  Now,  we  do  not 
mean  to  say  that  the  subject  of  electro-physics  is  either  unin- 
teresting or  unimportant,  and  we  agree  entirely  with  the  author 
that  DO  man  has  any  business  to  use  electricity  as  a  tlierapeutic 
agent  until  he  understands  its  fundamental  principles;  but  in  a 
work  devoted  to  ob?tetrics  and  gynfecoloiry  we  naturally  expect 
that  those  subjects  will  receive  the  chief  consideration,  while 
other  matters  will  be  given  attention  only  in  so  far  as  they  bear 
dii  ectly  upon  the  main  question.  Much  of  the  detail  concern- 
ing magnetism,  static  electricity,  dynamos,  and  other  electrical 
apparatus  has  no  direct  bearing  upon  that  portion  of  the  book 
that  is  devoted  to  the  main  issue. 

In  the  consideration  of  the  treatment  of  fibroid  tumors  the 
author  is  cautious,  reporting  a  number  of  cases  cured,  or  symp- 
tomatically  cured,  and  a  number  in  which  failure  resulted. 
Symptomatically  cured — what  does  that  mean  ?  Simjily  that 
there  is  relief  for  the  time  being;  but  with  the  tumor  still  present, 
the  foils  et  origo  mali,  what  assurance  is  there  that  the  symp- 
toms will  not  come  back  again,  like  the  evil  s;)irit  in  the  para- 
ble? The  comparison  between  electrical  treatment  and  hys- 
terectomy as  it  is  now  most  favorably  practiced,  we  mean  with 
the  Trendelenburg  posture  and  the  complete  removal  of  the 
organ,  is  not  what  it  was  five  years  ago.  Wo  are  not  convinced 
that  galvano-|nincture  is  the  harmless  measure  it  is  usually  sup- 
posed to  be,  and  the  elimination  of  the  question  of  treatment  of  a 
pedicle  has  removed  the  greatest  bugbear  from  hysterectomy. 
The  treatment  of  cancer  of  the  vaginal  portion  of  the  cervix 
with  galvanism,  a  number  of  needles  being  inserted  into  the 


8o 


BOOK  NOTICES. 


[N.  Y.  Med.  Johe., 


tissue,  seems  irrational  and  antiquated.  If  impairunent  of  nutri- 
tion is,  as  stated,  the  object  of  such  an  operation,  why  not  ex- 
tend the  logic  of  the  question  to  the  complete  removal  of  the 
diseased  structures  with  the  gavano-cautery  after  Byrne's 
method,  which  lias  jiroduced  better  results  than  any  other 
method  that  has  ever  been  devised  for  the  destruction  of  can- 
cerous tissue  ? 

As  regards  the  relief  of  |)ain  and  haemorrhage  of  the  uterus, 
we  agree  in  the  main  with  the  author  as  to  the  beneficial  effects 
of  electricity.  These  form  the  most  important  indications,  in  our 
opinion,  for  the  use  of  such  an  agent.  But  for  the  relief  of  pain 
the  reviewer  lias  found  currents  of  low  tension,  of  from  twenty 
to  forty  milliamperes,  more  etlicient  than  the  more  powerful 
currents  which  the  author  has  recommended.  We  quite  agree 
in  his  recommendation  of  the  faradaic  current  for  the  treatment 
of  undeveloped,  or  under-developed,  or  imperfectly  contracted 
organs.  Its  use  is  based  upon  rational  princi[)les  and  it  will  be 
sure  to  do  good  if  properly  applied. 

The  author  still  advocates  the  use  of  electricity,  preferably 
the  galvanic  current,  in  the  treatment  of  ectopic  gestation.  But 
the  merit  of  that  treatment  seems  far  less  than  it  did  a  few  years 
ago.  There  is  an  element  of  doubt  as  to  its  value  which  it  would 
bave  been  heresy  to  mention  a  few  years  ago.  Scarcely  any  one 
who  has  seen  much  of  abdominal  surgery  has  not  had  cases  of 
real  or  supposed  ectopic  gestation  that  have  been  successfully 
treated  by  abdominal  section,  and  these,  with  the  great  number 
of  their  adherents,  are  not  likely,  in  view  of  past  experience,  to 
go  back  to  the  treatment  by  electricity,  wliich  leaves,  in  many 
cases  at  least,  so  many  questions  unanswered.  Though  the  risk 
of  abdominal  section  may  be  greater,  it  results  in  definite  in- 
formation, and  when  we  consider  the  dangers  attending  inac- 
tion the  average  mortality  attending  operative  measures  is 
astonishingly  small. 

One  of  the  foremost  advantages  of  electro-therapeutics,  as 
we  have  stated  repeatedly,  is  to  gain  time,  to  demonstrate  both 
to  physician  and  patient  the  utility  or  tlie  inutility  of  palliative 
measures.  But  with  such  a  condition  as  ectopic  gestation  pal- 
liation is  procrastination,  and  the  condition  is  too  serious  for 
any  halfway  measures. 

A  Manual  of  the  Practice  of  Medicine,  prepared  especially  for 
Students.  By  A.  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of 
Physical  Diagnosis  in  the  University  of  Pennsylvania.  Illus- 
trated. Philadelphia:  W.  B.  Saunders,  1893.  Pp.  xviii-17 
to  501.    [Price,  $2.50.] 

In  the  five  hundred  odd  pages  comprised  in  this  volume  the 
author  has  included  a  tremendous  amount  of  material.  lie  states 
that  he  has  prepared  the  work,  at  the  request  of  many  students, 
to  serve  as  an  outline  of  the  practice  of  medicine,  "  which  shall 
be  enlarged  upon  by  diligent  attendance  upon  lectures  and  criti- 
cal observation  at  the  bed.side."  For  this  purpose  we  can  com- 
mend the  book,  as  it  is  not  intended  to  supplant  the  usual  text- 
books. Necessarily  the  aetiology,  pathology,  symptoms,  compli- 
cations, prognosis,  and  treatment  are  described  with  a  terseness 
that  will  tax  the  student's  memory.  As  a  book  to  study  for  a 
quiz,  it  seems  to  be  very  satisfactory. 

Occasionally  an  erroneous  f)r  incomplete  statement  has  crept 
in,  as  on  page  109,  where  it  is  stated  that  "normal  blood  con- 
tains approximately  5,000,000  red  corpuscles." 


A  Clinical  Study  of  Diseases  of  the  Kidneys,  including  System- 
atic Chemical  Examination  of  the  Urine  for  Clinical  Pur- 
poses. Systematic  Microscopical  Examination  of  Urinary 
Sediments.  Systenuitic?  A[>plication  of  Urinary  Analysis  to 
Diagnosis  and  Prognosis.  Treatment.  By  Cui-rouu  Mitch- 


ell, A.  M.,  M.  D.  Second  Edition.  Chicago:  W.  T.  Keener, 
1891.    Pp.  xii  to  431.    [Price,  $3.] 

This  book,  written  by  a  [)ractiti(mer  of  the  homoeopathic 
school,  is  noticeable  as  indicating  the  broadening  views  and  in- 
creasing accuracy  in  the  practices  of  that  school.  It  has  been 
written  with  particular  reference  to  the  bearing  of  uranalysis 
upon  the  diagnosis  and  treatment  not  only  of  diseases  of  the 
kidneys,  but  also  of  associated  disorders. 

The  literature  of  the  subject  has  been  carefully  digested,  the 
views  of  the  best  authors  have  been  used  without  stint,  and  due 
credit  for  the  same  has  regularly  been  given.  Those  portions 
of  the  work  devoted  to  diagnosis,  prognosis,  and  dietetics  we 
can  most  highly  commend,  but,  as  to  those  devoted  to  treat- 
ment, we  are  not  in  a  position  to  criticise  or  indorse.  A  care- 
ful distinction  of  symptoms,  and  their  indications  for  the  use  of 
various  I'emedies,  is  gone  into  with  great  minuteness,  and  this 
poi'tion  of  the  book  will  be  useful  to  any  physician,  whether  he 
belongs  to  the  author's  school  or  not. 


Rectal  and  Anal  Surgery,  with  a  Full  Description  of  the  Secret 
Metliods  of  the  Itinerant  Specialists.  By  Edmund  Andrews, 
M.  D.,  LL.  D.,  and  Edward  Wyllis  Andrews,  A.  M.,  M.  D. 
Third  Edition,  revised  and  enlarged,  with  Illustrations  and 
Formulary.  Chicago :  W.  T.  Keener,  1892.  Pp.  xiii  to  1G4. 
[Price,  $1.50.] 

This  little  work  is  principally  an  exposition  of  the  methods 
and  practices  of  itinerant,  advertising,  and  quack  specialists  in 
diseases  of  the  rectum  and  anus.  It  is  useful  in  exposing  the 
work  of  these  men  who  go  about  the  country  professing  to  pos- 
sess some  secret  art  or  knowledge,  unknown  to  the  general  pro- 
fession, whereby  they  are  able  to  cure  tliose  who  are  otherwise 
incurable.  "What  seems  to  be  of  value  in  these  methods  the  au- 
thors have  not  hesitated  to  recommend.  As  a  work  on  rectal 
surgery,  however,  the  book  can  hardly  be  indorsed.  Many  of 
the  recognized  operations  are  either  omitted  altogetlier  or  given 
such  passing  notice  as  is  out  of  proportion  to  their  imjiortance. 

The  chapter  on  Neuroses  of  the  Rectum  and  Anus,  while 
brief,  is  perhaps  the  best  in  the  book,  and  well  worth  reading. 
A  formulary  is  given  in  the  appendix  which  will  be  very  useful 
to  those  beginning  practice  in  this  line. 

A  Manual  of  Ohstetrics.  By  A.  F.  A.  King,  A.  M.,  M.  D.,  Pro- 
fessor of  Obstetrics  and  Diseases  of  Women  and  Children 
in  the  Medical  Department  of  the  Columbian  University, 
Washington,  D.  C,  etc.  Fifth  Edition,  with  One  Hundred 
and  Fifty  Illustrations.  Philadelphia:  Lea  Brothers  &  Co.^ 
1892. 

This  manual,  which  the  author  states  is  primarily  intended 
for  his  students  in  the  Columbian  and  Vermont  Universities, 
bears  evidence  of  its  popularity  in  the  fact  that  it  has  reached 
a  fifth  edition.  It  is  condensed  and  compact — no  small  merit 
in  a  book  for  students — and  it  bears  on  many  of  its  pages  the 
stamp  of  that  originality  and  that  clearness  of  ex|>ression  which 
have  made  the  author  a  successful  teacher  of  obstetrics  for 
many  years. 

Transactions  of  the  Southern  Surgical  and  Gyncecological  Asso- 
ciation. Volume  IV.  Fourth  Session,  held  at  Richmond, 
Va.,  November  10,  11,  and  12,  1891.  Published  by  the  As- 
sociation, 1892. 

This  volume,  uniform  in  its  appearance  with  the  volumes  of 
Transactions  of  the  American  Gyncecological  Society,  contains  a 
great  quantity  of  very  good  material.  The  list  of  contributors 
would  suggest  that  the  association  was  national  rather  than 
Southern,  and  includes  quite  a  number  who  are  very  apt  to  be 


Jan.  21,  1893.]  BOOK  NOTICES.— REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


87 


heard  from  in  any  part  of  the  country  where  aggressive  and  pro- 
gressive work  is  being  done.  We  can  not  doubt  the  advantage 
that  must  accrue  to  the  members  of  this  society  and  to  the  com- 
munities in  wliich  they  practice  by  this  interchange  of  ideas. 
There  is  a  manifest  advantage  in  the  union  of  surgeons  with 
gynsoi'ologists  in  these  days  in  which  g^njecology  stands  prin- 
cipally for  surgery.  But  there  may  also  be  a  danger  from  such 
intimacy,  for  gynajcology  is  too  broad  a  field  to  be  circum- 
scribed by  any  exclusive  line  of  practice,  and  the  man  who 
would  be  most  useful  in  this  field  must  be  both  surgeon  and 
physician. 

Dueaseii  of  the  Kidneys  and  Bladder :  a  Text-book  for  Students 
of  Medicine.    By  W.  F.  MoNutt,  M.  D.,  M,  R.  C.  S.  Edin., 
L.  R.  C.  P.  Edin.,  Professor  of  the  Principles  and  Practice  of 
Medicine,  University  of  California,  etc.   Philadelphia :  J.  B. 
Lippincott  Company,  1892.   Pp.  4-7  to  242.    [Price,  $2.50.] 
Tnis  work  is  composed  of  a  series  of  lectures  delivered  at 
the  University  of  California.    It  is  particularly  notable  for  the 
numerous  and  unusual  names  applied  to  the  different  diseases  of 
which  it  treats.    There  are  no  fewer  than  twelve  different  vari- 
eties of  nephritis  treated  of,  not  including  tubercular,  suppurat- 
ing, surgical,  and  malignant  disease,  and  the  other  subjects  of 
the  work  are  proportionately  subdivided,  all  of  which  will  tend 
to  confuse  the  student.    Otherwise  the  woi-k  is  a  good  resume 
of  the  subject.    We  wonder,  however,  that  the  author  should 
jump  from  the  kidney  to  the  bladder,  omitting  the  ureters  alto- 
gether. 


Reports  oit  lljt  Jrognss  of  ^elrinne. 


OTOLOGY. 

By  CHARLES  STEDMAN  BULL,  M.  D. 

Experiments  with  the  Tuning  Fork  in  determining  the 
Permeability  of  the  Eustachian  Tube. — Politzer  {Ann.  des 
maladie.%  de  Voreille  et  du  larynx.,  May,  1892)  gives  the  follow- 
ing results  of  his  experiments  :  1.  In  cases  of  unilateral  disease 
of  the  middle  ear  with  obstruction  of  the  Eustachian  tube,  due 
to  swelling  of  the  lining  mucous  membrane,  or  to  the  accu- 
mulation of  secretion,  or  to  actual  narrowing  of  the  canal, 
the  note  of  tuning  fork  C,  held  in  front  of  the  nostrils,  is  heard 
more  distinctly  by  the  normal  ear.  2.  In  cases  of  unilateral 
disease  of  the  middle  ear  in  which  the  canal  of  the  Eustachian 
tube  is  not  obstructed,  the  vibrations  of  tuning  fork  C-,  trans- 
mitted by  the  openings  of  the  nostrils,  are,  in  the  majority  of 
the  cases,  perceived  more  distinctly  by  the  diseased  ear.  3.  In 
unilateral  labyrinthine  disease,  in  which  tlie  objective  examina- 
tion and  the  other  symptoms  leave  no  doubt  as  to  the  nature  of 
the  disease,  the  tuning  fork  C*,  placed  in  front  of  the  nostrils,  is 
perceived  solely  by  the  healthy  ear,  whether  in  repose  or  dur- 
ing deglutition. 

The  Opening  of  the  Mastoid  Process  in  Cases  of  Acute 
Otitis  Media  following  Influenza.— Politzer  {Ann.  des  mala- 
dies de  Voreille  et  du  laryn.c,  May,  1892)  considers  that  it  is 
very  important  to  know  whether  the  abscess  is  situated  in  the 
middle  or  inferior  segment  of  the  vertical  portion  fif  the  hy- 
pojihysis,  especially  the  superficial  cells  situated  under  the  corti- 
cal layer.  He  insists  upon  the  point  that  the  mastoid  al)scess 
follow  ing  a  protopathic  otitis  media  is  susceptible  of  spontaneous 
resolution,  with  absorption  of  the  pus  in  the  cells,  while  mas- 
toiditis following  la  grippe  is  but  little  likely  to  terminate  thus 
favorably,  as  the  pus  here  seems  to  exert  a  destructive  action 


upon  the  surrounding  tissue,  and  leads  to  caries  of  the  apophy- 
sis. In  this  form  of  otitis  media,  if  before  perforation  has  oc- 
curred the  drum  membrane  looks  red  and  swollen,  and  if  there 
is  at  the  same  time  spontaneous  pain  in  the  apophysis,  aggra- 
vated by  pressure,  the  drum  membrane  must  be  punctured  in 
order  to  aduiit  of  free  exit  to  the  pus.  This  operation  some- 
times suffices  to  prevent  a  mastoiditis.  Ice  must  also  be  applied 
to  the  mastoid.  But  when  the  otitis,  with  severe  symptoms, 
has  lasted  more  than  eight  or  ten  days  without  perforation  of 
the  drum  membrane,  it  is  probable  that  au  abscess  already  ex- 
ists in  the  apophysis,  and  the  latter  must  be  opened.  The  tym- 
panutn  must  also  be  irrigated  daily  with  some  warm  antiseptic 
solution,  and  Leiter's  coil  must  be  assiduously  employed.  He 
describes  his  method  of  opening  the  mastoid  as  follows:  The 
hair  is  to  be  entirely  shaved  off,  and  the  skin  is  then  to  be 
thoroughly  cleansed  with  soap  and  water  and  an  antiseptic  solu- 
tion. Then  a  vertical  incision  is  to  be  made,  half  a  centimetre 
behind  the  insertion  of  the  concha,  slightly  concave  forward 
and  about  five  centimetres  long,  through  all  the  tissues  down  to 
the  bone  itself.  Then  the  periosteum  is  to  be  removed  from 
the  bone,  so  as  to  expose  a  surface  of  bone  about  a  centimetre 
and  three  quarters  square  in  extent.  Then,  by  means  of  a 
Schwartze  gouge,  a  large  superficial  piece  of  bone  is  to  be  re- 
moved, and  tiiis  is  continued  until  the  abscess  is  uncovered. 
Then  all  the  diseased  tissue  must  be  removed  with  a  large  cut- 
ting spoon,  and  the  wound  thoroughly  cleansed  with  a  subli- 
mate solution.  The  hole  is  then  to  be  packed  with  iodoform 
gauze.  This  must  be  dressed  once  or  twice  a  day  until  all  dis- 
charge has  ceased  and  the  granulations  look  red  and  healthy. 
When  this  condition  has  been  reached,  an  attempt  may  be  made 
to  close  the  opening  in  the  skin. 

The  Otic  Sign  in  Cerebral  Diseases.— Gell6  {Ann.  des 
maladies  de  Voreille  et  du  larynyx,  May,  1892)  considers  that 
clinical  observation  shows  the  importance  of  recognizing  the 
presence  or  disappearance  of  this  functional  sign,  known  as  the 
binaural  reflex  of  accommodation,  whether  there  is  deafness  or 
not  in  diseases  of  the  middle  ear,  in  those  of  the  internal  ear, 
or  in  intracranial  diseases,  which  produce  vertigo,  tinnitus  au- 
rium,  deafness,  facial  paralysis,  etc.  The  absence  of  transition 
of  the  synergetic  irritation  in  cases  of  sclerosis  is  a  mechanical 
fact,  which  explains  the  simultaneous  loss  of  the  effect  of  cen- 
tripetal impressions  of  the  tuning  fork  on  the  hearing,  added  to 
other  signs  of  the  presence  of  otitis  media.  When  a  haemor- 
rhage or  an  inflammation  has  seriously  altered  the  labyrinthine 
contents,  the  reflex  of  synergetic  accommodation  is  equally 
wanting.  It  is  gone  from  both  sides,  and  coincides  with  a  lim- 
ited deafness  and  witli  various  disturbances  of  equilibrium  and 
of  the  senses,  which  constitute  the  syndroina  of  labyrinthine 
lesions. 

Otitis  Interna  Syphilitica.- Oharagac  {Rev.  de  laryngo- 
logie  et  d'otologie,  June  1-5,  1892)  considers  that  the  labyrinth 
and  the  acoustic  nerve  may  be  attacked  by  constitutional  syphi- 
lis at  different  phases  of  its  evolution,  either  primarily  without 
any  other  lesi')n  of  the  auditory  apparatus,  or  secondai'ily  by 
propagation  from  the  middle  ear.  When  the  otitis  interna  is 
isolated,  sometimes  the  auditory  nerve  is  attacked,  and  some- 
times the  trouble  is  caused  by  osseous  or  congestive  lesions  of 
the  labyrinthine  walls.  One  of  the  principal  characteristics  of 
syphilitic  internal  otitis  is  the  rapidity  with  which  it  develojis. 
Intense  tinnitus,  with  frequent  and  painful  attacks  of  vertigo, 
accotnpanies  the  deafness.  There  may  also  occur  an  irido- 
chorioiditis,  with  acute  pain  limited  to  the  region  of  the  ear  and 
nocturnal  cephalalgia.  Deafness  supervenes  without  any  known 
external  cause,  and  may  amount  to  absolute  and  total  loss  of 
liearing.  In  many  cases  the  drum  membrane  and  drum  cavity 
are  normal  or  but  little  affected.    Syphilis  of  the  labyrinth  may 


88 


REPOBTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y,  Mbd.  Jo0r., 


present  itself  as  the  single  symptom  of  general  syphilis,  and  is 
usually  a  late  manifestation. 

The  Treatment  of  Pityriasis  of  the  Ear.— Albespy  {Rev.  de 
laryngologie  et  d'otologie,  Aug.  1,  1892)  recommends  that  all  the 
hairs  at  the  entrance  of  the  external  auditory  canal  be  pulled  out 
and  all  the  epidermal  masses  be  carefully  removed  by  syringing 
with  warm  boric-acid  solutions  and  by  forceps.  Antiseptic  cotton 
is  then  taken  and  rolled  into  a  cylinder  about  3  ctm.  long  and 
corresponding  in  diameter  to  that  of  the  canal.  Tiiis  cotton  cylin- 
der is  soaked  in  a  solution  of  silver  nitrate  (1  to  20),  introduced 
into  the  canal  and  left  there  for  twenty-four  hours.  When 
these  cylinders  are  removed  their  surface  is  covered  with 
blackened  and  burned  scales.  The  skin  beneath  is  red,  but  does 
not  bleed.  These  applications  are  renewed  daily  until  there  are 
no  more  scales  and  the  walls  of  the  canal  look  smooth.  The  solu- 
tion is  then  changed  to  one  of  salicylic  acid,  Caniida  balsam, 
and  collodion,  and  the  cotton  cylinders  are  soaked  in  this. 

A  Tragus  Retractor.— Baber  {Arch,  of  Otol.,  xxi,  1)  has 
devised  a  retractor  which  consists  of  a  ring  of  fiat  metal  about 
a  centimetre  and  a  half  wide,  made  to  fit  firmly  on  the  last 
phalanx  of  the  surgeon's  left  forefinger,  the  ring,  however,  be- 
ing left  incomplete  so  that  its  size  can  be  varied  according  to 
circumstances.  The  end  of  the  flat  band  of  metal  forming  the 
ring  is  bent  back  obliquely  at  an  angle  of  about  45°,  making  a 
blunt  hook  about  twelve  millimetres  in  length.  The  same  in- 
strument does  for  both  ears,  and  it  is  conveniently  made  of 
aluminum.  In  examining  the  right  ear  the  retractor  is  fixed  on 
the  left  index  finger  so  that  the  hook  points  toward  its  dorsal 
surface,  and  while  the  auricle  is  drawn  upward  and  backw^ird 
with  the  left  middle  finger  and  thumb,  the  tragus  is  held  a.side 
by  a  forward  movement  of  the  forefinger  carrying  the  instru- 
ment. To  iipply  the  retractor  to  the  left  ear  it  is  fixed  on  the 
left  ring  finger  with  the  hook  pointing  toward  its  palmar  sur- 
face. The  auricle  is  then  pulled  upward  and  backward  with 
the  thumb  and  first  two  fingers  of  the  same  hand,  while  by 
pressing  the  ring  finger  downward  the  tragus  is  easily  re- 
tracted. 

Sarcomatous  Growth  in  the  External  Auditory  Canal. 

— Sheild  {Arch,  of  Otol.,  xxi,  1)  reports  the  case  of  a  young 
married  lady  who  had  suff'ered  from  childhood  from  left  otor- 
rhcea.  At  the  age  of  ten  years  Wilde's  incision  was  done. 
In  December,  1890,  an  abscess  formed  back  of  the  ear  and 
opened  spontaneously.  At  that  time  there  was  also  a  strange 
swelling  toward  the  posterior  wall  of  the  canal.  When  Sheild 
saw  the  patient  there  was  a  growth  as  large  as  a  large  cher- 
ry, which  completely  filled  the  canal  and  resembled  a  large 
mucous  polypus.  It  was  sessile,  firm,  non-sensitive,  and  appar- 
ently grew  from  the  posterior  wall  of  the  bony  canal.  The 
watch  and  tuning  fork  were  heard  on  contact  only.  On  March 
10th  portions  of  the  tumor  were  removed  by  snare  and  forceps 
and  the  rest  well  broken  up.  There  was  free  haemorrhage 
during  the  operation.  Pure  chromic  acid  was  then  applied  to 
the  spot.  On  April  6th  a  nodule  as  large  as  a  pea  could  be 
seen  growing  from  the  upper  and  posterior  wall  of  the  canal. 
On  the  next  day  the  nodule  was  thoroughly  removed  and  the 
bone  was  persistently  scraped  with  a  sharp  scoop  until  a  shal- 
low cavity  was  made,  A  probe  being  then  passed  in,  passed 
through  a  sinus  inward  and  backward  toward  the  mastoid  cells, 
from  which  pus  came.  The  galvano-cautery  was  then  applied  to 
the  bone  repeatedly.  Several  days  later  a  fine  curved  tube  was 
passed  into  the  sinus  and  several  drachms  of  a  ten-volume  solu- 
tion of  hjdrogen  peroxide  was  injected  into  the  mastoid  cells, 
and  this  was  done  daily  for  a  week  or  more.  By  October  the 
sinus  had  closed  and  there  was  no  sign  of  a  return  of  the 
growth.  There  was  no  sense  of  hearing  except  on  contact. 
The  surface  of  the  tumor  removed  was  entirely  denuded  of 


epithelium;  the  basic  substance  was  composed  of  embryonio 
tissue,  with  fusiform,  round  and  irregular  cells,  some  having 
many  nuclei,  and  having  the  character  of  myeloid  cells.  In  the 
midst  of  this  tissue  were  many  channels,  vascular  and  lym- 
phatic, which  branched  in  all  directions  and  were  lined  with 
fiattened  cells.  The  appearances  were  mainly  those  of  a  mye- 
loid growth. 

A  Handy  Form  of  Intratympanic  Syringe.— Pritchard 
{Arch,  of  (/tol.,  xxi,  \)  has  devised  a  modification  of  Hart- 
mann's  .syringe,  which  has  the  following  advantages:  1.  The 
rubber  reservoir,  instead  of  being  in  a  direct  line  with  the  metal 
tube,  is  fixed  at  an  obtuse  angle  and  is  oval  in  shape;  the  in- 
strument does  not  therefore  interfere  with  due  illumination  of 
the  meatus.  2.  Beneath  the  reservoir  and  of  the  same  size  a 
spoon-shaped  metal  plate  is  attached  to  the  metal  tube;  this 
serves  as  a  point  d^appui  in  applying  pressure  with  the  thumb 
to  the  reservoir,  which  can  thus  be  easily  manipulated  with  one 
hand.  3.  The  fine  metal  tube  is  straight,  but  if  it  be  deemed 
necessary  to  direct  the  stream  of  fluid  at  an  angle,  a  small 
second  tube  is  provided,  curved  at  the  tip  and  attachable  to 
the  straight  tube  by  a  simple  plug  joint. 

Deaf-mutism  with  Auditory  Atrophy  and  Anomalies 
of  Development  in  the  Membranous  Labyrinth  of  both 
Ears. — Scheibe  {Arch,  of  Otol.,  xxi,  1)  reports  the  following 
results  of  examination  of  the  ears  in  a  deaf-mute:  The  middle 
ear  was  normal,  with  exception  of  the  hyperplasia  and  partial 
degeneration  of  the  tensor  tympani.  The  labyrinth  showed 
atrophy  of  the  nerves  of  the  cochlea,  sacculus,  and  posterior 
am[)ulla,  as  well  as  alterations  in  the  membranous  structure 
of  the  cochlea  and  sacculus.  The  rudiment  of  the  membrana 
tectoria  was  surrounded  with  cells,  in  some  places  giving  the 
impression  that  Corti's  membrane  originated  as  a  cuticular 
secretion,  while  in  others  it  seemed  to  develop  between  the 
cells  themselves.  The  ridge  on  the  stria  vascularis  proceeded 
directly  from  the  bridge,  which  stretched  from  the  sulcus  to 
the  stria.  The  abnormal  insertion  of  Reissner's  membrane 
which  existed  might  be  either  a  disturbance  of  development  or 
dependent  on  the  enlargement  of  the  stria  vascularis.  Another 
abnormal  development  was  the  cell-holding  otolithic  membrane 
of  the  sacculus.  The  deaf-mutism  was  chiefly  due  to  the 
atrophy  of  the  nerves.  There  was  no  trace  in  the  labyrinth  of 
any  former  inflammation.  The  atrophy  was  confined  to  the 
nerves  of  the  cochlen,  sacculus,  and  posterior  ampulla. 

The  Labyrinth  after  Death  from  Diphtheria.  —  Moos 
{Arch,  of  Otol..,  xii,  1)  emphasizes  the  following  facts  from 
these  examinations:  1.  Groups  of  cocci  upon  the  external  wall 
of  the  sacculus,  together  with  molecular  products  of  disintegra- 
tion, and  also  in  the  perilymphatic  tubercular  reticulum  of  the 
utricle.  2.  Micrococci  and  streptococci  upon  the  ligaments 
of  the  membranous  semicircular  canals,  in  the  layer  of  connec- 
tive tissue  of  the  crista  of  the  sagittal  ampulla,  in  the  vessels  of 
the  Havei'sian  canals  imbedded  in  leucocytes,  and  upon  their 
vascular  external  wall,  along  the  endosteum  of  the  first  coch- 
lear turn,  and  between  the  layers  of  the  lamina  spiralis  ossea. 
These  changes  in  the  periosteum  and  adjacent  bone  he  now 
believes  to  be  due  to  direct  action  of  the  micro-organisms. 
Three  ditferent  degrees  of  destruction  were  observed  :  1.  Dis- 
integration of  the  greater  part  of  the  spiral  ligament,  and 
later  atrophy  or  the  formation  of  lacunte.  2.  Development  of 
a  sequestrum  of  the  adjoining  cochlear  capsule  close  to  the 
periosteum,  crescentic  in  shape,  and  mostly  parallel  with  the 
periosteal  layer  of  the  ligament.  3.  Progress  of  the  osseous 
necrosis  toward  the  labyrinthine  wall.  The  periosteum  also 
showed  hyaline  and  colloid  degeneration,  as  did  also  the  con- 
tents of  the  medullary  spaces. 

The  destructive  changes  in  the  main  trunk  of  the  acoustic 


Jan.  21,  1893.J 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


89 


nerve  were  eni)rraous,  in  some  instances  involving  its  entire 
transverse  section.  The  axis  cylinder  resisted  longest.  My- 
cotic degeneration  appeared  independently  in  the  peripheral 
branches  of  the  nerve  and  also  in  the  ganglion  cells.  The  al- 
terations in  the  region  of  the  cochlear  duct  were  the  conse- 
quences of  more  or  less  extensive  haamorrhage,  and  partly  of 
a  more  or  less  considerable  coagulation  necrosis.  The  main 
source  of  the  hemorrhages  viras  situated  in  the  region  of  tlie 
spiral  ligament,  of  the  endosteum  of  the  first  two  cochlear 
turns,  and  also  in  the  periosteum  of  the  osseous  lamina  of  the 
first  and  second  turns.  The  coagulation  necrosis  was  the  con- 
sequence of  the  immigration  of  microbes  in  great  number. 

Lymphoma  of  the  Tonsils. — Baber  {Arch,  of  Otol.,  xxi,  2) 
reports  the  case  of  a  girl,  aged  fourteen  years,  a  tali,  thin  child, 
who  suffered  from  what  appeared  to  be  great  hypertrophy  of 
the  tonsils  which  had  existed  tor  two  years.  They  were  both 
cut  off  and  did  not  bleed  much.  Six  months  later  the  tonsils 
were  again  much  enlarged  and  ulcerated.  They  were  again  re- 
moved. One  month  later  the  right  tonsil  was  scraped  out  with 
a  gland  scoop.  Subsequently  the  glands  on  the  right  side  of 
the  neck  attained  the  size  of  a  small  orange.  The  inguinal 
glands  were  also  much  enlarged,  as  were  also  the  glands  in  the 
axilla.  The  tonsils  continued  to  increase  in  size  in  spite  of  re- 
peated scraping  with  the  scoop.  Steady  emaciation  continued 
and  the  patient  died  in  May  of  pneumonia.  The  day  before 
death  all  the  enlarged  glands  in  the  neck,  axilla,  and  groin  dis- 
appeared. Microscopic  examination  of  a  portion  of  the  growth 
removed  from  the  tonsils  revealed  a  well-developed  reticulum, 
presenting  a  great  number  of  endothelial  plates.  Numerous 
lymphoid  cells  resembling  white  blood-corpuscles  were  inclosed 
in  its  meshes.  There  was  a  sprinkling  of  small  round  cells  in 
places. 

The  Treatment  of  Chronic  Suppurative  Otitis.— Gradle 
{Arch,  of  Otol.,  xxi,  2)  concludes  that  as  long  as  the  pus  of 
otorrhoea  smells  foetid,  the  treatment  employed  exerts  no  cura- 
tive influence  on  the  disease,  and  the  converse  also  holds  true. 
Whenever  we  succeed  in  thoroughly  removing  all  stale  pus,  the 
discharge  remains  free  from  foetid  odor  as  long  as  it  does  not 
stagnate  again.  If  the  mechanical  cleansing  by  syringing  has 
not  been  thoroughly  done,  the  use  of  boric  acid  or  any  disin- 
fectant does  not  make  the  discharge  odorless.  The  time  of  treat- 
ment is  materially  shortened  by  the  use  of  antiseptic  powders. 
The  antiseptic  action  of  boric  acid  is  increased  by  the  addition 
of  salicylic  acid.  Sometimes  retained  pus  can  be  removed  by 
irrigation  through  the  Eustachian  tube.  The  most  convenient 
tube  for  the  purpose  is  the  silver  tube  ordinarily  made  to  fit 
the  barrel  of  the  hypodermic  syringe.  If  polypi  or  granulation 
tissue  dam  up  the  pus  mechanically,  no  treatment  except  their 
removal  will  deodorize  the  discharge  or  cure  the  disease.  In 
the  case  of  exostosis  of  the  walls  of  the  meatus,  the  surgical  indi- 
cation for  their  removal  hinges  on  the  impossibility  of  deodoriz- 
ing the  pent  up  discharge.  Gradle  thinks  that  the  deodorizing 
efticacyof  the  alcoholic  ethereal  iodoform  solutions  can  be  better 
relied  upon  if  the  instillation  is  followed  by  filling  the  ear  with 
antiseptic  glycei'in,  kept  in  by  a  tight  plug  of  cotton. 

Antrectomy  as  a  Treatment  for  Chronic  Purulent  Otitis 
Media. — Lane  {Arch,  of  Otol.,  xxi,  2)  considers  it  obvious  that 
in  those  cases  in  which  a  deep-seated  and  enlarged  antrum  is 
always  covered  by  three  quarters  of  an  inch  or  more  of  very 
dense  bone,  suppurative  disease  is  here  infinitely  more  danger- 
ous to  the  life  of  the  individual  than  where  the  antrum  is  in 
immediate  relationship  or  in  direct  communication  with  large 
cells  in  the  mastoid  bone.  The  pain  which  is  suffered  in  these 
cases  of  deep-seated  antrum  is  in  most  in.stances  duo  to  a  chronic 
inflammation  of  the  dura  mater  in  immediate  relation  with  the 
antrum.  In  such  cases  the  antrum  should  be  exposed  by  careful 


use  of  the  mallet  and  gouge  and  by  scraping  the  cavity  with 
sharp  spoons,  and  then  by  subsequent  removal  of  overhanging 
bone,  so  as  to  make  the  gouged  inner  wall  of  the  antrum  the 
floor  or  apex  of  a  cone.  Then  by  fixing  for  a  considerable  tima 
a  metal  tube  in  such  a  position  that  its  end  rests  on  the  oblit- 
erated inner  wall  of  the  antrum,  the  cavity  of  the  antrum  is 
permanently  obliterated,  and  the  floor  of  the  cone  becomes  filled 
with  fibrous  tissue.  The  middle  ear  is  then  cleared  of  its  con- 
tents, all  remains  of  the  drum  head  are  removed,  and  the  aper- 
ture of  communication  with  the  antrum  is  enormously  enlarged 
by  the  removal  of  its  outer  boundary. 

Two  New  Aural  Instruments. — Dench  {Arch,  of  Otol., 
xxi,  2)  has  devised  an  instrument  for  inflating  the  middle  ear 
with  either  air  or  medicated  vapor,  without  removing  the  in- 
flating bulb  from  the  proximal  extremity  of  the  catheter,  in 
making  this  change  in  the  fluid  inflated.  The  apparatus  consists 
of  a  small  wide-mouthed  bottle  in  which  is  placed  a  sponge 
saturated  with  the  volatile  fluid,  the  vapor  of  which  we  desire 
to  force  into  the  tympanic  cavity.  The  stopper  of  the  bottle  is 
provided  with  two  short  tubes,  one  on  either  aspect,  which  are 
connected  with  the  inflating  bulb  on  the  one  hand  and  the  Eus- 
tachian catheter  on  the  other,  by  means  of  flexible  rubber  tubes. 
By  means  of  a  small  thumb-screw  on  the  top  of  the  stopper  the 
core  of  the  latter  can  be  easily  rotated,  and  by  simply  turning 
this  thumb  screw  through  an  arc  of  ninety  degrees  the  current 
of  air  from  the  bulb  is  driven  either  directly  through  the  rubber 
tubes  into  the  catheter  and  thence  into  the  middle  ear,  or  is  made 
to  pass  down  through  the  bottle  before  entering  the  catheter, 
thus  charging  it  with  the  vapor  contained  within  the  reservoir. 
A  quarter-turn  of  the  thumb-screw  suflices  to  effect  the  change 
from  air  to  medicated  vapor  or  the  reverse,  the  catheter  mean- 
while remaining  undisturbed  in  position. 

The  second  instrument  is  a  metal  tongue  for  the  Eustachian 
tube.  It  consists  of  an  ordinary  pure  silver  Eustachian  catheter 
of  medium  size,  along  the  convexity  and  superior  aspect  of 
which  are  secured  several  small  guides.  The  tip  of  the  catheter, 
instead  of  being  cut  off'  at  right  angles  to  the  bore,  is  so  formed 
that  the  section  presents  the  shape  of  an  ellipse.  The  superior 
aspect  of  the  instrument  for  two  inches,  beginning  at  the  proxi- 
mal extremity,  is  graduated  in  the  fractional  parts  of  an  inch. 
The  bougies  are  made  of  German  silver  and  are  bulb-tipped. 
The  shaft  is  of  the  same  size  in  every  instance,  but  the  tips  vary 
from  2  to  5  of  the  French  scale.  In  operating  the  instrument 
the  shaft  is  threaded  through  the  guides  upon  tiie  catheter,  and 
when  the  bulbous  tip  is  drawn  up  to  the  first  guide  it  is  found 
that,  owing  to  the  oblique  section  of  the  end  of  the  catheter, 
the  bulb  of  the  dilator  completes  the  superior  wall  of  the  tip  of 
the  catheter,  thus  permitting  a  current  of  air  to  be  forced 
throngli  the  instrument  and  into  the  Eustachian  tube,  with  the 
bougie  in  position.  To  the  proximal  end  of  the  shaft  of  the 
bougie  a  small  handle  is  fastened  by  means  of  a  screw,  thus  en- 
abling the  operator  to  advance  the  bougie  to  any  desired  extent, 
the  distance  being  indicated  by  the  passage  of  the  handle  over 
the  graduations  already  mentioned. 

Cerebral  Abscess  after  Otitis  Media  Acuta  healed  by  Op- 
eration.— Truckenbrod  {Arch,  of  Otol..^  xxi,  2)  reports  a  case  of 
this  kind  occurring  in  a  gentleman  aged  fifty-four,  and  is  the  sec- 
ond case  of  the  kind  on  record.  In  this  case  the  chief  diagnostic 
point  was  the  aphasia  which,  according  to  Wernicke,  indicates 
a  disturbance  in  the  posterior  third  of  the  first  left  temporal 
convolution  of  the  brain.  Hence  it  was  assumed  that  the  ab- 
scess was  situated  in  the  temporal  lobe.  There  was  also  cir- 
cumscribed pain  in  that  region  throughout  the  entire  course  of 
the  attack.  The  paresis  of  the  right  facial  nerve,  the  convul- 
sions in  the  right  arm,  and  the  weakness  in  the  right  band, 
aided  the  correct  diagnosis.    The  agrai)hia  and  dyslexia  were 


90 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


fN.  Y.  Med.  Jouh., 


also  all  explained  by  the  increused  pressure  in  the  sl'inll.  Tlio 
mastoid  was  opened  in  this  case,  and,  although  no  disease  was 
discovered,  there  were  traces  of  former  disturbances.  The 
teginen  was  then  chiseled  away,  the  dura  mater  and  membranes 
were  divided,  the  brain  was  punctured,  and,  after  pus  was  re- 
vealed, the  brain  was  pierced  with  tlie  knife  up  to  the  cavity. 
Drainage  was  accomplished  by  means  of  a  broad  tube.  The  re- 
covery was  rapid  and  excellent,  and  in  six  weeks  the  cicatrix 
had  closed.  In  two  weeks  after  the  operation  the  patient  wrote 
lon.!i  letters  with  ease. 

The  Mechanical  Treatment  of  Tension  Anomalies.— Blake 
(^Arch.  of  Otol.^  xxi,  2)  liere  discusses  in  a  bi'ief  ])aper  some  in- 
teresting points  connected  with  slight  derangement  of  the  com- 
parative adjustment  of  the  com[ionent  parts  of  the  sound-trans- 
mitting apparatus  of  the  ear.  A  small  strip  of  rubber,  three 
millimetres  wide  and  twelve  millimetres  long,  introduced  by 
forceps  into  the  auditory  canal,  and  the  two  ends  allowed  to 
spring  outward  against  the  wail  of  the  canal,  causes  a  pressure 
by  the  convex  portion  of  the  resultant  ellipse  of  rubber  upon 
the  short  process  of  the  malleus,  which  was  subsequently  esti- 
mated to  be  equal  to  the  support  of  fifteen  milligrammes.  A 
consideration  of  the  angle  at  which  the  plane  of  surface  of  the 
membrana  tympani  is  set  to  the  long  axis  of  the  external  canal, 
and  of  the  adjustment  of  the  rubber  strip,  one  end  of  which 
rests  upon  the  anterior  wall  of  the  canal,  directly  opposite  the 
presenting  surface  of  the  short  process  of  the  malleus,  shows 
that  the  pressure  exerted  by  an  elastic  substance  thus  placed 
would  be  directly  in  the  line  whicli  would  favor  the  most  com- 
plete apposition  of  the  malleo-incudal  articulating  surfaces  with 
reference  to  the  transmission  of  mechanical  movement  from  the 
first  to  the  second  bone.  It  would  also,  by  counterfeiting  in  a 
measure  from  without  the  effect  of  muscular  traction  from 
within,  favor  that  action  of  counterbalance  in  the  preponderat- 
ing weight  of  the  ossicula  above  the  axial  line  of  vibration  which 
is  most  favorable  to  the  transmission  of  sTiort  sound-waves  fall- 
ing upon  the  membrana  tympani  below.  In  dealing  with  this 
class  of  cases  the  treatment  really  consists  merely  in  the  appli- 
cation of  well-recognized  surgical  rules  modified  to  meet  the 
peculiar  contingencies,  and  should  be  apportioned  to  the  deli- 
cacy of  the  apparatus  with  which  it  has  to  deal.  The  treat- 
ment must  also  be  long  continued  to  obtain  any  permanent  re- 
sult in  a  condition  which  has  become  essentially  chronic  by  the 
time  it  is  bronglit  to  the  attention  of  the  surgeon.  The  adjust- 
ment of  such  mechanical  appliances  must  always  be  a  matter  of 
more  or  less  experiment,  since  the  questions  of  the  weight  and 
position  of  the  dressing  and  the  degree  of  pressure  exercised  by 
it  are  variable  factors  which  must  be  apportioned  to  the  indi- 
vidual needs  of  the  case. 

The  so-called  Bezold  Variety  of  Mastoiditis ;  Opening 
of  the  Mastoid  ;  Craniotomy ;  Death ;  Autopsy ;  Abscesses 
in  the  Temporal  Lobe  and  Cerebellum ;  Sinus  Tlirombosis 
on  the  Other  Side. — Knapp  {Arch,  of  Otol.,  xxi,  3)  reports  a 
case  occurring  in  a  young  woman  who  suffered  from  repeated 
attacks  of  naso  pharyngeal  catarrh,  extending  into  both  ears, 
for  about  a  year.  The  left  ear  recovered.  The  fourth  and  later 
attacks  showed  implication  of  the  right  mastoid,  with  marked 
meningitic  irritation.  The  upper  part  of  the  sterno-cleido-raas- 
toid  muscle  became  red,  swollen,  and  painful.  Ten  days  after 
her  conlinement  a  deep  incision  was  made  into  the  swollen  head 
of  the  muscle,  liberating  a  quantity  of  pus.  Tlie  relief  being 
only  temporary,  the  mastoid  was  opened  from  base  to  tip,  and 
the  wound  kept  open  by  a  perforated  silver  tube.  The  patient 
felt  relieved  and  comparatively  well  for  two  weeks.  Then 
symptoms  of  cerebral  irritation  returned  and  lasted  until  her 
death,  three  months  later.  These  symptoms  were  persistent 
headache,  nausea,  occasional  vomiting,  dizziness,  stupor,  impair- 


ment of  speech,  loss  of  appetite,  and  constipation.  The  pulse 
at  first  varied  between  70  and  88,  later  sank  to  GO.  The  tem- 
perature varied  between  98*4°  and  100°.  There  were  no  con- 
vulsions, delirium,  chills,  or  abnormal  sensation.  The  ear  never 
gave  her  any  more  trouble,  and  there  was  never  any  discharge 
from  the  canal,  though  the  drum-head  was  red  and  bulging. 
Two  months  before  death  a  swelling  was  noticed  below  the  head 
of  the  sterno-mastoid  muscle  on  the  other  side.  The  left  ear 
remained  liealthy.  Optic  neuritis  developed  in  both  eyes  dur- 
ing the  last  months  of  life.  Craniotomy  was  done  the  day  be- 
fore she  died.  The  opening  in  the  mastoid  was  enlarged  and 
extended  into  the  cranial  cavity.  The  dura  mater  and  lateral 
sinus  were  found  healthy.  Then  the  wound  was  extended  into 
the  tympanic  attic,  but,  no  pus  being  found  here  and  the  bone 
being  thick  and  hard,  the  middle  cranial  fossa  was  opened 
through  the  squamous  portion  of  the  temporal,  just  above  the 
auditory  canal.  There  was  no  extradural  suppuration,  and  the 
dura  mater  and  superficial  layers  of  the  brain  were  healthy. 
She  lived  about  an  hour  after  the  operation.  The  autopsy 
showed:  1.  Perforation  in  the  medial  bony  surface  of  the  tip  of 
the  mastoid.  2.  The  upper  part  of  the  drum  filled  with  granu- 
lation tissue.  3.  The  right  lateral  sinus  healthy.  4.  The  dura 
healthy  throughout.  5.  The  pia  mater  of  the  right  temporal 
lobe  and  right  cerebellar  hemisphere  milky  and  its  small  veins 
filled  with  pus.  6.  The  smuses  in  the  median  line,  those  adja- 
cent to  the  median  line  on  the  right  side,  and  all  the  sinuses  on 
the  left  side,  and  the  left  internal  jugular  vein,  were  filled  with 
pus.  7.  In  the  right  temporal  lobe  an  abscess  as  large  as  a  wal- 
nut, and  in  the  right  cerebellar  hemisphere  another  of  the  same 
size.  8.  Microscopic  si)ecimens  and  cultivations  from  the  cra- 
nal  abscesses  showed  small  bacilli  and  the  Staphylococcus  au- 
reus. 

Two  Unusual  Cases  of  Intracranial  Inflammation  fol- 
lowing Purulent  Otitis  Media  with  Mastoiditis.— Bench 
{Arch,  of  OtoL,  xxi,  3),  in  reporting  two  cases  of  the  above 
nature,  refers  to  the  great  danger  in  such  cases  of  the  intra- 
cranial structures  being  involved  in  the  inflammatory  process,, 
from  the  extension  of  the  itiflammation  from  the  external  sur- 
face of  the  temporal  bone.  In  rare  cases  the  pus  formed  in  the 
middle  ear  or  mastoid  appears  beneath  the  periosteum,  giving 
rise  to  the  ordinary  post-auricular  abscess.  The  symptoms  are 
then  apt  to  abate  somewhat,  since  the  tension  is  relieved.  Dur- 
ing tills  interval,  however,  the  pus  burrows,  dissecting  up  the 
periosteum  over  a  large  area,  and  thus  depriving  it  greatly  of 
its  nutrition.  The  next  step  is  a  necrosis  of  this  bone  over  a 
small  area,  and,  as  the  small  sequestrum  breaks  down,  pus  is  ab- 
sorbed by  the  dura  mater  and  a  meningitis  set  up.  It  is  not 
necessary  even  for  necrosis  to  occur  in  order  to  set  up  a  men- 
ingitis, for  numerous  venous  channels  exist  between  the  ex- 
ternal and  internal  periosteum  which  can  easily  carry  the  in- 
fection to  the  interior  of  the  cranial  bones.  In  young  children, 
before  the  ossification  of  the  petro-squamous  suture,  infection 
is  especially  liable  to  take  place ;  for,  in  many  instances,  this 
suture  incloses  a  fold  of  dura  mater,  which  increases  the  chance 
of  infection. 

The  first  case  reported  was  that  of  a  child,  aged  ten  months, 
in  whom,  although  the  mastoid  cortex  had  been  perforated  at 
the  operation  and  satisfactory  communication  with  the  middle 
ear  established,  yet  during  the  time  in  which  the  post-auricular 
abscess  remained  unopened,  the  perios'eum  had  been  stripped 
from  the  bone  over  a  largo  area,  which  subsequently  failed  to 
regenerate.  In  this  way  perforation  at  the  sutural  line  took 
place,  and,  as  the  external  opening  over  the  mastoid  gradually 
closed,  infection  occurred  through  the  sutural  perforation  from 
the  pus  within  the  abscess  cavity,  leading  to  meningeal  inflam- 
mation and  disintegration. 


Jan.  21,  1893.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


01 


The  second  case  occurred  in  a  man,  aged  forty,  and  at  the 
autopsy  a  haimorrha^tic  pachymeningitis  was  found  extending 
over  the  entire  right  side,  but  most  marked  over  the  frontal  and 
teinporo-splienoidal  regions.  There  was  also  a  small  amount  of 
pus  on  the  intern;il  surface  of  the  dura.  Tlie  hrain  was  normal. 
Here  the  ()ns  from  the  middle  ear  not  being  able  to  find  an  exit 
through  the  mastoid  colls,  owing  to  existing  osteo-sclerosis,  dis- 
sected up  the  periosteun)  of  the  external  auditory  canal  and, 
entering  the  temporal  fossa,  burrowed  benenth  the  periosteum, 
■denuding  the  squamous  and  mastoid  portions  of  the  temporal 
bone  over  a  large  area,  and  causing  a  circumscribed  necrosis  of 
the  squamous  portion  of  the  temporal  bone.  Meningitis  then 
followed  and  assumed  the  lipemorrljagic  form. 

Destruction  and  Partial  Ossification  of  both  Laby- 
rinths, probably  in  consequence  of  Meningitis.— Steinbriigge 
{Arch,  of  Otol.,  x'si,  3)  reports  the  case  of  a  ten-year-old  boy 
who  was  brought  to  the  hospital  comatose  and  died  the  next 
day.  At  the  autopsy  the  macroscopic  examination  of  the  ears 
showed  a  large  perforation  in  the  right  membrana  tympani, 
with  sclerosis  of  the  mastoid.  There  was  a  cicatrix  in  the  left 
membrana  tympani,  with  thickening  of  the  tympanic  mucous 
membrane  and  of  that  of  the  labyrinth  and  antrum.  In  the 
loft  cochlea  the  lower  turn  was  plugged  with  connective  tissue 
ant]  newly  formed  bono.  The  ligamentum  spirale  was  partly 
ossified  and  separated  from  the  scalse.  The  connective  tissue 
extended  into  the  aquaeductus  cochleaB.  The  nerve  fibers  of 
the  acoustic  nerve  in  the  internal  auditory  canal  were  preserved 
in  places.  At  the  entrance  of  the  central  canal  of  the  modiolus 
the  nerve  fibers  were  alrao-t  entirely  destroyed.  The  vestibule, 
ampullaa,  and  semicircular  canals  were  partly  filled  with  con- 
nective tissue  and  partly  with  bony  tissue,  the  ossification  being 
furthest  advanced  in  the  semicircular  canals.  The  right  laby- 
rinth showed  in  general  the  same  changes  as  the  left. 

Sinus  Thrombosis,  attended  with  Remarkable  Ocular 
Symptoms. — Sheild  {Arch,  of  Otol.,  xxi,  3)  reports  the  case 
of  a  man,  aged  thirty- five,  who  had  long  suffered  from  right 
otorrhcea.  The  right  eye  was  more  prominent  than  the  left. 
There  was  complete  right  ptosis,  followed  three  days  later  by 
left  ptosis,  and  there  was  occasionally  slight  delirium.  The  pa- 
tient had  a  dry,  cracked  tongue,  and  lay  in  a  drowsy  state.  The 
exophthalmos  was  so  marked  as  to  suggest  the  presence  of  tu- 
mors in  the  orbit.  The  lids  were  greatly  swollen  and  the  left 
iris  was  dilated  and  immovable.  Well-marked  optic  neuritis 
was  present  in  both  eyes.  A  thrombosed  vein  existed  at  the 
root  of  the  nose.  The  discharge  from  the  right  ear  was  pro- 
fuse, the  drum  head  was  destroyed,  and  the  drum  cavity  tilled 
with  granulations.  There  was  no  cedema  or  tenderness  over  the 
mastoid,  but  there  was  distinct  fullness  and  local  tenderness  over 
the  upper  part  of  the  jugular  vein.  The  thrombosed  vein  at 
the  root  of  the  nose  suppurated  ju>t  before  the  patient's  death. 
The  exophthalmia  undoubtedly  depended  on  venous  engorge- 
ment, due  to  blocking  of  the  cavernous  sinuses  by  clots,  which 
extended  by  way  of  the  petrosal  and  transverse  sinuses  from 
the  right  lateral  sinus.  The  angular  and  frontal  veins  were 
also  thrombosed.  The  evident  implication  of  the  third  nerve 
on  the  left  side  was  due  to  pressure  in  the  cavernous  sinus.  The 
right  facial  paralysis  was  due  to  direct  implication  of  the  trunk 
of  the  seventh  nerve  in  the  aqueduct  of  Falloppius.  Tho  origin 
of  the  mischief  was  caries  of  the  right  mastoid  and  throm- 
bosis of  the  lateral  sinus.  There  were  three  small  absce^ses 
in  the  cerebral  cortex,  and  a  fourth  in  the  right  corpus  stria- 
tum, embolic  in  origin.  The  ophthalmic  veins  were  full  of 
firm  thrombi.  The  cavernous  and  petrosal  sinuses  were  full 
of  pus. 

Head  Injuries  with  Aural  Complications.— Shopi)ard 
{Arch,  of  Otol.,  xxi,  3)  makes  tho  following  points:  1.  The  di- 


vision made  by  Buck  of  fractures  of  the  temporal  bone  into  (1) 
fracture  or  diastasis  of  the  tympanic  or  squamous  portion,  in  the 
region  of  the  middle  ear,  without  implication  of  the  pars  pe- 
trosa,  and  (2)  fracture  of  both  the  tympanic  and  petrous  bones, 
is  both  tenable  and  practical. 

2.  Fractures  of  the  temporal  bone,  without  fatal  conse- 
quences and  even  without  loss  of  hearing,  occur  more  frequent- 
ly than  is  generally  believed. 

3.  In  all  cases  of  suspected  fracture  of  this  part  of  the  skull 
a  thorough  examination  should  be  made  of  the  external  audi- 
tory canal,  membrana  tvmjiani,  and  tympanic  cavity. 

Note  on  the  Operation  for  reforming  the  Auditory 
Meatus. — Gilford  {Arch,  of  OtoL,  xxi,  3)  reports  briefly  th« 
case  of  a  patient  with  lupus  of  (he  left  auricle  and  adjacent 
tissues,  whose  auditory  canal  was  so  filled  up  with  cicatricial 
tissue  that  he  had  for  months  maintained  an  opening  for  the 
exit  of  the  slight  purulent  discharge  only  by  keeping  a  small 
quill  constantly  i)ressed  down  into  what  was  left  of  the  meatus. 
Under  chloroform  the  cicatricial  tissue  and  granulations,  which 
entirely  filled  the  canal,  were  cut  out,  together  with  a  large 
tuberculous  nodule,  extending  deeply  into  the  tissues  at  the 
junction  of  the  pinna  with  the  cheek.  The  canal  was  then 
thoroughly  scraped  with  a  sharp  spoon,  and,  after  having  been 
cleaned  with  hydrogen  peroxide,  it  was  plastered  throughout 
with  thin  Thiersch  flaps  taken  from  the  forearm.  Aristol  was 
then  filled  in  around  a  small  glass  tube  which  reached  nearly  to 
the  middle  ear,  and  a  moist  dressing  was  then  applied  and 
left  for  two  days.  The  flaps  healed  perfectly,  and  for  several 
weeks  tho  man  had  a  well-formed  canal  lined  with  healthy  epi- 
thelium. 

An  injection  of  tuberculin  led  to  the  discovery  of  a  tubercu- 
lous deposit  in  the  mastoid  cells,  the  eradication  of  which  de- 
manded the  destruction  of  the  greater  part  of  the  recently 
formed  canal. 

The  Anatomy  and  Embryology  of  the  Middle  Ear  in 
Man  and  the  Mammalia.— Dreyfuss  {Arch,  intemat.  de  la- 
ryngologie,  de  rhinologie  et  d'otologie,  Sept.-Oct.,  1892)  gives 
the  following  results  of  his  investigations  :  1.  The  malleus  and 
the  incus  are  derived  from  the  first  visceral  arch  and  represent 
the  proximal  extremity.  2.  The  blastema  of  the  proximal  ex- 
tremity of  the  first  visceral  arch  is  contiguous  to  the  blastema 
of  the  ring  of  the  stapes.  3.  Later  the  blastema  of  the  proxi- 
mal extremity  of  the  first  visceral  arch  is  transformed  into  the 
foetal  connective  tissue  of  the  tympanic  cavity.  4.  The  handle 
of  the  malleus  and  the  inferior  branch  of  the  incus  are  de- 
veloped simultaneously  from  the  common  ring  of  the  skeleton 
of  the  first  visceral  arch.  5.  The  upper  branch  or  process  of 
the  incus  is  developed  later.  6.  The  ring  of  the  stapes  is 
found  at  first  free  in  the  mesodermal  connective  tissue.  7.  The 
ring  of  the  stapes  is  situated  between  the  proximal  blastema 
of  the  first  visceral  arch  and  the  proximal  blantema  of  the  sec- 
ond. 8.  In  the  prechondral  capsule  of  the  labyrinth  there  are 
early  formed  two  distinctly  defined  zf)nes:  one  oval  lamina,  that 
of  the  oval  window;  and  one  round  lamina,  that  of  tiie  round 
window.  9.  The  preohondrium  of  the  round  window  is  changed 
directly  into  connective  tissue.  10.  The  orbicular  ligament  of 
the  base  of  the  stapes  is  formed  chiefly  from  the  prechondrium 
of  the  oval  window  and  from  certain  cells  of  connective  tissue. 
11.  The  ring  of  the  stapes  forms  alone  the  future  btai)es.  12. 
The  lenticular  apophysis  of  the  incus  is  not  an  independent  for- 
mation, but  merely  the  extreme  end  of  the  inferior  process  of 
the  incus.  13.  The  communication  between  the  extremity  of 
Reichert's  cartilage  and  tho  capsule  of  the  semicircular  canak 
is  formed  by  means  of  an  intercalary  piece.  14.  Tho  styloid 
apophysis  of  Politzer  is  composed  of  tho  proximal  end  of  Reich- 
ert's cartilage,  of  the  intercalary  piece,  and  of  the  limiting  zone 


92 


MISCELLANY. 


[N.  Y.  Med.  Joub. 


of  the  capsule  of  the  semicircular  canals.  15.  The  drum  mem- 
brane is  situated  in  the  first  branchial  fissure,  and  is  con)i)Osed 
in  the  beginning  of  three  layers.  16.  The  middle  layer  of  the 
drum  membrane  is  a  non-os-ified  part  of  the  tympanic  ring. 
17.  The  external  auditory  canal  is  formed  by  the  development 
of  a  fold ;  the  drum  membrane  is  at  first  a  part  of  the  facial 
wall.  18.  The  slender  process  of  the  malleus  unites  in  man, 
at  the  sixth  month  of  foetal  life,  with  the  bony  neck  of  the 
malleus.  19.  The  upper  part  of  the  future  tympanic  cavity  is 
filled  in  the  fa5tus  with  mucous  tissue,  in  which  are  inclosed  the 
ossicles.  20.  The  handle  of  the  malleus  is  early  developed  by 
a  lacuna  between  the  situation  of  the  temporal  scale  or  shell 
and  that  of  the  tympanic  ring.  21.  The  fissure  of  Rivinus  and 
the  membrana  flaccida  of  Shrapnel!  mark  the  point  of  exit  of 
the  handle  of  the  malleus  from  the  upper  part  of  the  tympanum. 
22.  The  fissure  of  Rivinus  does  not  exist  at  any  period  of  either 
intra-uterine  or  extra-uterine  life. 


l[t  i  s  f  f  1 1  a  n  5 . 


The  Bacteriological  Investigation  of  Supposed  Cholera  Cases. — The 

directors  of  the  Carnegie  Laboratory  of  the  Bellevue  Hospital  Medical 
College,  Dr.  A.  Alexander  Smith  and  Dr.  Frederic  S.  Dennis,  have 
issued  the  following  announcement : 

"  In  view  of  the  possible  advent  of  cholera  to  this  country  during 
the  coming  summer  and  the  great  importance  of  biological  examina- 
tions in  the  diagnosis  of  this  disease,  the  directors  of  the  Carnegie 
Laboratory  announce  that  they  have  arranged  for  short  courses  on  this 
subject,  to  be  open  to  representatives  of  health  boards,  health  officers,  and 
properly  accredited  medical  men.  It  is  designed  that  these  courses 
shall  have  the  same  general  scope  and  fulfill  the  same  purpose  as  the 
cholera  courses  given  at  the  Hygienic  Institute  in  Berlin  by  Professor 
Robert  Koch  in  1886  and  1887.  They  will  be  under  the  direction  of 
Dr.  Edward  K.  Dunham,  who  has  worked  considerably  on  cholera  in 
Germany  and,  recently,  in  this  country. 

"  It  is  extremely  desirable  that  there  should  be  medical  men  through- 
out the  country  who  are  trained  in  the  biological  diagnosis  of  epidemic 
cholera,  so  that  if  doubtful  cases  appear  in  any  locality  there  may  be 
at  hand  men  competent  to  at  once  make  satisfactory  biological  examina- 
tions. The  first  cases  of  Asiatic  cholera  in  the  beginning  of  an  epi- 
demic are  always  doubtful  cases,  and  it  is  only  by  means  of  biological 
examinations  that  a  definite  conclusion  can  be  reached  as  to  their 
nature. 

"The  courses  will  begin  about  the  20th  of  January,  1893,  and  each 
course  will  continue  for  about  two  weeks.  The  fee,  to  cover  expenses 
incurred,  will  be  $23.  Applications  for  admission  to  the  courses  should 
be  made  in  advance  to  the  directors  of  the  Carnegie  Laboratory." 

The  Segistration  of  Physicians,  Midwives,  and  Pharmacists  ac- 
cording to  Local  Legislation. — AVe  are  indebted  to  Dr.  R.  Harvey 
Reed,  of  Mansfield,  Ohio,  for  a  copy  of  the  new  ordinance  adopted  by 
that  city  to  the  following  effect : 

It  shall  be  the  duty  of  every  physician,  midwife,  and  pharmacist 
practicing  in  the  city  of  Mansfield,  Ohio,  to  register  in  a  suitable  book 
prepared  therefor  by  the  health  officer,  which  register  shall  contain 
the  name,  the  street  address,  the  college  at  which  sai<l  physician,  mid- 
wife, or  pharmacist  graduated,  and  date  of  said  graduation,  and,  fur- 
ther, that  on  and  after  the  adojition  of  this  ordinance  no  person  shall 
be  permitted  to  practice  the  art  of  medicine,  suigory,  midwifery,  phar- 
rnacv,  or  denti.^try  or  sell  medicine  or  drugs  from  house  to  house  or  on 
the  streets  without  registering  with  the  liealth  officer,  and  furnishing 
him,  when  bo  required,  a  sample  bottle  of  the  medicine  to  be  sold  for 
analysis,  and  displaying  to  him  a  certificate  from  the  State  Board  of  Phar- 
macy, in  the  case  of  druggists,  or  a  diploma  of  graduation  from  a  rec- 


ognized chartered  medical  or  dental  school,  in  the  case  of  a  physician, 
surgeon,  midwife,  or  dentist. 

And  that  such  persons  shall  not  fje  eligible  to  receive  a  license 
from  an}'  city  officer  until  he  has  displayed  the  above-mentioned  docu- 
ments or  drugs,  as  the  case  may  be,  to  the  health  officer  and  received  a 
certificate  from  him  to  the  proper  city  officer,  who  then  shall  have  the 
privilege  of  issuing  the  said  person  the  necessary  license,  which  shall 
not  be  less  than  $10  or  more  than  $50  a  day. 

And,  further,  that  any  person  violating  this  ordinance  shall  be  suh- 
ject  to  a  fine  of  not  less  than  $50  or  more  than  $100  for  each  offense. 

In  the  selling  of  drugs,  this  ordinance  is  not  intended  to  apply  to 
regularly  recognized  traveling  salesmen  who  deal  directly  with  the  phy- 
sicians or  druggists  of  the  city. 

The  New  York  Academy  of  Medicine. — At  the  next  meeting  of  the 
Section  in  Laryngology  and  Rhinology,  on  Wednesday  evening,  the  25th 
inst..  Dr.  Robert  C.  Myles  will  read  a  paper  on  Diseases  of  the  Acces- 
sory Smuses ;  the  Treatment  and  Indications  for  Operation. 

At  the  next  meeting  of  the  Section  in  Obstetrics  and  Gynecology, 
on  Thursday  evening,  the  26th  inst..  Dr.  E.  H.  Grandin  will  read  a  paper 
entitled  A  Clinical  Study  of  Puerperal  Peritonitis. 


ffo  Contribatora  and  Correspondents. —  The  attention,  of  all  who  pui-potf 

favoring  us  with  commuiiications  is  respectfully  called  to  the  follow- 
ing : 

Authors  of  articles  intended  for  publication  under  t/ie  head  of  "  original 
contributions  "  are  respectfully  informed  tliat,  m  accepting  such  arti- 
cles, we  always  do  so  with  the  understanding  that  the  following  condi- 
tions are  to  be  observed :  (i)  when  a  manuscript  is  sent  to  this  jour- 
nal, a  similar  manuscript  or  any  abstract  thereof  rmist  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  ;  (S)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revisio7i,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specif  ed  issue  ;  {3)  any 
conditions  which  an  author  ivishcs  complied  with  must  be  distincth' 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  tlie  mamiscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  tJieir  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  unth  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
I  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.  Ko  at" 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor- 
respondents  asking  for  informalicyn  that  we  are  capable  of  giving, 
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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  ivill  confer  a  favor  by  keeping  us  in- 
formed o  f  the  dates  of  their  .'societies'  regular  meetings.  Brief  notiJL 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet- 
ings will  he  inserted  when  they  are  received  in  time. 

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to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  wc  shall  take  pleasure  in 
'  inserting  the  substance  of  such  communications. 

All  communications  in/ended  for  the  editor  should  be  addressed  to  him 
in  care  of  tlu-  publishers. 

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dressed to  tKe  publishers. 


THE  I^EW  YORK  MEDICAL  JOURNAL,  January  28,  1893. 


Original  Commumcations. 


ON  CERTAIN  ORGANIC  EXTRACTS: 

THEIR  PREPARATION 
AND  PHYSIOLOGICAL  AND  THERAPEUTICAL  EFFECTS. 

By  WILLIAM  A.  HAMMOND,  M.  D., 

SUROEON-GKNERAL,  U.  8.  ARMY  (rETIBKD  LIST). 

Since  the  experiments  of  Brown- Sequard,  more  than 
three  years  ago,  observers  in  various  parts  of  the  world  have 
been  engaged  in  similar  investigations,  not  only  with  the 
juice  of  the  testicles,  but  with  extracts  obtained  from  other 
glands  of  the  body.  So  far,  however,  as  I  am  aware,  no 
systematic  researches  have  been  undertaken  along  the  line 
of  those  the  details  of  which  I  am  about  to  give,  and  with 
which  I  have  been  occupied  almost  continuously  since  the 
summer  of  1S89. 

In  the  New  York  Medical  Journal  for  August  31,  1889, 
I  published  a  report  of  some  of  the  results  obtained  by  me 
with  the  expressed  juice  of  the  testicles  of  the  ram.  The 
cases  reported  were  one  of  traumatic  neuritis,  which  was 
entirely  cured  by  one  injection,  after  having  lasted  longer 
than  a  year ;  two  of  cardiac  weakness,  with  some  of  the 
symptoms  of  so-called  neurasthenia,  one  of  which  has  re- 
mained entirely  cured  without  subsequent  treatment,  and 
the  other  (Case  II),  after  repeated  injections  at  different 
periods,  is  now  entirely  well ;  one  of  sexual  impotence,  in 
which  there  has  been  no  relapse  ;  two  of  muscular  rheuma- 
tism and  lumbago,  which  have  remained  cured ;  one  of 
hemiplegia,  the  result  of  cerebral  hajmorrhage,  in  which  the 
patient  was  improved  in  walking,  as  reported,  but  who  sub- 
sequently died  from  a  second  attack  ;  one  of  melancholia, 
with  fixed  delusions,  which  underwent  no  improvement  and 
of  which  I  know  nothing  subsequently ;  and  one  patient 
suffering  from  cardiac  asthma,  the  result  of  excessive  men- 
tal work,  and  whose  cure  has  continued  to  this  day. 

In  regard  to  these  cases  I  said  : 

"  It  is  not  necessary  for  me  to  draw  any  conclusions 
from  these  experiments,  as  they  speak  for  themselves.  It 
will  be  seen  that  there  is  evidence  to  show  that  we  have  in 
the  testicular  juice  a  valuable  addition  to  our  materia  medi- 
ca,  the  precise  worth  of  which,  however,  it  is  not  yet  in  our 
power  to  establish." 

So  far,  I  have  nothing  to  retract  from  what  was  stated 
in  the  article  in  question ;  but  the  paragraph  before  the 
final  one  I  am  obliged,  as  the  result  of  much  more  exten- 
sive observation,  to  take  back,  so  far,  at  least,  as  it  ex- 
presses a  preference  for  the  expressed  and  fresh  juice.  It 
is  as  follows  : 

"  One  point  further  seems  to  call  for  some  consideration. 
I  have  observed  that  some  of  the  experimenters  sterilize  the 
testicular  juice  before  using  it.  If  there  is  any  virtue  what- 
ever in  the  liquid,  it  would  be  entirely  destroyed  by  such  a 
process.  It  might  as  well  be  boiled  as  sterilized.  Experi- 
ments with  such  a  substance  are  absolutely  valueless.  Suf- 
ficient immunity  against  the  propagation  of  disease  can  be 
obtained  by  examining  the  fluid  microscopically  before  it 


is  injected  into  the  system.  Whatever  is  capable  of  killing 
the  germs  of  disease  would  be  equally  capable  of  killing  the 
vital  germs  upon  which  the  testicular  juice  depends  for 
whatever  efficacy  it  may  jjossess." 

So  far  from  these  statements  being  correct,  I  am  satis- 
fied that  the  method  I  am  about  to  describe  results  in  the 
procuring  of  a  far  more  powerful  agent  than  is  the  fresh 
juice,  and  that  the  latter  can  not  always  be  used  with  safety, 
liable  as  it  is  to  produce  local  abscesses  and  serious  consti- 
tutional disturbance.  In  more  than  a  third  of  the  cases  in 
which  I  have  used  it  abscesses  were  produced,  and  in  sev- 
eral painful  swelling  of  the  arm  into  which  the  injection 
was  thrown,  with  fever,  and  in  one  case  delirium. 

Since  that  time  I  have  not  only  continued  to  use  the 
extract  of  the  ram's  testicles  in  those  cases  in  which  I  con- 
ceived it  to  be  indicated,  but  have  extended  my  observa- 
tions to  a  study  of  the  influence  exerted  on  the  human 
body  by  the  extract  of  other  organs,  especially  that  of  the 
brain,  the  spinal  cord,  the  pancreas,  the  thyreoid  gland, 
and  the  heart.  For  the  three  years  past  I  have  pursued 
these  investigations,  and  if  I  have  not  rushed  into  print  as 
soon  as  some  others  it  is  only  for  the  reasons  that  time  has 
been  required  to  prepare  the  extracts  according  to  the  pro- 
cesses I  have  found  most  advantageous,  and  that  I  did  not 
wish  to  commit  myself  to  opinions  that  further  examina- 
tion might  prove  to  be  erroneous.  The  time  now,  however, 
seems  to  have  arrived  at  which  I  can  lay  the  main  points 
of  my  researches  before  the  medical  profession.  I  do  not 
give  them  all  at  this  time,  for  I  have  not  yet  reached  defi- 
nite conclusions  in  regard  to  all  the  matters  embraced  with- 
in the  line  of  my  investigations.  I  state,  however,  suffi- 
cient to  give  a  clear  idea  of  the  theory  upon  which  they  have 
been  conducted,  and  which,  as  it  will  presently  be  seen,  ad- 
mits of  very  extended  amplification.  I  am  quite  sure  that 
the  system  I  am  about  to  bring  to  the  notice  of  the  profes- 
sion is  not  only  well  founded  in  fact,  but  is  in  accordance 
with  physiological  law,  and  that  we  have  in  it  philosophical 
means  of  combating  disease,  of  which  I  can  only  lay  some 
part  of  the  foundation,  but  which,  through  the  accumula- 
tion of  material  by  other  observers,  will  eventuate  in  the 
erection  of  a  permanent  and  worthy  therapeutical  structure. 

This  system,  briefly  stated,  is  as  follows : 

Organic  beings  possess  the  power  of  assimilating  from 
the  nutritious  matters  they  absorb  the  peculiar  pabulum 
which  each  organ  of  the  body  demands  for  its  develop- 
ment and  sustenance.  The  brain,  for  instance,  selects  that 
part  which  it  requires,  the  heart  the  material  necessary  for 
its  growth  and  preservation,  and  so  on  with  the  liver,  the 
lungs,  the  muscles,  and  the  various  other  organs  of  the 
body.  No  rhistake  is  ever  committed.  The  brain  never 
takes  liver  nutriment,  nor  the  liver  brain  nutriment ;  but 
each  selects  that  which  it  requires.  There  are,  however, 
diseased  conditions  of  the  various  organs  in  which  this 
power  is  lost  or  impaired,  and,  as  a  consequence,  disturb- 
ance of  function,  or  even  death  itself,  is  the  result. 

Now,  if  we  can  obtain  the  peculiar  matter  that  an  organ 
of  the  body  requires  and  inject  it  directly  into  the  blood, 
we  do  away  with  the  performance  of  many  vital  processes. 


94 


HAMMOND:   ON  CERTAIN  ORGANIC  EXTRACTS. 


[N.  Y.  Mkd.  Jouh., 


which  are  accomplished  only  by  the  expenditure  of  a  large 
amount  of  vital  force. 

Let  us  suppose  a  person  suffering  from  an  exhausted 
brain,  the  result  of  excessive  brain-work.  Three  hearty 
meals  are  eaten  every  day,  but,  no  matter  how  judiciously 
the  food  may  be  arranged,  the  condition  continues.  Now, 
if  we  inject  into  that  person's  blood  a  concentrated  extract 
of  the  brain  of  a  healthy  animal,  we  supply  at  once  the 
pabulum  which  the  organ  requires.  Then,  if  under  this 
treatment  the  morbid  symptoms  disappear,  we  are  justified 
in  concluding  that  we  have  successfully  aided  Nature  in 
doing  that  which,  unassisted,  she  could  not  accomplish. 

That  is  the  system.  I  believe  it  is  applicable  not  only 
to  the  brain,  but  to  all  the  other  organs  of  the  body. 

And  yet  I  am  not  quite  sure  that  it  is  entirely  new.  I 
recollect  reading  nearly  forty  years  ago  an  account  of  some 
observations  made  by,  I  think,  a  German  physician  relative 
to  the  treatment  of  diseases  of  the  several  organs  of  the 
body  by  a  system  of  diet  consisting  of  the  corresponding 
organs  of  healthy  animals.  Thus  liver  disease  was  treated 
by  beef's  liver,  heart  disease  by  beef's  heart,  brain  disease 
by  beef's  brain,  and  so  on.  My  memory  seems  to  be  clear 
on  the  main  point,  but  I  have  searched  in  vain  for  the 
paper  to  which  I  refer.  The  fact,  however,  that  the  various 
foods  in  question  were  cooked  and  were  taken  into  the 
stomach  constitutes  a  great  difference  with  the  system 
which  I  am  now  discussing,  both  physiologically  and 
therapeutically,  and  the  results  do  not  admit  of  compari- 
son. The  germ  of  the  idea,  however,  is  the  same,  and  I 
cheerfully  yield  to  my  unknown  proto-observer  whatever 
distinction  may  be  claimed  on  the  score  of  priority. 

Besides,  there  have  been  isolated  observations  made 
within  the  last  two  or  three  years  by  German  and  French 
physicians  which  are  to  some  extent  in  accordance  with 
those  which  I  have  been  conducting,  but  they  do  not  seem  to 
have  led  to  any  definite  results  or  to  have  been  systematic- 
ally carried  out.  Generally  they  have  been  performed  with 
the  fresh  juice  of  the  organs,  and  although  at  first  sight 
this  method  would  appear  to  be  preferable  to  any  other, 
experience  shows  that  it  is,  as  I  have  said,  not  unattended 
with  danger.  Thus  the  organ  may  not  be  entirely  fresh, 
morphological  matter  is  almost  certain  to  be  injected,  it  is 
nearly  impossible  to  filter  the  juice  through  a  porous  stone 
filter,  and  when  passed  through  common  filtering-paper  sub- 
stances injurious  to  its  action  and  provocative  of  local  ab- 
scesses and  constitutional  disturbance  can  not  be  excluded. 
Indeed,  these  results  have  frequently  followed  from  the  ex- 
periments of  others,  and  I  have  myself,  as  I  have  stated, 
often  encountered  them,  notwithstanding  that  all  possible 
care  was  taken  in  the  preparation  and  administration  of  the 
agent.  The  method,  however,  which  I  have  finally  adopted 
never  produces  either  morbid  local  or  general  disturbance 
beyond  a  slight  smarting  at  the  time  of  injection  and  occa- 
sionally a  little  subsequent  itching  and  erythema,  and  it  is 
that  also  from  which  I  have  derived  the  maxima  of  benefi- 
cial effects.  It  has  been  arrived  at  after  many  trials  and 
consequent  disappointments,  and  it  is  one  which,  with  our 
present  knowledge  of  the  subject,  I  do  not  think  can  be  ad- 
vantageously departed  from. 


Taking  the  brain  as  a  type  of  the  process  employed — 
and  it  is  not  materially  varied  with  the  other  organs  of  the 
body — it  is  as  follows  : 

The  whole  brain  of  the  ox,  after  being  thoroughly 
washed  in  water  acidulated  with  boric  acid,  is  cut  into 
small  pieces  in  a  mincing  machine.  To  one  thousand 
grammes  of  this  substance  placed  in  a  wide-mouthed  glass- 
stoppered  bottle  I  add  three  thousand  cubic  centimetres  of 
a  mixture  consisting  of  one  thousand  cubic  centimetres 
each  of  a  saturated  solution  of  boric  acid  in  distilled  water, 
pure  glycerin,  and  absolute  alcohol.  This  is  allowed  to 
stand  in  a  cool  place  for  at  least  six  months,  being  wel 
shaken  or  stirred  two  or  three  times  a  day.  At  the  end  of 
this  time  it  is  thrown  upon  a  porous  stone  filter,  through 
which  it  percolates  very  slowly,  requiring  about  two  weeks 
for  entirely  passing  through.  The  residue  remaining  upon 
the  filter  is  then  inclosed  in  several  layers  of  aseptic  gauze 
and  subjected  to  very  strong  pressure,  the  exudcite  being 
allowed  to  fall  upon  the  filter  and  mixed  with  a  sufficient 
quantity  of  the  filtrate  to  cover  it.  When  it  has  entirely 
filtered  it  is  thoroughly  mixed  with  the  first  filtrate,  and  the 
process  is  complete. 

During  the  whole  of  this  manipulation  the  most  rigid 
antiseptic  precautions  are  taken.  The  vessels  and  instru- 
ments required  are  kept  in  boiling  water  for  several  min- 
utes, and  are  then  washed  with  a  saturated  solution  of 
boric  acid.  Bacteria  do  not  form  in  this  mixture  under  any 
circumstances,  but  it  is  necessary  to  examine  it  from  time 
to  time  microscopically  in  order  to  see  that  no  foreign 
bodies  have  accidentally  entered.  Occasionally,  from 
causes  which  I  have  not  determined,  the  liquid  becomes 
slightly  opalescent  from  the  formation  of  a  llocculent  pre- 
cipitate. This  is  albuminous  in  its  character.  It  some- 
times takes  place  in  a  portion  of  the  extract  kept  under 
apparently  identical  conditions  with  other  portions  that 
remain  perfectly  clear.  It  is  certainly  not  an  essential  con- 
stituent. It  can  be  entirely  removed  by  filtration  through 
Swedish  filtering  paper  previously  rendered  antiseptic  with- 
out the  filtrate  losing  any  of  its  physiological  or  therapeu- 
tical power. 

Five  minims  of  this  extract  diluted  at  the  time  with 
a  similar  quantity  of  distilled  water  constitute  a  hypodermic 
dose. 

The  most  notable  effects  on  the  human  system  of  a 
single  dose  are  as  follows,  though  in  very  strong,  robust, 
and  large  persons  a  somewhat  larger  dose  is  required, 
never,  however,  exceeding  ten  minims  : 

1.  The  pulse  is  increased  in  the  course  of  from  five  to 
ten  minutes,  or  even  less  in  some  cases,  by  about  twenty 
beats  in  a  minute,  and  is  rendered  stronger  and  fuller.  At 
the  same  time  there  is  a  feeling  of  distention  in  the  head, 
the  face  slightly  flushed,  and  occasionally  there  is  a  mild 
frontal,  vertical,  or  occipital  headache,  or  all  combined, 
lasting,  however,  only  a  few  minutes. 

2.  A  feeling  of  exhilaration  is  experienced  which  en- 
dures for  several  hours.  During  this  period  the  mind  is 
more  than  usually  active  and  more  capable  of  effort.  This 
condition  is  so  well  marked  that  if  the  dose  be  taken  at 
about  bedtime  wakefulness  is  the  result. 


Jan.  28,  1893.J 


HAMMOND':   ON  CERTAIN  ORGANIC  EXTRACTS. 


95 


3.  The  quantity  of  urine  excreted  is  increased  when 
other  things  are  equal  by  from  eight  to  twelve  ounces  in 
the  twenty-four  hours. 

4.  The  expulsive  force  of  the  bladder  and  the  peristaltic 
action  of  the  intestines  are  notably  augmented — so  much  so 
that  in  elderly  persons  in  whom  the  bladder  does  not  read- 
ily empty  itself  without  considerable  abdominal  effort,  this 
action  is  no  longer  required,  the  bladder  discharging  itself 
fully  and  strongly,  and  any  existing  tendency  to  constipa- 
tion disappears,  and  this  to  such  an  extent  that  fluid  opera- 
tions are  often  produced  from  the  rapid  emptying  of  the 
small  intestine. 

5.  A  decided  increase  in  the  muscular  strength  and  en- 
durance is  noticed  at  once.  Thus  I  found  in  my  own  case 
that  I  could  "put  up"  a  dumb-bell  weighing  forty- five 
pounds  fifteen  times  with  the  right  arm  and  thirteen  times 
with  the  left  arm,  while  after  a  single  dose  of  the  extract  I 
could  lift  the  weight  forty-five  times  with  the  right  arm  and 
thirty-seven  times  with  the  left  arm. 

6.  In  some  cases  in  elderly  persons  an  increase  in  the 
power  of  vision  is  produced  and  the  presbyopic  condition 
disappears  for  a  time. 

7.  An  increase  in  the  appetite  and  digestive  power. 
Thus  a  person  suffering  from  anorexia  and  nervous  dyspep- 
sia is  relieved  of  these  symptoms,  temporarily  at  least,  after 
a  single  dose  hypodermically  administered. 

These  effects  are  generally  observed  after  one  hypoder- 
mic injection,  and  they  continue  for  varying  periods,  some 
of  them  lasting  for  several  days.  In  order  that  they  may 
be  lasting,  two  doses  a  day  should  be  given  every  day  or 
every  alternate  day  as  may  seem  necessary,  one  in  the  morn- 
ing and  one  in  the  afternoon,  and  kept  up  as  long  as  the 
case  under  treatment  seems  to  require.  The  most  notable 
effects  are  seen  in  the  general  lessening  of  the  phenomena 
accompanying  advancing  years.  When  some  special  dis- 
ease is  under  treatment  the  indications  for  a  cessation  of 
the  injections  will  be  sufficiently  evident  either  by  an  ame- 
lioration or  cure  or  a  failure  to  produce  these  results. 

To  the  substance  obtained  in  the  manner  mentioned  and 
held  in  solution  I  have  given  the  name  of  cerebrine  as  the 
one,  in  view  of  its  origin,  most  appropriate. 

I  have  employed  the  solution  of  "  cerebrine  "  with  de- 
cided advantage  in  cases  of  nervous  prostration — the  so- 
called  neurasthenia — in  insomnia  due  to  cerebral  hyperiemia, 
in  migraine,  hysteria,  general  paresis,  hebephrenia,  and  epi- 
lepsy. In  these  latter — two  cases  of  the  petit-mal  variety — 
the  effect  has  been  so  marked  that  I  am  not  without  the 
hope  that  cures  will  result,  although  I  am  not  able  as  yet  to 
speak  positively  on  this  point,  the  patients  having  been  less 
than  a  month  under  treatment.  In  two  cases  of  the  grand 
mal  the  number  of  paroxysms  has  been  reduced  more  than 
one  half  and  greatly  mitigated  in  severity.  In  six  other 
cases  which  were  of  long  duration  I  could  perceive  no  cura- 
tive effect. 

In  the  case  of  general  paresis  no  permanent  therapeu- 
tical influence  was  apparent,  'though  for  several  days  the 
delire  de  grandeur  was  absent.  In  the  case  of  hebephrenia, 
however,  occurring  in  the  person  of  a  young  lady  eighteen 
years  of  age,  the  effect  has  been  most  happy,  the  symptoms 


entirely  disappearing  in  a  little  more  than  a  month's  treat- 
ment. 

In  two  cases  of  nervous  prostration,  the  result  of  long- 
continued  emotional  disturbance  and  in  which  there  were 
great  mental  irritability,  dyspepsia,  physical  weakness,  loss 
of  appetite,  and  constipation,  relief  was  rapidly  afforded. 
In  three  other  cases,  in  which  the  most  notable  symptom 
was  functional  cardiac  weakness,  the  effect  has  been  all  that 
could  have  been  desired.  In  these  cases  it  was  employed 
in  conjunction  with  "  cardine,"  the  extract  of  the  heart  of 
the  ox  made  in  the  manner  already  described. 

It  is  not  ray  intention  at  the  present  time  to  enter  into 
a  full  discussion  of  this  interesting  subject  or  to  allude  fur- 
ther to  experiments  in  the  treatment  of  other  diseases  which 
are  not  yet  concluded.  In  the  near  future  I  shall  enter  more 
largely  into  the  consideration  of  the  subject  in  all  its  details. 
I  may  add,  however,  that  I  have  used  with  excellent  results, 
in  cases  in  which  it  seemed  to  be  indicated,  the  extract  of 
the  testicles  of  the  bull  and  also  that  of  the  pancreas  of 
the  ox,  and  these  investigations  also  will  be  given  to  the 
profession  at  an  early  day. 

It  is  alleged  by  some  medical  writers  that  there  is  no 
difference  in  the  therapeutical  effects  of  medicines  whether 
they  be  taken  directly  into  the  blood  by  hypodermic  injec- 
tion or  ingested  into  the  stomach ;  but  it  is  scarcely  worth 
while  to  seriously  combat  this  assertion.  For,  while  it  may 
be  true  that  some  substances  are  not  altered  by  the  gastric 
juice  before  they  are  absorbed  into  the  system,  it  certainly 
is  not  true  of  many  others,  and  it  surely  is  erroneous  as  re- 
gards those  of  animal  origin.  Indeed  it  is,  I  think,  doubt- 
ful if  anything  capable  of  being  acted  upon  by  the  gastric 
juice  and  of  being  absorbed  into  the  blood  gets  into  the 
system  in  exactly  the  same  form  in  which  it  got  into  the 
stomach. 

Thus  the  vaccine  virus  may  be  swallowed  with  impunity, 
as  may  also  the  poison  of  the  rattlesnake  and  of  other  ani- 
mals secreting  toxic  agents.  Upon  one  occasion  I  gave  a 
young  dog,  by  the  mouth,  twenty  minims  of  fresh  rattle- 
snake poison  without  its  having  the  slightest  perceptible 
effect  upon  him.  I  need  not  say  that  this  quantity  would 
have  been  sufiicient  to  kill  at  least  fifty  men.  Woorara, 
which  is,  as  is  well  known,  fatal  to  animal  life  when  injected 
into  the  blood,  is  innocuous  when  taken  into  the  stomach, 
and  even  those  that  do  possess  some  action  when  swallowed 
exert  this  power  in  much  less  degree  and  require  larger 
doses  for  it  to  be  produced. 

Relative  to  the  animal  extracts  to  which  this  communi- 
cation refers,  I  have  ascertained  beyond  question  that  if 
they  are  inclosed  in  capsules  so  as  to  reach  the  stomach 
without  coming  in  contact  with  the  mucous  membrane  of 
the  mouth,  they  are  absolutely  without  physiological  or 
therapeutical  effect  so  far  as  can  be  perceived,  even  when 
given  in  quantities  of  a  teaspoonful  or  more.  But  if 
dropped  upon  the  tongue  in  double  the  quantity  used  for 
hypodermic  injections,  and  allowed  to  remain  in  the  mouth 
without  being  swallowed — thus  avoiding  the  action  of  the 
gastric  juice — they  are  absorbed,  and  exert  a  slower  but 
still  decided  effect.  If  employed  in  this  manner,  three  or 
four  doses  should  be  taken  daily.    Ten  minims  of  the  solu  - 


DeBLOIS:   the  AFTER-RESULTS  OF  NASAL  CAUTERIZATION.      [N.  Y.  Med.  Joub., 


tion  of  cerebrine  placed  upon  the  tongue  of  a  healthy  person 
will  cause  acceleration  of  the  pulse,  flushing  of  the  face,  and 
slight  headache  in  ten  or  fifteen  minutes,  together  with  the 
other  phenomena  I  have  mentioned. 

I  have  expressed  the  opinion  that  the  substance  extract- 
ed from  the  brain  and  other  organs  is  the  material  required 
for  the  nutrition  of  the  corresponding  organs  of  the  body, 
but  this  is  only  a  theory  to  which  I  am  not  in  the  slightest 
degree  attached,  though  I  think  it  physiological  and  plausi- 
ble. It  may  be  that  the  mixture  of  uric  acid,  alcohol,  and 
glycerin  exerts  a  metamorphic  influence  and  causes  the  for- 
mation of  a  ferment  having  the  power  of  restoring  to  the 
weakened  brain  or  other  viscus  the  lost  or  impaired  power 
of  assimilation.  However  this  may  be,  the  facts  remain 
unaltered. 

Washington,  D.  C,  January  I4,  1893. 


THE  AFTER-RESULTS 
OF  NASAL  CAUTERIZATION.* 
By  THOMAS  AMORY  De  BLOIS,  M.  D., 

BOSTON. 

It  seems  as  if  in  the  majority  of  cases,  if  we  come  to 
tabulate  our  results,  we  are  struck  at  once  by  the  fact  of 
the  small  number  of  patients  in  whom  we  are  able  to  fol- 
low the  results  of  treatment — that  is,  even  immediately 
after  operation.  How  much  more  is  this  true  if  we  seek 
to  know  the  result  of  operation,  say,  one  or  two  years  after- 
ward !  Of  course  it  is  very  flattering  to  our  vanity  to  be- 
lieve that  we  have  so  thoroughly  cured  our  patients  that 
they  do  not  require  any  more  advice.  But,  like  the  child 
6f  the  proverb  who,  once  having  been  burned,  in  future 
dreads  the  fire,  so  it  is  probably  true  that  many  of  them, 
rather  than  again  undergo  the  fiery  ordeal,  seek  some  other 
physician,  whom  they  fondly  believe  will  not  be  so  harsh  in 
his  treatment. 

We  have  all  seen  the  cocainized  membrane  sizzle  and 
fry  under  the  hot  platinum ;  we  have  in  ten  days  to  two 
weeks  thereafter  seen  the  patient  return  with  atrophied 
tissue  and  more  or  less  relieved  of  his  troubles ;  but  in 
how  many  of  these  cases  have  we  been  able  to  say  in 
two  years  in  what  condition  is  the  nose  or  throat  ?  Will 
the  condition  in  which  we  leave  it  continue,  will  atrophy 
progress,  or  will  the  former  hypertrophies  return  ?  You 
will  agree  that  much  depends  on  the  individual's  condition 
and  some  on  the  operation  itself. 

With  regard  to  the  operation,  I  do  not  think  it  makes 
much  difference  whether  the  erosion  is  produced  by  the 
action  of  acids  or  of  the  hot  wire,  heated  either  by  a 
lamp  or  by  the  electric  current.  The  acid  is  a  little  more 
painful  and  for  a  longer  period,  and  its  action  is  more 
difficult  to  limit,  but  the  results  arc  about  the  same.  If 
the  destructive  action  is  carried  on  long  enough  it  will 
produce  effects  as  far  down  as  the  bone  and  there  will 
be  a  buttoning  down  of  the  tissues  in  one  spot — of  course 

*  Read  before  the  American  Laryngological  As.sociation  at  its  foiu-- 
t»;enth  annual  congress. 


the  most  sensitive  and  probably  the  most  salient  that  the 
operator  is  able  to  reach  ;  this  eschar  will  be  prolonged 
front  or  back  according  to  his  fancy,  or  according  to  the 
results  of  his  experience.  Perhaps  the  wound  will  be 
broadened  so  as  to  involve  a  wider  band  of  mucous  mem- 
brane. This  may  result  in  the  first  instance  in  greater 
inflammation  and  the  period  of  healing  may  be  extended 
to  three  weeks.  Or  again  a  series  of  repeated  operations 
may  be  carried  on  and  the  mucous  surfaces  may  thus  be 
extensively  cicatrized.  Allowing  that  perfect  cicatrization 
takes  place  in  about  ten  days,  the  operation  will  proba- 
bly be  repeated,  perhaps  more  than  once,  and  after  this 
the  patient  is  lost  sight  of.  Having  come  upon  a  number 
of  these  cases  one  or  two  years  after  operation,  it  seemed 
as  if  it  might  be  interesting  to  observe  the  subsequent 
changes  which  took  place. 

Case  I. — Miss  M.  N.,  a  patient  whom  I  Lad,  as  I  behaved, 
thoroughly  burned  with  chromic  acid  at  the  Boston  Dispensary 
for  hypertrophy  of  both  lower  turbinated  bones  three  years 
previous,  stated  that  she  had  had  little  trouble  for  about  two 
years,  but  that  then  the  difficulty  of  breatliing  appeared  to  re- 
turn. Both  turbinates  showed  a  broadband  of  cicatricial  tissue, 
but^above  and  below  the  membrane  was  red  and  swollen. 

Case  II. — Mr.  .J.  O.  II. ;  burned  at  dispensary  by  a  colleague 
(galvano-cantery).  In  this  case  the  original  operation  was 
deeper  and  narrower  and  the  original  eschar  was  not  crowded 
to  the  front  as  in  the  first  case,  but  appeared  to  be  in  a  certain 
sense  adherent  to  the  bone.  So  far  as  the  part  burned  went, 
the  operation  remained  perfect,  but  there  was  still  the  prolifera- 
tion of  tissue  on  each  side  of  the  point  of  operation.  The  op- 
eration with  the  cautery  on  these  new  hypertrophies  was  of 
course  repeated. 

Case  III. — T.  O'K.  This  patient  I  remembered  well  as  hav- 
ing showed  signs  of  inflammatory  trouble  after  perhaps  a  too 
free  use  of  the  cautery  knife.  The  liberal  scars  produced  at  the 
time  of  operation  remained  and  he  bad  developed  a  condition 
of  atrophy  of  the  membrane  and  the  consequent  accompanying 
symi)tom  of  foetid  breath.  I  have  not  the  slightest  doubt  but 
this  condition  was  in  some  sense  helped  along  by  too  great  zeal 
in  the  line  of  mucous  destruction. 

Cases  IV  and  V  were  both  similar  to  Case  l—i.  e.,  where 
the  galvano-cautery,  wliich  was  the  instrument  used,  had  not 
been  carried  deep  enough,  the  white  eschar  was  there,  but  it  was, 
so  to  speak,  buoyed  up  by  the  tissues  beneath  until  it  formed 
almost  as  great  a  plug  as  before. 

Case  VI. — Moses  T.  This  was  a  most  peculiar  case.  This 
man  had  been  constantly  under  treatment  for  between  three 
and  four  years,  during  which  time  he  had  vibrated  between  the 
different  hospitals  and  dispensaries  and  bad  developed  the  repu- 
tation of  a  "  hosi)ital  rounder."  He  had  a  nose  of  huge  proportions 
in  the  first  ])lace,  and  this  was  filled  with  the  most  wonderful  de- 
velopment of  mucous  membrane  in  corrugated  folds.  All  this 
had  been  cut  and  snipped  and  burned,  but  without  any  appar- 
ent effect;  the  passageway  through  was  never  sufficiently  clear 
for  use,  and  yet  he  had  been  under  operative  treatment  for 
years. 

But  it  is  needless  to  cite  more  cases.  I  have  merely 
endeavored  to  draw  attention  to  the  different  forms  of 
sequeliB  of  nasal  cauterization.  First,  that  in  which  you 
do  not  burn  enough  and  the  parts  nearly  regain  their  former 
condition ;  second,  in  which  you  do  too  much  and  produce 
a  nose  lined  with  old  scars,  and  between  this  "  Scylla  "  and 


Jan.  28,  1893.] 


BRTAN:  SUPPURATING  ETHMOIDITIS. 


97 


"  Charybdis "  of  course  there  is  smooth  sailing,  but  we 
can  not  always  find  it ;  and,  fourth,  there  are  some  cases 
that  the  cautery  appears  never  to  reach. 


A  CASE  OF  SUPPURATING  ETHMOIDITIS.* 

By  J.  H.  BRYAN,  M.D., 

WASHINGTON. 

The  following  is  a  report  of  an  interesting  case  of  sup- 
puration of  the  ethmoid  cells,  terminating  in  caries,  and  it 
illustrates  a  condition  which  has  been  described  as  rhinitis 
caseosa  : 

In  October,  1891,  Mrs.  ,  aged  twenty-eight,  an  anffltuic 

and  hysterical  woman,  consulted  me.  Slie  gave  a  good  family 
history,  and  stated  that  up  to  the  time  she  contracted  influenza 
in  the  spring  of  1891  she  had  enjoyed  fairly  good  healtii,  and 
that  she  had  been  particularly  free  from  catarrhal  inflamma- 
tions affecting  the  upper  respiratory  tract.  Since  the  attack  of 
influenza,  from  which  she  made  a  very  slow  recovery,  she  has 
liad  what  she  regarded  as  a  severe  cold  in  the  head. 

Id  March  of  the  same  year  she  suffered  from  caries  of  the 
upper  left  second  molar  tooth.  Her  dentist  destroyed  the  nerve 
and  cut  the  tooth  down  in  order  to  apply  a  gold  crown.  She 
was  evidently  handled  roughly,  for  a  severe  alveolar  abscess  de- 
veloped after  the  gold  crown  had  been  fitted.  The  left  side  ot 
the  face  was  intensely  swollen  and  sensitive,  and  she  thought 
her  nasal  symptoms  were  greatly  aggravated. 

In  the  early  part  of  July  the  left  side  of  the  nose  became 
closed,  and  she  has  not  been  able  to  breathe  through  it  since. 
The  secretiaus,  at  first  watery  in  character,  have  become  thick, 
foetid,  and  very  profuse,  discharging  freely  both  from  the  front 
of  the  nose  and  into  the  post-nasal  space.  She  complains  also 
of  an  intense  pain  over  the  bridge  of  the  nose,  extending  along 
the  infra-orbital  ridge  to  the  temporal  region  of  the  left  side. 
Her  headaches  have  been  so  severe  that  slie  has  been  unable  to 
sleep  without  the  aid  of  anodynes.  The  impression  made  upon 
her  general  health  bus  been  very  severe.  She  has  no  appetite, 
and  is  nervous  and  hysterical.  There  is  no  exophtliahnia,  no 
disturbance  of  the  field  of  vision,  or  any  swelling  at  the  inner 
angle  of  the  orbit.  There  is  severe  pain  on  pressure  on  the  eye- 
ball, and  at  the  inner  angle  of  the  orl)it  a  crepitating  sensation, 
perceptible  to  the  patient,  is  jjroduced  by  slight  pressure.  She 
complains  of  pain  and  a  sense  of  pressure  back  of  the  eyeball. 

A  rhinoscopic  examination  showed  the  right  side  of  the  nose 
to  be  in  a  fair  state  of  health,  there  being  only  a  slight  turges- 
cence  of  the  inferior  turbinated  body.  On  the  left  side  two 
medium-sized  mucous  polypi  were  found  attached  to  the  ante- 
rior extremity  of  the  midille  turbinated  bone.  The  inferior  tur- 
binal  was  very  much  swollen  and  partially  blocked  up  the 
vestibule  of  the  nose,  which  was  filled  with  a  thick  caseous  and 
foul-smelling  secretion.  The  polypi  were  removed  with  the 
snare,  and  the  inferior  turbinated  body,  contracted  by  means  of 
cocaine,  allowed  the  middle  turbinated  body,  which  was  greatly 
swollen  and  projected  over  against  the  sseptum,  to  be  brought 
into  view.  A  posterior  rhinoscopic  examination  showed  the 
middle  and  inferior  turbinated  bodies  swollen,  and  the  same 
thick  caseous  secretion  passing  over  the  posterior  extremity  of 
the  nnddle  turbinal  into  the  post-nasal  space.  After  snaring 
off  the  polypi,  the  nose  was  cleared  of  all  secretion  so  that  a 
more  careful  examination  could  be  made.    The  secretion  was 


*  Read  before  the  American  Ijuiyngological  Association  at  its  four- 
teenth annual  congress. 


observed  to  come  both  from  the  middle  meatus  and  from  above 
between  the  middle  turbinated  body  and  the  sfeptum. 

Examination  with  electric  light  showed  the  left  antrum  to 
be  opaque  while  its  fellow  of  the  opposite  side  remained  trans- 
lucent as  high  as  the  infra-orbital  ridge,  thus  revealing  the  fact 
that  the  left  antrum  was  affected  and  complicated  the  inflam- 
mation of  the  ethmoid  cells.  The  nose  was  thoroughly  cleansed 
of  all  secretion,  the  second  molar  tooth  extracted,  and  the  an- 
trum perforated  at  that  point.  Upon  washing  out  the  cavity  it 
was  found  to  contain  about  a  teaspoonful  or  more  of  a  thick, 
muco-purulent  secretion,  dift'ering  ia  character  from  that  ob- 
served in  the  nose.  There  was  some  evidence  of  necrosis 
around  the  buccal  root,  and  upon  breaking  open  the  tooth  the 
pulp  cavity  and  the  roots  were  found  to  contain  decomposing 
nerve  tissue  which  had  not  been  removed,  and  which,  in  all 
probability,  was  the  cause  of  the  inflammation  having  extended 
into  the  maxillary  sinus.  The  inflammation  in  the  antrum  sub- 
sided in  the  course  of  a  week  under  the  local  applications  em- 
ployed, while,  on  the  other  hand,  the  caseous  secretion  showed 
no  tendency  to  diminish  after  the  nose  had  been  treated  daily 
with  the  peroxide  of  hydrogen  and  other  antiseptic  lotions  for 
several  weeks.  The  headache  and  orbital  pains  increased  in  in- 
tensity, and  the  general  health  of  the  patient  continued  to  grow 
worse. 

In  the  mean  time  the  polyi)i  redeveloped  and  were  removed 
as  before  by  means  of  the  snare.  In  doing  so  a  small  spiculum 
of  bone  was  removed  from  the  anterior  extremity  of  the  middle 
turbinated  body,  but  the  opening  made  was  not  sufficiently  large 
to  admit  of  the  abscess  discharging  its  entire  contents.  There 
was  a  slight  increase  in  the  amount,  but  not  enough  to  give  the 
patient  much  relief,  for  she  suffered  intensely  after  the  opera- 
tion and  passed  a  sleepless  night.  The  following  morning,  how- 
ever, as  she  was  on  her  way  to  my  office,  the  abscess  discharged 
spontaneously  a  great  quantity  of  thick  caseous  secretion  both 
from  the  front  of  the  nose  and  into  the  post-nasal  space.  While 
she  was  made  quite  ill  by  the  foetid  mass  passing  into  the  mouth  : 
and  came  near  fainting  in  the  street,  she  experienced  almost 
immediate  relief  from  the  headache  and  pain  in  the  eye. 

When  she  reached  the  office  I  found,  upon  examination,  the 
nose  was  entirely  free  from  secretion;  and  while  the  contour 
of  the  middle  turbinated  body  was  maintained,  it  had  apparently 
been  drawn  outward  toward  the  orbit,  thus  obliterating  the 
middle  meatus.  The  opening  caused  by  the  detachment  of  the 
polypi  could  not  be  found,  and  no  rough  bone  was  detected 
with  the  probe. 

The  patient  was  kept  under  observation  for  ten  days,  and 
during  that  time  the  nose  was  free  from  secretion  ;  the  pain  in 
her  head  and  eye  ceased,  and  her  general  health  improved. 
Within  the  past  week  I  have  had  an  opportunity  of  examining 
the  patient  again,  and  I  found  the  parts  in  much  the  same  con- 
dition as  when  last  examined,  except  that  the  anterior  extremity 
of  the  middle  turbinated  body  seems  to  have  been  drawn  nearer 
to  the  orbit  than  the  rest  of  the  body. 

In  1874  Duplay  (1)  described  an  affection  of  the  nose 
as  rhinitis  caseosa,  a  disease  that  had  been  previously  al- 
luded to  by  Nelaton  (2).  lie  states  that  the  affection  is 
very  rare,  and  is  characterized  by  an  accumulation  in  the 
interior  of  the  nasal  cavities  of  a  caseous  material  analogous 
to  the  contents  of  certain  sebaceous  cysts,  and  that  the  dis- 
ease frequently  goes  unrecognized. 

It  is  evident  that  Duplay  was  mistaken  and  misinter- 
preted the  symptoms  of  the  cases  he  had  under  observa- 
tion, judging  from  the  silence  with  which  the  subject  is 
treated  by  most  of  the  German,  English,  and  American  au- 


98 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Mkd.  Joub., 


thorities.  Potiquet  (3)  denies  the  existence  of  such  a  dis- 
ease, and  states  that  Duplay's  conclusions  were  based  on 
errors  in  diagnosis.  Cozzolino  (4),  on  the  other  hand,  says 
that  it  is  a  very  rare  disease,  and  considers  it  a  desquama- 
tive rhinitis  observed  principally  in  scrofulous  subjects.  He 
considers  it  also  analogous  to  a  condition  of  the  middle  ear 
where  cholesteatomatous  masses  are  found  in  the  tympanum 
and  mastoid  cells,  and  suggests  the  name  of  cholesteatoma- 
tous rhinitis.  Schleicher  (5)  believes  the  caseous  secretion  is 
accounted  for  by  the  degeneration  of  mucous  polypi.  Len- 
nox Browne  (6)  says  that  no  satisfactory  account  of  the  dis- 
ease has  been  given;  but  it  seems  to  be  due  to  long- re- 
tained secretions  originating  in  the  superior  meatus,  or  in 
one  or  more  of  the  accessory  cavities  of  the  nose,  and  that 
it  is  usually  associated  with  caries  of  the  ethmoid  bone.  He 
states  that  Hall  has  seen  the  sphenoidal  sinus  filled  with 
this  caseous  material  in  five  instances,  in  dissecting-room 
subjects  of  advanced  age,  in  which  there  was  no  disease  of 
the  bone  present.  In  my  case  I  believe  the  affection  com- 
menced as  a  simple  rhinitis  in  the  course  of  an  attack  of  la 
grippe,  and  extended  to  the  ethmoid  bone,  terminating  in 
suppuration  and  in  caries  of  the  bony  trabeculae  of  the  eth- 
moid cells.  I  have  met  with  this  caseous  secretion  in  two 
other  instances,  but  in  neither  of  them  was  the  secretion  so 
profuse  as  in  the  above  case.  It  occurred  once  in  a  case  of 
caries  of  the  middle  turbinated  body,  and  in  the  other  in  a 
case  of  abscess  of  the  antrum  of  long  standing  in  which 
there  was  caries  of  the  alveolar  process. 

In  well-marked  cases  the  diagnosis  of  abscess  of  the 
ethmoid  cells  is  not  a  difficult  matter,  but  in  the  majority 
of  instances  the  symptoms  are  obscure,  and  there  is  fre- 
quently an  implication  of  one  or  more  of  the  neighboring 
sinuses  so  that  it  is  almost  impossible  at  times  to  state 
positively  which  is  the  source  of  the  pus.  The  diagnosis 
must  then  be  made  from  the  following  symptoms,  some  of 
which  may  be  occasionally  absent :  A  swollen  condition  of 
the  middle  turbinated  body,  the  presence  of  pus  in  the  mid- 
dle meatus,  and,  if  the  posterior  cells  are  involved,  the 
presence  of  pus  flowing  over  the  posterior  extremity  of  the 
middle  turbinated  body  into  the  post-nasal  space ;  the  ab- 
sence of  the  pulsating  light  reflex,  which  is  observed  in  ab- 
scess of  the  antrum ;  swelling  at  the  inner  angle  of  the 
orbit ;  exophthalmus ;  narrowing  of  the  field  of  vision ; 
crepitation  on  pressure  over  the  inner  angle  of  the  orbit ; 
pain  in  the  orbit  and  along  the  infra- orbital  ridge.  The 
presence  of  pus  in  the  middle  meatus  is  common  to  inflam- 
mations of  the  frontal  and  maxillary  sinuses  as  well  as  to 
that  of  the  ethmoid  sinus,  and  it  is  very  difficult  at  times  to 
trace  it  to  its  source ;  but,  according  to  Max  Schaeffer  (7), 
in  pain  we  have  a  much  more  reliable  symptom  in  differ- 
entiating between  abscesses  of  the  various  sinuses.  In  case 
of  the  frontal  sinus  pain  is  felt  at  the  root  of  the  nose,  and 
extends  along  the  supra-orbital  ridge,  while  in  ethmoidal 
affections  it  extends  along  the  infra- orbital  ridge  ;  and  in 
my  experience  it  is  noticeably  absent  in  chronic  abscesses 
of  the  antrum. 

The  complications  of  suppurating  ethmoiditis  most  fre- 
quently met  with  are  abscess  of  the  antrum,  abscess  of  the 
orbit,  and  meningitis. 


While  in  the  above-cited  case  the  antral  complication 
was  purely  accidental  and  was  dependent  upon  a  carious 
tooth,  it  is  a  very  frequent  complication,  as  is  evidenced  by 
the  fact  that  Bosworth,  in  his  valuable  paper  on  the  various 
forms  of  disease  of  the  ethmoid  cells,  read  before  this  asso- 
ciation at  its  last  meeting,  mentioned  thirteen  cases  of  sup- 
purating ethmoiditis,  seven  of  which  were  complicated  with 
abscess  of  the  antrum.  The  frequency  of  this  complication 
may  be  accounted  for  in  several  ways:  1.  The  opening  of 
the  anterior  ethmoid  cells  and  that  of  the  antrum  lie  very 
close  together  in  the  hiatus  semilunaris,  and  inflammations 
of  the  nose  affecting  one  cavity  would  be  most  likely  to  ex- 
tend to  the  other.  2.  Mechanical  obstruction,  either  from 
polypi  or  hypertrophic  rhinitis,  causing  the  mucus  to  be 
confined  in  both  sinuses,  and  a  consequent  purulent  inflam- 
mation resulting.  3.  Pus  accumulating  in  the  middle 
meatus  and  working  its  way  into  the  antrum.  4.  Owing  to 
an  anomalous  condition  of  the  ethmoid  bone  in  which  the 
anterior  and  posterior  ethmoid  cells  communicate  with  the 
antrum.  We  do  not  know  how  often  this  anomaly  occurs, 
and  in  some  instances  where  the  neighboring  sinuses  com- 
municate with  each  other,  the  openings  may  be  patho- 
logical ;  but  in  others  they  are  natural,  as  is  well  illustrated 
in  a  specimen  in  the  Army  Medical  Museum,  in  which  the 
frontal  sinus  opens  directly  into  the  summit  of  the  antrum. 

While  the  indications  for  treatment  in  the  above  case 
were  perfectly  plain,  and  the  patient  could  have  been  saved 
much  suffering  had  she  accepted  surgical  aid,  we  must  re- 
member, before  resorting  to  severe  measures,  that  these  ab- 
scesses sometimes  discharge  spontaneously,  and  others  are 
relieved  in  the  course  of  the  removal  of  polypi.  In  the 
great  majority  of  cases,  however,  it  will  be  found  necessary 
to  open  the  cells  so  that  free  drainage  can  take  place,  and 
any  necrosed  or  carious  bone  removed.  For  this  purpose  I 
have  found  the  snare  and  a  sharp  curette  preferable  to  the 
drill. 

1.  Traite  de  pathologic  externe,  t.  iii,  1874. 

2.  Elements  de  pathologie  chirurgicale  de  Nelaton,  iii,  sec- 
ond ed.,  1874,  p.  715. 

3.  Gazette  des  hopitaux,  February  2,  1889. 

4.  Annates  des  maladies  de  Voreille,  etc.,  October,  1889. 

5.  Annales  des  maladies  de  Voreille,  etc.,  July,  1890. 

6.  Diseases  of  the  Throat  and  Nose,  third  edition,  London> 
p.  580. 

7.  Deutsche  med.  Wochenschrift,  October  9,  1890. 
806  Seventeenth  Street. 


A  CLINICO-PATHOLOGICAL  STUDY  OF 
INJURIES  OF  THE  HEAD, 

WITH  SPECIAL  REFERENCE  TO 
LESIONS  OF  THE  BRAIN  SUBSTANCE. 
By  CHARLES  PHELPS,  M.  D., 

SURGEON  TO  BBLLBVtTE  AND  ST.  VINCENT'S  HOSPITALS. 

{Concluded  from  page  71.) 
THROMBOSIS   OF   THE  SINUSKS. 

The  occurrence  of  thrombi  in  the  sinuses  of  the  dura 
mater  and  base  of  the  skull  in  three  cases,  under  varying 
circumstances,  is  not  in  all  of  them  susceptible  of  adequate 


Jan.  28,  1893.] 


PHELPS:  INJURIES  OF  THE  HEAD. 


99 


explanation.    In  the  first  case,  which,  like  the  second,  in- 
volved fracture  at  the  base,  the  posterior  part  of  the  skull 
was  subjected  to  crushing  violence.    There  was  extensive 
epidural  clot,  large  subdural  clot  which  filled  the  right  in- 
ferior occipital  fossa,  and  a  firm  cortical  clot  beneath  the 
seat  of  fracture  surrounded  by  an  inflammatory  exudation. 
The  surface  of  the  posterior  part  of  the  right  occipital  lobe 
was  softened  and  the  seat  of  minute  extravasations.  There 
were  small  lacerations  of  the  inferior  surface  of  both  frontal 
lobes,  and  one  of  considerable  size  in  the  right  cerebellum, 
beneath  the  thickest  part  of  the  subdural  extravasation. 
The  wall  of  the  posterior  part  of  the  superior  longitudinal 
sinus  was  infiltrated  with  blood,  and  the  cavity  occupied 
by  a  thrombus.    A  second  large  and  partially  decomposed 
thrombus  was  situated  in  the  torcular  Herophili,  and  ex- 
tended through  the  right  lateral  and  petrosal  sinuses  into 
the  jugular  vein.    In  the  second  case  a  simple  fissure  ex- 
tended from  the  right  parietal  bone  into  the  posterior  fossa, 
terminating  in  the  jugular  foramen.    There  was  slight  epi- 
dural and  considerable  subdural  hiemorrhage  at  the  origin  of 
the  fracture.   There  were  several  lacerations  in  the  anterior 
part  of  the  brain,  and  on  the  left  side  the  interior  of  the  tem- 
poro-sphenoidal  and  that  of  the  frontal  lobe  were  excavated 
and  distended  by  a  clot  from  a  haemorrhage,  which  had  also 
broken  through  into  the  lateral  ventricles  and  occipital  lobes 
and  filled  them  with  fluid  blood.    There  was  cortical  haem- 
orrhage at  the  base,  which  had  surrounded  the  optic  chiasm 
and  extended  to  the  anterior  border  of  the  pons.  The 
thrombus  occupied  the  torcular  Herophili  and  extended 
through  the  lateral  and  petrosal  sinuses  into  the  jugular 
vein.    In  the  third  and  final  case  there  was  no  fracture,  in- 
tracranial hasmorrhage,  or  laceration.    There  was,  however, 
general  contusion,  with  moderate  oedema  and  distention  of 
the  minute  cerebral  vessels  with  coagula.    This  condition 
extended  to  the  corpora  striata,  optic  thalami,  pons,  and 
cerebellum,  and  was  most  pronounced  at  the  base  and  upon 
the  left  side.    The  thrombus  was  decolorized,  and  occupied 
both  lateral  and  both  petrosal  sinuses.    It  extended  into 
the  right  jugular  vein,  and  was  colored  only  near  the  tor- 
cular Herophili.    I  have  detailed  all  the  accompanying  le- 
sions, though  I  do  not  believe  that  they  were  all  related  to 
the  formation  of  the  thrombi.    In  the  first  case  the  infil- 
tration of  the  wall  of  the  sinus  points  to  its  laceration  by 
direct  violence  as  the  first  step  toward  the  coagulation  of 
its  contents.    The  portion  of  the  sinus  in  which  it  began 
was,  moreover,  directly  beneath  the  point  at  which  sufficient 
violence  was  inflicted  to  comminute  the  skull,  to  rupture  its 
membranes,  and  to  cause  localized  inflammation  in  connec- 
tion with  the  haemorhage.    The  surrounding  inflammation 
might,  at  first  sight,  suggest  an  inflammatory  origin,  but 
the  absence  of  inflammatory  products  in  the  sinus  wall  cor- 
roborates the  view  I  have  taken.    It  is  more  difficult  to  ac- 
count for  the  thrombus  in  the  second  case.    There  is  no 
positive  evidence,  but  a  possible  clew  exists  in  the  termina- 
tion of  the  fissure  in  the  jugular  foramen.    It  may  be  that 
some  injury  done  to  the  vein  led  to  the  beginning  of  throm- 
bosis at  this  point.    It  had  no  evident  relation  to  the  other 
intracranial  lesions  which  can  aid  in  solving  the  problem. 
In  the  third  case  the  thrombus  was  the  only  localized  le- 


sion, and  again  a  different  and  conjectural  explanation  must 
be  sought.  There  was  general  contusion  and  general  throm- 
bosis of  the  minute  cerebral  veins.  It  is  impossible  to  as- 
sume either  that  venous  canals  of  such  size  should  have 
primarily  participated  in  the  effect  of  a  general  contusion, 
or  that  the  obstructing  coagula  should  have  extended  sec- 
ondarily into  the  sinuses.  It  might  more  naturally  be  as- 
sumed that  the  thrombus,  which  was  already  decolorized, 
was  an  antecedent  lesion  which  had  led  to  the  venous  ob- 
struction and  oedema  of  the  brain  tissue.  There  was,  how- 
ever, no  indication  of  previous  disease,  and  the  man  was  at 
his  work  when  struck  down  by  the  blow  which  caused  his 
death.  These  cases  are  pathologically  independent  of  each 
other,  and  may  have  no  significance  in  symptomatology  or 
treatment.  In  another  case  I  suspected  thrombosis  of  the 
internal  jugular  vein,  on  account  of  an  oedema  of  one  side 
of  the  face  and  neck,  but  his  recovery  precluded  a  confir- 
mation of  my  suspicion. 

I  am  unacquainted  with  any  similar  instances  of  trau- 
matic thrombosis  of  these  sinuses.  They  were  unconnected 
with  pressure  or  any  inflammatory  process  within  or  without 
their  walls,  or  with  any  dyscrasia  of  the  patient.  In  the 
first  and  second  cases  I  have  been  able  to  suggest  an  expla- 
nation ;  in  the  third  case  I  am  still  without  definite  opinion. 

LACERATIONS. 

Lacerations  and  contusions  of  the  brain  are  unques- 
tionably first  in  frequency  and  importance  among  all  the 
injuries  of  the  head.    They  play  a  part  in  all  fatal  cases, 
and  dominate  the  symptoms  in  almost  all  cases  of  recov- 
ery.    Even  when  death  is  the  immediate  result  of  haem- 
orrhage or  inflammation,  or  when,  though  life  be  saved, 
the  mind  is  lost,  they  still  ride  behind.    In  every  fatal  case, 
with  fracture  or  without,  where  necropsy  has  been  per- 
mitted, one  at  least  of  these  lesions  has  been  found  to  exist. 
In  every  one  in  which  necropsy  has  been  denied,  as  well  as 
in  every  case  of  recovery,  the  interpretation  of  symptoms 
in  the  light  of  what  has  been  disclosed  by  previous  post- 
mortem examination  has  pointed  to  the  same  conditions. 
They  do  not  occur,  however,  with  equal  frequency.  While 
in  fifty-eight  cases  there  were  forty- eight  with  lacerations, 
there  were  but  thirty  with  marked  contusions  ;  or,  different- 
ly estimated,  there  were  twenty-eight  cases  of  laceration 
without  noticeable  contusion,  and   but  ten  of  contusion 
without  laceration.    The  lacerations  may  be  single  or  mul- 
tiple;  they  may  be  confined  to  the  cortex,  or  extend  a  vari- 
able distance  into  the  subcortical  structure ;  they  may  origi- 
nate subcortically  and  completely  disintegrate  the  interior 
of  a  lobe  without  encroaching  upon  the  cortex,  or  they  may 
reach  the  pia ;  they  may  lacerate  the  pia  and  rupture  the 
arachnoid,  with  or  without  diffusion  of  haemorrhage,  or  the 
membranes  may  remain  intact.    In  a  large  proportion  of 
cases  the  laceration  will  be  with  well  marked  diffusion  of 
haemorrhage.    Topographically,  there  is  no  lobe  or  convolu- 
tion which  may  not  be  wounded.    It  will  be  seen  from  the 
necropsies  recorded  that  the  base  of  the  brain,  especially 
upon  the  frontal  and  temporo-sphenoidal  lobes,  suffers  most 
seriously  and  most  frequently,  and  that  the  interior  of  the 
frontal  lobes  is  oftenest  the  site  of  extensive  destruction. 


100 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Joub., 


Several  cases  will  be  noted  in  which  the  haemorrhage  from 
a  lacerated  frontal  lobe  has  broken  through  the  lateral  ven- 
tricles into  the  posterior  regions  of  the  brain.  I  present  a 
specimen  of  small  laceration  in  almost  the  exact  center  of 
the  cerebellum  (Case  XXXIV).  I  have  no  record  of  lacer- 
ation of  the  optic  thalami,  fornix,  velum  interpositum,  or 
corpus  callosum,  though  such  injuries  have  been  described. 
I  also  present  a  specimen  of  laceration  of  the  pons  (Case 
XXVI).  Instances  of  laceration  of  the  corpora  striata  and 
gyrus  fornicatus  are  included  in  the  series  (Cases  XX, 
XXIX,  XXX,  XXXV).  The  general  appearances  of  these 
lacerations  have  Been  noted  by  previous  writers  under  the 
name  of  contusions,  and  they  require  but  cursory  mention. 
As  they  present  themselves  in  the  cortex,  they  are  simply 
lacerated  wounds  containing  more  or  less  coagulum  with 
underlying  shreds  and  granular  detritus  of  brain  tissue. 
After  the  removal  of  the  coagulum  the  bottom  of  the 
wound  is  usually  pultaceous,  and  stained  with  blood  or  of 
a  grayish  color.  Sometimes  the  peripheral  brain  tissue  is 
softened  and  dotted  with  miliary  extravasations,  and  some- 
times it  is  of  normal  consistence  and  appearance.  It  is 
rarely  the  case  that  there  is  not  some  resulting  haemorrhage 
which  infiltrates  the  pia,  perhaps  trivial  in  amount,  perhaps 
sufficient  to  thickly  cover  the  base  or  vertex  and  the  lateral 
aspects  of  the  brain.  The  wound  may  be  circular,  oval,  or 
irregular  in  outline,  not  larger  than  a  pea,  or  covering  the 
whole  extent  of  the  inferior  surface  of  the  tempore- sphe- 
noidal lobe.  In  case  of  subcortical  laceration  the  lesion 
may  be  a  simple  extravasation  of  blood  into  the  deeper 
brain  tissue,  as  small  as  in  the  specimens  from  the  pons 
and  central  cerebellum  which  I  have  just  exhibited,  and 
either  as  harmless  as  it  is  trivial  in  extent  or  of  deadly  im- 
port. In  another  instance,  as  in  more  than  one  of  the  ne- 
crologies which  I  have  just  recorded,  the  whole  internal 
structure  of  both  frontal  lobes  may  be  disintegrated  and 
destroyed ;  and  when  the  clot  and  mangled  brain  have  been 
turned  out,  nothing  but  the  cortical  shell  remains. 

The  subsequent  changes  which  these  wounds  undergo 
are  not  numerous.  If  of  considerable  size,  death  ensues  in 
the  majority  of  cases  before  sufficient  time  has  elapsed  to 
permit  any  change  of  importance.  The  end  to  be  hoped 
for,  as  in  any  wound  with  loss  of  tissue,  is  cicatrization. 
In  an  experience  in  the  dead-house  lasting  over  many  years, 
it  has  not  been  my  fortune  to  meet  with  an  instance  of  such 
reparative  process,  yet  I  have  seen  many  cases  of  recov- 
ery where  I  am  positive  laceration  had  existed.  There  is 
a  remarkable  illustrative  specimen  in  the  Museum  of  St. 
George's  Hospital,  quoted  by  Mr.  Hewitt,  in  which  two 
large  lacerations  of  the  cerebrum,  occurring  without  frac- 
ture, had  cicatrized  after  many  years.  The  cerebral  surface 
was  excavated  and  the  pia  and  arachnoid  were  carried  over 
the  depression,  leaving  a  cavity  filled  with  loose  areolar  tis- 
sue and  serum.  The  man's  intellect  had  been  clear,  and  he 
had  suffered  no  cerebral  symptoms. 

If  the  patient  survives,  the  process  of  reparation  is  evi- 
dently slow.  In  certain  cases  in  which  old  lacerations  were 
discovered  after  death  from  more  recent  injury,  there  was 
no  contraction  of  the  wounds  and  no  inflammatory  changes 
of  importance  had  begun.    The  edges  of  the  wounds  were 


slightly  rounded,  and  the  coagula  which  they  contained 
were  softened  and  their  color  had  become  rusty  or  yellow. 

In  necropsic  cases  of  recent  laceration  an  interval  of 
from  a  few  moments  to  one  day,  or  several,  has  probably 
elapsed.  The  appearances  are  practically  the  same  what- 
ever the  interval  may  have  been.  There  is  no  tendency  to 
meningeal  or  visceral  inflammation  in  any  cases  which  I 
have  observed,  with  the  exception  of  the  occasional  forma- 
tion of  abscess  from  subcortical  laceration.  As  in  the  case 
of  general  contusion,  with  profuse  oedema  and  death  after 
fifteen  days,  no  inflammatory  changes  have  been  discovered 
even  upon  careful  microscopical  examination.  In  an  ex- 
ceptional case  (Case  VII)  the  temporo-sphenoidal  lobe  had 
been  seriously  lacerated,  and  after  the  lapse  of  six  months 
was  the  seat  of  interstitial  inflammation  and  atrophy. 

CONTUSION. 

Contusion  may  be  regarded  as  occurring  in  three  forms 
— general  and  limited,  affecting  the  brain,  and  meningeal, 
involving  the  membranes.  The  limited  form  may  be  either 
cortical  or  subcortical.  Any  two  or  all  three  of  these  may 
coexist  in  the  same  case. 

Limited  contusion  of  the  brain  differs  from  laceration 
as  a  contusion  elsewhere  differs  from  a  wound.  There  is 
no  palpable  solution  of  continuity  in  the  brain  fibers,  and 
consequently  the  haemorrhagic  extravasation  can  only  be 
minute  in  quantity  and  of  punctate  or  miliary  form.  In 
reparation  only  absorption,  not  cicatrization,  is  required, 
and  recovery  should  occur  in  the  major  and  not,  as  in 
laceration,  in  the  minor  proportion  of  cases.  It  is  there- 
fore less  frequently  met  with  in  post-mortem  observations. 
As  in  cortical  or  subcortical  laceration,  either  form  of  lim- 
ited contusion  occasionally  results  in  abscess.  In  the  sub- 
cortical forms  it  may  be  difficult  or  impossible  to  determine 
which  one  of  the  two  is  the  responsible  lesion.  I  have  very 
carefully  described  such  an  abscess  in  a  case  reported  in 
the  New  York  Medical  Journal,  March  19,  1890,  and  in- 
cluded in  the  present  series.  This  abscess,  which  compli- 
cated fracture  at  the  base,  and  two  others  complicating 
compound  fracture  of  the  vertex,  comprise  the  small  pro- 
portion of  cases  which  represents  the  danger  of  this  form 
of  inflammation.  In  the  case  first  mentioned,  though  frac- 
ture at  the  base  existed  and  made  it  technically  one  of  that 
class,  there  was  also  compound  fracture  of  the  vertex  in 
connection  with  which  the  abscess  was  formed.  So  we  may 
properly  consider  all  the  abscesses  as  complicating  the  latter 
form  of  fracture.  In  all  three  cases  the  dura  was  carefully 
examined  at  the  time  of  accident  and  found  to  be  unin- 
jured, and  after  an  interval  of  more  than  two  weeks  with- 
out the  occurrence  of  meningeal  inflammation,  the  abscess 
was  developed.  In  each  the  external  wound  had  been 
healthy  and  had  nearly  closed.  These  data  seem  to  prove 
that  suppurative  inflammation  of  the  brain  substance  is  the 
result  of  primary  injury  of  the  brain  itself,  and  not  second- 
ary to  meningeal  inflammation  extended  from  the  point  of 
fracture.  The  time  for  cortical  and  meningeal  suppurations 
passed  with  the  coming  of  aseptic  methods,  and  at  the 
same  time  hernia  cerebri  practically  disappeared  from  the 
field  of  surgery.    These  cases,  however,  show  that  com- 


Jan.  28,  1893.] 


PHELPS:  INJURIES  OF  THE  BEAD. 


101 


pound  fractures  still  sustain  a  relation  to  deep  abscess.  It 
is  not  dependent  upon  the  extent  of  the  attendant  lacera- 
tion or  contusion,  for  that  is  likely  to  be  as  great  under 
other  circumstances.  It  is  more  probably  due  to  exposure, 
for,  though  uninjured,  the  dura  and  cortex  may  not  be  im- 
pervious to  atmospheric  influences.  The  explanation  of  this 
subcortical  suppuration  is,  at  all  events,  neither  more  nor 
less  difficult  than  that  of  subcutaneous  suppuration  upon 
the  surface  of  the  body.  The  dogmatic  assertion  that 
traumatic  abscess  of  the  brain  never  occurs  except  there 
has  been  wound  of  the  scalp  or  fracture  of  the  skull  is 
erroneous.  Though  the  cases  which  I  record  here  con- 
form to  this  proposition,  I  am  cognizant  of  at  least  two 
cases  which  do  not.  One  was  a  small  parietal  abscess 
which  I  saw  some  years  ago ;  the  other  an  abscess  of  enor- 
mous size  in  the  frontal  lobe  from  a  blow  received  in  the 
ball-field,  without  the  occurrence  of  superficial  injury  of  any 
sort  beyond  moderate  contusion.  The  latter  specimen  is 
still  in  the  Museum  of  the  Carnegie  Laboratory.  The  im- 
portant fact  in  connection  with  cerebral  abscess  at  the  pres- 
ent day  is  that  it  occurs  from  direct  brain  lesion  independ- 
ent of  injuries  of  the  scalp,  skull,  or  meninges. 

General  contusion  of  the  brain  is  more  frequent  than 
the  limited  form,  but  much  less  frequent  than  laceration. 
I  am  accustomed  to  recognize  it  in  three  post-mortem  con- 
ditions :  General  hyperajmia,  with  or  without  cedema, 
punctate  or  miliary  htemorrhages,  and  thrombosis  of  the 
minute  cerebral  vessels.  They  occur  separately  or  together. 
Examples  of  each  are  afforded  by  the  necropsies  I  have 
described,  and  the  appearances  they  present  are  sufficiently 
indicated  in  the  enumeration  of  post-mortem  conditions 
■which  I  have  made.  I  will  only  refer  to  two  very  recent 
cases  (Cases  XXXIII  and  XXXIV)  as  well-marked  instances 
of  excessive  general  hyperaemia  from  general  contusion  ac- 
companying laceration,  and  to  one  other  (Case  XXIV)  in 
which  death  was  due  to  general  contusion  with^dema.  The 
very  moderate  hypersemia  which  often  exists  in  connection 
with  other  lesions  I  have  not  specially  considered,  though 
it  may  be  of  serious  importance. 

Meningeal  contusion,  as  a  distinct  complication,  occa- 
sions hajmorrhage  and  inflammation.  Its  relation  to  gen- 
eral contusion  of  the  brain  is  not  closely  defined.  The 
two  conditions  occur  together  or  separately,  and  severity  of 
one  when  they  are  coincident  is  not  always  proportionate 
to  that  of  the  other.  I  may  instance  as  illustrative  of  this 
uncertain  relation  two  cases — the  one  of  oedema  to  which 
I  but  just  now  referred,  in  which  the  brain  tissue  was  sod- 
den and  the  ventricles  distended  with  serum,  while  the 
meningeal  vessels  were  but  slightly  congested  and  the  sub- 
arachnoid spaces  notably  dry ;  the  other,  my  single  case  of 
acute  arachnitis  to  which  I  shall  refer  later,  in  which  the 
whole  subcortical  tissue  was  very  markedly  hyperaimic  and 
the  smaller  vessels  filled  with  coatjula.  I  do  not  regard 
simple  meningeal  hyperaeraia  as  other  than  a  factor  in  the 
more  important  lesion  of  laceration  or  general  contusion, 
with  which  it  may  happen  to  be  associated. 

Haemorrhage  is  of  frequent  occurrence.  The  vessels  of 
the  pia  are  ruptured  and  the  blood  is  effused  ordinarily  in 
a  rather  thin  sheet  over  one  or  both  hemispheres,  but  may 


present  itself  in  patches  scattered  over  any  part  of  the 
brain.  When  the  hjemorrhage  is  more  profuse  and  the 
clot  thicker,  it  can  probably  be  traced  to  its  source  in  a 
cortical  laceration.  The  coexistence  of  both  forms  of  cor- 
tical haemorrhage  is  not  infrequent.  If  the  fact  be  fullv 
recognized  that  cortical  ha;morrhages  of  traumatic  origin, 
unconnected  with  cortical  laceration  and  without  fracture 
as  well  as  with  it,  are  the  result  of  meningeal  contusion,  the 
subject  will  not  require  further  comment. 

Traumatic  arachnitis,  so  far  as  these  records  show, 
does  not  result  from  direct  injury  transmitted  through 
fracture  of  the  skull,  nor  from  an  inflammatory  process 
propagated  from  a  cortical  laceration.  This  complication 
was  once  supposed  to  be  the  great  danger  to  be  feared 
from  injuries  of  the  head,  and  when  death  ensued  it  was 
always  charged  with  the  fatal  result.  An  examination  of 
the  fifty- eight  post-mortem  observations  I  have  made  dis- 
closes only  seven  cases  in  which  it  was  possibly  present, 
and  only  five  in  which  it  was  positively  determined.  Two 
of  these  occurred  in  connection  with  fractures  at  the  base, 
and  the  remainder  in  simple  injuries  of  the  brain  in  which 
no  fracture  existed.  One  of  the  former  was  an  acute 
arachnitis ;  the  other  six  were  characterized  by  a  subarach- 
noid serous  effusion.  They  all  negative  the  theory  of  di- 
rect violence,  or  of  an  extension  of  a  prior  inflammatory 
process.  The  acute  arachnitis  (Case  XVIII)  was  localized 
in  the  right  and  left  occipital  regions,  while  the  attendant 
fracture  and  subcortical  lesion  were  in  the  parietal  region 
of  one  side,  and  separated  from  it  by  an  interval  in  which 
there  was  no  j^urulent  effusion.  General  contusion  was 
also  present.  In  the  case  of  subacute  arachnitis  which 
complicated  a  fracture  at  the  base  (Case  IV),  the  depressed 
portion  of  the  fracture  which  was  in  the  vertex  was  con- 
fined to  the  external  table,  the  local  lesion  was  subcortical, 
and  there  was  evidence  of  general  contusion.  In  the  five 
other  cases,  in  which  there  was  more  or  less  evidence  of 
subacute  arachnitis,  there  was  no  fracture  at  all ;  in  three 
there  was  no  laceration,  but  general  contusion  or  cortical 
hajmorrhage  from  meningeal  contusion ;  in  one  of  the  other 
two  the  subarachnoid  effusion  was  localized  on  the  opposite 
side  of  the  brain  from  the  site  of  the  laceration  ;  and  in  the 
other  and  last  of  the  series  the  lacerations  were  old  and 
considerably  antedated  the  immediate  cause  of  death. 
There  can  be  no  doubt  that  all  of  these  were  the  result  of 
meningeal  contusion. 

Paralysis. — Another  complication  which  has  been  sup- 
posed to  be  a  direct  result  of  fracture  is  paralysis  from 
bony  compression  of  the  cranial  nerves.  This  condition  is 
represented  in  a  single  case.  In  this  there  was  compres- 
sion of  the  optic  nerve.  There  was  fracture  extending 
through  both  anterior  fossae,  involving  the  left  optic  fora- 
men, and  pinching  the  optic  nerve  at  that  point  (Case  LIX). 
Loss  of  sight  was  immediate,  and  ophthalmic  examination 
showed  the  condition  of  the  nerve  and  eye  to  be  normal. 
Subsequent  examinations  discovered  progressive  atrophy. 
The  patient  recovered,  but  loss  of  sight  was  permanent. 
In  other  cases  in  which  loss  of  function  occurred  in  parts 
to  which  cranial  nerves  are  distributed,  as  elucidated  by 
post-mortem  examination,  the  cause  was  found  to  exist  in 


102 


PEELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Jonit., 


lesion  of  the  cortical  centers  or  in  compression  of  the  nerve 
by  blood  effused  into  its  intra-osseous  canal  of  exit.  There 
is  so  little  displacement  in  fracture  of  the  base  that  such 
instances  as  the  one  detailed  are  probably  of  great  infre- 
quency. 

CONTRE-COUP. 

I  have  called  attention  to  the  fact  that  fractures  are 
usually  the  result  of  direct  violence,  expending  its  force 
upon  the  vertex  or  transmitted  in  continuity  to  the  base, 
and  that  fractures  by  contre-coup  are  exceptional.  Lacera- 
tions and  contusions  of  the  brain,  on  the  contrary,  are  al- 
most invariably  produced,  either  wholly  or  in  part,  in  this 
way.  In  the  minority  of  cases  in  which  some  encephalic 
lesion  exists  directly  beneath  the  point  at  which  violence 
has  been  inflicted,  there  has  usually  been  further  and  more 
serious  damage  done  to  the  brain  in  some  distant  part. 
There  has  been  either  laceration  or  general  contusion  dis- 
covered in  each  case  subjected  to  post-mortem  examination. 
If  the  cases  of  gunshot  laceration  are  excluded,  and  also 
those  of  general  contusion  in  which  a  question  might  arise 
as  to  the  kind  of  violence  to  which  the  lesion  should  be 
ascribed,  there  are  only  five  instances  in  which  the  violence 
inflicted  was  exclusively  direct.  It  is  almost  safe,  therefore, 
to  assume  in  any  given  case  that  if  a  lesion  of  the  brain 
exists,  it  has  been  produced  by  contre-coup  at  a  distance 
from  the  seat  of  direct  injury.  A  careful  examination  of 
the  cases  cited  shows  this  distant  point  to  be  almost  always 
upon  the  opposite  side  of  the  brain,  and  confirms  all  pre- 
vious observations  that  it  is  likely  to  be  at  the  base  in  the 
middle  or  anterior  lobe.  The  reasons  which  have  been  ad- 
duced to  explain  the  frequent  occurrence  of  brain  injury  by 
contre-corip  and  its  seat  by  preference  have  no  relation  to 
these  necropsies  and  need  not  engage  our  consideration. 

CONCUSSION   AND  COMPRESSION. 

All  traumatisms  involving  brain  symptoms  were  for  many 
years  classified  as  cases  of  concussion  or  compression.  The 
classification  was  undoubtedly  simple  and  of  easy  compre- 
hension. If  the  intracranial  space  was  diminished  by  the 
intrusion  of  bone,  serum,  extravasated  blood,  or  pus,  it  was 
compression.  Otherwise  all  symptoms  were  referred  to  a 
hypothetical  vibration  of  the  brain  within  the  skull,  a  merely 
functional  disorder  produced  by  violence.  Twenty  years  ago 
Mr.  Prescott  Hewitt  described  several  forms  of  contusion, 
in  which  he  included  lacerations,  and  questioned  the  occur- 
rence of  concussion  as  a  distinctively  pathological  condition 
without  the  existence  of  anatomical  change.  Previous  to 
this  time  several  observers  had  noted  structural  changes  in 
certain  fatal  cases,  but  had  not  regarded  them  as  either 
necessary  or  invariable.  Some  years  later  von  Bergmann,  in 
a  clinical  lecture,  admitted  the  existence  of  both  concussion 
^  and  compression,  with  an  ietiological  difference,  and  in- 
sisted upon  their  clinical  identity.  He  attributed  concus- 
sion to  a  direct  injury  from  a  single  impulse,  modified  by 
the  elasticity  of  the  skull,  by  which  the  brain  suflered  a 
diffuse  disturbance  of  nutrition  without  appreciable  lesion. 
He  considered  it  a  suspension  of  cortical  activity  followed 
by  a  stimulation,  and  eventually  by  a  depression  of  the 


medulla.  lie  recognized  it  as  occurring  in  three  degrees : 
1.  Involving  paralysis  of  the  cortex  only.  2.  Paralysis  of 
the  cortex  and  stimulation  of  the  medulla.  3.  Paralysis 
of  both  cortex  and  medulla,  with  brief  and  unobserved 
medullary  stimulation.  Cortical  paralysis  was  indicated 
by  unconsciousness ;  medullary  stimulation  by  slowness  of 
pulse  and  increase  of  arterial  tension ;  and  medullary 
paralysis  by  rapidity  of  pulse  and  decreased  arterial  tension. 
In  compression,  he  regarded  the  brain  condition  as  being 
identically  the  same,  and  as  manifested  by  the  same  symp- 
toms, but  due  to  change  of  cranial  capacity  and  not,  as  in 
concussion,  to  change  of  cranial  form.  Finally,  he  con- 
sidered diagnosis  as  only  possible  by  the  duration  of  the 
symptoms.  This  clinical  lecture  was  admirably  translated 
by  Dr.  John  C.  Schapps,  late  house  surgeon  at  St.  Vincent's 
Hospital,  and  appeared  in  the  Annals  of  Suryery  in  1882. 
The  views  of  von  Bergmann,  of  which  I  have  presented 
a  resume,  are  of  great  weight  and  authority,  and  probably 
represent  the  cumulation  of  thought  and  observation  up  to 
that  time.  I  do  not  know  that  very  much  of  importance 
has  been  added  since.  I  am  quite  in  accord  with  his  opin- 
ion that  concussion  and  compression  should  be  regarded  as 
one,  but  would  go  further,  and,  having  consolidated  the 
two,  would  abolish  them  both  together,  so  far  as  they  are 
terms  used  to  express  a  pathological  condition.  The  diflS- 
culty  with  all  explanations  of  concussion  is  that,  of  neces- 
sity, they  are  largely  theoretical.  To  account  conclusively 
for  unseen  pathological  changes,  or  to  authoritatively  deny 
their  existence,  requires  that  the  syllogism  be  very  care- 
fully constructed.  In  this  instance,  in  every  fatal  case 
where  the  clinical  history  has  corresponded  to  that  of  re- 
covering cases  a  carefully  conducted  necropsy  has  revealed 
organic  lesion.  In  all  cases  that  have  been  cited  to  prove 
that  no  post-mortem  lesion  exists  not  one  has  been  ob- 
served with  suflScient  exactitude  to  make  it  of  the  slightest 
statistical  vftlue.  There  is  nothing  in  analogy  to  warrant 
at  the  present  time  the  assumption  that  any  fatal  disorder 
terminates  without  involvingf  structural  change.  Even  dis- 
orders  of  the  nervous  system,  long  considered  functional, 
have  with  closer  investigation  fallen  more  and  more  into 
line  with  organic  diseases.  It  is  tenable  ground,  therefore, 
to  hold  from  both  negative  and  positive  post-mortem  ob- 
servation, as  well  as  from  general  analogy,  that  brain  injury 
produces  structural  change  with  the  same  certainty  that  it 
occasions  palpable  symptoms.  If  the  terms  concussion  and 
compression  be  used  to  indicate  a  group  of  symptoms,  or  a 
variation  of  pathological  condition,  it  is  objectionable,  both 
on  the  score  of  propriety  and  as  being  likely  to  lead  to  er- 
roneous diagnosis.  If  they  be  discarded,  the  form  of 
injury  the  patient  has  suffered  in  a  given  case — as  lacera- 
tion, general  contusion,  or  fracture  with  haemorrhage — is 
more  likely  to  be  accurately  determined  than  if  attention 
be  directed  solely  to  a  symptomatic  condition  that  may  not 
clearly  exist.  If  unconsciousness  and  variation  of  pulse  be 
accepted  as  the  sole  pathognomonic  and  invariable  condi- 
tions of  traumatism,  there  will  still  remain  many  cases  of 
uncertain  status.  Examples  may  be  cited  from  the  forego- 
ing necrologies  in  which,  from  the  earliest  moment  at  M'hich 
the  patient  could  be  reached,  there  was  neither  unconscious- 


Jan.  28,  1893.] 


PEELPS:  INJURIES  OF  TEE  EE  AD. 


103 


ness  nor  a  typical  variation  of  pulse.  There  can  be  no 
doubt,  however,  that  unconsciousness  is  one  of  the  earliest 
and  most  constant  symptoms  of  serious  brain  injury.  The 
opinion  that  consciousness  resides  in  the  cortex  as  a  whole, 
and  that  unconsciousness  is  paralytic  or  inhibitory,  is  con- 
firmed by  the  negative  results  of  physiological  experiment 
and  by  the  artificial  production  of  cerebral  anaemia.  It 
may  properly  be  regarded,  therefore,  as  symptomatic  of 
brain  injury  with  diffuse  effect,  but  not  necessarily  of  dif- 
fuse injury.  The  primary  retardation  and  subsequent  ac- 
celeration of  the  pulse  which  have  been  experimentally 
proved  to  be  attributable  to  medullary  lesion  are  not  as 
constant,  and  consequently  of  less  symptomatic  importance. 
In  a  majority  of  cases,  at  the  first  moment  assistance  can 
be  rendered,  the  pulse  is  accelerated  as  it  would  be  in 
serious  injury  of  other  parts  of  the  body.  The  ambulance 
service  is  exceedingly  rapid,  so  that  if  the  retardation  of  the 
pulse  is  so  evanescent  as  a  symptom,  it  has  no  great  practi- 
cal diagnostic  value. 

The  temperature,  which  has  not  heretofore  received  at- 
tention as  an  important  factor  in  the  genesis  of  symptoms 
or  in  the  diagnosis  and  prognosis  of  brain  injuries,  seems 
to  me  of  primary  importance. 

Analysis  of  the  temperatures  which  have  been  recorded 
in  these  histories  confirms  the  impression  which  I  formed 
early  in  my  study  of  these  cases — that  an  elevation  of  tem- 
perature was  an  early,  continuous,  and  very  constant  symp- 
tom in  all  classes  of  head  injury.  I  have  a  record  of  tem- 
peratures in  45  cases  in  which  the  diagnosis  was  confirmed 
by  necropsy  as  well  as  in  10  other  fatal  cases  and  in  28  cases 
of  recovery,  a  total  of  83  out  of  124  altogether.  I  think 
there  can  be  no  doubt  of  the  propriety  of  including  the 
cases  of  death  without  necropsy  and  the  recoveries,  since 
the  diagnosis  was  in  each  well  established.  I  have  a  defi- 
nite recollection  that  in  a  considerable  number  of  other 
cases  in  which  the  temperature  was  carefully  observed  and 
recorded,  but  in  which  the  charts  were  unfortunately  lost, 
that  the  averages  were  not  essentially  different. 

Four  cases,  which  proved  to  be  fatal,  were  admitted 
with  subnormal  temperatures — from  94°  to  98°.  In  two 
a  subsequent  rise  in  temperature  was  immediate,  continu- 
ous, and  very  considerable  ;  in  the  other  two  death  ensued 
in  a  few  hours  without  reaction — in  all  the  pulse  indicated 
medullary  paralysis,  and  the  lesions  were  afterward  found 
to  be  extensive  and  severe.  In  six  other  cases  the  patient 
was  not  admitted  to  a  surgical  ward  till  the  second  day  or 
later  after  the  reception  of  the  injury,  so  that  the  first  tem- 
perature taken  could  not  be  considered  primary,  but  in 
each  case  it  was  then  notably  elevated — from  101°  to 
104'8°.  In  one  recovering  case  of  fracture  of  the  base  with 
epidural  hcemorrhage  it  was  normal,  and  never  exceeded 
99°.  In  the  remaining  seventy-two  cases,  without  excep- 
tion, the  temperature  on  admission  was  above  normal.  In 
the  majority  it  exceeded  100°,  and  ranged  all  the  way  from 
98"8°  to  106°,  It  would  be  difficult  to  trace  a  relationship 
between  the  character  or  location  of  the  lesion  and  the 
comparative  elevation  of  temperature.  The  increase  was 
usually  progressive,  without  much  recession,  and  the  maxi- 
mum was  reached  just  before  death  and  sometimes  after- 


ward. The  highest  temperatures  attained  were  109°  in  one 
case,  108°  in  one,  107°+  in  eight,  106°+  in  ten,  and  105°  + 
in  nine,  or  in  twenty-eight  cases  it  was  above  105°.  In 
eleven  other  cases  it  ranged  from  104°+  to  103°+.  In 
three  cases  the  post-mortem  temperature  was  108'8°,  109°, 
109-4°.  Sufficient  data  have  been  given  to  show  that  in 
probably  no  condition,  except  insolation,  is  the  temperature 
so  uniformly  high  as  in  cases  of  encephalic  lesion. 

Unconsciousness  as  an  early  symptom  sometimes  fails 
without  apparent  explanation  in  cases  in  which  brain  injury 
is  undoubted.  A  variation  of  temperature,  therefore,  is  the 
one  invariable  symptom,  and  if  the  patient  has  rallied  from 
immediate  shock,  it  is  always  an  elevation.  Perhaps,  like 
the  retardation  of  the  pulse,  depression  of  temperature  may 
always  be  the  primary  change,  but,  if  so,  like  the  primary 
pulse  change,  it  is  too  evanescent  to  be  practically  diag- 
nostic. In  many  trivial  head  injuries  elevation  of  tem- 
perature is  absolutely  the  only  symptom  ever  recognized. 
The  symptoms  should  be  rated  in  order  of  constancy,  ele- 
vation of  temperature,  unconsciousness,  and  acceleration  of 
pulse. 

Since  this  elevation  of  temperature  is  a  constant  phe- 
nomenon, whatever  the  nature  of  the  lesion  or  wherever 
situated,  it  would  seem  to  be  due  to  an  affection  of  the  cor- 
tex as  a  whole,  and  not  to  special  lesions  of  localized  heat 
centers.  To  this  extent  it  might  be  comparable  to  experi- 
mental results  in  the  attempt  to  discover  cortical  centers 
for  organic  functions.  To  what  degree  and  in  what  man- 
ner the  demonstrated  heat  centers  are  implicated  in  the 
general  cortical  change  is  not  within  the  scope  of  this  paper 
to  discuss,  nor  within  my  province  or  competency  to  deter- 
mine. 

The  primary  effect  of  brain  injuries  may  therefore  still 
be  attributed  to  an  affection  of  the  cortex  in  its  totality,  in 
accordance  with  von  Bergmann's  view,  but  manifested  by 
two  symptoms  in  place  of  one — an  iti variable  variation  in 
temperature  and  a  nearly  invariable  loss  of  consciousness. 
There  is  no  reason  to  doubt  that  the  medulla  is  next  in- 
volved, and  the  effect  of  its  stimulation  and  subsequent 
paralysis  have  been  too  thoroughly  demonstrated  to  admit 
of  question.  The  diagnostic  value  of  the  symptoms  it 
affords,  however,  has  not  been  apparent  in  these  histories. 
I  have  not  quoted  the  pulse  records,  because  they  have  not 
been  sufficiently  characteristic  to  justify  the  necessary  ex- 
penditure of  time  and  labor. 

The  post-mortem  observations  disclose  in  every  instance 
gross  lesions .  in  one  or  more  regions  of  the  brain  or  its 
membranes,  which  give  a  material  basis  for  the  symptoms 
which  preceded  death,  whatever  may  have  been  the  in- 
tervening processes  which  connected  the  structural  change 
with  its  outward  manifestations.  It  is  for  this  reason  that 
I  would  exclude  the  terms  concussion  and  compression 
from  systems  of  classification  and  descriptive  histories  of 
cases. 

SYMPTOMATOLOGY. 

The  symptoms  of  injuries  of  the  head,  excluding  those 
which  are  casual  and  without  diagnostic  significance,  are 
fairly  numerous.  Fracture  at  the  base  has  two  symptoms 
peculiar  to  itself,  and  fracture  of  the  vertex  has  also  two  ; 


101 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Jotje., 


the  others  are  common  to  both  forms  of  fracture  and  to 
purely  encephalic  injuries.  Those  peculiar  to  fracture  at 
the  hase  are  serous  discharges  from  the  ears  or  nose,  and 
haemorrhages  from  the  ears,  nose,  or  mouth,  and  into  the 
orbital,  subconjunctival,  or  cervical  subcutaneous  tissue. 
The  characteristic  symptom  of  fracture  of  the  vertex,  aside 
from  a  possible  local  serous  discharge,  lies  in  its  perception 
by  sight  or  touch.  The  symptoms  of  encephalic  injuries, 
as  a  class,  whether  they  occur  independently  or  as  complica- 
tions of  fracture,  are  superficial  injuries ;  peculiarities  of 
temperature,  pulse,  and  respiration ;  unconsciousness ;  de- 
lirium ;  irritability  ;  paralysis ;  muscular  rigidity  ;  convul- 
sions ;  anaesthesia  and  hyperajsthesia  ;  pupillary  changes  ; 
and,  in  a  late  stage,  dementia.  Other  symptoms,  as  cepha- 
lalgia, vomiting,  vertigo,  incontinence  of  urine  and  faeces, 
are  frequent,  but  of  lesser  clinical  value. 

The  haemorrhages,  serous  discharges,  and  visual  or  tac- 
tile detection  of  fracture  are  pathognomonic.  The  haemor- 
rhages occurred  in  twenty  cases  and  the  serous  discharge 
in  one,  and  the  necropsy  in  each  confirmed  the  indication 
the  symptom  had  afforded.  In  the  fourteen  cases  in  which 
they  were  absent,  the  line  of  fracture  in  each  was  found  to 
be  such  as  to  preclude  the  escape  of  blood  during  life 
through  any  of  the  recognized  channels.  The  direct  evi- 
dence of  fractured  vertex  was  present  in  five  cases,  includ- 
ing three  of  gunshot  wound. 

There  were  simjjle  contusions,  large  haematoma,  or 
wounds,  perceptible  in  fifty  out  of  the  fifty-eight  cases. 
These  superficial  injuries  were  of  great  importance,  not 
only  by  affording  positive  proof  that  violence  had  been  suf- 
fered in  cases  where  unconsciousness  of  the  patient  and 
absence  of  history  rendered  such  confirmation  essential,  but 
by  indicating  the  point  at  which  it  had  been  inflicted. 

Sufficient  has  been  said  of  variations  of  pulse  and  tem- 
perature and  of  unconsciousness,  and  little  need  be  added 
in  regard  to  peculiarities  of  respiration.  In  the  majority 
of  cases  it  was  simply  rapid  or  normal,  and  the  chart  rec- 
ords have  not  been  transcribed  for  the  same  reason  that 
they  were  omitted  in  case  of  the  pulse.  It  was  occasion- 
ally slow,  in  some  instances  not  more  than  seven  or  eight 
in  the  minute,  sometimes  irregular  or  stertorous,  sometimes 
of  the  Cheyne-Stokes  variety,  and  in  two  or  three  instances 
dependent  in  character  upon  the  presence  of  pulmonary 
oedema.  As  in  case  of  the  pulse  symptoms,  I  have  been 
struck  by  the  habitual  absence  of  distinctive  respiratory  in- 
dications of  medullary  implication  in  serious  cortical  dis- 
turbances. 

Delirium,  or  some  form  of  mental  impairment,  is  of 
rather  frequent  occurrence.  It  sometimes  replaces  uncon- 
sciousness as  the  earliest  noticeable  symptom,  and  some- 
times appears  as  a  much  later  manifestation.  It  may  be 
violent  and  simulate  alcoholic  mania,  or  it  may  be  mild  and 
co^exist  with  stupor.  The  most  characteristic  form  of  men- 
tal disorder  which  I  have  encountered  in  cases  of  head  in- 
jury is  that  of  nocturnal  delirium,  with  more  or  less  mental 
disturbance  by  day,  and  in  time  lapsing  into  permanent  de- 
mentia as  a  termination,  or  sequel,  of  the  traumatic  lesion. 
It  may  follow  at  once  upon  recovery  of  consciousness,  or  it 
may  succeed  active  delirium.    At  night  the  patient  often 


requires  mechanical  restraint,  while  during  the  day  he  an- 
swers questions  intelligently,  is  coherent  in  his  speech,  and 
may  appear  entirely  rational.  His  memory,  however,  is  de- 
fective, or  wanting  altogether,  in  regard  to  all  the  circum- 
stances attending  his  injury.  He  has  delusions  and  fails  to 
recognize  his  surroundings.  He  is  prone  to  drink  his  urine, 
and  is  often  apathetic.  His  mind  may  finally  become  clear, 
his  memory  of  lost  events  return,  and  his  mental  recovery 
be  complete.  In  other  cases  his  condition  becomes  one  of 
dementia  and  some  degree  of  mental  impairment  is  perma- 
nent. Such  a  condition  as  I  have  described  I  presume  is 
not  novel  to  the  alienist,  but  I  note  it  as  a  special  charac- 
teristic of  injuries  of  the  brain  substance,  not  as  a  sequel, 
but  as  a  symptomatic  condition  of  recent  lesion. 

Another  allied  symptom  is  the  sensitiveness  to  external 
irritations  in  cortical  lesions.  It  seems  to  be  not  only  a 
hyperanaesthesia  of  the  cutaneous  surfaces,  but  also  a 
marked  mental  irritability.  There  is  not  only  exaggerated 
muscular  movement  from  slight  irritations  and  disturb- 
ances, but  the  patient  manifests  great  vexation  and  impa- 
tience, though  apparently  unconscious.  It  is  not  usually 
followed  by  muscular  spasm. 

Convulsions,  muscular  rigidity,  and  muscular  tremor 
may  also  be  classed  as  irritative  symptoms.  The  first  and 
second  occur  in  a  considerable  number  of  cases,  a  majority 
of  which  prove  fatal,  and  upon  necropsic  examination  dis- 
close haemorrhages  and  extensive  lacerations  and  possibly 
general  contusion.  In  the  case  of  atrophy  of  the  temporo- 
sphenoidal  lobe,  already  described,  convulsions  were  exceed- 
ingly severe ;  but  they  followed  operation,  and  a  single  one 
occurred  fifteen  days  after  the  original  injury,  so  that  it  is 
by  no  means  certain  that  there  was  any  aetiological  connec- 
tion between  the  lesion  and  the  symptom.  It  is  fair  to  as- 
sume that  they  are  always  evidence  of  serious  lesion,  even 
when  recovery  follows.  The  few  instances  of  muscular 
tremor  were  in  men  addicted  to  drink,  but  not  intoxicated, 
and  who  died  from  the  effects  of  extensive  structural 
changes. 

Paralysis  and  anaesthesia,  general  and  local,  are  recog- 
nized indications  of  traumatic,  not  less  than  of  iodiopathic, 
affections  of  the  encephalon.  In  the  present  series  of  cases 
they  have  occurred  perhaps  oftener  than  indicated  in  the 
histories,  since  in  so  many  instances  consciousness  never 
returned.  In  this  condition  paralysis  of  the  extremities 
and  certain  of  the  local  paralyses — facial,  ocular,  or  even 
glosso-pharyngeal — can  be  recognized  ;  but  many  others,  as 
well  as  sensory  disturbances,  remain  hidden.  The  multi- 
plicity of  lesions,  which  is  the  rule  rather  than  the  excep- 
tion, is  confusing.  In  testing  cutaneous  sensibility  the  re- 
sults are  sufficiently  contradictory  and  unsatisfactory  even 
under  more  favorable  conditions.  Yet,  despite  all  these  dif- 
ficulties, in  two  cases  of  lesion  of  the  gyrus  fornicatus  the 
observations  were  productive  of  some  result.  In  three 
cases  of  conjugate  deviation,  the  necropsies  afforded  more 
or  less  satisfaction  according  to  the  view  taken  of  the  loca- 
tion of  the  cerebral  center.  In  a  general  way,  however, 
while  traumatisms  may  in  some  instances  be  of  service  in 
the  solution  of  various  unsettled  questions  in  cerebral  local- 
ization, such  cases  will  probably  continue  to  be  exceptional^ 


Jan.  28,  1893.] 


PHELPS:  INJURIES  OF  THE  HEAD. 


105 


The  fact  that  defined  lacerations  are  so  largely  situated  at 
the  base  of  the  brain,  out  of  the  region  in  which  functional 
areas  have  been  located,  still  further  diminishes  the  chances 
that  traumatism  will  aid  much  in  perfecting  cerebral  to- 
pography. It  is  none  the  less  important,  in  all  cases  of 
profound  unconsciousness,  to  examine  critically  for  such 
forms  of  paralysis  as  are  undoubtedly  recognizable  as  well 
as  for  those  the  discovery  of  which  is  likely  to  be  more 
problematical. 

Pupillary  changes  are  valuable  positive  evidence  of  or- 
ganic injuries,  but  are  less  important  as  negative  signs.  In 
a  minority  of  fatal,  as  well  as  of  recovering  cases,  I  have 
found  the  pupils  to  be  abnormal,  either  variable,  unsym- 
metrical,  dilated,  or  contracted.  Unilateral  dilatation  is 
probably  the  most  frequent  deviation  from  the  normal  con- 
dition, and  is  likely  to  be  associated  with  other  and  more 
decisive  symptoms. 

I  shall  not  stop  to  consider  casual  or  remote  general 
symptoms,  though,  in  connection  with  others  more  charac- 
teristic, they  sometimes  acquire  a  value  which  is  not  in- 
trinsic. Vomiting  and  incontinence  of  urine  and  ficces  are 
among  the  most  constant  symptoms  encountered  in  head 
injuries ;  but  the  one  is  not  less  frequent  in  peritonitis  and 
pregnancy,  and  the  other  is  quite  as  common  in  a  great 
variety  of  functional  and  organic  disorders  of  the  brain 
which  have  no  relation  to  traumatism.  There  can  be  no 
doubt,  however,  of  the  value  of  such  indications  when  they 
occur  under  circumstances  which  render  traumatism  prob- 
able, either  by  the  history  or  by  the  concurrence  of  more 
directly  suggestive  symptoms.  In  the  same  connection 
occipital  headache  might  be  mentioned  as  so  general  in  re- 
covering cases  of  fracture  of  the  base  with  epidural  haemor- 
rhage as  to  assume  almost  diagnostic  importance. 

I  have  not  specifically  noted  in  the  various  cases  the 
symptoms  which  were  not  manifested,  but  with  the  excep- 
tion of  temperatures,  when  unmentioned,  they  may  be  re- 
garded as  absent. 

The  results  of  head  injuries  have  been  sufiiciently  indi- 
cated as  recovery,  death,  and  dementia. 

niAGNOSIS. 

The  diagnosis  of  injuries  of  the  head  as  a  class  is  al- 
ways of  interest,  is  usually  practicable,  and  under  some 
circumstances  is  one  of  the  most  important  in  the  domain 
of  surgery.  Grievous  error  has  entailed  equal  disgrace 
upon  the  surgeon  and  suffering  upon  the  patient.  These 
lesions  are  first  to  be  distinguished  from  all  other  morbid 
conditions,  especially  from  those  involving  loss  of  con- 
sciousness or  delirium,  and,  secondly,  they  are  to  be  dis- 
criminated from  each  other.  It  is  unnecessary  to  enumer- 
ate or  consider  all  those  diseases  which  may  simulate  their 
symptoms.  The  one  of  primary  and  paramount  importance, 
and  which  demands  most  earnest  and  careful  attention,  is 
the  coma  produced  by  alcohol.  Its  importance  can  not  be 
overestimated,  not  only  because  it  is  the  one  with  which 
the  condition  of  traumatic  coma  is  most  likely  to  be  con- 
founded, but  because  error  in  diagnosis  inflicts  so  much 
unnecessary  suffering,  additional  danger,  and  possible  dis- 
grace upon  the  patient,  while  it  places  the  most  serious  re- 


sponsibility upon  the  surgeon.  The  number  of  instances 
in  which  injuries  of  the  brain  have  been  mistaken  for  alco- 
holic coma  and  the  patient  left  to  die  in  the  cells  of  a 
police  station,  or  committed  to  the  alcoholic  ward  at  Belle- 
vue,  or  even  sent  from  a  police  court  to  a  term  of  impris- 
onment, is  inexcusably  great.  A  large  proportion  of  such 
cases  which  came  into  my  service  at  Bellevue,  previous  to 
the  past  year,  were  transferred  from  the  alcoholic  ward. 
It  is  a  pleasure  to  acknowledge  that  within  the  year  great 
progress  has  been  made  in  the  acquisition  of  knowledge 
among  those  who  render  first  aid  to  the  injured,  even  to 
the  extent  of  realizing  that  an  unconscious  man  with  a 
scalp  wound  is  not  necessarily  drunk,  and  that  even  a 
drunken  man  may  be  so  seriously  injured  as  to  require 
hospital  treatment.  Unconsciousness  and  the  existence  of 
superficial  injury  of  the  head  should  in  any  case  arrest  at- 
tention and  awaken  suspicion  of  brain  lesion.  Coma  ought 
not  to  be  ascribed  to  alcohol,  except  by  the  strictest  pro- 
cess of  exclusion.  Symptoms  which  are  most  likely  to 
characterize  differertt  forms  of  head  injury  should  be 
sought  seriatim.  It  should  be  remembered,  finally,  that, 
even  if  the  patient  be  intoxicated,  this  circumstance  should 
strengthen  rather  than  allay  suspicion  of  traumatism.  I 
believe  the  temperature  affords  the  means  of  absolute  diag- 
nosis. I  have  shown,  from  the  histories  I  have  recorded 
and  upon  which  this  paper  is  founded,  that  variation  of 
temperature  in  head  injuries  is  invariable,  and  that  in  the 
exceptional  instances  in  which  it  is  depressed  the  severity 
of  associated  symptoms  will  take  them  out  of  the  category 
of  doubtful  cases.  In  alcoholic  coma  the  temperature  is 
subnormal,  and  I  have  found  this  rule  to  be  absolute.  The 
one  case  which  seemed  to  be  exceptional  was  reported  to 
me  as  having  a  temperature  of  100°.  Investigation  proved 
it  to  be  the  result  of  petit  mal  from  opium  smoking  in  a 
young  prostitute  of  the  Chinese  quarter  who  had  not  yet 
become  accustomed  to  her  mode  of  life.  I  have  made 
some  observations  to  determine  the  exact  temperature  in 
alcoholic  coma.  I  have  succeeded  in  obtaining  upward  of 
twenty  cases  in  which  coma  was  more  or  less  profound, 
and  the  temperature  ranged  from  96°  to  98°,  with  a  usually 
full  and  slow  or  normal  pulse,  and  the  depression  of  tem- 
perature was  directly  proportionate  to  the  depth  of  coma. 
I  had  expected  at  the  present  time  to  have  collected  a  larger 
number  of  cases,  but  I  have  found  my  opportunities  unex- 
pectedly limited.  Whether  it  be  the  quality  of  whisky  or 
the  moral  tone  of  the  lower  stratum  of  society  which  has 
improved  I  know  not,  but  examples  are  no  longer  to  be 
had  for  the  asking.  I  believe,  however,  the  absolutely 
uniform  results  in  this  number  of  cases  makes  it  more 
than  probable  that  a  larger  number  in  the  future  will  cor- 
roborate the  conclusion  which  has  been  reached. 

In  the  diagnosis  of  apoplexy  or  non-traumatic  cranial 
hajmorrhage,  I  have  found  that  the  observations  of  Bourne- 
ville  coincide  with  those  more  recently  made.  They  show 
that  in  the  commencement  of  the  attack  the  temperature  is 
subnormal,  that  it  then  becomes  normal,  and  remains  at 
that  point  if  the  patient  recovers,  but  if  he  dies  it  rises  to 
a  marked  degree.  In  twenty-three  cases  taken  from  an 
accessible  record,  of  which  seven  proved  fatal,  the  temjiera- 


106 


PHELPS:  INJURIES  OF  THE  HEAD. 


[N.  Y.  Med.  Jode., 


ture  in  two  of  the  latter  rose  to  102°  and  104°  ;  in  all  the 
others,  fatalities  included,  the  highest  temperature  was 
100°  +  .  This  is  in  marked  contrast  to  traumatic  lesions  in 
which  the  temperature  continues  to  rise  from  the  depres- 
sion, if  one  existed,  and  remains  elevated  while  the  result 
remains  in  abeyance.  A  case  which  suggests  the  occasional 
difficulty  in  the  diagnosis  of  idiopathic  from  traumatic  le- 
sion is  that  (Case  CVIII)  of  the  man  previously  quoted  who 
was  seized  with  an  apoplectic  effusion  into  his  lateral  ven- 
tricles and  one  occipital  lobe,  and  fell  from  his  cab,  causing 
a  cerebellar  laceration.  There  is  still  another  in  this  series 
very  like  it,  in  which  a  man  after  an  apoplectic  seizure  fell 
backward,  and,  like  the  first,  lacerated  his  cerebellum.  In 
both  cases  the  previous  history  was  known  and  it  was  pos- 
sible to  diagnosticate  both  lesions. 

It  is  unnecessary  to  refer  to  urjemic  coma,  opium  nar- 
cosis, hysteria,  etc.,  as  the  diagnostic  problems  they  present 
are  elementary. 

The  active  delirium  which  may  occur  in  the  period  im- 
mediately succeeding  the  reception  of  a  brain  injury  is 
sometimes  very  difficult  to  distinguish  from  that  which  re- 
sults from  alcoholic  excess.  The  difficulty  may  be  fur- 
ther increased  by  the  fact  that  the  subject  is  of  known 
intemperate  habits,  and  very  likely  intoxicated  when  first 
brought  under  observation.  In  those  cases  in  which  de- 
lirium is  the  first  symptom  noted,  and  probably  replaces 
unconsciousness  (as  in  Case  I),  the  condition  becomes  very 
deceptive.  In  this  instance  we  are  not  aided  by  the  tem- 
perature, which  is  almost  always  elevated  in  alcoholic  de- 
lirium, and  elevation  may  be  and  often  is  very  great.  I 
have  within  a  few  days  seen  a  case  in  which,  with  quite  ex- 
tensive superficial  injury  of  the  head,  there  was  alcoholism 
to  the  verge  of  delirium,  a  high  temperature,  a  previous 
history  of  epilepsy,  and  present  epileptiform  convulsions 
followed  by  facial  paralysis.  The  diagnosis,  which  excluded 
brain  injury  and  which  proved  to  be  correct,  was  made 
from  observation  of  the  course  of  the  temperature  for  the 
first  few  hours.  I  am  aware  of  no  single  diagnostic  sign 
upon  which  dependence  can  be  placed,  and  yet  I  have 
never  seen  a  case  in  which  it  was  not  possible  to  make  the 
distinction  between  the  two  forms  of  mental  disturbance. 
There  are  few  head  injuries  in  which  there  are  not  at  least 
one  or  two  characteristic  symptoms  which  can  be  detected 
if  sufficient  care  be  exercised  in  the  examination  of  the 
case.  It  seems  to  me  that  there  are  differences  even  in 
the  character  of  the  delirium  which  may  be  recognized 
though  not  easily  formulated. 

The  diagnosis  from  each  other  of  the  several  injuries 
which  may  be  inflicted  upon  the  cranium  and  its  contents  is 
fraught  with  difficulties.  The  lesions  are  likely  to  be  mul- 
tiple and  the  symptoms  to  be  equally  referable  to  either  one 
of  their  number ;  the  symptoms  of  circumscribed  lesion  are 
often  lost  in  those  from  one  of  a  diffuse  character,  and  simi- 
lar results  constantly  ensue  from  totally  different  causes.  A 
more  exhaustive  study  of  the  diagnostic  value  of  individual 
symj)toms  in  their  relation  to  each  other,  and  to  established 
structural  changes,  is  therefore  requisite  than  I  have  yet 
been  a])le  to  undertake.  There  are,  however,  well-estab- 
lished facts,  as  well  as  strong  diagnostic  probabilities,  which 


are  likely  to  multiply  and  to  make  diagnosis  possible  in  an 
increasing  number  of  cases.  Thus,  it  is  well  known  that 
certain  ha;morrhages  positively  indicate  a  definite  fracture 
at  the  base.  A  trivial  injury  of  the  vertex  and  one  or  two 
general  symptoms  may  suggest  its  whole  extent  and  com- 
plications. Again,  paralysis  of  an  extremity  in  a  recent 
head  injury  will  positively  determine  some  lesion  of  a  defi- 
nite portion  of  the  parietal  cortex  on  the  opposite  side.  In 
the  absence  of  depressed  fracture,  and  with  the  knowledge 
that  occurrence  of  laceration  or  limited  contusion  at  this 
point  is  unusual,  the  ascription  of  the  paralysis  to  hsemor- 
rhage  becomes  justifiable.  These  conclusions  are  legitimate 
and  founded  upon  positive  knowledge  and  logical  inference 
combined.  There  can  be  no  doubt,  I  think,  that  greater 
diagnostic  significance  will  attach  to  individual  symptoms 
in  the  light  of  further  pathological  observation.  As  an  ex- 
ample, the  present  series  of  necrologies  seem  to  show  that 
the  peculiar  mental  conditions  I  have  described  are  usually 
preceded  by  lesion  of  the  brain  tissue,  and  if  it  be  of  tbre 
membranes,  that  it  is  meningeal  contusion  with  inflamma- 
tioti.  I  have  insisted  upon  the  importance  of  temperature 
in  the  recognition  of  head  injuries  as  a  class.  I  am  not  at 
present  prepared  to  raise  the  question  of  its  diagnostic  re- 
lation to  individual  lesions. 

PROGNOSIS. 

The  prognosis  may  be  first  considered  from  the  numer- 
ical results.  The  total  number  of  cases  is  one  hundred  and 
twenty-four,  of  which  forty-nine  ended  in  recovery,  or  near- 
ly forty  per  cent.  The  fractures  at  the  base  number  seventy, 
of  which  twenty-one  ended  in  recovery,  or  exactly  thirty 
per  cent. 

The  popular  belief,  and  possibly  the  general  professional 
impression,  is  that  this  fracture  is  a  peculiarly  fatal  acci- 
dent. I  have  already  expressed  the  opinion  that  fracture 
at  the  base  is  devoid  of  danger  except  for  its  complications, 
but  it  is  so  often  attended  with  grave  lesions  of  the  brain 
and  meninges  that  it  is  not  strange  that  by  a  species  of  me- 
tonymy it  should  come  to  stand  for  the  traumatism  as  a 
whole. 

It  is  difficult  to  estimate  the  comparative  danger  of  the 
several  lesions,  from  the  fact  that  they  are  so  generally  mul- 
tiple, and  all  together  conspire  to  bring  about  the  fatal  re- 
sult. It  is  also  true  that  the  severity  rather  than  the  form 
of  lesion  is  to  be  made  the  basis  of  prognosis.  It  may  be, 
therefore,  of  no  great  practical  importance  to  attempt  to  infer 
from  the  necropsies  the  relative  responsibility  of  individual 
lesions  in  causing  death  in  each  instance.  So  far  as  I  may 
judge  from  comparisons  of  symptomatology  with  post-mor- 
tem appearances,  when  opportunity  has  been  afforded,  I  be- 
lieve death  has  directly  resulted  in  fully  fifty  per  cent,  from 
laceration  and  attendant  ha3morrhage.  In  the  remainder  it 
might  be  chargeable  to  epidural  hemorrhage,  contusion,  ab- 
scess, or  arachnitis,  though  doubtless  in  every  case  some 
other  lesion  was  contributory. 

The  prognosis  made  from  initial  symptoms  must  depend 
upon  their  general  severity  and  upon  the  extent  to  which 
the  vital  powers  are  implicated.  It  sometimes  happens  that 
the  patient  survives  when  the  obvious  extent  of  the  lesion 


Jan.  28,  1893.J 


PHELPS:  INJURIES  OF  THE  HEAD. 


107 


has  made  recovery  seem  practically  hopeless.  A  fracture 
through  both  middle  and  one  anterior  fossa,  and  probably 
both,  might  well  put  an  end  to  hope,  and  yet  such  a  case 
(Case  LXIX)  did  recover.  I  find  that  none  of  my  patients 
have  lived  in  whom  the  temperature  has  risen  to  105°,  but 
in  more  than  one  that  degree  was  approximated.  I  am  not 
at  all  certain  it  might  not  exceed  105°  consistently  with  re- 
covery. A  very  high  temperature,  or  disturbance  of  respi- 
ration at  an  early  period,  or  muscular  rigidity,  are  always 
calculated  to  excite  the  gravest  apprehension.  The  late 
prognosis  presents  no  diflSculties,  but  it  ceases  to  be  of  pro- 
fessional interest. 

TREATMENT. 

I  propose  to  confine  whatever  I  may  have  to  say  in 
regard  to  treatment  to  questions  of  operation.  I  omit  all 
reference  to  medication,  as  it  involves  matters  of  detail 
for  which  time  is  wanting.  I  premise  only  a  brief  men- 
tion of  what  may  be  properly  designated  adjuvants  in  gen- 
eral treatment.  The  necessity  of  shaving  the  head,  which 
is  conceded  in  cases  with  symptoms  of  marked  severity,  is 
equally  existent  in  every  case  in  which  there  seems  to  be  a 
possibility  of  intracranial  injury.  It  permits  the  discovery 
of  diagnostic  contusions  which  are  so  often  disclosed  only 
upon  post-mortem  examination.  It  relieves  the  brain,  in 
some  cases  at  least,  of  a  superincumbent  and  thermogenetic 
weight,  which  is  positively  contraindicated  and  is  a  factor 
of  appreciable  influence.  It  facilitates  the  use  of  the  ice 
cap,  which  in  cases  of  high  temperature  and  delirium  is  an 
appliance  of  the  highest  therapeutic  value.  I  have  found 
it  so  effective  that  I  desire  to  emphasize  its  importance.  I 
have  sometimes  been  compelled  to  maintain  its  use  for  a 
length  of  time,  as  whenever  it  was  discontinued  the  tem- 
perature again  increased  and  delirium  returned.  The  resort 
to  a  simple  form  of  mechanical  restraint  is  often  requisite 
for  the  mere  purpose  of  retaining  the  patient  in  bed.  It 
incidentally  becomes  at  the  same  time  a  means  of  quieting 
nervous  excitement  and  of  husbanding  physical  strength. 

Trephining  may  be  regarded  with  less  apprehension  by 
the  timid  since  the  advent  of  aseptic  methods.  Its  pro- 
priety may  now  be  decided  simply  in  view  of  its  probable 
advantage,  or  its  more  probable  futility.  It  may  be 
counted  quite  as  safe  as  the  use  of  the  exploring  needle  in 
suspected  abscess,  and  safer  than  explorative  laparotomy. 
I  should  not  deem  it  necessary  to  insist  upon  this  point 
were  it  not  that  I  am  so  often  surprised  by  denials  of  what 
I  had  taken  to  be  conceded  facts.  If,  as  I  am  informed, 
the  temperature  rises  to  a  high  degree  after  craniectomy  or 
trephining  in  children,  it  is  so  foreign  to  my  experience  in 
traumatism  that  I  am  constrained  to  attribute  it  to  other 
causes  than  to  simple  perforation  of  the  cranium.  I  have 
often  found  it,  on  the  contrary,  to  be  followed  by  a  depres- 
sion of  temperature  when  no  result  had  been  attained  be- 
yond the  mere  removal  of  the  button  of  bone.  The  incis- 
ion of  the  dura,  or  the  further  exploration  of  the  brain, 
might  be  differently  regarded,  for  while  trephining,  done 
with  due  regard  to  time  and  method,  could  hardly  inure  to 
the  serious  disadvantage  of  the  patient,  uncalled-for  and  in- 
judicious interference  with  the  intracranial  contents  might 


be  of  positive  disservice.  This  possibility  is  not  a  contrain- 
dication to  going  further  after  trephining,  if  its  propriety 
becomes  evident.  In  such  case  I  have  always  found  the 
temperature  to  rise  as  it  does  in  injuries  of  the  brain 
generally.  In  the  small  abscess  which  I  incised  through 
the  angular  gyrus  it  rose,  in  the  sixteen  hours  which  pre- 
ceded death,  from  102-2°  to  108°.  In  the  very  large  ab- 
scess in  the  frontal  lobe,  upon  which  I  operated  only  last 
month,  the  temperature  rose  from  99*2°  in  twenty-four 
hours  to  102'2°,  and  recovery  is  even  now  complete.  I 
should  expect  an  elevation  of  temperature  in  any  case,  but 
I  should  not  expect  any  serious  results  from  incision  of  the 
dura  or  brain  per  se.  So  far  as  subsequent  danger  or  in- 
convenience from  hernia  cerebri  is  concerned,  I  may  repeat 
a  statement  previously  made,  that  in  the  surgery  of  to-day 
it  has  ceased  to  be  an  intimidation  to  the  surgeon. 

I  am  quite  of  the  same  mind  with  those  surgeons  who 
believe  that  this  operation  should  be  done  in  every  de- 
pressed fracture  where  elevation  and  thorough  exploration 
can  not  be  otherwise  accomplished.  I  believe  with  them 
that  the  absence  of  general  symptoms  does  not  relieve  the 
surgeon  from  the  responsibility  of  operation.  This  view 
was  held  by  my  former  preceptors,  the  late  Dr.  James  R. 
Wood  and  Dr.  J.  W.  S.  Gouley,  at  a  time  when  to  hold 
such  opinion  was  almost  an  opprobrium.  It  commended 
itself  to  my  judgment  then  as  it  does  now.  It  is  doubtful 
if  such  an  operation  has  been  known  to  do  harm  when  it 
has  failed  to  do  good.  It  is  certain  that  harm  has  come 
in  more  than  one  instance  where,  because  of  the  absence  of 
general  symptoms,  it  has  been  neglected.  It  is  impossible 
to  tell  in  a  depression  of  the  external  table  of  moderate  or 
perhaps  insignificant  extent  what  more  extensive  comminu- 
tion of  the  internal  table  may  not  exist.  It  is  this  possi- 
bility of  even  the  smallest  bony  spicula  penetrating  the 
brain  and  causing  serious  nervous  disturbance  in  the  indefi- 
nite future  that  demands  thorough  examination  of  every 
cranial  fracture.  It  should  be  held  obligatory  on  precisely 
the  same  grounds  as  the  examination  and  cleansing  of  a 
wound  in  the  external  soft  parts.  The  observance  of  such 
precaution  is  free  from  danger  ;  its  neglect  may  lead  to 
either  present  or  future  serious  complications. 

If  the  depressed  fracture  is  simple  or  its  existence  is  in 
doubt,  there  should  be  no  hesitancy  in  making  sufficiently 
free  incision  to  determine  the  exact  cranial  condition.  It 
is  of  very  common  occurrence  that  a  large  haematoma  ex- 
ists in  connection  with  diagnostic  symptoms  of  intracranial 
injury,  and  that  there  is  no  other  means  than  this  of  acquir- 
ing knowledge  which  may  be  of  vital  importance.  If  the 
result  is  nugatory,  the  incision,  made  under  aseptic  condi- 
tions, will  be  closed  by  primary  union.  It  is  certainly 
better  to  have  made  many  fruitless  incisions  than  to  have 
allowed  a  single  life  to  be  jeopardized  by  an  undiscovered 
fracture. 

.In  case  the  fracture  proves  to  be  a  simple  fissure,  a 
different  rule  of  conduct  will  obtain.  The  probabilities 
will  be  against  the  existence  of  depression  of  the  inner 
table,  and  after  the  fissure  has  been  traced,  with  or  without 
incision,  as  far  as  practicable,  or  till  it  has  become  nar- 
rowed to  a  line,  the  wound  should  be  closed.    If,  how 


1U8 


ELIOT:  ADDRESS. 


[N.  Y,  Med.  Joub., 


ever,  the  general  symptoms  should  indicate  complication, 
further  exploration  may  become  proper  and  necessary. 

The  indications  for  trephination  are  wanting  at  the  pres- 
ent time  in  the  great  majority  of  cases  which  involve  intra- 
cranial lesion.  If  the  existence  of  epidural  haemorrhage 
is  evident  and  its  location  is  accessible,  the  propriety  of 
operation  is  unquestioned.  If  the  existence  of  circum- 
scribed lesion  of  the  brain  can  be  inferred  from  local 
paralyses,  anaesthesia,  or  muscular  rigidity,  or  from  the 
initial  symptom  of  convulsion,  I  think  the  propriety  of 
operation  may  be  assumed.  In  the  greater  number  of 
cases,  those  in  which  only  symptoms  of  diffuse  lesion  can 
be  recognized,  the  use  of  the  trephine  is  entirely  empirical 
and  without  justification,  unless  undertaken  for  special 
reason.  If  in  time  lacerations  at  the  base  come  to  be  diag- 
nosticated with  reasonable  certaint}',  it  may  then  be  proper 
to  inquire  whether  their  exposure  by  the  trephine  or  other- 
wise, disinfection,  and  drainage  would  be  practicable  and 
advantagious. 

The  accidental  result  of  trephination,  in  at  least  two  or 
three  cases,  suggests  its  employment  on  purely  medico-legal 
grounds.  I  will  instance  the  case  (Case  CVIII),  already 
quoted  as  an  example  of  mixed  iodiopathic  and  traumatic 
lesions,  of  a  man  who  fell  from  his  cab  after  an  apoplectic 
effusion  and  secondarily  lacerated  his  cerebellum.  He  was 
paralyzed,  ansesthetic,  and  absolutely  unconscious.  He  was 
trephined,  and  a  large  amount  of  serous  fluid  drained  away 
from  the  surface  of  the  brain.  His  temperature  fell  in  six 
hours  from  103"4°  to  98"6°.  He  became  conscious,  could 
articulate,  spoke  rationally  and  intelligently,  and  gave  his 
name  and  address.  At  the  end  of  fourteen  hours  his  tem- 
perature again  rose  and  he  died.  The  possibilities  of  such 
a  case  are  not  less  practical  than  dramatic.  The  instances 
I  have  encountered  of  such  transient  returns  to  conscious- 
ness have  been  sufficiently  prosaic  and  unimportant.  The 
very  next,  perhaps,  might  disclose  a  criminal  and  avenge 
the  crime.  In  any  one  of  the  many  homicidal  assaults  iu 
which  the  victim  is  found  unconscious  and  the  assailant 
has  escaped  unknown,  I  believe  it  to  be  legitimate  to 
trephine  for  this  direct  purpose.  Even  temporary  restora- 
tion of  the  mental  faculties  might  suffice  the  ends  of  jus- 
tice. The  prospect  of  success  is  certainly  not  altogether 
chimerical,  for  I  have  cited  a  case  in  which  just  such  a  hy- 
pothetical result  was  absolutely  attained. 

The  general  principles  of  operative  interference  in  cra- 
nial fractures  and  encephalic  injury  may  be  recapitulated 
and  formulated  as  follows :  Incision  of  the  scalp,  trephina- 
tion, incision  of  the  dura  mater,  and  perforation  of  the 
brain,  severally  or  together,  should  have  resort  without  fear 
or  hesitation  when  indicated.  Incision  of  the  scalp  and 
trephination  are  devoid  of  danger  and  are  always  justifiable 
for  exploration,  which  in  itself  constitutes  an  indication, 
incision  of  the  dura  mater  and  incision  or  perforation  of 
the  brain  are  more  serious  procedures,  and  should  be  made 
only  when  positively  indicated  by  the  general  symptoma- 
tology. 

I  have  sketched  as  rapidly  and  systematically  as  possi- 
ble in  this  paper  the  conclusions  to  be  derived  from  the 
.series  of  histories  and  necrologies  by  which  it  is  preceded. 


So  far  as  they  are  confirmatory  of  previous  observations, 
they  will  have  the  value  which  attaches  to  independent 
study.  If  in  any  particular  they  differ  from  accepted 
teaching,  the  inclusion  of  the  historical  data  will  make  it 
easy  either  to  verify  their  truth  or  to  refute  their  error. 

I  beg  to  acknowledge  my  indebtedness  to  the  courtesy 
of  my  colleagues.  Dr.  J.  W.  S.  Gouley  and  Dr.  F.  S.  Dennis, 
and  also  to  the  successive  house  surgeons  at  Bellevue  and 
St.  Vincent's  Hospitals,  for  their  intelligent  co-operation  in 
the  work  of  observation. 


REMARKS  AT  THE  MEETING  OF  THE 
BOARD  OF  MANAGERS  OF 
THE  NEW  YORK  SOCIETY  FOR  THE  RELIEF  OF 
WIDOWS  AND  ORPHANS  OF  MEDICAL  MEN, 

December  21,  1892. 
By  ELLSWORTH  ELIOT,  A.M.,  M.  D., 

PRESIDBNT  or  THE  SOCIBTT. 

Printed  at  the  Unanimous  Request  of  the  Board. 

At  the  jubilee  of  this  society  in  April  last,  our  secre- 
tary. Dr.  Currier,  gave  a  condensed  history  of  its  origin 
and  usefulness.  With  worthy  mention  he  spoke  of  its 
founder.  Dr.  Edward  Delafield,  whose  name,  on  account  of 
this  and  other  benevolent  acts,  in  the  list  of  benefactors  of 
the  medical  profession  in  our  city  easily  leads  all  the  rest. 
Nor  were  the  labors  of  Dr.  William  Detmold  forgotten,  by 
whose  wisdom  the  by-laws  were  so  wisely  modified  that  our 
pecuniary  management  was  placed  upon  the  soundest  finan- 
cial basis.  Our  secretary  was  not  then  perhaps  aware  of  the 
fact  that  this  vigilant  friend  of  the  society  had,  at  a  certain 
epoch  in  its  history,  the  forecast  to  save  several  thousand 
dollars  to  its  treasury,  which  should  be  permanently  re- 
corded. He  told  us  of  the  legacies  of  Dr.  Delafield  and  Dr. 
Beadle,  to  the  amount  of  $5,000  each  ;  of  that  of  Dr.  Jacob 
Harsen,  of  $10,000  ;  of  Dr.  Alonzo  Clark,  whose  legacy  is  es- 
timated at  $20,000  ;  and  of  several  others  who  left  smaller 
amounts  as  God  gave  them  ability.  Were  it  not  for  these 
legacies  and  the  contributions  made  by  the  wealthier  physi- 
cians, small  indeed  would  be  the  pittance  which  the  society 
could  give  to  the  widows  and  orphans  of  their  less  fortu- 
nate, perhaps  less  thrifty,  brethren. 

To  Dr.  Currier's  document,  prepared  with  much  care 
and  great  labor,  I  am  indebted  for  most  of  the  statistics 
which  I  present  to-night. 

On  October  5,  1892,  our  assets  were  $182,546.76. 
During  the  year  past  we  aided  twelve  widows  and  four 
children  of  deceased  members,  and  our  expenditure  in  the 
management  was  $280.95. 

The  past  history  of  this  society  is  most  creditable. 
From  1852,  when  relief  was  first  given  to  a  widow,  to  the 
year  1892,  twenty-seven  widows  and  twenty-two  children 
have  been  relieved,  one  of  the  former  for  more  than  thirty 
years.  Let  me  call  attention  to  the  amounts  paid  by  mem- 
bers whose  widows  and  orphans  have  had  this  inestimable 
advantage.  One  member  who  paid  $40  has  had  paid  to 
his  widow  and  children  $2,790.    Another  widow,  the  pay- 


Jan.  28,  18l»3.J 


ELIOT:  ADDRESS. 


109 


ment  having  been  $40,  has  received  $6,615.  To  another 
widow,  the  payment  being  $250,  $8,652.50  has  been  paid. 
Another  widow  still  lives  to  give  hearty  thanks  for  the 
good  example  of  her  husband,  who,  having  contributed 
$40  to  the  funds  of  the  society,  entitled  her  to  relief  already 
for  more  than  thirty  years  to  an  amount  exceeding  $10,000, 
and  the  end  is  not  yet.  May  the  $400  which  she  annually 
receives  so  smooth  her  pathway  to  the  grave  that  many 
years  shall  elapse  before  she  has  the  opportunity  of  becom- 
ing an  angel  in  heaven  ! 

The  largest  amount  which  our  by-laws  now  require  in 
order  to  secure  the  advantage  of  this  society  is  $225,  the 
payment  of  which  may  be  extended  for  a  period  of  twenty 
years.  Several  of  our  beneficiaries  enjoy  this  privilege  by 
the  payment  of  less  than  $50  to  the  treasury  of  the  society. 

As  a  rule,  physicians  leave  scanty  means.  "  Ye  have 
the  poor  always  with  you  "  is  as  true  in  regard  to  physicians 
as  it  is  of  others.  The  large  number  now  crowding  the 
profession  will  probably  result  in  an  increase  of  this  class. 
Why  do  not  more  avail  themselves  of  the  privileges  of  this 
society  ?  If  they  would  do  so,  physicians  would  not  be 
asked  for  alms,  as  not  infrequently  happens,  by  their  desti- 
tute widows  and  children. 

The  society  has  had  during  its  existence  of  fifty  years, 
as  far  as  can  be  ascertained,  three  hundred  and  thirty- one 
members.  We  have  now  but  one  hundred  and  thirty-five, 
although  there  are  not  less  than  two  or  three  thousand  who 
are  eligible.  So  far  as  I  have  learned,  there  is  but  one 
physician  in  Westchester  County,  and  none  in  Richmond 
and  Queens,  who  are  members.  Our  membership  is  not 
€qual  to  what  it  was  ten  years  ago.  Fortunately  this  is  not 
true  of  our  property.  The  annual  increase  has  exceeded 
$2,000;  in  one  year  we  added  more  than  $6,000.  The 
last  year  our  increase  was  $4,396.48.  During  the  last  year, 
under  the  presidency  of  my  predecessor.  Dr.  Herrick,  we 
increased  the  number  of  our  members.  We  should  not  be 
satisfied  unless  we  annually  make  some  gain,  though  a  large 
and  rapid  increase  is  not  desirable,  as  it  might  result  in  a 
diminution  of  the  amount  we  now  pay  to  the  widow  and 
orphan.  Still,  all  are  invited  to  join,  and  none  are  repelled. 
A  slight  effort  upon  the  part  of  each  one  of  us  would  prob- 
ably accomplish  as  much  in  this  direction  as  is  desirable. 

Dr.  Currier  informed  us  that  eighteen  dinners — at  one 
of  which  "  the  host  said  that  he  had  never  met  so  temperate 
a  body  of  men  " — had  been  successfully  given  in  order  to 
increase  the  membership  and  the  funds.  In  our  day  it  has 
not  been  deemed  wise  to  continue  them. 

At  the  last  revision  of  the  by-laws,  in  1889,  it  was  de- 
cided that  the  life-membership  fee  should  remain  at  $100, 
as  it  was  thought  that  many  of  the  wealthy  of  our  profes- 
sion would  give  this  amount  or  more  in  aid  of  those  less 
fortunate  ;  and  in  almost  every  instance  a  request  to  join 
as  an  act  of  charity  has  so  commended  itself  to  their  ap- 
proval as  to  receive  prompt  acquiescence  ;  in  one  instance 
with  a  note  of  hearty  thanks  for  the  privilege.  I  am  sure 
that  many  others,  if  their  attention  were  properly  called  to 
the  subject,  would  do  likewise.  They  could  be  assured  that 
more  than  ninety-nine  cents  of  every  dollar  given  would  go 
to  some  destitute  widow  or  orphan.    True,  we  have  Ishma- 


elites  in  our  profession,  who,  instead  of  becoming  members 
of  our  societies  and  contributing  to  their  support,  waste 
their  energy  in  finding  fault  with  the  management.  Living, 
they  contribute  nothing  to  the  general  fund ;  dying,  they 
remember  those  only  as  selfish  as  themselves. 

The  wealthy  and  flourishing  may  learn  a  lesson  from 
some  facts  in  our  history.  In  the  historical  sketch  of  the 
society,  printed  in  the  1875  edition  of  our  by-laws,  is  this 
statement :  "  A  member  had  died,  leaving  his  widow  a 
handsome  competence.  But  about  ten  years  after  his 
death,  owing  to  unfortunate  investments,  her  property  had 
all  been  lost,  and  she  claimed  and  received  aid." 

I  remember  another  instance  where  a  bachelor  joined, 
and  made  payments  to  the  amount  of  $40,  little  thinking  it 
would  ever  be  a  direct  benefit  to  him.  He  subsequently 
married,  and  the  table  prepared  by  Dr.  Currier  shows  that 
his  widow  and  child  received  $6,337.50,  and  the  annuity 
would  have  been  continued  to  this  day,  and  perhaps  years 
longer,  had  not  the  widow  received  a  legacy  which  made 
further  relief  unnecessary. 

Another  physician  told  me  he  joined  the  society  to  help 
others,  as  his  family  would  have  ample  provision  at  his 
death.  His  payments  amounted  to  $135.  His  widow  and 
children  received  $5,590.  He  had  miscalculated  or  mis- 
fortune overtook  him. 

Some  of  us  remember  a  physician  whose  success  appar- 
ently made  him  one  of  Fortune's  favorites.  He  lived  in  a 
fashionable  part  of  the  city,  drove  a  spanking  team  of 
horses  with  a  liveried  coachman,  gave  frequently  elaborate 
entertainments,  and  seemed  to  have  at  command  all  the 
surroundings  of  a  physician  in  a  large  and  lucrative  prac- 
tice. To-night  we  have  voted  to  appropriate  to  his  widow, 
who  makes  affidavit  that  she  has  no  property,  $400. 

We  want  more  legacies,  more  benefactors,  and  more 
life  members.  We  should  be  glad  to  see  such  an  in- 
crease in  our  assets  that  the  penniless  widow  would  re- 
ceive $500  annually  instead  of  the  $400  we  now  allow.  At 
first  it  was  $100  for  the  widow  and  $25  for  a  child. 

It  should  not  be  considered  respectable  for  a  wealthy 
physician  to  die  without  the  pale  of  life  membership ;  and 
if  in  their  wills  this  society  were  mentioned  as  a  legatee,  it 
would  be  in  harmony  with  the  definition  of  "  pure  religion 
and  undefiled,"  "  to  visit  the  fatherless  and  widows." 

This  society  has  always  been  most  piously  inclined  to 
carry  out  the  designs  of  its  early  members.  They  had  a 
by-law  to  this  effect :  "  In  special  cases  the  aged  father, 
the  widowed  mother,  or  aged  sister  of  a  deceased  member, 
who  has  been  dependent  upon  said  member  for  support, 
may  receive  assistance  at  the  discretion  of  the  board  of 
managers  on  a  three-fourths  vote  of  the  members  present." 
When  the  lawyers  gave  their  opinion  that  this  was  con- 
trary to  the  charter,  our  standing  committee  were  instructed 
to  procure,  if  possible,  such  alterations  as  would  enable  us 
to  carry  into  effect  the  intentions  of  our  founders.  The 
committee  have  reported  progress,  and  hope  at  the  next 
session  of  the  Legislature  to  secure  the  amendments  de- 
sired. 

Our  society  has  been  accused  of  hoarding  money,  instead 
of  dealing  with  a  liberal  hand,  by  some  who,  if  well  in- 


110 


LEA  Dim 


ARTICLES. 


[N.  Y.  Mbd.  Joch., 


formed,  would  have  words  of  praise  for  our  wise  prudence. 
We  have  a  by-law  which  will  prevent  an  accumulation  be- 
yond a  proper  limit.  We  shall  hail  the  day  when  we  can 
increase  the  annuities,  but  we  shall  not  knowingly  place 
ourselves  in  a  position  where  it  will  be  necessary  to  take  a 
step  backward. 

So  far  as  I  have  been  able  to  learn,  ours  is,  with  the  ex- 
ception of  societies  in  Philadelphia  and  Massachusetts,  the 
only  one  of  the  kind  in  this  country.  It  was  patterned 
after  one  in  London  having  the  same  name,  which  was  es- 
tablished in  1788.  The  experience  of  one  hundred  and 
one  years,  says  one  of  their  late  reports,  has  fully  proved 
the  need  that  existed  for  this  society.  In  1888  £.3,221 
were  distributed  among  sixty-two  widows  and  thirteen  or- 
phans of  deceased  members — a  smaller  annuity  to  each 
than  we  grant.  Like  ours,  it  has  received  legacies,  and  in 
such  favor  is  it  held  that  members  of  the  royal  family  have 
been  its  patrons. 

Our  society  must  suffer  no  detriment  while  in  our  keep- 
ing, and  we  shall  not  do  our  whole  duty  as  a  board  of 
managers  unless,  after  the  example  of  our  predecessors,  we 
deliver  it  at  the  appointed  time  to  our  successors  on  a  higher 
level  than  it  now  holds. 


The  Cincinnati  College  of  Medicine  and  Surgery. — Dr.  J.  Trush 
has  resigned  the  chair  of  theory  iind  practice  of  medicine  in  consequence 
of  ill  health,  and  the  vacancy  thus  created  has  been  filled  by  the  trans- 
fer of  Dr.  E.  W.  Mitchell  from  the  chair  of  materia  medica  and  thera- 
peutics. Dr.  G.  A.  Fackler,  professor  of  materia  medica  and  therapeu- 
tics at  the  Women's  Medical  College,  has  accepted  the  appointment  to 
the  vacancy  created  by  the  transfer  of  Dr.  Mitchell.  The  college  moved 
into  its  new  building,  on  Vine  Street,  near  Liberty,  on  January  1st.  A 
change  has  been  made  with  particular  reference  to  the  further  develop- 
ment of  the  clinical  department  of  the  school. 

Medical  Education  in  Chicago. — "  It  is  stated,"  sa3's  the  Journal  of 
the  American  3/ediral  Association,  "  that  both  the  Rush  Medical  College 
and  the  College  of  Physicians  and  Surgeons,  of  Chicago,  have  offered 
to  give  up  their  entire  property  to  the  Chicago  University,  and  the  fac- 
ulties to  resign  unconditionally,  in  order  that  a  medical  department  may 
be  organized  on  a  level  with  other  schools  in  this  already  wonderfully 
well  organized  institution.  It  is  stated  that  $1,000,000  is  in  sight  for 
the  endowment  of  such  a  medical  department." 

The  Medical  Society  of  the  County  of  New  York. — The  programme 
for  the  meeting  of  Monday  evening,  the  23d  inst.,  included  a  paper  on 
Cancer  of  the  Cervix  Uteri  complicating  Pregnancy,  by  Dr.  Henry  C. 
Coe  ;  a  eulogy  of  the  late  Dr.  James  R.  Leaming,  by  Dr.  J.  Leonard 
Coming ;  and  a  paper  entitled  Practical  Data  in  the  Application  of 
Water  to  some  Intraetal)le  Diseases,  by  Dr.  Simon  Baruch. 

Honors  to  Medical  Men  in  France. — According  to  the  British  Medi- 
cal Journal,  M.  Poan,  M.  Proust,  and  M.  Dujardin-Beaumetz,  of  Paris, 
have  been  named  commanders  ;  M.  Guyon  and  M.  E.  Roux,  officers ; 
and  M.  Metsehnikoff,  M.  Netter,  M.  Thoinot,  and  M.  Galliard,  of  Paris, 
M.  Gimbert,  of  Cannes,  M.  Heydenreich,  of  Nancy,  and  M.  Fochier,  of 
Lyons,  Knights  of  the  Legion  of  Honor. 

The  Medical  Week. — This  is  the  title  of  an  edition  of  the  Semnine 
medicalc,  of  Paris,  jjrinted  in  English.  The  journal  consists  of  twelve 
large  double-columned  i)ages  giving  matter  drawn  from  various  coun- 
tries and  presented  in  far  better  English  than  we  remember  to  have 
seen  in  any  other  French  jiublication.  The  journal  is  published  in 
Spanish  also,  under  the  title  of  //«  Seinana  Medica. 

The  New  Haven,  Conn.,  Medical  Association, — The  special  order 
for  the  next  meeting,  on  W^cdiicsday  evening,  February  1st,  is  a  discus- 
sion on  scarlet  fever. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A   Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Applbton  &,  Co.  Frank  P.  Fobtkb,  M.  D. 


NEW  YORK,  SATURDAY,  -lANUARY  28,  1893, 


MEDICAL  ETHICS  AMONG  OUR  MILITARY  BRETHREN. 

The  code  of  medical  ethics,  as  regards  the  relations  of  physi- 
cians to  each  other,  is  an  admirable  expansion  of  the  principle 
"Do  as  you  would  be  done  by."  It  throws  every  safeguard 
around  the  interests  of  the  attending  physician  when  he  is 
brought  in  contact  by  the  bedside  of  his  patient  with  his  medi- 
cal brethren  in  consultation,  in  emergencies  or  in  cases  of  in- 
terference. The  code  allows  nothing  to  be  done,  said,  hinted 
at,  or  insinuated,  or  any  course  of  conduct  pursued  that  would, 
directly  or  indirectly,  tend  to  diminish  the  trust  reposed  in  the 
attending  physician  or  affect  his  reputation  injuriously.  For 
one  medical  man  to  supplant  another  in  the  whole  extent  of  his 
practice  and  oblige  him  to  retire  to  a  distant  field  would  seem 
to  he  an  impossibility  under  such  a  code,  and  yet  it  seems  that 
recently  such  a  wholesale  infraction  of  medical  ethics  has  been 
committed  in  one  or  two  instances  by  members  of  the  profes- 
sion in  the  military  service. 

The  Army  Medical  Department  has  for  years  taken  a  just 
pride  in  the  purity  of  its  constitution  and  administration.  Since 
its  organization  vacancies  have  been  filled  by  competitive  ex- 
amination before  a  board  of  medical  oflBcers  anxious  to  preserve 
the  high  standing  of  their  corps.  Other  officers  of  the  army 
have  owed  their  positions  to  influence — the  congressional  or 
other  influence  that  sent  them  to  the  Military  Academy  at  West 
Point  or  the  stronger  influence  that  appointed  them  to  posi- 
tions in  some  of  the  staff  corps.  The  medical  officer  alone  has 
owed  his  position  to  his  own  intelligence,  assiduity,  and  ability. 
For  years  also  the  Medical  Department  of  the  Army  has  taken 
pride  in  its  own  integrity  and  adherence  to  the  code  of  ethics 
as  modified  by  military  customs.  Rank  and  promotion  have 
followed  appointment  by  virtue  of  years  of  service,  irrespective 
of  any  influence  possessed  by  family  or  friends.  Leaves  of  ab- 
sence and  other  privileges  of  the  officer  have  also  been  inde- 
pendent of  outside  influence,  and  his  service  at  desirable  posts 
in  the  East  or  at  undesirable  posts  in  the  West  has  been  pre- 
scribed and  so  well  understood  by  everybody  that  when  an 
order  was  issued  changing  his  station  it  was  accepted  by  him 
and  recognized  by  his  medical  brethren  in  and  out  of  the  serv- 
ice as  right  and  just.  Thus  since  its  organization  has  the  Army 
Medical  Department  been  ruled,  its  officers  free  from  the  jeal- 
ousies and  ill-feelings  generated  by  preferment  or  advantages 
due  to  political  influence  and  looking  to  the  department  itself 
and  its  well-understood  line  of  action  for  protection  against  any 
of  its  members  who  should  endeavor  to  make  use  of  any  such 
influence  on  his  own  behalf. 

Recently,  however,  the  traditions  of  the  department  have 
been  rudely  shaken,  so  rudely  as  to  create  anxiety  in  the  minds 


Jan.  28,  1893.] 


MINOR  PARAGRAPHS. 


Ill 


of  its  officers  lest  the  rule  of  influence  should  hereafter  replace 
that  of  nieilical  ethics  and  departmental  equity.  Several  in- 
stances of  the  power  of  influence  have  occurred,  and  they  have 
eulininated  in  one  of  such  importance  as  to  attract  the  attention 
not  only  of  the  medical  oflicers  of  the  army  but  of  the  profes- 
sion in  civil  life.  Dr.  Mosely,  an  officer  of  rank  and  standing, 
and  justly  entitled  to  his  preferment  by  virtue  of  continued 
service  at  Western  stations,  was  assigned  as  attending  surgeon 
in  Washington.  The  rule  of  the  department  led  him  to  expect 
a  stay  of  a  certain  number  of  years  at  tliis  station,  and  lie  made 
arrangements  for  himself  and  his  family  accordingly ;  but  be- 
fore he  had  become  well  established  in  his  new  practice  an 
order  was  issued  replacing  him  by  Dr.  R.  M.  O'Reilly,  whose 
record  of  service  by  no  means  entitled  him  to  the  position.  In- 
fluence must  have  done  this.  Under  the  terms  of  this  order  Dr. 
Mosely  would  have  been  required  to  vacate  his  position  as  if  he 
were  unfit  for  it;  he  would  also  have  been  exposed  to  heavy 
pecuniary  losses  in  effecting  a  new  settlement.  Moreover,  some 
army  medical  man  would  have  had  to  remain  beyond  his  term 
at  an  undesirable  station  in  place  of  his  influential  comrade 
who  had  succeeded  in  overturning  tlie  just  and  equitable  meth- 
ods of  the  department. 

The  code  of  ethics  would  make  the  njedical  man  who  used 
his  influence  to  the  detriment  of  another  the  subject  of  a  medi- 
cal oourt.  There  are  of  course  courts  in  the  army,  but  the  in- 
jury to  the  reputation  of  a  medical  man,  in  which  lies  the 
gravamen  of  the  matter  under  consideration,  would  not  be 
recognized  by  them.  In  1882  an  officer  of  the  adjutant-gen- 
eral's bureau  made  use  of  senatorial  influence  to  have  an  order 
effecting  him  revoked.  The  gravamen  of  his  case  was  that  he 
had  been  indiscreet  enough  to  protest  against  his  order,  inform- 
ing his  superiors  tliat  he  purposed  asking  political  assistance 
for  its  revocation.  This  was  insubordination.  Had  he  kept 
quiet  and  left  himself  "in  the  hands  of  his  friends,"  there 
would  have  been  no  case  against  him,  as  there  would  be  none 
against  a  medical  officer  whose  friends  helped  him  to  something 
desirable. 

There  seems  to  be  no  preventive  or  remedy  for  such  evils 
among  our  military  brethren,  unless  the  secretary  of  war  can 
be  prevailed  upon  to  view  the  matter  from  the  proper  stand- 
point. In  the  case  in  question  the  secretary,  "  upon  considera- 
tion of  written  and  verbal  communication  received  by  him 
from  the  surgeon-general  of  the  army  bearing  on  the  subject,"  ! 
has  suspended  the  order  assigning  Dr.  O'Reilly  to  duty  as  at- 
tending surgeon  at  Washington.  The  secretary  should  have 
done  more ;  he  should  have  revoked  the  order. 


MINOR    PA  RA  GRA  PUS. 

SECRET  METHODS  IN  MEDICINE. 

In  our  issue  for  .lanuary  7th  we  published  an  article  on  The 
Radical  Cure  of  Hernia  by  Hypodermic  Injection,  by  Dr.  Wil- 
liam 0.  Kloman,  of  Baltimore.  It  had  escaped  our  notice  that 
the  author  did  not  state  what  preparation  was  used ;  otherwise 
we  should  not  have  allowed  the  article  to  appear.  When  our 
attention  was  called  to  the  matter  we  presumed  that  the  author. 


who  had  before  contributed  unobjectionable  matter  to  our  col- 
umns, had  in  this  instance  by  mere  oversight  omitted  to  give 
the  proper  information  as  to  the  nature  of  the  substance  used 
in  the  treatment  that  he  was  writing  about;  but  we  regret  to 
say  that  correspondence  with  him  has  failed  to  elicit  that  infor- 
mation, and  that  we  have  learned  from  trustworthy  sources  that 
the  alleged  remedy  in  question  is  being  managed  by  methods 
that  are  abhorrent  to  every  worthy  physician.  Those  of  our 
readers  who  have  followed  the  course  of  this  journal  closely — 
especially  those  who  recall  what  we  said  when  the  first  accounts 
of  Koch's  tuberculin  were  published — do  not  need  to  be  told 
that  we  regard  the  use  of  secret  remedies  and  procedures  as 
reprehensible  in  the  extreme,  and  most  if  not  all  such  remedies 
and  procedures  as  valueless.  Nevertheless,  in  view  of  our  hav- 
ing unwittingly  published  the  article  mentioned,  we  feel  called 
upon  to  say  specifically  that  we  did  not  consciously  lay  before 
our  readers  an  article  exploiting  what  has  turned  out  to  be  a 
secret  procedure. 

THE  AMERICAN  RAILWAY  SURGEON. 

The  American  Lancet  appears  to  have  no  very  exalted  opin- 
ion of  the  six  thousand  railroad  surgeons  who  practice  under 
contract.  It  says  of  them  that  they  seem  to  be  content  to 
"  work  for  nothing  and  board  themselves,"  and  that  their  lowly 
status  is  their  own  concern.  Rut  it  is  pointed  out  as  an  evi-_ 
dence  of  tlie  willingness  of  great  and  wealthy  corporations  of 
the  country  to  fatten  themselves  by  withholding  from  medical 
men  a  just  return  for  work  conscientiously  performed.  What 
compensation  these  gentlemen  get  wo  do  not  know,  but  at  least 
their  work  is  humane  and,  to  the  best  of  our  knowledge,  credit- 
ably performed. 


A  URINARY  INDICATION  IN  THE  QUESTION  OF  OPERATING 
FOR  EPILEPSY. 

The  Union  medicale  for  January  5th  gives  a  summary  of  an 
article  by  M.  Gilles  de  la  Tourette,  published  in  the  Archives 
medicales  belgex,  in  which,  after  calling  attention  to  the  fre- 
quency with  which  no  legion  is  found  on  trephining,  owing  to 
the  difficulty  of  distinguishing  hysterical  epilepsy  from  epilepsy 
due  to  a  neo[)lasm,  the  author  states  that  he  and  M.  Cathelineau 
have  observed  in  M.  Charcot's  service  that  in  cases  of  epilepsy 
due  to  a  neoplasm  there  is  always  a  noticeable  increase  of  the 
fixed  residues  of  urea  and  phosphates  in  the  urine  at  the  time 
of  a  paroxysm,  whereas  in  hysterical  epilepsy  there  is  a  per- 
ceptible diminution  of  the  same  elements  at  that  time. 


THE  LIBRARY  OF  THE  SURGEON-GENERAL'S  OFFICE. 

We  are  very  sorry  to  learn  that  the  appropriation  for  the 
purchsise  of  books  has  been  reduced  in  the  Army  Appropriation 
Bill  from  $10,000  to  $6,000,  also  that  in  the  Sundry  Civil  Ap- 
propriation Bill,  as  reported  by  the  committee  of  appropria- 
tions to  the  House,  the  usual  item  for  printing  the  next  volume 
of  the  Index  Catalogue,  $12,000  has  been  omitted.  This  action 
seems  to  be  a  great  mistake,  and  we  hope  it  will  be  corrected 
speedily  ;  otherwise  the  library  will  sufl'er  and  the  work  of  com- 
pleting the  publication  of  the  Index  Calnlogue  will  have  to  be 
interrupted.  The  country  should  consider  itself  pledged  to  ita 
completion  without  unnecessary  delay. 


NOVEL  IDEAS  OF  FKMININE  ANATOMY. 

The  Sun  lately  gave  an  account  of  a  military  drill  gone 
through  with  by  nineteen  young  women.  At  the  order 
"Charge  bayonets,"  according  to  the  account,  "nineteen  lips 


112 


MINOR  PARAORAPES.— ITEMS.— LETTERS  TO  THE  EDITOR         [N.  Y.  Med.  Jouk., 


were  pressed  firmly  together,  nineteen  eyes  flashed  unknown 
terrors,  and  nineteen  mnskets  were  pointed,"  etc.  Now,  with- 
out the  least  intention  of  questioning  the  general  truthfulness 
of  the  legend  "If  you  see  it  in  the  Sun  it's  so,"  we  shall  need 
persuasion  before  we  can  believe  that  these  nineteen  young 
women  had  but  one  eye  and  one  lip  apiece,  or  that  nine  and  a 
half  of  them  pressed  two  lips  together,  flashed  terror  with  two 
eyes  each,  and  pointed  each  two  muskets. 


STUDIES  FROM  THE  PATHOLOGICAL  LABORATORY  OF  THE 
COLLEGE  OF  PHYSICIANS  AND  SURGEONS. 

The  second  volume  of  this  valuable  serial,  for  the  collegiate 
year  1891-1892,  has  just  appeared.  It  consists  of  reprint'*  of 
articles  by  Dr.  T.  Mitchell  Prudden,  Dr.  Ira  Van  Gieson,  Dr. 
John  Winters  Brannan,  Dr.  George  C.  Freeborn,  Dr.  Rowland 
Godfrey  Freeman,  and  Dr.  William  Hallock  Park.  Five  of  the 
articles  (172  pages)  are  reprinted  from  this  journal,  three  (69 
pages)  from  the  Medical  Record,  and  two  (7  pages)  from  the 
Proceedings  of  the  New  York  Pathological  Society. 


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  24,  1893 : 


DISEASES. 

Week  ending  Jan.  17. 

Week  ending  Jan.  24. 

Cases. 

Deaths. 

Cases. 

Deaths. 

19 

18 

14 

11 

8 

4 

10 

5 

138 

18 

144 

7 

Cerebro-spinal  meningitis. . .  . 

2 

1 

3 

4 

87 

13 

95 

7 

113 

42 

83 

23 

5 

0 

8 

1 

The  Eichmond  Academy  of  Medicine  and  Surgery. — The  special 
order  for  the  meeting  of  Tuesday  evening,  the  24th  inst.,  was  a  dis^cus- 
sion  on  tul)al  pregnancy. 

Dr.  Roberts  Bartholow. — We  are  glad  to  see  the  announcement,  in 
the  Medical  News  for  the  21st  inst.,  that  this  distinguished  Philadelphia 
physician  has  been  completely  restored  to  health  and  resumed  his  prac- 
tice. 

Change  of  Address.— Dr.  A.  Ernest  Gallant,  to  No.  35  West  Fifty- 
third  Street. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  January  2L  1893  : 
RoTHGANGER,  George,  Assistant  Surgeon.    Ordered  to  the  Navy  Yard, 

Mare  Island,  Cal. 

RiXEY,  P.  M.,  Surgeon.  Ordered  to  the  U.  S.  Steamer  Dolphin.  Feb- 
ruary 6,  1893. 

Gatewood,  J.  D.,  Passed  Assistant  Surgeon.  Detached  from  the  U.  S. 
Steamer  Dolphin,  and  granted  two  months'  leave  from  February 
6,  1893. 

Harris,  H.  N.  T.,  Passed  Assistant  Surgeon.  Assigned  to  special  duty 
in  the  Bureau  of  Medicine  and  Surgery. 

Society  Meetings  for  the  Coming  Week: 

Tuesday,  January  31st :  Medical  Society  of  the  County  of  Onondaga 
(Semi-annual — Syracuse),  N.  Y. ;  Boston  Society  of  Medical  Sciences 
(private). 

Wednesday,  February  1st :  Society  of  the  Alunmi  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. ;  Penobscot,  Me.,  County  Medical 


Society  (Bangor);  New  Haven,  Conn.,  Medical  Association;  Bridge- 
port, Conn.,  Medical  Association. 

Thursday,  February  2d:  New  York  Academy  of  Medicine;  Brooklyn 
Surgical  Society ;  Society  of  Physicians  of  the  Village  of  Canandai- 
gua;  Boston  Medico-psychological  Association;  Obstetrical  Society 
of  Philadelphia ;  United  States  Naval  Medical  Society  (Washington). 

Friday,  February  3d:  Practitioners'  Society  of  New  York  (private); 
Baltimore  Clinical  Society. 

Saturday,  February  J^th:  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.  391. — Our  decided  impression  is  that  no  formality  would  be 
necessary  in  your  case,  but  it  would  perhaps  be  well  for  you  to  commu- 
nicate with  the  Board  of  Regents  of  the  University  of  the  State  of  New 
York,  Albany. 


fetters  to  i\t  (Kbitor. 


ANOTHER  CASE  OF  UNCONSCIOUS  CEREBRATION. 

New  York,  January  12,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  In  your  Journal  for  November  15,  1890,  I  wrote  a 
short  note  On  a  New  System  of  Exact  Dosage  in  the  Catapho- 
retic  Use  of  Drugs.    I  described  in  this  a  new  and  simple  cata- 


Electrode  deHcribed  by  Dr.  Peterson.  Dr.  McBride's  electrode,  from  OaU- 
New  York  Medical  Journal,  Novem-  larcfs  Medical  Journal,  August, 
ber  15,  1890.   Not  patented.  1892.  Patented  in  September,  1892. 

phoretic  electrode  which  Messrs.  Waite  &  Bartlett  had  made 
for  me,  the  cuts  of  which  they  have  now  published  in  their  an- 
nual catalogue  for  over  two  years.  These  cuts  are  here  repro- 
duced. 


Jan.  28,  1893.] 


PROCEEDINGS  OF  SOCIETIES. 


113 


In  OaillariVs  Medical  Journal  for  August,  1892,  Dr.  Ed- 
ward H.  McBride,  of  Springtield,  Mo.,  has  an  article  on  a 
Cataphoric  Electrode,  in  which  he  describes  very  carefully  my 
electrode  and  methods,  and  exhibits  cuts  of  his  discovery.  Dr. 
McBride's  cuts  are  reproduced  by  the  side  of  mine,  showing 
that  the  instruments  are  precisely  the  same,  and  the  artist  in 
copying  my  electrode  scarcely  took  pains  to  change  the  let- 
tering on  the  cuts.  At  the  same  time  I  do  not  wish  to 
imply  that  Dr.  McBride  actually  appropriated  my  work  of  a 
year  or  two  previous.  This  may  be  one  of  those  cases  of 
minds  widely  separated  working  in  the  same  channels  by  tele- 
pathic inHuenco.  The  doctor  has,  however,  gone  one  step  fur- 
ther than  I,  in  that  ho  i)atented  his  telepathically  conceived 
cataphoric  electrode  at  Washington  in  September  last,  and  the 
thought  of  patenting  it  had  not  occurred  to  me  at  all. 

Frederick  Peterson,  M.  D. 


IProteebings  of  Siincties. 


THE  NEW  YORK  NEUROLOGICAL  SOCIETY. 
Meeting  of  January  3,  1893. 
The  President,  Dr.  M.  Allen  Starr,  in  the  chair. 

Oxaluria  and  its  Relations  to  Certain  Forms  of  Nerv- 
ous Diseases. — Dr.  I.  Adler  read  a  paper  on  this  subject. 
He  stated  that  the  presence  of  oxalate-of-calcium  crystals  in  the 
urine  bad  been  the  subject  of  much  discussion.  Our  present 
knowledge  regarding  the  subject  was  rather  unsatisfactory. 
There  was  much  that  was  still  obscure  pertaining  to  it,  and  on 
very  few  of  even  the  fundatiiental  points  had  unanimity  of 
opinion  been  attained.  Most  plants  and  vegetables  used  us  food 
contained  oxalic  acid,  some  of  them  a  very  large  per.'cntage,  and 
all,  or  nearly  all,  of  it  that  was  taken  into  the  system  reappeared 
in  the  urine — some  perhaps  in  the  faeces.  From  this  it  appeared 
that  oxalic  acid  did  occur  in  the  urine  of  healthy  persons.  On 
this  point  all  authors  were  now  agreed.  It  was  also  probable 
that  oxalic  acid  might  originate  in  the  cour.<e  of  normal  meta- 
bolic changes.  The  presence  of  oxalic  acid  in  the  urine  had 
once  been  believed  to  be  due  to  the  incomplete  oxidation  of 
uric  acid,  but  this  theory  was  no  longer  held.  The  fact  that 
uric  acid  could  be  separated  into  urea  and  oxalic  acid  did  not 
prove  that  theory. 

Oxaluria  as  an  independent  type  of  disease,  the  author  said, 
did  not  exist.  He  then  reviewed  Cantani's  treatise  on  this  sub- 
ject, in  which  that  author  had  asserted  that  oxaluria  was  a  dis- 
tinct disease  characterized  by  certain  well-marked  symptoms, 
including  insomnia,  loss  of  appetite,  melancholia,  suicidal  tend- 
encies, he;idaclic,  constipation,  sexual  impotence,  emaciation, 
etc.  These  symptoms,  the  author  said,  were  not  due  to  tlie 
presence  of  oxalic  acid  in  the  urine.  To  prove  this  fact  he  had 
had  a  careful  quantitative  analysis  made  of  the  amount  of  oxalic 
acid  (also  dctermiuing  the  amount  of  urea  and  uric  acid)  con- 
tained in  the  urine  of  a  large  number  of  persons  suffering  from 
various  diseases,  such  as  neurasthenia,  the  gouty  diathesis,  etc. 
In  some  of  these  cases  the  symptoms  ascribed  by  Cantani  to 
oxaluria  had  been  present,  but  no  possible  relation  could  bo 
traced  between  them  and  the  amount  of  oxalic  acid  in  the 
urine. 

In  conclusion,  the  author  made  the  following  statements: 
Oxalic  acid  is  a  normal,  although  possibly  not  a  constant,  con- 
stituent of  the  urine.    The  amount  present  in  a  given  quantity 


of  urine  can  be  determined  with  any  degree  of  accuracy  only  by 
a  quantitative  analysis.  The  chief  source  of  oxalic  acid  in  the 
ui'ine  is  the  oxalic  acid  contained  in  the  food.  It  is  probable, 
however,  that  minute  quantities  are  produced  in  the  course  of 
normal  metabolism.  Impeded  respiration  and  diseases  of  the 
heart  and  lungs  do  not  of  themselves  tend  to  produce  an  excess 
of  oxalic  acid.  The  existence  of  a  pathological  oxaluria  sui 
generis  can  not  be  established.  The  nervous  symptoms  ascribed 
to  pathological  oxaluria  are  not  caused  by  an  excess  of  oxalic 
acid  in  the  urine.  Where  such  excess  does  occur,  and  can 
not  be  accounted  for  by  the  ingesta,  it  is  probably  one  of  sev- 
eral symptoms  of  metabolic  changes  primarily  caused  by  altera- 
tions in  the  nervous  or  digestive  system  or  both.  In  examining 
the  urine  for  oxalic  acid,  it  is  of  the  utmost  importance  to  con- 
sider its  other  ingredients  as  well,  particularly  urea  and  uric 
acid. 

Dr.  C.  A.  Herter  referred  to  the  various  methods  of  mak- 
ing a  quantitative  analysis  of  the  amount  of  oxalic  acid  in  the 
urine  and  the  enormous  labor  involved.  He  did  not  agree  to 
Dr.  Adler's  statement  that  a  great  many  cases  of  so-called  oxa- 
luria were  not  pathological.  He  was  not  prepared  to  accept 
the  proposition  that  there  was  no  such  thing  as  pathological 
oxaluria.  He  was  inclined  to  think  that  in  cases  where  there 
was  defective  digestion,  especially  in  the  intestines,  the  carbo- 
hydrates were  likely  to  be  transformed  into  oxalic  acid,  where 
normally  they  would  not  be  so  transformed.  He  did  not  be- 
lieve, however,  that  oxalic  acid  was  ever  the  cause  of  the  symp- 
toms named  by  Di\  Adler.  Other  constituents  of  the  urine 
must  bo  taken  into  consideration — such,  for  instance,  as  uric 
acid  and  creatinine.  The  latter  was  a  substance  in  which  even 
more  nitrogen  was  excreted  than  in  uric  acid.  The  ethereal 
sulphates  in  the  urine  must  also  be  considered.  They  were 
often  present  in  excess  of  neurasthenic  conditions  where  there 
was  oxaluria  and  where  there  was  also  an  excess  of  uric  acid. 
The  speaker  was  inclined  to  think  that  the  old  theory  of  the 
formntion  of  oxalate  of  calcium  out  of  uric  acid  was  an  ex- 
ploded one. 

Dr.  L.  Weber  said  that  his  clinical  observations  were  fully 
in  accord  with  the  ideas  expressed  in  Dr.  Adler's  paper.  He 
did  not  believe  in  the  existence  of  a  disease  to  be  designated 
oxaluria,  but  he  had  met  with  many  cases  of  a  disordered  state 
of  the  system,  brought  on  by  various  causes,  in  which  he  had 
found  (not  by  quantitative  analysis,  but  by  frequent  and  careful 
examination  with  the  microscope)  oxalic  acid  in  the  urine,  be- 
sides in  every  case  an  increased  amount  of  uric  acid. 

Dr.  Charles  Heitzman  stated  that  he  saw  many  cases  of 
so-called  oxaluria,  and  that  the  appearance  of  the  patients  was 
usually  characteristic.  Sleeplessness,  indigestion,  and  fits  of 
melancholia  were  the  more  common  symptoms  he  had  found  in 
them.  Contrary  to  Dr.  Adler's  experience,  he  had  usually 
found  the  specific  gravity  of  the  urine  high— from  1*024  to 
1'036.  Regarding  the  treatment,  the  speaker  recommended  a 
meat  diet,  the  exclusion  of  sugars  and  farinaceous  substances, 
and  vigorous  outdoor  exercise.  He  felt  convinced  that  there 
was  a  condition  of  the  system  wherein  the  amount  nf  oxalic 
acid  excreted  by  the  urine  was  far  in  excess  of  that  taken  in 
with  the  food,  and  he  could  not  agree  to  Dr.  Adler's  state- 
ment that  there  was  no  such  thing  as  a  really  pathological  oxa- 
luria. 

Dr.  Mary  Putnam  Ja(,'obi  said  it  seemed  to  her  that  Dr. 
Adler's  conclusion  that  tiie  oxalate  of  calcium  contained  in  the 
urine  was  rather  an  accessory  product  of  a  disordered  function 
than  a  cause  in  producing  it  was  very  true.  She  referred  to 
some  experiments  made  by  Dr.  Chadwick,  of  Boston,  in  a  series 
of  cases  in  which  the  patients  were  operated  upon  on  the  sup- 
position that  there  was  a  stone  in  the  pelvis  of  the  kidney.  No 


lU 


PROCEEDINGS 


OF  SOCIETIES. 


[N.  Y.  Mkd.  Jouk., 


stone  was  found,  but  the  symptoms  disappeared.  In  these  cases 
the  attacks  of  renal  colic  were  followed  by  a  copious  discharge 
of  oxalate-of-calcium  crystals  in  the  urine,  after  which  the  pa- 
tients remained  quite  free  from  pain  for  some  time. 

Dr.  E.  D.  Rockwell  said  he  had  been  much  interested  to 
note  the  frequency  with  which  oxalate-of-calcium  crystals  liad 
appeared  in  the  urine  in  certain  neurasthenic  cases  associated 
with  a  disordered  heart's  action.  Such  a  case  had  recently 
come  under  his  observation.  A  physician  who  suffered  from 
neurasthenia  and  liad  frequent  attacks  of  palpitation  noticed 
repeatedly  that  this  excessive  heart's  action  was  always  asso- 
ciated with  an  abundance  of  oxalate-of-calcium  crystals  in  the 
urine.  The  speaker  had  also  often  found  them  present  in  large 
quantities  in  spermatorrhoea. 

The  President  said  that  we  could  not  study  neurasthenic 
conditions  carefully  without  coming  to  the  conclusion  that  the 
trouble  lay  in  the  chemistry  of  nutrition.  It  was  very  easy  to 
jump  to  the  conclusion  that  any  substance  of  an  abnormal  char- 
acter in  the  urine  or  faeces  gave  rise  to  a  certain  morbid  condi- 
tion, but  this  was  a  wrong  conclusion.  The  oxalates,  the  urates, 
indican,  etc.,  might  occur  in  excess  in  the  urine,  but  they  were 
end-products.  The  statements  made  in  Dr.  Adler's  paper,  based 
on  such  careful  quantitative  analyses  of  the  urine,  should  be  re- 
garded as  very  valuable.  It  was  much  more  difficult  to  destroy 
a  wrong  theory  than  to  originate  a  new  one. 

Dr.  Adler  said  that  the  local  precipitation  of  the  oxalates 
seemed  to  be  independent  of  any  positive  excess  excreted. 
Calculi,  consisting  of  the  oxalates,  might  form  in  the  kidney 
and  bladder  without  there  being  an  absolute  excess  of  the  salts 
in  the  urine. 

A  Case  of  Cystic  Tumor  of  the  Brain  operated  upon  with 
Success. — Dr.  Leo  Steiglitz  showed  a  woman,  twenty-five  years 
of  age.  She  had  been  married  in  April,  1891.  Previous  to  her 
marriage  she  had  always  been  well.  There  was  no  hereditary  taint 
of  any  kind,  and  there  was  no  history  of  traumatism  or  convul- 
sions. In  October,  1891,  while  quietly  talking  with  her  hus- 
band, she  had  suddenly  felt  twitchings  in  the  thumb  and  fore- 
finger of  her  right  hand.  The  convulsive  twitchings  had  spread 
rapidly,  extending  up  to  the  shoulder  and  face,  and  had  led 
finally,  within  the  space  of  a  few  minutes,  to  a  general  seizure, 
with  loss  of  consciousness,  cyanosis,  frothing  at  the  mouth,  and 
tonic  and  clonic  convulsions.  An  attack  .similar  in  character  to 
the  first  one  had  occurred  seven  weeks  later,  and  been  followed 
by  a  number  of  others.  Suspicion  of  a  localized  cerebral  lesion 
was  aroused,  although  the  patient  ofl:ered  absolutely  no  further 
symptoms;  she  had  no  trace  of  headache,  nausea,  giddiness, 
choked  disc,  etc.  She  was  put  upon  the  use  of  bromides,  and 
after  January  19,  1892,  she  bad  no  general  convulsions  at  all, 
but  siraply  convulsive  twitchings  confined  to  the  right  hand 
and  forearm  and  always  beginning  in  the  thumb  and  forefinger. 
These  attacks  occurred  almost  daily.  Although  no  history  of 
syphilis  could  be  obtained  from  either  the  patient  or  her  hus- 
band, she  was  put  on  antisyphilitic  treatment  for  a  time,  but 
no  improvement  followed.  In  February  a  marked  paresis  of 
the  right  hand  developed.  The  deep  reflexes  were  increased, 
more  marked  on  the  right  than  on  the  left  side.  The  dyna- 
mometer test  showed  twenty-five  on  the  right  side,  fifty-five  on 
the  left.  The  urine  contained  neither  albumin  nor  sugar. 
There  was  no  temperature  disturbance.  There  was  no  disorder 
of  sensation  in  any  part  of  the  hand  or  arm,  except  a  general 
feeling  of  numbness.  The  diagnosis  arrived  at  was:  organic 
lesion,  [)robably  a  tumor,  situated  in  the  left  anterior  cerebral 
convolution.  An  operation  was  perfoi'ined  on  the  i)atient  by 
Dr.  Gcrster  on  June  25th,  at  Mt.  Sinai  Hospital.  A  lateral 
opening  in  the  skull  having  been  made,  the  dura  was  seen  to 
bulge  but  elightly  into  it.    An  area  on  the  dura  of  about  the 


size  of  half  a  dollar  showed  a  diffuse  yellowish  tinge,  different 
from  the  color  of  the  adjacent  dura.  The  application  of  the 
poles  of  a  small  faradaic  battery  to  the  unopened  dura  by  Dr. 
B.  Sachs  promptly  determined  the  center  for  the  movements  of 
the  hand  and  fingers,  and  the  point  corresponded  with  the  dis- 
colored area  referred  to.  When  the  dura  was  opened,  the  cor- 
tex of  the  brain  showed  no  apparent  change.  A  vertical  incis- 
ion into  its  substance  was  followed  by  a  gush  of  yellow  serous 
fluid,  none  of  which,  unfortunately,  was  saved.  Perhaps  an 
ounce  of  fluid  escaped.  The  walls  of  the  cyst  were  found  to  be 
perfectly  smooth.  A  small  layer  of  gray  matter  was  removed 
from  the  center  exposed,  upon  the  advice  of  Dr.  Sachs,  to  pre- 
vent disturbances  which  might  develop  from  possible  secondary 
sclerotic  changes.  There  was  but  little  shock  after  the  opera- 
tion. On  the  day  following  it  the  patient  had  lost  all  power  in 
her  right  thumb  and  forefinger,  and  could  move  her  other 
fingers  and  the  entire  right  arm  but  very  slightly.  This  symp- 
tom gradually  improved.  On  July  21st  she  had  slight  convul- 
sive twitchings  in  her  right  hand,  right  arm,  and  face.  On 
July  28th  she  had  more  violent  twitchings.  On  August  7tL  the 
scalp  wound  was  opened  and  adhesions  were  found  between  the 
flap  of  skin  and  the  dura.  Probing  revealed  no  recurrence  of 
fluid  in  the  cyst.  The  adhesions  were  separated  and  a  flexible 
gold  plate  was  inserted.  On  August  9th  there  was  slight 
twitching  in  the  three  ulnar  fingers;  the  patient  could  move 
her  fingers,  hand,  and  arm  quite  extensively.  Upon  examina- 
tion in  November,  it  was  found  that  she  had  lost  the  sensation 
of  position  in  the  fourth  and  fifth  fingers  of  the  right  hand  ;  she 
could  not  tell  whether  they  were  flexed  or  extended.  The 
strength  of  her  hand  and  arm  was  greatly  increased.  On  De- 
cember 10th  there  was  considerable  twitching  in  the  right  arm 
and  in  the  face.  The  patient  had  been  kept  on  doses  of  from 
fifteen  to  thirty  grains  of  potassium  bromide  daily  since  the 
operation. 

The  speaker  was  inclined  to  believe  that  there  had  been  a 
glioma  at  the  bottom  of  this  patient's  trouble.  In  that  case 
there  was  reason  to  fear  a  further  growth  of  the  gliomatous  ma- 
terial presumably  left  in  the  walls  of  the  evacuated  cyst.  Symp- 
toms had  already  developed  that  tended  to  confirm  these  fears. 
As  to  the  further  treatment,  he  would  like  to  have  another  op- 
eration performed  and  the  entire  cyst  or  its  remains  removed^ 
if  possible. 

Dr.  A.  G.  Gersteu,  who  had  operated  on  the  patient,  said 
that  at  the  time  of  the  operation  the  advisability  of  removing 
the  cyst  wall  had  been  considered,  and  it  was  decided  that  it 
could  not  be  done,  on  account  of  the  delicacy  and  thinness  of 
the  membrane.  In  his  opinion,  it  could  not  have  been  separated 
without  tearing  it  into  shreds.  In  operations  on  the  skull  he 
preferred  the  gouge  and  mallet  to  the  trephine ;  he  was  not 
hampered  by  the  size  and  shape  of  the  trephine,  and  could  re- 
move as  little  or  as  much  of  the  bone  as  he  chose.  He  also  re- 
ferred to  the  profuse  haemorrhage  accompanying  operations 
upon  the  head  and  the  serious  difliculty  the  surgeon  often  found 
jn  checking  it.  Peripheral  constriction  by  means  of  an  elastic 
bandage  proved  inadequate.  The  haemorrhage  was  not  alone 
from  the  scalp,  but  from  the  diploic  substance  and  the  vessels 
that  coursed  through  the  brain  itself. 

The  President  said  that  the  futility  of  periplieral  constric- 
tion as  a  means  of  checking  haamorrhage  in  operations  about  the 
head  had  been  testified  to  by  Dr.  Weir  and  others.  The  least 
hsemorrhage  he  had  ever  seen  in  such  a  case  had  been  in  a  pa- 
tient who  was  kept  in  the  sitting  posture  during  the  entire  course 
of  the  operation.  In  another  case — that  of  a  patient  operated 
on  a  short  time  before  by  Dr.  Briddon — chloroform  had  been 
administered  instead  of  ether,  and  the  amount  of  blood  lost  had 
been  much  less.    Regarding  the  excision  of  the  cyst  wall,  the 


Jan.  28,  1893.] 


PROCEEDINGS 


OF  SOCIETIES. 


115 


president  doubted  if  that  was  possible.  Furthermore,  there  was 
probably  gliomatous  infiltration  into  the  brain  substance.  In  a 
brain  cyst  evacuated  by  Dr.  McBurney  drainage  had  been  kept 
up  for  fifteen  days,  when  the  walls  were  found  to  be  adherent 
and  there  was  no  cavity  left.  Out  of  eighty-seven  recorded  op- 
erations for  the  removal  of  brain  tumor,  forty-six  per  cent,  had 
been  successful  in  the  finding  of  the  tumor  and  in  the  recovery 
of  the  patient.  Successful  operations  for  the  relief  of  epilepsy 
were  very  rare. 

Hemiatrophy  of  the  Tongue.— The  President  showed  a 
woman  who  had  been  perfectly  well  until  the  preceding  June, 
when  she  had  suddenly  been  seized  with  pain  in  the  back  of  the 
neck  and  the  occiput,  and  the  next  day  she  had  noticed  that 
something  was  wrong  with  her  tongue.  It  deviated  decidedly 
to  the  left  and  had  continued  to  do  so  ever  since.  It  had  be- 
come noticeably  atrophied,  and  presented  well-marked  reaction 
of  degeneration.    There  was  no  pain  or  disturbance  of  taste. 


AMERICAN  ^LARYNGOLOGICAL  ASSOCIATION. 

Fourteenth  Annual  Congress,  held  at  Boston  on  Monday,  Tues- 
day, and  Wednesday,  June  20,  21,  and  22,  1892. 

The  President,  Dr.  S.  W.  Langmaid,  of  Boston,  in  the  Chair. 

[Continued  from  page  85.) 

The  After-results  of  Nasal  Cauterization.— A  paper  on 
this  subject  was  read  by  Dr.  T.  A.  De  Blois,  of  Boston.  (See 
page  96.) 

Dr.  J.  Wright,  of  Brooklyn :  I  quite  agree  with  the  author 
that  one  can  tell  better  two  years  after  the  cauterizing  opera- 
tion than  he  can  two  weeks  or  months  afterward  what  will  be 
the  result.  There  is  frequently  something  which  underlies  the 
aatiology  of  hypertrophic  rhinitis  which  is  more  than  local.  A 
great  many  cases,  without  doubt,  are  due  to  systemic  disturb- 
ance, and  it  seems  to  me  that  we  should  try  milder  measures 
before  proceeding  to  burning,  cutting,  or  similar  heroic  treat- 
ment. I  always  place  these  patients  under  anticatarrhal  treat- 
ment (if  Dr.  Bosworth  will  allow  me  to  use  the  term)  for  a  few 
weeks  before  resorting  to  operative  procedures.  By  correcting 
disturbance  of  the  stomach,  etc.,  one  gets  better  results  in  vas- 
cular engorgements  of  the  turbinated  bodies.  I  do  not  know 
that  dyspepsia  produces  actual  hypertrophic  rhinitis,  but  it  cer- 
tainly is  an  underlying  factor  in  vaso-motor  disturbance  of  the 
turbinated  bodies.  What  is  true  of  dyspepsia,  I  believe,  is  true 
also  of  rheumatism  and  possibly  of  gout.  Many  of  these  people, 
too,  are  of  irritable  temperament,  and  if  their  nose  is  in  such  a 
condition  that  they  do  not  respire  quite  as  well  as  usual,  they 
notice  it  more  than  other  people,  and  complain. 

Dr.  J.  0.  MuLHALL,  of  St.  Louis  :  I  presume  that  I  use  the 
galvano-cautery  as  much  as  any  other  member  of  the  associa- 
tion. I  think  I  have  used  it  certainly  not  fewer  than  four  thou- 
sand times.  I  have  used  it  i)ersistently  for  twelve  years,  and, 
although  I  did  not  have  tlie  pleasure  of  hearing  Dr.  De  Blois  read 
his  paper,  yet,  in  view  of  these  facts,  I  wish  to  say  a  few  words. 
I  have  yet  to  see  any  evil  results  from  the  cautery,  although 
patients  still  come  under  my  observation  who  were  operated 
upon  ten  years  ago.  Leaving  out  experiments  with  hay  fever, 
I  have  never  attempted  to  use  tlie  cautery  unless  actual  hyper- 
trophy was  present — not  merely  api)arent  hypertrophy.  Then 
the  method  of  its  use  has  a  great  deal  to  do  with  avoidance  of 
bad  after-effects.  I  read  a  paper  by  Lennox  Browne  several 
years  ago  in  which  he  deplored  certain  accidents  which  had 
followed  the  use  of  the  galvano-cautery,  but  when  I  came  to 
his  method  of  using  it  I  knew  that  such  accidents  must  some- 
times occur.  The  whole  secret  of  the  correct  method  is  to  keep 
the  electrode  at  almost  a  white  beat  from  before  contact  until 


after  its  withdrawal  from  the  tissue  cauterized.  That,  of  course, 
requires  some  dexterity.  I  also  take  the  precaution  to  use  aseptic 
methods  before  and  after  operating.  The  patient  keeps  cotton 
in  the  nostril  until  he  gets  home,  so  as  to  filter  the  air.  While 
temporary  reaction  may  sometimes  take  place,  simulating  a 
coryza,  yet  I  have  never  seen  any  permanent  ill  result. 

Dr.  Morris  J.  Asoh,  of  New  York  :  I  have  used  the  galvano- 
cautery  ever  since  it  has  been  brought  into  practical  use  and 
have  seen  no  bad  effect  from  it.  The  only  slight  trouble  which 
I  have  seen  has  been  occasional  adhesion  between  the  mucous 
membranes  covering  the  turbinated  body  and  sfeptura.  In  Ger- 
many they  use  the  cautery  a  great  deal.  One  author  touches 
the  cauterized  surface  with  methyl  blue,  and  advises  absolutely 
dry  treatment ;  but  I  find  patients  object  to  the  methyl  blue, 
for  it  stains  handkerchiefs  long  afterward,  and  I  have  not  found 
any  advantage  in  its  use  after  cauterization.  Like  Dr.  Mulhall, 
I  give  strict  attention  to  antisepsis. 

Dr.  D.  B.  Delay  AN,  of  New  York :  Hypertrophic  rhinitis 
presents  three  states — the  acute,  subacute,  and  chronic.  One 
should  never  cauterize  in  the  acute  stage ;  in  the  subacute  stage 
there  are  better  means.  Only  recently  I  refused  to  cauterize  a 
patient  with  the  acute  form  ;  he  went  to  another  gentleman, 
was  cauterized,  and  came  back  to  me  about  a  month  afterward 
with  a  thoroughly  deformed  nose.  The  method  suggested  by 
Dr.  Glasgow  for  the  relief  of  congestive  headache,  consisting  in 
bloodletting  by  fine  submucous  incisions  on  the  turbinated 
bodies,  I  have  found  very  valuable  in  subacute  or  mild  chronic 
cases  of  hypertrophic  rhinitis.  After  making  the  incisions, 
which  I  do  with  an  ophthalmologist's  knife,  I  pack  the  nares 
with  cotton  to  prevent  returgescence,  and  in  twenty-four  hours 
the  turbinated  is  found  notably  reduced.  This  method  avoids 
that  great  objection  to  the  galvano-cautery — namely,  destruc- 
tion of  the  raucous  membrane.  Where  the  cautery  is  called  for, 
I  think  the  pure  trichloracetic  acid,  applied  as  recommended  by 
Professor  Gleitsmann,  has  the  effect  of  preventing  the  forma- 
tion of  a  large  eschar,  the  healing  is  more  prompt,  and  the  irri- 
tation less. 

The  paper  is  a  timely  one  in  calling  attention  to  the  possible 
dangers  of  the  cautery,  especially  in  the  hands  of  the  unskilled 
practitioner  and  in  improper  cases.  One  of  the  chief  dangers 
is  the  formation  of  a  cicatrix  which  will  bridge  the  nostril  and 
]eave  the  patient  in  a  worse  condition  than  ever.  Nine  tenths 
of  the  damage  results  from  neglect  of  after-treatment.  The  pa- 
tient should  be  seen  the  next  day  after  operating,  or  within 
forty-eight  hours  at  least.  The  healing  process  should  be  en- 
couraged to  take  place  as  fast  as  possible,  granulations  should 
be  kept  down,  and  the  case  should  not  be  dismissed  until  it 
is  certain  that  cicatrization  is  well  advanced  and  that  adhesion 
of  opposing  surfaces  is  impossible. 

Dr.  John  O.  Roe,  of  Rochester :  I  have  had  some  experience 
in  the  use  of  trichloracetic  acid  after  the  employment  of  the 
galvano-cautery  as  proposed  by  Dr.  Gleitsmann,  and  the  results 
have  been  excellent ;  it  lessens  the  inflammatory  reaction  and 
promotes  healing  of  the  parts.  The  trichloracetic  acid  coagu- 
lates the  albumin  in  the  wound  so  that  it  seems  to  be  hermetic- 
ally sealed,  and  renders  it  antiseptic  by  excluding  germs.  By 
following  it  up  with  an  antiseptic  dressing  afterward,  the  wound 
readily  heals. 

The  galvano-cautery,  like  all  other  good  things,  is  a  good 
thing  when  properly  used,  but  a  very  bad  thing  when  improp- 
erly used.  We  meet  with  pseudo-specialist:^,  amateur  rhinolo- 
gists,  and  general  practitioners,  who  also  do  u  little  throat  and 
nose  work,  who  think  all  that  is  required  in  treating  the  nose  is 
to  burn  it  out ;  and  in  consequence  of  such  treatment  I  have 
often  seen  the  whole  interior  of  the  nose  rendered  a  mass  ot 
scar  tissue. 


116 


PROCEEDINOS  OF  SOCIETIES. 


[N.  Y.  Med.  Joub., 


A  case  illustrating  tlie  evil  consequences  of  the  improper  use 
of  the  galvano-cantery  came  under  my  observation  recently. 
The  patient  was  a  man  who  had  been  treated  by  a  number  of 
different  physicians  and  in  a  variety  of  ways — lie  had  been  a 
kind  of  "  rounder."  The  one  who  had  cauterized  him  most 
extensively  was  his  family  physician,  who  did  some  nose  work) 
and  I  found  that  instead  of  lessening  the  hypertrophy,  it  had 
greatly  increased  it,  until  both  nostrils  had  become  completely 
obstructed  by  a  mass  of  scar  tissue.  Each  time  he  had  been 
cauterized  this  scar  tissue  had  increased.  I  simply  removed 
this  mass  of  thickened  tissue  which  bad  resulted  from  the  in- 
flammatory reaction,  freeing  the  nostrils,  and  the  man  was  en- 
abled to  breathe  through  his  nose  for  the  first  time  in  a  long 
while.  In  such  cases  of  extreme  hypertrophy  I  always  remove 
the  tissue  instead  of  using  the  cautery,  for  when  removed  by 
surgical  means  it  heals  kindly,  and  tiie  patient  has  a  serviceable 
nostril. 

In  order  to  bring  about  the  best  result  in  this  case  it  became 
necessary  to  remove  this  mass  of  scar  tissue  entirely.  After 
this  was  done  and  the  cut  surface  healed,  free  nasal  respiration 
was  established.  The  use  of  the  galvano-cautery  is  only  clearly 
indicated  in  cases  in  which  there  is  a  condition  of  vascular 
turgescence.  In  these  cases  a  deep  linear  cauterization  with  a 
fine  cautery  point  gives  most  happy  results,  as  it  not  only  oblit- 
erates the  injured  blood-vessels,  but  so  binds  the  tissues  down 
to  the  deeper  structures  that  turgescence  of  the  tissue  is  pre- 
vented. In  those  cases  where  there  isafirm  hy|)ertrophy  of  the 
turbinated  bodies  the  use  of  the  galvano-cautery  is  contraindi- 
cated,  and  in  such  cases  I  never  employ  it.  Not  only  does  it 
often  aggravate  the  hypertrophy  (as  illustrated  in  the  case 
I  have  alluded  to),  but  extensive  scar  tissue  is  the  result,  par- 
ticularly if  the  burning  is  sufficient  to  destroy  the  hyper- 
trophied  tissue.  In  these  cases  the  retnoval  of  the  hyper- 
trophied  tissue  by  other  surgical  means  should  in  every  instance 
be  performed. 

The  President:  I  have  been  gratified  by  the  many  remarks 
and  also  by  the  criticisms  upon  this  paper,  and  I  was  very  glad 
particularly  to  find  Dr.  Wright  so  in  accord  with  what  1  myself 
expressed  in  a  communication  before  this  society  some  years 
ago,  entitled  The  Constitutional  Causes  of  Throat  Disease. 
Some  cases — one  in  particular — were  given  in  which  the  nose 
alone  was  concerned,  where  the  cause  was  directly  referable  to 
the  constitutional  state.  My  ordinary  course  before  using  the 
cautery  has  been  to  study  the  constitutional  condition  of  the  pa- 
tient, to  find  out  why  the  turbinates  swell,  and  then  determine 
what  action  is  to  be  taken.  If  cocaine  reduced  the  swelling,  it 
showed  that  sufficient  contractile  power  was  left,  or  rather  that 
there  was  not  so  much  hypertrophy  but  what  Nature,  if  assisted, 
could  prevent  or  limit  the  tendency  to  recurrent  turgescence. 
In  such  cases  I  have  been  accustomed  to  use  the  cautery  both  to 
destroy  the  sensitiveness  of  the  mucous  membrane  so  that  it 
might  not  be  so  easily  irritated  by  external  causes,  and  to 
create  sometimes  by  puncture  an  adhesive  inflammation  within 
the  tumor.  If,  as  Dr.  Roe  has  so  well  said,  there  is  so  much 
hyperplastic  deposit  that  Nature,  when  assisted,  can  not  get 
rid  of  it,  surgical  interference  is  called  for,  and,  like  Dr.  Koe,  I 
frequently  use  some  cutting  instrument  instead  of  the  cautery. 
I  can  not  conceive  that  any  ill  would  follow  the  cautery  used 
by  any  member  of  this  association ;  but  those  who  have  pre- 
ceded me  have  given  instances  where  the  ignorant  application 
— the  routine  application — of  it  has  caused  great  injury.  That, 
I  think,  all  will  concede.  Of  course,  in  order  to  avoid  adhesion, 
the  greatest  precaution  is  required  to  limit  tlie  application  to 
one  side  of  the  nasal  fossa,  and  great  care  must  he  taken  after- 
ward to  prevent  contact  of  the  wound  with  the  opposite  healthy 
snrfac'C. 


I  wish,  with  Dr.  Delavan,  to  indorse  the  principle  involved 
in  the  method  of  Dr.  Glasgow.  I  have  often  used  it  in  getting 
rid  of  swollen  turbinated  tissue. 

Regarding  accidents,  like  the  occurrence  of  erysipelas,  these 
are  liable  to  take  place  after  any  other  surgical  procedure  as 
well  as  after  treatment  of  the,  nose,  especially  when  the  usual 
surgical  precautions  are  not  observed. 

Dr.  Faelow,  of  Boston:  Some  years  ago  I  saw  a  case  of 
iritis  follow  the  application  of  glacial  acetic  acid  within  the 
nose.    I  can  not  say  whether  there  was  any  causal  relation. 

The  President  remarked  that  he  thought  it  probably  a 
mere  coincidence;  the  iritis  might  have  been  of  rheumatic 
origin. 

Dr.  De  Blois:  I  have  been  much  interested  in  the  discus- 
sion which  has  taken  place  on  my  paper,  although  it  has  di- 
verged somewhat  from  the  original  subject.  It  was  intended 
merely  to  portray  some  of  the  conditions  found  years  after  the 
operation  and  not  immediately  afterward. 

A  Case  of  Suppurating  Ethmoiditis.— Dr.  J.  II.  Bryan,  of 
Washington,  read  a  paper  with  this  title.    (See  page  97.) 

Dr.  J.  Weight,  of  Brooklyn  :  I  was  much  interested  in  that 
part  of  the  paper  relating  to  rhinitis  caseosa.  Several  years  be- 
fore I  ever  heard  of  this  condition  I  had  a  case  which  I  suppose 
some  would  designate  by  that  term.  It  occurred  in  a  young 
Swedish  girl  who  was  in  the  best  of  health,  but  had  an  ob- 
struction of  the  nostril,  and  on  examination  I  found  a  white 
ma*s  above  the  middle  turbinated ;  on  washing  it  out  I  was 
astounded  at  the  amount  of  caseous  matter  which  came  away. 
It  did  not  seem  possible  that  a  single  nasal  cavity  could  contain 
80  much.  I  examined  it  under  the  microscope,  but  found  little  of 
interest;  there  were  a  few  crystals  such  as  one  frequently  sees 
in  sebaceous  cysts.  The  mucous  membrane  was  not  much 
atrophied.  On  examining  the  material  which  came  away  more 
carefully,  1  found  something  which  looked  like  the  paring  of  a 
finger  nail  or  sliver  of  a  pearl  button.  I  believe  it  is  not  a  dis- 
ease in  itself,  but  a  result  of  inflammation  of  the  ethmoid,  or  of 
irritation  from  retained  secretions  in  a  case  of  mucous  polypi. 
Why  in  some  cases  the  secretion  undergoes  this  peculiar  de- 
generation I  am  unable  to  say. 

Regarding  ethmoidal  disease,  it  seems  to  me  we  are  nmch 
behind  those  abroad  in  the  investigation  and  treatment  of  tliis 
disease.  It  seems  to  me  very  difficult  to  treat  when  of  long 
standing.  I  have  had  several  cases  which  I  have  really  not 
known  what  to  do  with.  In  order  to  treat  them  I  think  it  is 
always  necessary  to  remove  the  anterior  end  of  the  middle  tur- 
binated body.  We  should  remember  that  when  treating  the 
ethmoidal  sinuses  we  are  very  near  the  base  of  the  brain,  and 
should  advance  with  very  great  caution.  I  have  curetted  out 
the  sinuses  and  then  syringed  with  warm  carbolized  solution 
through  a  syringe  to  which  was  attached  a  long  slender  needle. 
The  cases  which  I  have  had  have  improved,  but  I  have  seen 
none  cured  which  had  existed  two  or  three  years. 

Dr.  C.  E.  Dennison,  of  Colorado  (by  invitation) :  With  the 
permission  of  the  association  I  would  like  to  relate  a  case  that  I 
may  have  the  beneflt  of  the  opinion  of  the  members  as  to  the 
diagnosis.  The  case  was  that  of  a  man  of  about  twenty-two 
who  had  pulmonary  tuberculosis.  He  began  to  be  troubled 
when  asleep,  whether  lying  or  sitting,  by  having  to  clear  his 
throat,  the  amount  of  secretion  thrown  out  at  once  amounting, 
after  a  time,  to  an  ounce  or  an  ounce  and  a  half,  being  thin, 
yellowish,  and  containing  a  multitude  of  tubercle  bacilli.  Dur- 
ing the  day  he  would  si)it  up  from  the  lungs  perhaps  two  ounces 
of  muco-fibrinous  and  purulent  material,  but  this  on  several  ex- 
aminations was  found  to  contain  no  tubercle  bacilli.  The  ques- 
tion which  I  would  like  answered  is,  Where  did  the  secretion 
come- from  which  awoke  him  from  sleep?    I  do  not  think  it 


Jan.  28.  1893.J 


BOOK  NOTICES. 


117 


oarae  from  a  lung  cavity.  Could  it  have  come  from  the  mastoid 
cells  which  were  believed  to  be  diseased?  Rhinoscopic  exami- 
nation was  negative. 

Dr.  J.  Wkkuit,  of  Brooklyn  :  Of  course  I  do  not  know  how 
thoroughly  the  nasal  cavity  was  examined  in  this  case,  but  I 
have  seen  a  case  somewhat  similar,  the  quantity  of  secretion 
thrown  out  coming  on  at  night,  in  which  the  sphenoidal  sinus 
w  as  full  of  pus.  I  can  not  conceive  how,  in  Dr.  Dennison's 
rase,  the  secretion  could  come  down  from  the  mastoid  cells. 

Dr.  Delavan  :  The  following  was  a  rather  peculiar  case 
of  disease  of  the  ethmoid  cells.  The  patient,  an  elderly  gen- 
tleman suffering  from  nasal  polypus,  had  on  the  left  side  of 
the  nose  a  very  putrid  discharge,  with  considerahle  pain  and 
sense  of  oppression  and  weight.  I  diagnosticated  ethmoidal  dis- 
ease, removed  the  polypus,  removed  the  anterior  end  of  the 
middle  turbinated,  found  an  abscess  cavity  there,  and  supposed 
the  patient  would  be  cured.  Yet,  although  very  much  relieved, 
the  discharge  continued,  and  I  found  there  was  an  immense 
amount  of  thickened  tissue  in  the  vicinity  of  the  opening  lead- 
ing to  the  antrum  of  Ilighmore.  Various  means  were  discussed 
for  effecting  free  drainage  of  the  antrum,  and  finally  it  was 
drained  through  the  nose  by  enlarging  the  natural  opening.  By 
washing  out  twice  a  week  there  has  been  such  improvement 
that  further  interference  has  not  been  considered  necessary. 
The  case  is  interesting  as  sliowing  that  we  may  have  here  a 
complication  of  conditions;  the  value  of  free  drainage;  and 
that,  in  some  cases  at  least,  we  can  get  along  without  the  ordi- 
nary surgical  interference. 

Dr.  Alexander  W.  MaoCoy,  of  Philadelphia:  My  experi- 
ence with  cases  of  chronic  ethmoidal  discharge,  usually  associ- 
ated with  necrosis  sooner  or  later,  is  that  they  are  of  long  dura- 
tion and  extremely  ditficult  to  cure.  I  have  a  physician  friend 
who  has  had  necrosis  of  the  ethmoidal  cells  from  twenty  to 
twenty-five  years.  It  is  a  source  of  annoyance,  but  he  refuses 
to  have  further  operative  interference.  While  the  cases  are 
much  relieved  by  curetting,  yet  the  permanent  results  are  not 
completely  satisfactory.  In  my  experience,  it  has  been  extreme- 
iv  ditficult  to  get  rid  of  all  the  necrosed  tissue. 

Dr.  Muliiall  inquired  of  Di-.  MacCoy  whether  he  used  gen- 
eral anaesthesia  in  curetting,  and  Dr.  MacCoy  replied  in  the 
negative. 

Dr.  Beyan  replied  to  an  interrogatory  that  he  had  used 
;ii  iieral  anajsthesia  in  curetting  the  ethmoid  cells  in  but  one 
case,  and  that  lie  would  never  use  it  again.  He  agreed  with  the 
speakers  that  the  disease  was  a  tedious  one  to  both  patient  and 
physician. 


3^00 h  flotices. 


Text-hook  of  Ophthalmology.  By  Dr.  Ernest  Fuchs,  Professor 
of  Ophthalmology  in  the  University  of  Vienna.  Authorized 
Translation  from  the  Second  Enlarged  and  Improved  Ger- 
man Edition.  By  A.  Duane,  M.D.,  Assistant  Surgeon,  Oph- 
thalmic and  Aural  Institute,  New  York.  With  Numerous 
Illustrations.  New  York  :  D.  Appleton  &  Co.,  1892.  Pp. 
xiii  to  788. 

This  is  a  translation  of  one  of  the  most  recent  foreign  works 
iin  ophthalmology,  as  it  is  easily  one  of  the  very  best.  It  is  es- 
sentially a  text-book  and  occujjies  deservedly  high  rank  for  the 
I  K  nrness  and  simplicity  of  its  style  and  its  presentation  of  the 
lifst  modern  thought.  The  translator  has  done  his  work  ex- 
tremely well,  and  has  made  such  additions  as  seemed  to  him 
necessary  to  adapt  the  book  to  American  readers. 


The  work  consists  of  four  parts,  treating  of  the  Examination, 
the  Diseases  of  the  Eye,  the  Anomalies  of  Refraction  and  Ac- 
commodation, and  Operations  upon  the  Eye.  There  is  extremely 
little  to  criticise  in  the  entire  book,  but  the  reviewer  would  call 
attention  to  the  following  points :  In  the  chapter  on  Purulent 
Conjunctivitis,  speaking  of  the  importance  of  protecting  the 
sound  eye  from  infection.  Professor  Fuchs  makes  no  mention  of 
Buller's  shield,  the  use  of  which  is  the  simplest  and  best  method 
to  employ,  as  it  admits  of  inspection  of  the  sound  eye  without 
removal  of  the  protective  dressing.  The  section  on  trachoma- 
tous conjunctivitis  is  one  of  the  best  ever  written,  pai'ticularly 
with  regard  to  the  symptomatology  and  pathology  of  the  dis- 
ease, but  we  think  the  author  places  too  much  reliance  on  the 
treatment  with  caustics,  and  devotes  too  little  attention  to  mod- 
ern operative  methods  of  treatment.  In  this  country  at  least, 
the  use  of  jequirity  has  been  almost  entirely  abandoned. 

In  the  chapter  on  Convergent  Squint,  the  most  complex  and 
difficult  subject  in  all  ophthalmology,  the  author  is  disposed  to 
place  too  much  reliance  on  operative  procedures  and  too  little 
on  the  prolonged  use  of  atropine  and  fully  correcting  glasses. 

The  chapter  on  Squint  Operations  is  exceptionally  good,  and 
the  subject  of  muscular  insufficiencies  is  very  clearly  presented, 
though  hardly  with  that  fullness  which  an  American  ophthal- 
mologist would  expect.  In  the  additions  to  this  subject  by  the 
translator,  we  think  that  he  attaches  too  much  importance  to 
the  beneficial  effects  of  partial  tenotomies,  which  are  far  from 
being  permanent,  and  alleges  for  this  method  of  operating  too 
brilliant  and  exact  results.  The  element  of  time  frequently 
falsifies  the  first  favorable  prognosis  of  the  result  of  a  partial 
tenotiimy  in  these  cases. 

With  these  few  exceptions,  the  reviewer  must  express  the 
most  cordial  commendation  of  Professor  Fuchs's  work  in  its 
American  dress. 

Ou  tlines  of  Zoology.  By  J.  Arthur  Thomson,  M.  A.,  F.  R.  S.  E., 
Lecturer  on  Zoology  in  the  School  of  Medicine,  Edinburgh; 
Joint  Author  of  the  "  Evolution  of  Sex  " ;  Author  of  "  The 
Study  of  Animal  Life."  With  Thirty-two  Full-page  Illus- 
trations. New  York:  D.  Appleton  &  Co.,  1892.  Pp. 
xvi-641. 

We  have  often  mentioned  zoology  as  among  the  sciences 
that  ought  to  be  more  generally  studied  by  physicians  in  this 
country  than  they  are  at  present.  By  their  neglect  much  in- 
formation capable  of  being  turned  to  practical  account  is  sacri- 
ficed, to  say  nothing  of  the  mental  training  attendant  upon 
studying  systems  of  classification.  The  trouble  is  that  these 
studies  are  apt  to  be  looked  upon  as  necessarily  "  dry,"  but  it  is 
just  such  books  as  that  which  Mr.  Thomson  has  here  given  us — 
and  their  number,  we  are  glad  to  say,  is  fast  multiplying — that 
ought  to  dispel  this  false  notion.  The  book  is  thoroughly 
"readable"  from  beginning  to  end.  Perhaps  the  most  striking 
illustration  of  the  truth  of  this  statement  is  to  be  found  in  the 
paragraphs  devoted  to  the  "  courtship  "  of  spiders,  beginning 
on  page  288,  in  which  the  author  cites  Mr.  and  Mrs.  Peckham's 
interesting  observations  on  the  sexual  relations  of  these  crea- 
tures, as  recorded  in  Occasional  Papers  of  the  Natural  History 
i^ociety  of  Wisconsin  (.Milwaukee,  1889) ;  but  that  is  only  one 
of  the  more  noticeable.  We  should  be  sorry,  however,  to  give 
the  impression  that  the  book  depended  for  its  value  on  its  en- 
tertaining (juality  ;  the  author  is  really  very  clever  in  imparting 
accurate  scientific  knowledge,  largely  by  virtue  of  his  skill  in 
tabular  and  diagrammatic  representation.  Through  the  book 
there  runs  a  thread  of  suggestion,  with  very  little  of  specula- 
tion, connecting  the  facts  of  zoology  with  the  doctrines  of  evo- 
lution and  descent — doctrines  that  must  be  of  interest  to  per- 
sons of  all  shades  of  opinion  and  belief. 


118 


BOOK  NOTICES.— MISCELLANY. 


[N.  Y.  Med.  Jouh., 


BOOKS,  ETC.,  RECEIVED. 

A  Text-book  of  Practical  Therapeutics,  with  Especial  Refer- 
ence to  the  Application  of  Remedial  Measures  to  Disease  and 
their  Employment  upon  a  Rational  Basis.  By  Hobart  Amory 
Ilare,  M.  D.,  B.  Sc.,  Professor  of  Therapeutics  and  Materia 
Medica  in  the  Jefferson  Medical  College  of  Philadelphia,  etc. 
Third  Edition,  enlarged  and  thoroughly  revised.  Philadelphia: 
Lea  Brothers  &  Co.,  1892.    Pp.  xiii-17  to  696. 

Disease  in  Children.  A  Manual  for  Students  and  Practi- 
tioners. By  James  Carmichael,  M.D.,  F.  R.C.  P.  Ed.,  Physi- 
cian Royal  Hos[)ital  for  Sick  Children,  etc.  Illustrated  with 
Thirty-one  Charts.  New  York:  D.  Appleton  «fe  Co.,  1892. 
Pp.  xvi-591.    [The  Students'  Series.]    [Price,  $3.] 

Transactions  of  the  American  Gynajcological  Society.  Vol- 
ume XVII,  for  the  Year  1892.  Philadelphia:  W.  J.  Dornan, 
1892.    Pp.  .xxxix-493. 

Hemianopsia  or  Ilemianopia.  A  Clinical  Lecture  delivered 
at  the  New  York  Post-graduate  Medical  School.  By  William 
Oliver  Moore,  M.  D.    [Reprinted  from  International  Clinics.] 

Total  Extirpation  of  the  Uterus:  Improved  Method  of  treat- 
ing the  Stump.  By  Charles  P.  Strong,  M.  D.,  Boston,  Mass. 
[Reprinted  from  the  Boston  Medical  and  Surgical  Journal.] 

A  Contribution  to  the  Study  of  Abdominal  Pregnancy.  By 
Henry  C.  Coe,  M.  D.,  of  New  York.  [Reprinted  from  the 
Medical  News.] 

The  Elective  Caesarean  Section ;  the  most  Favorable  Time  for 
Operation.  By  Henry  C.  Coe,  M.  D.,  New  York.  [Reprinted 
from  the  American  Journal  of  Obstetrics.] 

Phthisis  Bulbi  and  Artificial  Eyes.  A  Clinical  Lecture  de- 
livered at  the  New  York  Post-graduate  Medical  School.  By 
William  Oliver  Moore,  M.  D.  [Reprinted  from  International 
Clinics.] 

A  Consideration  of  some  of  the  Affections  of  Tendon  Sheaths 
and  Bursas,  and  their  Relations  to  Injuries  and  Diseases  of  the 
Joints.  By  Royal  Whitman,  M.  D.,  New  York.  [Reprinted 
from  the  Medical  Record.] 

Observations  on  Tubercular  Knee-joint  Disease  in  Children. 
By  Royal  Whitman,  M.  D.,  New  York.  [Reprinted  from  the 
Archives  of  Pediatrics.] 

Hyperaesthesia  of  the  Vaginal  Orifice  a  Cause  of  Refiex  Pel- 
vic Pain.  By  Charles  P.  Strong,  M.  D.,  Boston.  [Reprinted 
from  the  Boston  Medical  and  Surgical  Journal.] 

Is  Evolution  trying  to  do  away  with  the  Clitoris?  By  Rob- 
ert T.  Morris,  M.  D.,  New  York.  [Reprinted  from  the  American 
Journal  of  Obstetrics.] 

Some  Common  Errors  in  the  Physical  Training,  Education, 
and  Dress  of  Girls.  By  J.  Schenck,  M.  D.,  Mount  Carmel,  111. 
[Reprinted  from  the  Transactions  of  the  Illinois  Slate  Medical 
Society.] 

Purulent  Brain  Deposits,  and  Phlebitis  and  Thrombosis  of 
the  Cerebral  Veins  and  Sinuses  following  Ear  Disease.  By 
Frank  Allport,  M.  D.,  Minneapolis,  Minn.  [Reprinted  from  the 
Journal  of  the  American  Medical  Association.] 

Large  Cavernous  Angeioma,  involving  the  Integument  of  an 
Entire  Auricle,  successfully  treated  by  Dissection,  Free  Resec- 
tion of  Diseased  Tissue,  and  Ligation  of  the  Afferent  Tnmks  in 
situ  by  a  Special  Method.  By  Rudolph  Matas,  M.  D.,  New  Or- 
leans, La.    [Reprinted  from  the  Medical  News.] 

A  New  Method  of  checking  Bleeding  after  Tonsillotomy. 
By  Robert  II.  M.  Dawbarn,  M.  D.,  New  York.  [Reprinted  from 
the  Medical  Record.] 

Arterial  Saline  Infusion.  A  Report  of  Three  Additional 
Cases  by  the  New  Te<;hnique;  also  of  a  Case  of  Infant  Diar- 
rhoea treated  by  Saline  Infusion.  By  Robert  H.  M.  Dawbarn, 
M.  D.,  New  York.    [Reprinted  from  the  Medical  Record.] 


Observations  on  Cholera  and  Quarantine.  A  National 
Quarantine  implies  National  Seclusion.  By  0.  W.  Chancellor, 
M.  D.,  Baltimore.  Md. 

A  Clinical  Study  of  Eleven  Cases  of  Asiatic  Cholera  treated 
by  Hypodermoclysis  and  Enteroclysis.  By  Judson  Daland, 
M.  D.,  Philadelphia,  [Reprinted  from  the  University  Medical 
Magazine.] 

Uterine  Fibromata;  Removal  of  Twenty-seven,  with  Two 
Deaths.  By  J.  M.  Baldy,  M.  D.,  Philadeljihia.  [Reprinted  from 
the  f/niversity  Medical  Magazine.] 

A  Case  of  Mastoid  Disease  following  an  Operation  for  the 
Removal  of  Adenoid  Vegetations.  By  Gorham  Bacon,  M.  D., 
New  York.  [Reprinted  from  the  Transactions  of  the  American 
Otological  Society.] 

Antipyrine  for  the  Relief  of  Headaches.  By  Graeme  M. 
Hammond,  M.  D.,  New  York.  [Reprinted  from  the  Journal  of 
Nervous  and  Mental  Disease.] 

The  Principles  and  Ajjplication  of  the  Axis-traction  Forceps, 
with  Special  Reference  to  the  Instrument  devised  by  Tarnier. 
By  Stanley  P.  Warren,  M.  D.,  Portland,  Me.  [Reprinted  from 
the  Transactions  of  the  Maine  Medical  Association.] 

Simplicity  an  Element  of  Success  in  Surgery.  By  R.  Stans- 
bury  Sutton,  M.  D.   [Reprinted  from  the  Medical  Mirror.] 

Eleventh  Annual  Report  of  the  Hospital  for  Women  and 
Children,  Newark,  N.  J.    December,  1892. 

Report  of  the  Board  of  Directors  and  Superintendent  of  the 
North  Carolina  Insane  Asylum,  for  the  Two  Years  ending  No- 
vember 30,  1892. 

Thirty-ninth  Annual  Report  of  the  New  York  Infirmary  for 
Women  and  Children.    For  the  Year  1892. 


The  Medical  Society  of  the  State  of  New  York  will  hold  its  eighty 
seventli  annual  meeting  at  the  City  Hall,  in  Albany,  on  Tuesday, 
Wednesday,  and  Thursday,  February  Vth,  8th,  and  9th,  under  the  presi- 
dency of  Dr.  Lewis  S.  Pilcher,  of  Brooklyn.  The  provisional  programme 
includes  the  following  titles :  The  president's  inaugural  address ;  The  Re- 
lation, in  the  Male  and  Female,  of  Genital  Disease  to  Mental  and  Nerv- 
ous Affections,  by  Dr.  Landon  Carter  Gray,  of  New  York ;  The  Epileptic 
Interval;  its  Phenomena  and  their  Importance  as  a  Guide  to  Treatment, 
by  Dr.  William  Browning,  of  Brooklyn  ;  Refiex  Disturbances  in  the 
Causation  of  Epilepsy,  by  Dr.  William  C.  Krauss,  of  Buffalo ;  Mental 
Epilepsy,  by  Dr.  J.  Montgomery  Mosher,  of  Ogdensburg  ;  The  Develop- 
ment of  Epilepsy  after  Traumatic  Injury  to  the  Skull,  by  Dr.  B.  Sachs^ 
of  New  York  ;  The  Treatment  of  Ura?mic  Convulsions,  by  Dr.  R.  C.  M. 
Page,  of  New  York  ;  The  Registration  of  Midwives,  by  Dr.  J.  L.  Kort- 
right,  of  Brooklyn  ;  The  Relative  Value  of  Certain  Obstetrical  Opera- 
tions (General  Review  of  the  Operations  to  be  Discussed,  by  Dr.  Egbert 
H.  Grandin,  of  New  York  ;  The  Limitations  of  Embryotomy,  by  Dr.  N. 
Clifton  Edgar,  of  New  York  ;  The  Limitations  of  the  Caesarean  Section, 
by  Dr.  Robert  A.  Murray,  of  New  York ;  The  Anatomical  Limitations  of 
Symphyseotomy,  by  Dr.  J.  E.  Kelly,  of  New  York ;  The  Clinical  Limita^ 
tions  of  Symphyseotomy,  by  Dr.  Charles  Jewett,  of  Brooklyn) ;  Practical 
Antisepsis  and  Asepsis,  by  Dr.  Howard  A.  Kelly,  of  Baltimore  ;  Epitaphs 
from  the  Tombstones  of  Medical  History,  by  Dr.  Joseph  H.  Hunt,  of 
Brooklyn  ;  The  Management  of  Suppuration  complicating  Tuberculous 
Disease  of  the  Bones  and  Joints  (papers  by  Dr.  V.  P.  Gibney,  of  New 
York  ;  Dr.  Roswell  Park,  of  Buffalo  ;  Dr.  Henry  Ling  Taylor,  of  New 
York  ;  and  Dr.  Louis  A.  AVeigel,  of  Rochester) ;  The  Present  State  of 
Knowledge  as  to  Carcinoma  (The  Pathology  of  Carcinoma,  by  Dr.  H.  C. 
Coe,  of  New  York  ;  The  ^iitiology  of  Carcinoma,  by  Dr.  Roswell  Park, 
of  Buffalo ;  The  Value  of  Internal  Medication  in  the  Treatment  of  Car- 
cinoma, by  Dr.  Jarvis  S.  Wight,  of  Brooklyn  ;  The  Results  Obtainable 


Jan.  28,  1893.] 


MISCELLANY. 


119 


from  the  Use  of  Aniline  Products  in  Carcinoma,  by  Dr.  Willy  Meyer,  of 
New  York ;  Caustics  in  the  Treatment  of  Carcinoma,  by  Dr.  Daniel  Lewis, 
of  New  York ;  The  Knife  in  the  Treatment  of  Carcinoma,  by  Dr.  N.  Ja- 
cobson,  of  Syracuse) ;  Tuberculous  Epididymitis,  by  Dr.  Herman  Mynter, 
of  Buffalo  ;  Newer  Methods  of  Diagnosis  and  Treatment  of  Stomach  and 
Intestinal  Diseases  (The  Practical  Value  of  the  Newer  Methods  of  E.k- 
aniination  in  the  Diseases  of  the  Stomach,  with  a  Consideration  of  the 
Indications  given  for  Diet  and  Treatment  by  such  Examinations,  by  Dr. 
Henry  L.  Eisner,  of  Syracuse  ;  The  Methods  of  obtaining  and  examin- 
ing the  Stomach  Contents  in  Disease  for  Purposes  of  Diagnosis,  by  Dr. 
J.  Fuhs,  of  Brooklj-n  ;  The  Disturbances  of  the  Motor  Function  of  the 
Stomach  ;  their  Diagnosis,  Symptoms,  and  Treatment,  by  Dr.  C.  G. 
Stockton,  of  Buffalo ;  The  Physiological  Effects  of  Electricity  in  the 
Stomach,  the  Indications  for  its  Administration  and  Use  in  Gastric  Dis- 
ease, and  the  Methods  of  using  the  Same,  by  Dr.  Max  Einhorn,  of  New 
York) ;  the  President's  Anniversary  Address  (in  the  Senate  Chamber), 
on  The  Evolution  of  the  American  Surgeon  ;  Report  of  a  Case  of  Severe 
Abdominal  Injury  terminating  in  Recovery,  by  Dr.  J.  S.  Cooley,  of  Glen 
Cove  ;  The  Treatment  of  Inguinal  Hernia,  by  Dr.  Alexander  Dallas,  of 
New  York  ;  Certain  Types  of  Septicaemia  resulting  from  Aboition,  by 
Dr.  Andrew  F.  Currier,  of  New  York  ;  Puerperal  Sepsis,  its  Prevention 
and  Cure,  by  Dr.  W.  W.  Potter,  of  Buffalo ;  Hoarseness,  by  Dr.  W. 
Franklin  Chappell,  of  New  York  ;  The  Diagnosis  and  Nomenclature  of 
Fevers,  by  Dr.  Nelson  G.  Richmond,  of  Fredonia  ;  Congenital  Opacities 
of  the  Lens,  by  Dr.  W.  F.  Mittendorf,  of  New  York ;  Are  Stoerk's  Blen- 
norrhoea  and  Laryngitis  Sicca  One  and  the  Same  Disease  ?  by  Dr.  W. 
Freudenthal,  of  New  York. 

The  Pennsylvania  Medical  Practice  Bill. — The  following  is  the 
text  of  the  bill  to  which  we  made  brief  editorial  reference  in  our  last 
issue : 

"  An  act  to  establish  a  State  Board  of  Medical  Examiners  and  Li- 
censers and  to  define  the  powers  and  duties  of  such  board. 

"  Whereas,  the  safety  of  the  public  is  endangered  by  incompetent 
physicians  and  surgeons,  and  due  regard  for  public  health  and  the  pres- 
ervation of  human  life  demands  that  none  but  competent  and  properly 
qualified  physicians  and  surgeons  shall  be  allowed  to  practice  their 
profession. 

"Section  1.  Be  it  enacted  by  the  Senate  and  House  of  Representa- 
tives of  the  Commonwealth  of  Pennsylvania  in  General  Assembly  met, 
and  it  is  hereby  enacted  by  the  authority  of  the  same,  that  within  one 
month  after  the  passage  of  this  act  the  Governor  shall  appoint  a  State 
Board  of  Medical  Examiners  and  Licensers,  consisting  of  nine  members, 
three  to  serve  for  one  year,  three  for  two  years,  and  three  for  three 
years,  in  the  first  instance ;  and  thereafter  annually  the  Governor  shall 
appoint,  by  and  with  the  advice  and  consent  of  the  Senate,  three  mem- 
bers to  serve  for  three  years  in  place  of  those  whose  terms  then  expire. 
The  said  persons  so  appointed  shall  be  graduates  of  some  legally 
chartered  college  or  university  having  the  power  to  confer  medical  de- 
gree, citizens  of  the  United  States  and  of  this  Commonwealth,  who 
shall  have  been  in  the  active  practice  of  medicine  or  surgery  for  a 
period  of  not  less  than  ten  years,  but  no  two  of  whom  shall  be  residents 
of  the  same  coimty,  and  none  of  whom  shall  be  a  member  of  the  faculty 
or  staff  of  any  medical  school  or  university.  Each  member  of  the  said 
lioard  shall  receive  a  certificate  of  appointment  from  the  Governor,  and 
shall  file  the  same  within  twenty  days  with  the  prothonotary  of  the 
Court  of  Common  Pleas  of  the  county  in  which  said  njemberis  registered 
under  existing  law. 

"  Sec.  2.  The  said  board  shall  be  known  by  the  name  and  style  of 
the  State  Board  of  Medical  Examiners  and  Licensers  of  the  Common- 
wealth of  Pennsylvania,  and  shall  have  a  common  seal,  and  may  make 
and  adopt  all  necessary  rules  and  regulations  and  by-laws  not  inconsist- 
ent with  the  Constitution  and  laws  of  this  Commonwealth  or  of  the 
United  States,  and  shall  have  power  to  locate  and  maintain  an  office 
within  this  State  for  the  transaction  of  business.  Five  members  of  the 
said  board  shall  constitute  a  quorum  for  the  transaction  of  business. 

"  Sec.  3.  Every  appointment  to  fill  a  vacancy  or  vacancies  in  the 
said  board  shall  be  for  the  unexpired  term,  and  the  said  vacancy  or 
vacancies  shall  be  filled  by  the  Governor  within  sixty  days  after  notifi- 
cation of  the  same  by  the  board,  and  he  shall  have  power  to  remove 


any  member  of  said  board  for  criminal,  scandalous,  or  dishonorable 
conduct. 

"Sec.  4.  The  said  board  shall  organize  at  Harrisburg  within  three 
months  from  the  date  of  its  appointment,  and  shall  elect  from  its  own 
number  a  president  and  a  secretary  who  shall  also  act  as  treasurer,  both 
of  whom  shall  hold  their  offices  for  one  year,  or  until  their  successors 
are  chosen. 

"  Sec.  5.  The  members  of  the  said  board  shall  each  receive  a  salary 
not  exceeding  three  hundred  dollars  per  annum,  to  be  paid  out  of  the 
fees  for  examination.  The  secretary  and  treasurer  shall  receive  an  ad- 
ditional salary,  to  be  fixed  by  the  board,  and  shall  file  with  the  presi- 
dent of  the  board  a  bond  in  the  sum  of  one  thousand  dollars,  condi- 
tioned for  the  faithful  performance  of  his  duties.  The  necessary 
expenses  of  the  said  board  shall  also  be  paid  out  of  the  fees,  and  any 
balance  remaining  from  the  fees  after  the  disbursements  herein  specified 
shall  be  paid  into  the  treasury  of  the  Commonwealth. 

"  Sec.  6.  The  said  board  shall  examine  all  applicants  for  license  to 
practice  medicine  or  surgery  in  this  Commonwealth  who  are  properly 
qualified  according  to  the  provisions  of  Sec.  1  of  this  act,  and  no  one  shall 
be  excluded  or  rejected  on  account  of  adherence  to  any  special  system  or 
school  of  practice.  It  shall  hold  two  stated  meetings  in  each  year — one 
at  Pittsburgh  and  one  at  Philadelphia  respectively — and  may  hold  special 
meetings  at  such  times  and  places  as  it  may  deem  proper.  All  exami- 
nations, when  practicable,  shall  be  conducted  in  writing,  and  all  ex- 
amination papers,  together  with  the  reports  and  action  of  the  examiners 
thereon,  shall  be  preserved  among  the  records  of  the  said  board  for  a 
period  of  five  years,  during  which  time  they  shall  remain  open  for  in- 
spection at  the  office  of  the  said  board. 

"  The  applicants  shall  be  examined  in  anatomy,  physiology,  chemis- 
trv,  pathology,  hygiene,  toxicology,  differential  diagnosis,  surgery,  and 
obstetrics ;  and  each  applicant,  upon  receiving  from  the  secretary  of 
the  board  an  order  for  examination,  shall  draw  by  lot  a  confidential 
number,  which  he  or  she  shall  place  upon  his  or  her  examination  paper, 
so  that  when  said  papers  are  passed  upon  by  the  examiners  the  latter 
shall  not  know  by  what  applicant  said  papers  have  been  prepared,  and 
upon  each  day  of  examination  all  candidates  shall  be  given  the  same 
set  of  questions. 

"  Skc.  "7.  Any  person  on  paying  ten  dollars  to  the  secretary  of  said 
board,  and  on  presenting  satisfactory  proof  of  being  over  twenty-one 
years  of  age,  of  good  moral  character,  and  of  having  received  a  suffi- 
cient preliminary  education  as  defined  by  said  board,  and  a  diploma 
from  some  legally  incorporated  medical  college  or  university  having 
authority  to  confer  degrees  in  medicine,  shall  be  entitled  to  examina- 
tion by  the  said  board,  and  in  case  of  failure  at  any  examination  shall 
have  the  privilege  of  subsequent  examinations  without  the  payment  of 
an  additional  fee.  Each  applicant  who  shall  have  passed  a  satisfactory 
examination  shall  receive  from  the  said  board  under  seal  a  license  to 
practice  medicine  and  surgery  in  the  Commonwealth  of  Pennsylvania, 
and  the  said  board  may  at  its  discretion  grant  licenses  without  exami- 
nation to  persons  holding  licenses  from  similarly  constituted  boards  of 
examiners  or  boards  of  health  in  other  States. 

"  Skc.  8.  The  secretary  shall  record  in  a  book  to  be  kept  for  this 
purpose  in  the  office  of  the  said  board  the  name,  age,  sex,  residence, 
date,  and  place  of  examination,  the  examination  number,  the  examina- 
tion average  on  each  branch,  the  general  average,  and  date  of  issue  of 
license  in  case  such  license  is  granted.  Said  book  shall  be  opened  to 
public  inspection,  and  on  or  before  the  last  day  of  December  of  each 
year  the  said  board  shall  pviblish  or  cause  to  be  published  a  list  of  the 
names  and  addresses  of  such  persons  as  shall  have  received  licenses  from 
the  .«aid  board  within  twelve  months  immediately  thereto  preceding. 

"  Sec.  9.  After  the  first  day  of  July,  Anno  Domini  one  thousand 
eight  hundred  and  ninety-three,  no  person  shall  enter  upon  the  practice 
of  medicine  or  surgery  in  the  State  of  Pennsylvania  unless  he  or  she 
has  complied  with  the  provisions  of  this  act,  and  shall  have  exhibited 
to  the  prothonotary  of  the  Court  of  Common  Pleas  of  the  county  in 
which  he  or  she  desires  to  practice  medicine  or  surgery  a  license  duly 
granted  to  him  or  her  by  the  said  State  Board  of  Examiners  and 
Licen.sers,  whereupon  he  or  she  shall  be  entitled,  upon  payment  of  one 
dollar,  to  be  duly  registered  in  the  oHice  of  the  prothonotary  of  the 
Court  of  Common  Pleas  in  said  county,  and  any  person  violating  any 


120 


MISCELLANY. 


[N.  Y.  Med.  Joub.- 


of  the  provisions  of  this  act  shall  be  guilty  of  a  misdemeanor,  and,  upon 
conviction  thereof  in  the  Court  of  Quarter  Sessions  of  the  county  where 
the  offense  shall  have  been  committed,'  shall  pay  a  fine  of  not  less  than 
one  hundred  dollars  nor  more  than  five  hundred  dollars  for  each 
offense,  one  half  of  which  fine  shall  be  paid  to  the  prosecutor. 

"  Sec.  10.  Nothing  in  this  act  shall  apply  to  commissioned  medical 
oflficers  of  the  United  States  Army  or  Navy,  or  of  the  United  States 
Marine-Hospital  Service,  nor  to  any  member  of  the  house  or  resident 
staff  of  any  legally  chartered  medical  college  or  university  or  hospital 
during  his  term  of  service  therein,  nor  physicians  of  other  States  meet- 
ing duly  registered  physicians  of  this  State  in  consultation,  nor  to  those 
practicing  dentistry  exclusively.  And  nothing  in  this  act  shall  be  con- 
strued to  prohibit  the  practice  of  medicine  and  surgery  within  this 
Commonwealth  by  any  practitioner  who  shall  have  been  duly  registered 
before  the  first  day  of  July,  Anno  Domini  one  thousand  eight  hundred 
and  ninety-three,  according  to  the  terras  of  the  act  entitled  '  An  act  to 
provide  for  the  registration  of  all  practitioners  in  medicine  and  sur» 
gery,'  approved  the  eighth  day  of  June,  Anno  Domini  one  thousand 
eight  hundred  and  eighty-one. 

"Sec.  11.  For  the  purpose  of  this  act  the  words  '  to  practice  medi- 
cine or  surgery'  shall  mean  to  treat,  operate  on,  or  prescribe  for,  any 
physical  ailment  of  another,  for  money,  gift,  or  reward.  But  nothing  in 
this  act  shall  be  construed  to  prohibit  service  in  cases  of  emergency  or 
the  domestic  administration  of  family  remedies. 

"Sec.  12.  All  acts  or  parts  of  acts  of  Assembly  inconsistent  here- 
with shall  be  and  are  hereby  repealed." 

This  bill,  as  we  have  before  stated,  has  the  cordial  support  of  the 
Medical  Society  of  the  State  of  Pennsylvania.  The  following  letter, 
addressed  to  us  by  Dr.  D.  Benjamin,  of  Camden,  N.  J.,  shows  how  the 
medical  profession  feels  about  the  matter : 

"A  strange  state  of  things  exists  now  in  Pennsylvania.  The  medi- 
cal colleges  are  in  a  real  dilemma.  They  are  so  anxious  to  have  their 
diplomas  recognized  as  a  legal  license  to  practice  that  some  of  the  very 
influential  professors  of  the  colleges  have  opposed  the  bill  creating  a 
medical  examining  board  that  has  been  before  the  Legislature  for  years 
past ;  and  the  State  now  has  no  board. 

"  The  States  around  Pennsylvania  having  such  examining  boards, 
the  result  is  that  over  twenty  per  cent,  of  the  graduates,  being  unable 
to  pass,  or  afraid  to  go  before  the  State  boards,  are  compelled  to  locate 
in  Pennsylvania. 

"  The  M.  Ds.,  especially  the  half-cut  kind  of  machine-made,  as  it 
were,  are  getting  so  thick  that  you  can  stir  them  with  a  stick.  So  you 
Bee  the  State  will  have  to  pass  a  law  soon.  One  very  pleasing  feature 
of  the  situation  is  that  the  colleges  will  have  to  give  the  students  a 
medical  education  as  well  as  a  diploma,  which  they  are  not  all  doing  as 
yet.    As  a  proof  of  this  assertion,  let  me  offer  the  following : 

"  I  was  one  of  three  doctors  to  examine  applicants  for  resident 
physician  at  a  New  Jersey  ho.spital.  Among  the  applicants  was  a 
young  man  who  had  just  been  graduated  from  a  leading  Philadelphia 
medical  college.  His  ignorance  on  every  branch  was  astonishing. 
Here  is  a  sample  of  one  of  the  written  questions  and  his  written 
answer : 

" '  Q.  Write  a  prescription  for  a  fifty-per-cent.  emulsion  of  cod-liver 
oil? 

"  '  Am. : 

"  '       Cod  liver  oil   J  j ; 

Tinchor  of  iron   3  ij ; 

Sulphat  of  quinia   3j; 

Syrupy  simplicis   q.  s. 

"'ad  Oss.' 

"  No  comment  is  necessary. 

"  I  believe  the  New  Jersey  law  is  aliout  the  best  you  can  get  at 
present." 

The  State  Board  of  Medical  Examiners  of  New  Jersey  has  issued 
through  its  secretary,  Dr.  Williaui  Perry  Watson,  the  following  circular, 
dated  January  11th:  Candidates  applying  for  a  license  (after  the  July, 
1893,  meeting  of  the  State  board  of  medical  examiners)  to  practice  medi- 
cine in  New  Jersey  will  be  examined  in  the  following  subjects  arranged 
in  sections  as  follows:  Sec.  1,  Materia  medica  and  therapeutics;  Sec.  2, 


Obstetrics  and  gynaecology;  Sec.  3,  Practice  of  medicine  (including 
diseases  of  the  skin,  nose,  and  throat) ;  Sec.  4,  Surgery  (including  sur- 
gical anatomy,  and  diseases  of  the  eye,  ear,  and  genito-urinary  organs) ; 
Sec.  5,  Anatomy ;  Sec.  6,  Physiology ;  Sec.  7,  Chemistry ;  Sec.  8,  His- 
tology, pathology,  and  bacteriology ;  Sec.  9,  Hygiene  and  medical  juris- 
prudence. The  following  percentages  will  be  required  also  after  that 
date  before  a  license  will  be  issued :  Candidates  examined  in  the  first 
class — i.  e„  graduates  of  five  years  or  more— shall  obtain  a  total  aver- 
age of  eighty  (80)  per  cent.  Candidates  examined  in  the  second  class — 
i. «.,  graduates  of  less  than  five  years — shall  obtain  a  total  average  of 
seventy-five  ("ZS)  per  cent.,  providing  that  in  no  one  section  shall  the 
percentage  be  less  than  thirty-three  and  a  third  (33^)  per  cent.,  in  which 
case,  however,  should  the  total  average  percentage  in  all  the  other  sec- 
tions be  above  seventy-five  (V5)  per  cent.,  the  candidates  may  be  granted 
a  second  examination,  immediately,  upon  that  section.  Candidates  ex- 
amined in  the  third  class — i.  e.,  non-graduates  who  have  taken  three 
full  courses  of  lectures  in  a  reputable  medical  school — shall  obtain  a 
total  average  of  eighty  (80)  per  cent.,  and  candidates  taking  their  pre- 
liminary or  final  exauiination  shall  obtain  a  total  average  of  eighty  (80) 
per  cent,  at  each  of  said  examinations. 


ffo  Contribators  and  Correspondents. —  The  attention  of  all  who  pirpost 

favoring  vntli  cominu)iications  is  respectfully  called  to  the  follow- 
ing : 

Authors  of  articles  intended  for  publication  under  the  head  of  "original 
contributions  "  are  respectfully  informed  that,  tn  accepting  such  arti- 
cles, we  always  do  so  with  the  understanding  that  the  following  condt 
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 — ?«* 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any: 
conditions  which  an  author  wishes  complied  with  must  be  distinct^ 
stated  in  a  communication  accompanying  the  manuscript,  and  /!<. 
new  conditions  can  be  considered  after  tJie  manuscript  lias  been  pm. 
into  the  type-setters''  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  art 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
I  at  large.  We  can  not  enter  into  any  correspondence  concerning  out- 
reasons  for  declining  an  a7-ticle. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer^  name  and  addrtss,  not  necessarily  for  publication.  No  nt. 
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  tite  aiiswer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
■under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particidar  cases  or  recommend  indi- 
vidual practitioners. 

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

Newspapers  and  other  publicatiojis  containing  matter  which  the  persor, 
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,  vie  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

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

All  communication  relating  to  the  business  of  the  journal  thauld  be  ad- 
dressed to  the  publishers. 


THE  JSTEW  YORK  MEDICAL  JOURNAL,  February  4,  1893. 


dPriginal  Communkations. 


THE  STERILIZATION  OF  MILK 
AT  LOW  TEMPERATURES, 
AND  THE  EQUIPMENT  OF  MILK  LABORATORIES  FOR 
INFANT  FEEDING. 
By  henry  KOPLIK,  M.  D. 

The  present  article  details  the  results  obtained,  during 
the  past  two  years,  with  completed  laboratory  facilities  for 
the  preparation  of  a  wliolesoine  food  for  infants  in  direct 
connection  with  their  treatment  in  the  dispensary.  In  in- 
fants and  children  the  treatment  of  a  certain  class  of  dis- 
eases— that  of  the  gastro-intestinal  tract — is  so  inseparably 
linked  with  the  particular  food  given  to  such  patients  that 
the  equipment  of  laboratories  for  the  preparation  of  infant 
food  in  direct  connection  with  a  service  for  the  treatment 
of  diseases  of  children  can  not  only  be  looked  upon  as  a 
decided  advance  over  former  methods,  but  in  the  future  the 
only  just  course  to  pursue.  The  physician  who  simply  pre- 
scribes for  his  little  patient — when  the  infant  must  depend 
very  often  upon  the  good  intentions  of  its  parents,  schooled 
neither  in  the  art  of  cleanliness  nor  in  that  of  cooking  even 
of  the  most  primitive  nature — scarcely  performs  more  than 
half  the  work  expected  of  him.  The  conditions  present 
among  the  immense  infant  clientele  of  the  poor  are  an 
overanxious  mother,  worn  out  by  unsuccessful  attempts  to 
make  amends  for  her  mistakes  and  those  of  others  ;  an  un- 
scrupulous public  caterer  who,  either  through  the  avenues 
of  chemical  science  or  the  less  noble  one  of  dairy  manipu- 
lation, looks  upon  these  little  infants  as  a  just  object  of 
experiment  or  gain.  We  wash  out  the  infant's  stomach, 
send  a  parent  home  with  such  an  infant,  and  after  twenty- 
four  or  forty-eight  hours  bring  the  patient,  through  the 
administration  of  albumins,  to  a  condition  of  tolerance  of 
food,  to  find  that  the  stomach  must  again  begin  the  diges- 
tion of  unwholesome  milk,  or  attempt  the  assimilation  of 
certain  chemical  compound  foods.  If  we  direct  a  parent  to 
prepare  the  milk  for  an  infant  in  a  certain  manner,  the  first 
requisite  is  to  obtain  a  wholesome  milk.  During  the  sum- 
mer months  in  a  large  city  like  New  York  it  is  not  an  ex- 
aggeration to  say  that  among  the  poorer  classes  a  whole- 
some milk  is  exceptional.  There  are  brilliant  exceptions  to 
this  statement.  A  careful,  cleanly  mother,  intelligent,  un- 
heedful  of  the  suggestions  of  her  neighbors,  will  follow  di- 
rections as  to  the  preparation  of  the  baby's  food,  the  dairy 
from  which  it  is  obtained  and  its  dilution,  to  the  letter. 
Such  infants  are  fortunate. 

In  the  experience  of  the  writer,  and  this  is  extensive 
among  the  poor,  it  has  occurred  to  him  to  occasionally  see 
an  infant  brought  up  by  a  careful  mother  on  the  bottle  in 
the  tenement  district  as  healthy  in  appearance  as  one  could 
desire.  This  only  proves  the  rule  stated  above — that  most 
infants  suffer  in  the  crowded  tenement  districts  of  the  city 
directly  from  the  lack  of  a  wholesome  food  basis  (milk),  or 
the  want  of  knowledge  in  its  preparation  on  the  part  of  the 
parent.    The  object  of  the  author  in  establishing  a  labora- 


tory in  connection  with  the  department  for  the  treatment 
of  diseases  of  children  in  his  own  dispensary  has  been  to 
give  his  infant  patients  a  wholesome  food  basis— that  is, 
milk ;  such  a  milk,  well  prepared,  he  was  certain  was  de- 
manded by  the  children.    If  not  adulterated,  it  should  not 
ferment  at  least  for  twenty-four  hours.    Given  a  patient 
who  is  severely  ill,  all  food  is  cut  off  for  twenty-four 
hours,  the  stomach  is  washed,  and  within  forty-eight  hours 
an  infant  who  was  brought  to  us  in  collapse  is  playing  in 
its  mother's  arms.    It  is  a  very  trying  twist  of  conscience 
to  allow  such  a  patient  to  return  to  the  milk  of  the  nearest 
grocer  or  dairy,  or  some  form  of  infant  food.    This  state 
of  affairs  has  been  happily  eliminated  from  the  author's 
practice.     We  can  with  a  well-eqiiipped  laboratory  not 
only  carry  out  the  most  absolute  cleanliness  in  the  food 
basis — milk — but  we  can  limit  and  regulate  the  daily  quan- 
tity, the  exact  diluent,  and  be  certain  that,  under  ordinary 
conditions,  success  will  follow  in  a  good  proportion  of 
cases.    There  is  still  a  percentage  of  cases  which  is  lost 
annually  and  in  which  all  our  efforts  fail.    In  such  infants 
it  seems  that  either  the  conditions,  when  we  are  brought 
face  to  face  with  the  case,  have  been  too  long  present,  the 
infant  is  extremely  atrophic  or  in  a  dying  condition,  or  the 
mother,  after  trying  for  a  short  time  to  administer  the  pre- 
scribed food  to  an  infant  and  being  rewarded  by  the  refusal 
of  the  little  one  to  partake  of  any  food,  instead  of  seeing- 
a  favorable  chance  to  allow  the  infant  to  recuperate,  has; 
promptly  left  the  service  and  gone  elsewhere.    (One  hun- 
dred and  four  of  a  total  of  six  hundred  and  ninety-three' 
children  had  this  fate  last  summer.) 

In  May,  1890,  the  author  exhibited  to  the  County  Medi- 
cal Society  an  apparatus  which  served  to  carry  out  his  first 
attempt  in  meeting  the  wants  of  his  little  patients.  The 
laboratory  at  that  time  was  a  large  wash  boiler  and  gas 
stove  in  an  old  storeroom  of  the  old  building  of  the  East- 
ern Dispensary,  in  which  the  author  was  and  is  still  attend- 
ing physician.  His  efforts  in  the  direction  of  preparing  a 
wholesome  milk  were  ably  seconded  by  Dr.  T.  T.  Gaunt, 
our  physician  in  chief.  At  this  time  the  attempt,  which 
was  still  crude,  to  bring  the  facts  obtained  in  the  scientific 
laboratory  into  direct  touch  with  daily  practice  did  not 
meet  with  enthusiastic  encouragement  from  all  sides.  In 
the  fall  of  that  year  results  were  made  known  through  an 
article  in  the  New  York  Medical  Journal.  Dr.  Richard 
Stein,  of  this  city,  brought  these  efforts  to  the  notice  of  the 
laity,  and  soon  means  were  not  wanting  to  equip  a  laboratory 
which,  though  not  beyond  impro.vement,  still  carries  out 
very  completely  the  ideas  of  the  author.  This  laboratory 
has  now  been  in  active  operation  for  two  years,  and  the 
milk  prepared  has  been  utilized  mostly  in  connection  with 
the  infants  and  children  who  are  treated  in  the  Good  Sa- 
maritan Dispensary,  both  in  the  service  of  other  physicians 
and  in  that  of  the  author.  The  milk  supply  is  drawn  from 
a  leading  reliable  dairy,  and  is  delivered  daily  in  refrigerator 
tubs  at  the  laboratory.  The  process  of  sterilization  is  under 
direct  control,  and  in  the  summer  months  the  laboratory  is 
a  part  of  the  service  of  the  department  of  diseases  of  ohiU- 
dren. 


122 


KOPLIK:   THE  STERILIZATION  OF  MILK. 


[N.  Y.  Mkd.  Jock., 


Cow's  milk  sterilized  at  temperatures  above  100°  Celsius 
undergoes  certain  gross  and  chemical  changes  unfitting  it  as 
an  article  of  food.  At  100°  C.  Munk  has  shown  that  the 
casein  elements  of  the  milk  undergo  changes  which  ren- 
der the  milk  less  desirable  from  a  digestible  standpoint. 
Leeds  and  Davis  have,  in  a  very  interesting  study,  confirmed 
these  points.  Ilueppe,  in  his  classical  study  upon  the  sterili- 
uation  of  milk,  finds  that  with  the  smallest  quantities  of  ren- 
net added  to  milk  a  retarded  action  is  shown  when  the  milk 
has  been  exposed  to  80°  Celsius  ;  but  the  coagulation  is 
still  as  complete  as  at  lower  temperatures.  The  action  of 
the  ferment  was  shown  more  delayed  from  85°  Celsius  and 
most  incomplete  at  100°  C,  with  the  following  limita- 
tions:  From  90°  Celsius  to  100°  Celsius  coagulation  in 
the  presence  of  rennet  was  not  only  delayed  hut  incom- 
plete. Under  similar  conditions  milk  which  had  been  ex- 
posed to  80°  to  85°  Celsius  showed  complete  coagulation 
though  somewhat  delayed.  Above  90°  Celsius,  therefore,  the 
action  of  the  ferment  was  not  only  more  markedly  delayed 
than  at  any  lower  temperature,  but  incomplete.  From  75° 
Celsius  upward  a  gradual  change  in  the  albuminoids  of  the 
milk  occurs.  In  the  above-mentioned  few  cardinal  points 
lie  the  limitation  and  art  of  rational  sterilization  of  milk. 
While  we  can  not  avoid  some  changes,  we  can  reduce  them 
to  a  certain  limit.  This  lies  between  85°  and  90°  Celsius. 
For  practical  every-day  clinical  work  lower  temperatures 
which  approach  the  Pasteur  limits — 65°  to  68°  Celsius — are 
unsatisfactory  for  milk.  A  single  exposure  of  milk  to  tem- 
peratures lower  than  85°  Celsius,  while  it  may  be  a  slight 
chemical  advantage,  will  not  retain  the  milk  in  a  sterile 
condition  for  twenty-four  hours,  even  if  such  milk  is  sud- 
denly cooled  after  exposure  to  the  above-mentioned  tem- 
perature. The  writer  has  worked  upon  this  problem  for  a 
long  time.  City  milk  was  raised  to  70°  Celsius  and  kept 
ranging  absolutely  between  this  point  and  75°  Celsius  for 
half  an  hour ;  it  was  then  suddenly  chilled  by  being  thrust 
into  cold  water ;  after  completed  cooling  it  was  stored  with- 
out ice.  Such  milk  fermented  invariably  within  twenty-four 
hours.  On  the  whole,  it  will  be  shown  that  85°  to  90°  Cel- 
sius— not  above — has  in  the  writer's  hands  proved  the  most 
satisfactory  and  rational  temperature  to  employ  for  milk 
which  is  to  be  distributed  without  control.  Such  milk  is 
wholesome  and  unchanged  after  twenty-four  hours,  and  may 
keep  even  in  warm  and  moist  weather  a  week  or  more 
■without  the  aid  of  ice.  Bitter  has,  by  complicated  ma- 
chinery, succeeded  in  keeping  milk  recently  collected  for 
twenty-four  hours,  when  previously  subjected  to  (in  large 
quantities)  70°  to  75°  Celsius  and  then  rapidly  cooled  by 
passing  over  coolers  to  18°  C.  This  has  been  used  in  Ger- 
many to  transport  milk  to  the  city  from  dairies.  When 
heated  to  70°  Celsius  and  rapidly  cooled  to  20°  a  successive 
number  of  times,  small  portions  of  milk  have  kept  for 
a  time  (Strub).  Dr.  Freeman,  of  New  York,  has  recently 
shown  an  apparatus  for  heating  milk  to  the  Pasteur  tem- 
perature once,  but  such  milk  must  be  carefully  stored  upon 
ice  or  in  an  ice  chest.  Pasteurized  milk,  or  rather  partially 
Pasteurized  milk,  has  for  a  long  period  been  used  in  excep- 
tional cases  both  in  Europe  and  in  this  country  ;  but,  after 
much  study  in  his  own  daily  work,  the  author  has  found  it 


practical  to  employ  the  lowest  temperature  at  which  milk 
exposed  for  half  an  hour  would  keep  wholesome,  free  from 
the  least  suspicion  of  change  for  twenty-four  hours  without 
the  aid  of  ice  in  the  warmest  and  most  humid  weather. 
After  many  discouraging  attempts  to  find  this  temperature, 
the  author  has  fixed  upon  the  temperatures  ranging  from  85° 
to  90°  Celsius  as  the  range  at  which  milk  may  be  safely 
sterilized  and  placed  in  the  hands  of  the  most  ignorant 
mothers  and  still  keep  for  twenty-four  hours  or  more,  even 
if  ice  is  not  used.  With  our  present  facilities  absolute  re- 
sults can  be  attained.  It  has  been  found  that  when  the  tem- 
perature of  the  milk  was  allowed  to  fall  below  the  above 
limits  the  milk  fermented  within  twenty-four  hours.  Above 
the  indicated  limit  sterilization  is  a  superfluous  process. 
The  milk  heated  above  this  point  shows  gross  changes 
which  milk  carefully  sterilized  within  85°  C.  to  90°  C. 
does  not.  Milk  sterilized  between  90°  C.  and  100°  C,  at 
least  in  New  York,  presents  to  the  naked  eye  a  distinctly 
boiled  appearance.  The  butter  in  the  milk  is  apt  to  separate 
and  float  on  the  surface,  and  to  the  taste  the  milk  has  a 
boiled  flavor.  The  coagulated  casein  on  the  bottle  is  more 
marked  when  the  temperature  has  been  allowed  to  rise 
above  90°  C.  than  in  the  milk  in  which  the  temperature  has 
been  carefully  gauged  between  85°  and  90°  C.  Again ^ 
children  thrive  better  on  milk  heated  at  the  lower  tempera- 
ture. In  the  apparatus  used  in  the  laboratory  designed  by 
the  author  it  is  not  possible  to  keep  milk  at  a  fixed  single 
temperature,  for  it  will  be  at  once  apparent  that  bottles  of 
milk  in  the  lower  portion  of  the  sterilizer  will  always  vary 
by  two  to  three  degrees  from  those  at  the  top,  and  this  has 
been  proved  by  repeated  measurements.  There  being  no 
practical  form  of  apparatus  by  which  a  very  large  number 
of  portions  (bottles)  of  milk  can  be  sterilized  at  the  Pasteur 
temperature  and  keep  without  ice  for  twenty- four  hours, 
the  lowest  safe  temperature  above  has  been  employed  and 
found  more  desirable  than  a  higher  one.  Milk  sterilized  be- 
tween 85°  and  90°  C.  after  twenty-four  hours  differs  in  gen- 
eral appearance  but  little  from  raw  milk.  The  casein,  to  be 
sure,  is  found  at  the  sides  of  the  bottle,  but  not  to  a  marked 
degree.  The  taste  is  as  little  like  that  of  boiled  milk  as 
possible,  and,  on  the  whole,  this  temperature  may  be  re- 
garded as  the  most  available.  A  very  important  part  of 
the  plan  of  the  laboratory  is  to  give  the  infant  its  milk  in 
separate  nursing  portions,  each  portion  being  enough  for 
one  nursing.  To  meet  this,  two  sizes  of  bottles  have  found 
most  general  use — a  bottle  holding  two,  another  from  four 
to  five  ounces  of  pure  milk.  To  this  end  ordinary  green 
glass  prescription  bottles,  three  and  six  ounce  size,  were 
used,  so  as  to  give  space  for  diluents.  In  other  words,  the 
bottles  were  not  filled  with  milk,  space  being  left  as  above. 
One  of  the  most  important  parts  of  the  general  plan  of 
giving  small  portions  of  milk  to  such  a  large  number  of  in- 
fants, and  this  in  a  rotating  material,  is  to  insure  the  abso- 
lute cleanliness  of  the  bottle  in  which  the  fresh  milk  is 
sterilized.  This  is  important,  for  it  will  be  seen  at  once 
that  these  bottles  are  returned  and  new  ones  issued  to 
homes  in  which  there  is  no  control  until  the  twenty-four 
hours  are  past,  when  new  portions  are  issued.  To  this  end 
the  bottles  when  they  are  returned  are  filled  with  a  warm 


Feb.  4,  1893.J 


KOPLIK:   THE  STERILIZATION  OF  MILK. 


123 


saturated  solution  of  soda ;  after  twelve  hours  they  are 
washed  with  a  brush  and  applicator  both  on  the  ofltside  and 
inside.  When  they  have  been  cleaned  and  dried,  the  bot- 
tles are  placed  in  large  ovens  which  are  heated  up  to  a 
temperature  of  160°  C.  to  170°  C.  The  dry  hot-air  oven 
of  Koch  is  the  model  form  used.    After  being  kept  at  this 


* 


Measurement  of  Oven  iuside 

2-l'x  2l"x  2i" 
Capacity  350  Nursing:  Bottle?. 


Sp 


Hot-air  oven  (Koch)  for  sterilizing  bottles,  double  walled.  B,  bnmer  and 
source  of  heat ;  R,  radiator ;  S^;,  space  between  outer  and  inner  wall  of 
oven  ;  T,  therm(  meter.  Measurement  inside,  24"  x  24"  x  ai".  Capacity, 
350  nursing  bottles. 


temperature  for  forty  minutes,  they  are  allowed  to  cool,  and 
only  then  are  filled  with  milk.  Any  infectious  material 
adherent  to  the  bottles  from  the  home  of  a  little  patient  is 
thus  made  harmless.  I  think  this  is  a  very  important  part 
of  my  plan.  After  the  above-described  dry-oven  steriliza- 
tion the  bottles  are  carefully  inspected  and  any  bottles  show- 
ing specks  of  a  suspicious  nature  are  rejected. 

The  apparatus  for  sterilizing  the  milk  consists  of  three 
very  large  sterilizers  constructed  in  compartments.  These 
sterilizers  are  made  of  stout  block  tin.  Each  sterilizer 
consists  of  five  compartments  and  a  steam  box.  Each 
compartment  measures  twenty  inches  in  diameter  and  eight 
inches  in  depth,  and  will  hold  fifty  large-size  bottles.  The 
compartments  are  furnished  with  perforated  bottoms,  and  fit 
one  on  top  of  the  other  in  such  a  manner  as  to  form  a  com- 
pact column  through  which  the  steam  percolates.  A  ther- 
mometer is  introduced  through  the  cover  of  the  top 
compartment  and  dips  into  the  body  of  a  bottle  of  milk  in 
this  compartment.  The  temperature  of  the  milk  can  be  ac- 
curately noted  from  the  outside  of  the  apparatus.  A 
stout  tin  pipe,  which  runs  the  whole  length  of  the  appara- 
tus in  each  compartment  and  fits  accurately  into  the  pipe 
of  the  compartment  above,  serves  to  deliver  the  steam  to 
the  top  of  each  compartment  and  thus  fill  the  same  uni- 
formly during  sterilization.  The  bottles,  which  are  filled 
with  the  requisite  quantity  of  milk,  are  placed,  uncorked,  in 
each  compartment  and  covered  with  a  clean  flannel  cloth. 
When  the  steam  is  turned  on  it  does  not  percolate  rapidly 
at  the  top  of  each  compartment,  being  prevented  by  the 
flannel  covering  of  the  bottles.   The  opening  in  the  tube  at 


the  side  of  each  compartment  fills  the  place  above  the  bot- 
tles with  steam.  When  the  whole  mass  of  milk  has 
reached  85°  C.  the  process  is  continued  for  an  additional 
half-hour.  The  bottles  are  then  taken  out  and  rapidly 
corked  with  sterile  rubber  corks.  The  whole  process  con- 
sumes an  hour.  At  first,  when  we  were  compelled  to  use 
water  in  the  steam  box  and  raised  this  to  the  steaming 
point,  much  more  time  was  consumed ;  but  this  year  super- 
heated steam  was  let  into  the  sterilizer  directly  from  engine 
boilers,  and  much  more  accurate  results  were  attained  in  a 
shorter  space  of  time.  As  stated,  three  sterilizers  have 
been  in  constant  use,  and  over  seven  hundred  portions  of 
milk  were  issued  daily  in  midsummer  without  any  diflS- 
culty.    There  have  also  been  two  hot-air  ovens  in  constant 


steam  sterilizer. — a,  separate  compartments  ;  b,  steam-tight  closure ;  c,  pei^ 
forated  bottoms ;  d,  extra  stout  tin  supply-pipe  ;  e,  opening  for  supply  of 
steam  to  top  of  compartments;  S steam  bos  and  supply  pipe. 

use  for  the  sterilization  of  bottles.  The  diagrams  of  these 
explain  themselves.  The  radiating  false  bottom  in  the 
sheet-iron  ovens  will  be  found  to  diffuse  the  heat  rapidly 
and  uniformly.  It  is,  I  believe,  an  American  patent  appli- 
ance, as  also  the  tube  running  through  the  sterilizers.  I 
stumbled  upon  them  in  my  travels  looking  for  suitable  ap- 
paratus. 

The  milk  utilized  in  the  laboratory  of  the(iood  Samari- 
tan Dispensary  is  obtained  from  a  reliable  State  dairy.  It 
is  delivered  to  us  in  cans  of  forty  quarts'  capacity  and  is 


i24 


KOPLIK:   THE  STERILIZATION  OF  MILK. 


[N.  Y.  Mkd.  Jo0h., 


packed  in  ice.  It  would  be  very  desirable  to  control  the 
collection  of  milk,  but  this  is  at  present  impossible,  if  for 
no  other  reason  than  the  lack  of  funds.  The  milk  is  tested 
daily  in  several  simple  ways.  It  must  have  from  twelve 
to  fourteen  per  cent,  of  cream,  and  a  test  portion  is  boiled 
for  ten  minutes  before  placing  in  the  nursing-bottles. 
Milk  when  boiled  will,  even  if  sweet  to  the  taste,  coagulate 
if  well  on  in  fermentative  changes.  Such  milk  is  danger- 
ous even  if  it  shows  small  curdled  particles  after  boiling. 
Sometimes  milk  which  tastes  sweet  will  turn  almost  solid 
upon  boiling,  showing  what  advanced  changes  are  present. 
The  chemical  tests  are  complicated  and  can  not  be  applied 
in  a  short  space  of  time.  Slight  acidity,  not  apparent  to 
the  taste,  will  reveal  itself  after  boiling  or  sterilization  by 
■marked  flocculence  of  the  milk  ;  such  milk  is  unfit  for  use  as 
&  food.  A  little  experience  will  enable  one  to  distinguish 
between  this  flocculent  precipitate  of  casein  due  to  acidity 
and  the  coagulated  casein  on  the  sides  of  the  bottle  pres- 
ent after  sterilization  in  all  good  milk. 

The  bottling  of  the  milk  is  performed  with  as  little 
handling  as  possible  by  means  of  very  large  glass  percolator 
funnels.  The  ladling  of  the  milk  into  these  funnels  tends 
to  evenly  distribute  the  cream  in  the  milk. 

The  corking  of  the  bottles,  as  stated  above,  is  performed 
rapidly  after  sterilization  is  completed.  The  corks  are 
•cleaned  with  a  brush,  boiled  for  an  hour  in  the  solution  of 
soda,  rinsed,  and  sterilized  in  steam.  Black  rubber  corks 
are  used,  and  when  brittle  are  rejected. 

It  has  been  found  advisable  this  year  to  furnish  very 
sick  infants  with  the  diluent  for  the  milk.  To  simply  di- 
rect the  mothers  to  dilute  the  milk  with  barley  water  is 
with  the  younger  infants  not  advisable.  Few  mothers 
know  how  to  prepare  the  barley  water  so  favorably  known 
to  the  profession.  These  patients  are  given  a  quantity  of 
sugar-of-milk  solution — four  per  cent. — in  distilled  water, 
sterilized.  Some  infants  who  vomited  milk  diluted  with 
almost  every  known  diluent,  retained  milk  diluted  at  home 
by  the  mother  with  this  water.  The  suggestion  of  using 
this  as  a  diluent  was  obtained  from  Professor  Soxhlet 
through  the  kindness  of  Mrs.  Felix  Adler,  a  patroness  of 
the  laboratory.  Lime  water  as  bought  in  the  stores  is  also 
a  very  good  diluent.  Barley  water  is  so  difficult  to  pre- 
pare in  the  proper  manner  that,  unless  we  have  a  very  intelli- 
gent patient  who  possesses  art  in  cooking,  it  is  only  a  disap- 
pointment. Each  bottle  of  sterilized  sugar  water  is  labeled 
with  directions  for  dilution  of  the  milk.  I  have  found  the 
directions  laid  down  and  adopted  by  Professor  Escherich, 
of  Gratz,  very  practical  and  convenient,  and  have  had  them 
printed  upon  these  labels.  . 

The  work  done  in  the  laboratory  may  be  estimated  from 
the  following  figures  for  two  seasons : 

Separate  nursing  portions  prepared   97,000 

Children  supplied   1,268 

Seven  hundred  and  twenty-nine  infants  received  the 
milk  for  only  one  or  two  days',  leaving  539  infants  of  the 
above  gross  number  who  received  the  milk  for  a  length  of 
time — one  week  to  five  months — sufficient  to  estimate  its 
benefits.  Excluding  as  much  as  possible  doubtful  results, 
it  is  thought  that,  of  .5:59  infants,  39.'}  can  be  put  down  as 


having  bepn  really  aided  or  benefited  by  the  administration 
of  the  milk. 

It  must  be  remembered  that,  as  with  all  other  treatment 
in  dispensaries,  the  great  percentage  of  clientele  is  an  im- 
patient, rotating  one.  If  immediate  results  are  not  at- 
tained, the  infant  is  carried  to  the  next  institution,  to  be 
the  subject  of  an  entirely  different  method  of  treatment. 
The  milk  has  less  force  to  retain  such  patients  than  a 
medicine,  and  whereas  a  mother  will  'come  for  days 
through  the  influence  of  a  mystic  prescription,  it  is  far 
more  difficult  to  convince  some  that  diet  and  not  medi- 
cine is  the  main  factor  of  treatment.  Physicians  them- 
selves will  often  place  the  very  sickest  of  their  infants  upon 
sterilized  milk  when  the  infant  stomach  is  in  no  condition 
to  digest  food  of  any  kind.  Instead  of  rest  to  the  stomach, 
it  is  burdened  with  milk ;  the  result  is  also  discouragement. 
Again,  after  a  baby  is  perfectly  well,  the  sterilized  milk  is 
discontinued  by  the  mother  on  her  own  responsibility, 
though  the  child  is  doing  very  well.  This,  I  have  found, 
is  due  to  an  impression  in  the  mind  of  the  mother  that  the 
infant  has  regained  health  and  strength  through  the  admin- 
istration of  the  medicines  rather  than  the  milk.  Sach  chil- 
dren are  frequently  returned  to  take  the  milk  again  as  soon  as 
relapses  favored  by  bad  food  set  in.  We  have  considered 
the  infants  as  benefited  when  the  symptoms  for  which  relief 
was  sought  had  ceased.  Many  infants  during  the  summer 
months  have  increased  in  weight  and  strength.  Outdoor 
exercise,  excursions,  sojourns  in  sanitariums  have  aided  the 
results  very  materially.  I  consider  open-air  exercise  and 
the  aids,  in  the  form  of  excursions  and  sanitariums,  placed 
at  the  disposal  of  the  infants  during  the  summer  months,  a 
very  important  factor  with  which  we  must  constantly  calcu- 
late in  these  cases.  This  accounts  for  the  very  unsatisfac- 
tory results  attained  with  sterilized  milk  in  institutions 
where  the  children  are  not  fortunate  to  obtain  this  constant 
change  of  air  and  atmosphere  which  falls  to  the  lot  of 
infants  living  even  in  the  crowded  tenements  of  the  city. 
In  some  institutions  the  facilities,  or  even  the  ordinary  num- 
ber of  nurses,  are  not  sufficient  to  give  the  infants  the  pas- 
sive exercise  in  the  open  air  which  is  their  physiological 
right.  The  result  is  obvious,  that  the  infant  only  breathes 
the  air  of  the  ward ;  it  is  not  taken  out  of  its  crib.  The 
result  even  in  breast-fed  children  is  unsatisfactory.  Such 
breast-fed  children  are  many  of  them  the  waxy,  flabby, 
breast-fed  infants  so  familiar  in  institutions.  In  these  facts 
we  can  see  how  far-reaching  is  the  subject  of  infant  feed- 
ing. I  do  not  consider  the  problem  of  infant  feeding 
solved,  but  certainly  our  present  methods  are  strides  in  ad- 
vance of  the  old. 

In  support  of  my  statement  that  many  children  receive 
sterilized  milk  who  would  do  much  better  if  all  milk  were 
excluded  for  a  time,  we  have  only  to  examine  the  death- 
rate  list  of  over  six  hundred  infants  supplied  last  summer 
with  milk  sterilized  in  our  laboratory  ;  forty  died.  Twenty 
of  this  number  died  after  the  third  day  of  administration 
of  the  milk,  and  thirty  during  the  first  week.  It  can  be 
seen  at  a  glance  that  these  cases  were  unsuitable  ones,  and 
should  have  been  bridged  over  a  critical  period  of  illness 
with  solutions  of  albuminoids^  such  as  Epstein's  solution 


Feb.  4,  1893.] 


SCOTT:    THE  TREATMENT  OF  PUERPERAL  INFECTION. 


125 


of  white  of  egg,  until  strength  returned.  Then  very  small 
quantities  of  diluted  milk  could  be  combined  with  beef  juice 
until  a  full  milk  diet  could  be  resumed.  At  a  discussion  in 
1891  upon  a  very  able  presentation  of  the  subject  of  gavage 
in  children,  at  the  American  Pisdiatric  Society,  by  Dr. 
Kerley,  I  insisted  that,  after  washing  out  the  stomach  ac- 
cording to  Epstein's  method,  the  infant  should  not  be  fed 
but  in  the  way  prescribed  by  Epstein — upon  albumin  water, 
made  by  dissolving  the  white  of  an  egg  in  a  pint  of  cold 
water,  and  straining. 

Such  a  solution  is  kept  upon  ice,  and  administered  by 
the  teaspoonful.  I  have  treated  children  brought  to  me  in 
the  collapsed  condition  present  in  genuine  cholera  infan- 
tum. They  were  kept  for  forty-eight  hours  upon  such  a 
diet,  in  spite  of  the  protestations  of  the  mother  that  the 
infant  would  starve.  The  recovery  was  brilliant  as  it  was 
remarkable.  Then,  and  then  only,  did  I  think  of  returning 
gradually  to  a  milk  diet.  I  have  been  led  to  extend  these 
observations  because  I  have  seen  physicians  begin  to  ad- 
minister milk  to  infants  still  suffering  from  symptoms  of 
gastro-enteritis.  This  is  a  grave  mistake.  Under  these 
conditions  a  milk  diet  is  more  frequently  harmful  than 
beneficial. 

The  infants  who  are  healthy  and  from  birth  have  had 
milk  sterilized  by  the  above- described  methods  show  the 
most  brilliant  results.  Or  infants  who  have  had  the  bene- 
fit of  the  mother's  breast  at  least  once  or  twice  a  day,  in 
addition  to  the  sterilized  milk,  thrive  very  well.  Atrophic 
infants  do  not  increase  in  weight  upon  this  milk  during  the 
summer,  but  they  can  be  tided  over  this  dangerous  period, 
and  later  on  can  partake  of  more  nourishing  foods.  Such 
cases  can  be  pointed  to  by  the  writer  to-day. 

To  sterilize  milk  at  a  safe  low  temperature  in  the  house- 
hold is  a  simple  matter.  If  the  cover  of  the  ordinary  tin 
pot  is  perforated  with  a  number  of  large  openings  an  inch 
in  diameter,  the  steam  can  escape  freely  in  such  an  appara- 
tus, in  which  a  simple  set  of  bottles  and  an  ordinary  pot^ 
ten  inches  deep  by  nine  inches  in  diameter,  is  used.  Milk 
put  in  when  the  water  is  steaming  will  reach  the  following 
temperatures :  At  an  initial  temperature  of  9°  Celsius,  milk 
in  such  a  pot  will,  in  ten  minutes,  reach  60°  C. ;  in  twenty 
minutes,  89°  C. ;  in  twenty-five  minutes,  92°  C.  It  is  thus 
seen  that,  at  the  most,  the  whole  process  should  not  last 
over  twenty-five  minutes.  This  milk,  after  twenty-four 
hours,  has  a  very  agreeable  taste,  and  the  raw  taste  can  be 
distinctly  detected. 

It  is  sometimes  desirable  in  older  children — from  a  year 
or  a  year  and  a  half  upward,  and  who  subsist  largely  upon 
milk — not  to  sterilize  the  milk  at  all,  but  to  'partially  Pas- 
teurize it.  This  may  be  done  as  follows :  The  whole  quart 
of  milk,  or  daily  supply  of  such  a  child,  is  heated  upon  the 
stove  carefully  in  a  clean  utensil,  and,  with  the  aid  of  a 
Celsius  thermometer,  the  whole  milk  is  raised  (stirring 
constantly)  to  70°  C.  The  milk  is  kept  at  70°  to  76° 
Celsius,  stirring  all  the  while,  for  half  an  hour.  It  is 
then  rapidly  cooled  by  surrounding  it  with  ice,  stirring- 
all  the  time,  and  then  placed  in  a  refrigerator.  This 
method  is  only  to  be  attempted  with  the  most  intelligent, 
and  it  will  be  found  very  satisfactory.     The  milk  does 


not  taste  boiled,  and  will  keep  much  better  and  longer  than 
raw  milk. 

Note. — So  much  has  been  written  on  the  subject  of  corking  the  bot- 
tles, notably  by  Escherich,  that  I  have  refrained  from  extended  expla- 
nations. If  the  bottles  are  corked  immediately  after  steaming,  while 
the  milk  is  still  very  warm,  every  purpose  of  sterilization  is  subserved. 
When  the  vapor  condenses  above  the  milk  on  cooling,  a  partial  vacuum 
remains.  Should  a  bottle  ci  ack  subsequent  to  corking  through  changes 
of  temperature,  air  will  force  its  way  through  the  milk  to  its  surface, 
causing  a  frothy  appearance  on  the  milk.  This  proves  that  the  corking 
is  efficient.  In  a  large  number  of  bottles,  the  cracked  ones  may  thus 
be  quickly  detected. 


THE  TREATMENT  OF  PUERPERAL  INFECTION. 
By  J.  FOSTER  SCOTT,  B.  A.  (Yale), 

M.  B.,  C.  M.  (EDIN.  UNIV.), 
RESIDENT  PHYSICIAN,  COLUMBIA  HOSPITAL,  WASHINGTON,  D.  C. 

There  is  scarcely  any  contingency  in  the  practitioner's 
round  of  work  of  such  vast  importance  as  the  intelligent 
perception  of  puerperal  infection  and  its  prompt  and  ra- 
tional treatment. 

Speaking  broadly,  there  are  two  kinds  of  puerperal  in- 
fection : 

1.  The  kind  which  is  lethal. 

2.  A  less  serious  and  more  common  type,  which  is  re- 
sponsible for  a  countless  throng  of  invalids  who  suffer  with 
pyosalpinx,  pelvic  abscesses,  exudates,  adhesions,  misplace- 
ments of  the  pelvic  organs,  etc. 

I  treat  a  puerperal  case  as  septic  which,  in  the  absence 
of  any  other  malcondition,  is  characterized  by  elevated 
temperature,  rigors,  and  offensive  lochia.  In  my  experi- 
ence, all  septic  cases  have  had  an  odor,  but  this  is  not  in- 
variably to  be  depended  on.  Having  recognized  the  con- 
dition, treat  the  endometrium,  the  torn  cervix,  or  vagina, 
or  periniBum  precisely  as  you  would  any  open  wound. 
Medicinal  and  dietetic  treatment  are  of  just  the  same  value 
here  as  in  any  open  wound  elsewhere.  Use  them  as  aids, 
but  not  reliances. 

In  my  estimation,  the  intra-uterine  douche,  as  ordi- 
narily given,  is  inadequate.  It  is  generally  considered  suf- 
ficient to  allow  a  gentle  current  of  corrosive- sublimate  solu- 
tion (1  to  5,000)  to  flow  into  the  uterine  cavity;  but  this 
positively  will  not  separate  any  adherent  shreds,  and  its 
germicidal  action  can  not  by  any  chance  penetrate  into  the 
thick,  fleshy  masses  of  debris  which  will  remain.  My  meth- 
od is  as  follows  : 

The  patient's  buttocks  are  held  in  position  over  the  edge 
of  the  bed,  and  the  vagina  is  well  opened  up  with  a  trivalve 
speculum  and  thoroughly  washed  with  some  antiseptic  solu- 
tion— e.  ff.,  lysol,  1  to  100.  Then  I  perform  Avhat  I  desig- 
nate as  a  soft  curettinff  of  the  cavity  of  the  uterus  by  swab- 
bing it  out  gently  by  means  of  a  twist  of  cotton,  saturated 
in  peroxide  of  hydrogen,  on  an  applicator.  I  use  the  fifteen- 
volume  solution  pure  as  it  comes  in  the  original  bottles. 
The  applicator,  armed  with  a  fairly  large  twist  of  cotton 
soaked  in  peroxide  of  hydrogen,  is  passed  up  to  the  fundus 
uteri  and  allowed  to  remain  for  a  minute  or  so.  It  is  then 
removed,  and  this  proceeding  repeated  several  times  over, 
for  the  peroxide  of  hydrogen  is  something  like  a  bee,  stiug- 


126 


MacCOY:  rare  FORMS  OF  LARYNGEAL  GROWTHS. 


[N.  Y,  Mkd.  Joub,, 


ing  once  and  then  becoming  inert.  It  intelligently  attacks 
every  shred  of  necrotic  tissue,  leaving  no  islands  untouched, 
■while  it  is  absolutely  nontoxic  to  vital  tissues.  Having 
repeated  its  application  several  times  over,  until  I  feel  sure 
every  part  has  been  reached  and  all  devitalized  tissue  loosened 
up,  I  then  irrigate  the  uterine  cavity  with  corrosive-sublimate 
solution  (1  to  5,000;  temperature,  110°  F.),  using  a  large- 
sized  glass  tube.  This  washes  away  all  froth  and  loosened 
debris,  and  makes  assurance  doubly  sure  that  you  have  the 
genital  tract  as  clean  and  aseptic  as  it  is  expedient  to  at- 
tempt. 

In  some  cases  a  mercuric,  or  iodoform,  or  sterilized- 
gauze  packing  clear  up  to  the  fundus  is  indicated.  This  is 
better  than  an  iodoform  suppository  introduced  into  the 
cavity  of  the  uterus,  as  it  acts  as  a  drain.  Ordinarily  it  is 
sufficient  to  blow  into  the  vagina  by  an  insuflSator  a  powder 
composed  of  seven  parts  of  boric  acid  to  one  part  of  iodo- 
form or  aristol.  If  the  perinseum  is  lacerated,  employ  means 
to  keep  it  surgically  clean  by  effective  antiseptic  absorbent 
pads. 

In  my  opinion,  this  peroxide  of  hydrogen  is  by  far  the 
most  valuable  therapeutic  agent  which  has  been  placed  be- 
fore us  in  recent  times.  Dr.  B.  W.  Richardson,  of  London, 
first  advocated  its  use  in  1859,  but  its  great  expense  until 
recently  has  delayed  its  wide  introduction.  I  would  refer 
those  who  are  interested  in  its  use  to  Richardson's  exhaust- 
ive articles  in  the  Scientific  American  Supplements  for  June, 
July,  and  August,  1892.  It  has  a  wide  range  of  applica- 
bility ;  but  for  such  cases  as  the  subject  of  this  article  it  is 
specially  suitable.  I  now  ablior  any  curette  in  puerperal 
cases ;  it  is  too  violent,  even  when  used  with  the  greatest 
caution  ;  it  is  impossible  by  its  use  to  remove  every  particle 
of  debris,  and  it  can  not  be  skillfully  used  by  many  general 
practitioners. 

With  the  OS  well  exposed  to  view  through  the  speculum, 
how  easy  it  is  to  introduce  a  dossil  of  cotton  saturated  with 
peroxide  of  hydrogen  up  to  the  fundus !  No  force  is  need- 
ed ;  necrotic  tissue  melts  down  in  its  presence  like  snow- 
flakes  under  a  burning-glass ;  the  froth  and  loosened  debris 
are  washed  out  by  a  gentle  current  of  mercuric-chloride 
solution  (1  to  5,000),  and  the  genital  tract  is  thoroughly 
and  effectually  cleansed. 

It  is  a  proceeding  which  any  practitioner  can  do  satis- 
factorily. In  some  cases  it  may  suffice  to  use  the  simple 
intra-uterine  douche  once  or  twice  daily,  and  only  use  the 
peroxide  every  other  day  or  so,  to  loosen  any  degenerating 
tissue.  In  my  experience,  offensive  lochia  rapidly  cease 
under  this  treatment. 

I  frequently  employ  this  soft  curetting  in  dispensary 
gynaecological  practice  where  the  old  way  would  have  re- 
quired an  anaesthetic  and  hospital  care. 

Next  in  importance  to  the  above-described  treatment  is 
keeping  the  lower  bowel  empty  of  faeces,  so  as  to  have  an 
active  vascular  and  lymphatic  pelvic  circulation.  For  an 
antipyretic  I  advocate  the  sponge-bath  with  alcohol ;  quinine, 
partly  as  a  febrifuge,  but  especially  for  its  tonic  effects  ; 
ergot  to  insure  expulsion  of  clots  and  a  rapid  involution  ; 
ice-bags  over  the  uterus,  if  there  are  great  tenderness  and 
inflammation  ;  iodine  externally  if  exudates  are  forming ;  a 


generous  diet,  with  alcoholic  stimulants ;  and  a  puerperium 
prolonged  until  all  danger  has  passed. 

If  it  is  to  be  borne  in  mind  that  there  is  always  a  dam- 
aged surface  at  the  placental  site,  where  the  uterine  mucous 
membrane  has  peeled  off,  exposing  the  lymphatic  canals, 
besides  lacerations  of  the  cervix,  vagina,  and  pudenda ;  if 
infection  was  early  detected,  and  measures  like  those  above 
mentioned  were  adopted  to  destroy  the  dangerous  colonies 
of  germs ;  and  if  the  same  attention  were  to  be  given  to  the 
rational  treatment  of  these  cases  as  to  other  less  severe  sur- 
gical wounds — then  there  could  be  no  reasonable  doubt  that 
thousands  of  women  would  pass  through  a  clean  puerperium 
and  escape  a  train  of  symptoms  which  so  often  causes 
chronic  invalidism  from  pelvic  sources  and  sometimes  death. 


EAKE  FORMS  OF  LARYNGEAL  GROWTHS.* 

By  ALEXANDER  W.  MacCOY,  M.  D., 

PHtLADBLrHIA. 

In  presenting  forms  of  laryngeal  growth  exceedingly 
rare  in  my  experience  as  an  individual  observer,  I  am  not 
unmindful  that  some  may  prefer  to  class  one  of  the  cases 
herein  reported  among  the  frequent  growths  seen  in  the 
larynx.  However,  the  consideration  of  these  two  cases  is 
from  the  standpoint  of  my  observations,  which  may  be 
greatly  afr  variance  with  yours. 

The  first  case  is  a  myxoma  which  came  under  my  care 
in  the  year  1890.  This  is  the  first  and  only  case  of  myx- 
oma of  the  larynx  which  I  have  seen  in  twelve  years'  work 
in  laryngology.  It  has  been  my  fortunate  experience  to 
have  seen  most  of  the  other  rare  tumors  of  the  larynx.  In 
a  very  cursory  investigation  of  the  subject  of  myxoma  of 
the  larynx  I  find  the  statement  "  exceedingly  rare,"  "  very 
rare "  made  by  every  observer  excepting  Fauvel.  In  the 
writings  of  Sir  Morell  Mackenzie  the  statement  is  made 
that  he  had  never  seen  a  primary  case  of  myxoma  of  the 
larynx.  In  Ashhurst's  Surgery,  in  the  article  written  by  Dr. 
J.  Solis-Cohen  on  Tumors  of  the  Larynx,  Dr.  Solis-Cohen 
mentions  only  four  cases  seen  by  him,  one  of  these  multi- 
ple. Since  the  time  the  article  was  written  Dr.  Solis-Cohen 
states  that  he  has  not  seen  another  case  of  the  kind.  The 
annals  of  this  society  contain  a  report  of  a  very  interesting 
and  remarkable  case  of  multiple  myxoma  of  the  larynx  re- 
ported in  1880  by  Dr.  Clinton  Wagner.  This  case  was  re- 
markable in  that  spontaneous  expulsion  of  the  tumors  took 
place  at  varying  intervals,  after  which  a  complete  cure  re- 
sulted. In  Fauvel's  work  on  the  larynx,  in  his  summary  of 
three  hundred  cases,  the  remarkable  showing  is  made  of 
fifty-three  cases  of  myxoma.  Of  these  fifty-three  cases,  I 
find  only  three  microscopic  examinations  of  myxomas.  If 
this  record  is  accepted,  it  is  certainly  remarkable,  but  if 
the  microscopic  test  is  taken,  there  are  but  three  cases,  in 
fact,  which  seems  nearer  the  ratio,  found  by  other  observers 
outside  of  France.  Fauvel  also  makes  the  statement  that 
the  myxomatous  growths  are  next  to  papillomata  in  fre- 
quency, and  remarks  that  the  number  of  myxomas  shown 

*  Read  before  the  American  Larvngological  Association  at  its  foup 
teenth  annual  congress. 


Feb.  4,  1893.] 


MUNSON  AND  OERTEL:  EHRLICH'S    DIAZO  REACTION: 


127 


by  liim  to  foreign  observers  at  one  of  his  seances  was 
greater  than  these  observers  had  witnessed  in  many  months 
ill  their  respective  countries.  The  report  of  my  case  is  as 
follows  : 

Mrs.  Lena  C,  aged  thirty-nine,  four  months  advanced  in 
IH-egnancy,  had  suffered  from  a  defective  voice  for  two  years. 
There  was  difficult  speaking,  which  was  greatly  increased  from 
prolonged  use  of  the  voice  ;  hoarseness  was  marked,  respiration 
jerky.  She  had  a  slight  and  frequent  cough.  No  marked  em- 
barrassment of  respiration  and  no  pain.  General  condition 
good.  Laryngoscopical  examination  revealed  a  tumor  on  the 
right  side  of  the  larynx  as  large  as  a  Lima  bean  and  resembling 
it  in  shape.  The  growth  appeared  to  spring  from  the  ventricle 
of  the  larynx  or  from  the  margin  of  the  orifice  of  the  ventri- 
cles, and  overlapped  the  right  vocal  band,  excepting  a  small  por- 
tion posteriorly,  which  was  only  exposed  during  phonation. 
The  left  vocal  band  was  also  covered  by  the  tumor  during  the 
phonatory  act.  The  growth  was  smooth  in  contour,  flattened 
from  side  to  side,  and  of  a  pale,  pinkish-yellow  color.  The 
capillary  network  of  vessels  covering  the  tumor  was  plainly 
visible  over  the  translucent  mass.  The  macroscopic  appearance 
of  the  formation  was  precisely  similar  to  that  of  a  nasal  myxo- 
ma. The  growth  was  easily  removed  by  a  Mackenzie  crushing 
forceps.  The  attachment  was  seen  to  have  been  around  the 
margin  of  the  laryngeal  ventricular  orifice.  The  voice  imme- 
diately became  normal,  and  all  laryngeal  discomfort  disap- 
peared. The  microscopical  examination  showed  the  tumor  to 
be  a  true  myxoma. 

The  second  case  was  one  of  fibroma,  which  can  not 
properly  be  considered  so  rare  as  a  myxoma,  yet,  in  com- 
parison with  the  frequency  of  papillomata,  must  be  consid- 
ered as  at  least  uncommon.  Eleven  per  cent,  is  given  bj 
Mackenzie  as  the  ratio  of  frequency.  Fauvel  gives  it  as 
five  per  cent.  While  I  can  not  give  the  average  percentage 
of  a  large  number  of  cases,  I  am  inclined  to  believe  that  it 
would  not  be  over  five  per  cent.,  possibly  less.  Individual 
experience  goes  for  little,  and  must  vary  enormously  with 
different  observers,  according  to  the  position  they  hold  in 
relation  to  the  profession  or  the  community  in  which  they 
live.  An  observer  of  great  eminence  as  an  expert  will  see 
many  more  cases  of  rare  and  peculiar  growths  than  will  one 
even  in  large  practice  in  the  natural  course  of  observation 
in  ordinary  lines  of  practice.  But  the  expert's  ratio  of  rare 
cases  of  a  class  would  not  express  the  consensus  of  opinion 
for  the  rest  of  laryngologists.  The  history  of  this  case  of 
fibroma  is  as  follows  : 

Mr.  G.,  aged  forty,  has  salFered  from  tuberculosis  for  about 
four  years.  The  tubercular  manifestations  are  well  marked  in 
the  right  lung — cavity,  induration,  cough,  expectoration,  etc. 
During  the  course  of  the  tubercular  infection  he  had  several 
severe  pulmonary  haemorrhages  and  many  slight  attacks  of 
"  spittiug  blood,''  continuing  up  to  the  present  time.  From  the 
beginning  of  this  history  his  voice  and  respiration  have  been 
altered.  At  the  time  of  examination  there  were  well-marked 
features  of  laryngeal  tuberculo.-is,  pyriforra  swelling  of  the 
arytaanoids,  papillomatous  vegetations  on  the  left  hand  and  over 
the  floor  of  the  larynx.  General  health  remarkably  fair,  con- 
sidering bis  history.  Laryngoscopic  ex amituaion,  made  when  he 
was  first  under  my  care,  showed  a  very  cumpiicateil  nnd  danger- 
ous condition  of  the  larynx.  Tht  subject  was  in  imminent  danger 
of  death  from  sulfocation.  Labored  and  stridulous  inspiration 
were  painfully  well  marked.    Illumination  of  the  larynx  showed 


the  laryngeal  cavity  completely  filled  by  a  large,  pear-shaped 
tumor,  smooth  in  outline,  movable,  and  bright-red  in  color. 
The  tumor  completely  cut  off  all  portions  of  the  larynx  below 
the  ventricular  bands.  The  attachment  appeared  to  be  on  the 
anterior  and  right  surface  of  the  thyreoid  cartilage  and  to  be 
chietiy  beneath  the  anterior  vocal  commissure.  How  respira- 
tion could  be  carried  on  at  all  was  an  interesting  study.  The 
only  free  space  noted  was  a  mere  slit  between  the  lowest  part  of 
the  growth  and  the  floor  of  the  larynx.  This  slit  was  formed 
during  expiration  by  the  expiratory  blast  raising  up  the  growth 
slightly,  and  the  inspiratory  effort  was  partly  accomplished  be- 
fore the  tumor  was  wedged  in  completely.  Durin:jt  phonation 
the  tumor  was  forced  well  upward,  appearing  much  larger  and 
tense,  as  if  suddenly  inflated.  After  phonation  the  growth 
quickly  receded  and  rested  on  the  ventricular  bands  and  floor 
of  the  larynx.  The  demand  for  relief  was  urgent.  After 
weighing  well  the  risks  with  and  without  a  tracheotomy,  I  de- 
cided to  remove  the  growth  without  a  prior  tracheotomy,  and 
to  do  it  at  once.  Various  strong  forceps  were  tried,  but  none 
of  them  would  hold  or  sustain  the  leverage  necessary.  I  then 
encircled  the  growth  with  a  cold  steel  wire  in  a  Sajous  curved 
snare,  and,  after  great  risk,  removed  a  large  portion  of  the  mass, 
which  was  very  dense  and  tough.  Immediate  respiratory  relief 
followed,  and  all  dangerous  sytnptoms  were  modified.  The  re- 
maining portion  of  the  tumor  will  be  removed  by  the  galvano- 
cautery  snare.  The  case  is  under  observation.  The  structure 
of  the  growth  showed  interlacing  bundles  of  dense  fibrous  tis- 
sue, the  outer  layers  composed  of  thickened  layers  of  mucous 
membrane. 


THE  CAUSE  OF 

EHRLICH'S  "DIAZO  EEACTION," 

WITH  A  DISCUSSION  OF 
ITS  DIAGNOSTIC  AND  CLINICAL  SIGNIFICANCE. 

By  E.  L.  MUNSON,  B.  A.,  M.  D.,  and  HORST  OERTEL, 

NEW  HAVEN  HOSriTAL,  NEW  HAVEN,  CONN. 

Ehrlich's  diazo  reaction,  originally  introduced  by  him 
as  pathognomonic  of  typhoid  fever,  has  recently  been  the 
subject  of  so  much  investigation  that  the  discovery  of  the 
setiological  factor  by  the  writers  will  be  of  general  interest, 
especially  as  bearing  on  the  clinical  and  diagnostic  impor- 
tance of  this  reaction.  This  test,  as  commonly  practiced, 
consists  in  adding  1  c.  c.  of  a  five-per-cent.  aqueous  solu- 
tion of  potassium  nitrite  to  25  c.  c.  of  a  solution  composed 
of  sulphanilic  acid,  3  grm. ;  concentrated  hydrochloric  acid, 
25  c.  c. ;  and  water  up  to  500  c.  c.  To  this  25  c.  c.  of  urine 
are  now  added,  and  the  whole  inade  strongly  alkaline  with 
strong  ammonia.  Normal  urine  yields  a  pale  orange-red 
color  on  the  addition  of  the  ammonia,  while  certain  patho- 
logical urines  give  the  deep  violet  red  color  character- 
istic of  this  reaction.  During  the  past  year,  while  engaged 
in  experimental  work  upon  the  various  abnormal  constitu- 
ents of  diabetic  urine,  it  was  noticed  that  a  urine  which 
was  known  to  contain  large  quantities  of  aceto  acetic  acid, 
and  which  struck  a  Bordeaux- red  with  a  solution  of  ferric 
chloride  (Gerhardt's  test),  also  gave  a  most  marked  diazo 
reaction,  those  two  reactions  always  running  parallel  in 
their  intensity. 

This  fact  strongly  suggested  the  possibility  of  some 
connection  between  the  diazo  reaction  and  one  or  perhaps 
all  of  the  abnormal  metabolic  products  eo  often  found  in 


MUITSON  AND  OERTEL:   EHRLICH'S     DIAZO  REACTION. 


(N.  Y.  Med.  Jock., 


diabetes  and  the  diazo  reaction.  The  bodies  which,  accord- 
ing to  personal  ob.servation,  could  come  into  (juestion  were 
aceto-acetic  acid,  ieta-hydroxy butyric  acid,  and  acetone — 
other  investigators,  however,  claiming  to  have  observed  the 
occurrence  of  a//>Aa-crotonic  acid  and  ethyl  aceto-acetate. 
These  bodies  were  all  synthetically  prepared  and  studied 
with  reference  to  the  two  reactions.  The  results  were  as 
follows : 


Substance. 

Diazo  reaction. 

Ferric-chloride 
test. 

Negative. 
Positive. 
Negative. 

t( 

Negative. 

Positive. 

Negative. 

Positive. 

It  is  seen  from  the  above  table  that,  while  both  ethyl 
aceto-acetate  and  aceto-acetic  acid  give  the  reaction  with 
ferric  chloride,  only  aceto-acetic  acid  gives  the  diazo  reac- 
tion. It  was  further  observed  that  prolonged  boiling  en- 
tirely destroys  the  reaction  given  by  the  addition  of  ferric 
chloride  to  aceto-acetic  acid,  while  the  same  treatment  to 
the  reaction  given  by  ethyl  aceto-acetate  does  not  in  the 
least  affect  it.  The  physical  and  chemical  properties  of 
aceto-acetic  acid  were  now  studied. 

It  was  found  to  be  an  odorless,  colorless,  tasteless,  and 
uncrystallizable  body  having  the  composition  CIIj  -  CO - 
CII2  -  COOH.  It  is  fairly  soluble  in  sulphuric  ether,  less 
so  in  acetic  and  benzol  ethers,  and  but  slightly  soluble  in 
chloroform.  It  is  readily  soluble  in  strong  alcohol  and  in 
water.  It  is  fairly  stable  in  ethereal  solution  as  a  free 
acid,  and  very  stable  in  an  aqueous  solution  of  the  barium 
salt,  at  variance  with  the  observations  of  Jaksch.*  It  de- 
composes under  100°  C.  in  the  formation  of  acetone  and  car- 
bon dioxide. 

CH3 

1  CH, 
CO  I 

I       =    CO  +  CO., 
CIL,  I 

I  -  CH3 
COOH 

It  responds  to  the  diazo  reaction  of  Ilhrlich  and  strikes 
a  Bordeaux-red  with  neutral  ferric  chloride  or  ferric  sul- 
phate in  the  cold,  these  reactions  permanently  disappearing 
on  boiling  for  five  minutes  or  on  adding  a  large  excess  of  a 
mineral  acid  and  then  again  carefully  neutralizing.  It 
yields  a  precipitate  of  iodoform  on  treating  with  the  tinc- 
ture of  iodine  and  ammonium  hydrate,  and  also  on  the  ad- 
dition of  iodine  in  potassium-iodide  solution  with  sodium 
hydrate.  It  can  be  readily  extracted  from  an  aqueous  so- 
lution by  slightly  acidifying  with  a  mineral  acid  and  shak- 
ing with  ether.  If  a  little  of  this  ethereal  extract  be 
evaporated  to  dryness  on  a  porcelain  dish  and  the  residue 
be  touched  with  a  drop  of  ferric-chloride  solution,  a  purplish 
red  color  is  produced.    On  distillation  it  yields  acetone. 

With  this  knowledge  of  the  properties  of  aceto-acetic 
acid,  the  attempt  was  made  to  show  that  the  diazo  and 
ferric-chloride  reactions  always  occurred  simultaneously  in 
a  urine,  that  both  reactions  always  ran  parallel  in  their 
intensity,   and   that   the  substance  in  the  urine  which 


*  lUbcr  Acetomirie  und  Liacduric.    Berlin,  1885. 


yielded  these  reactions  was  in  all  respects  identical  with 
aceto-acetic  acid.  To  this  end,  six  cases  representing 
widely  diverse  diseases,  whose  urines  gave  diazo  reactions 
of  varying  intensity,  were  carefully  examined.  The  clinical 
histories  of  these  cases  are  as  follows: 

1.  Diuhetes  Mellitus. — Patient,  thirty-two  years  of  age, 
had  diabetes  for  about  a  year,  and  was  under  treatment  about 
eight  months.  He  received  no  medicines  except  cathartics,  the 
treatment  consisting  exclusively  of  a  rigid  anti  carbohydratic 
diet.  His  urine  contained  large  quantities  of  aceto-acetic  acid, 
and  gave  intense  ferric-chloride  and  diazo  reactions.  There 
was  also  an  extraordinary  excretion  of  ammonia.  Patient  was 
subject  to  constant  frontal  iieadaches,  loss  of  memory,  vertigo, 
and  insomnia.  A  sudden  attack  of  pneumonia  finally  ensued 
and  proved  fatal  in  less  than  twenty-four  hours.  Had  never 
any  tcmi>eratnro  except  after  the  advent  of  tlie  pneumonia — in 
fact,  tlie  thermometer  generally  registered  a  degree  or  so  sub- 
normal. 

2.  Conmlescence  after  Eclanpna. — Patient  primipara,  twen- 
ty-one years  old.  Labor  perfectly  normal  and  of  short  dura- 
tion. Six  honrs  after  delivery  the  patient  complained  of  vio- 
lent headache,  nausea,  and  dizziness.  This  was  followed  by 
a  series  of  clonic  spasms  intermittent  over  a  period  of  eighteen 
hours.  The  urine  contained  a  large  amount  of  albumin,  hya- 
line and  granular  casts,  with  acetone  and  hydroxybutyric  acid 
in  small  quantities.  During  the  attacks  no  diazo  reaction  could 
be  obtained.  The  temperature  rose  temporarily  on  the  third 
day  to  its  maximum — 101°  F.  On  the  ninth  day  after  delivery, 
with  a  perfectly  normal  temi)erature,  an  intense  diazo  reaction 
was  observed  and  continued  for  six  days.  No  oxybutyric  acid 
was  present  during  this  period.  Drugs  employed  were  pilo- 
carpine and  citrate  of  caffeine.    Patient  made  a  good  recovery. 

3.  Typhoid  Ferer. — Patient  a  girl  of  eighteen  years.  No 
medication  except  quinine,  digitalis,  and  aromatic  spirits  of  am- 
monia in  tonic  doses.  The  hydrostatic  ice-coil  was  employed  as 
the  antipyretic.  Temperature  was  persistently  high  and  con- 
trolled with  difficulty.  During  the  second  week  of  the  disease, 
with  a  temperature  of  104"2°,  a  strong  diazo  reaction  appeared 
and  persisted  some  days,  although  during  that  time  the  tempera- 
ture fell  to  101°.  Patient's  pulse  was  weak  and  rapid.  Patient 
made  a  good  recovery. 

4.  Traumatic  Fever. — Patient,  a  man  of  thirty-five  years,  had 
a  dermoid  cyst  of  the  abdomen  for  v\  hicb  a  double  laparotomy 
was  ])erformed.  On  the  third  day  after  the  operation,  with  a 
teniperature  of  10r4°,  a  diazo  reiM;tion  could  be  obtained  from 
the  urine  and  persisted  for  tive  days.  Pulse  100  and  weak.  Pa- 
tient complained  of  vertigo  and  lieadache.  No  drugs  were  em- 
ployed. Patient  died  from  exhaustion  tive  weeks  after  the 
operation. 

5.  Chronic  Phthisis. — Patient,  a  man  of  twenty-seven  years, 
has  had  a  cough  for  about  a  year  and  lost  weight  rapi<lly.  A 
jdiysical  examination  showed  a  large  cavity  in  the  upi)er  lobe  of 
the  left  lung.  Patient  had  a  temperatui-e  of  101°.  The  diazo  re- 
action wa>'  not  constant.  Patient  had  no  cerebral  symptoms 
whatever. 

6.  Undingnosticated  ( Cerchral  Soften in<i — Sj/ph  ilitic  f). — Pa- 
tient,  a  num  of  thirty-four  years,  has  been  in  hospital  for  nine 
weeks.  A  physical  examination  shows  nothing  abnormal. 
Pulse  slow  and  weak,  54  ;  temperature  always  subnormal,  at 
times  9ti'4° ;  respirations  irregular  and  variable.  The  patient 
appears  very  weak  and  lies  in  a  semi-comatose  condition  from 
which  ho  is  with  difficulty  aroused.  The  urine  contains  large 
quantities  of  ammonia,  and  at  times  gives  a  marked  diazo  reac- 
tion. It  also  intermittently  contains  small  amounts  of  oxybutyric 
acid. 


Feb.  4,  1893. J 


MUNSON  AND  OERTEL :  EHRLICWS    DIAZO  REACTION:' 


129 


The  urines  of  the  above-given  cases  were  now  carefully  compared  with  an  aqueous  solution  of  the  barium  salt  of 
aceto-acetic  acid,  with  the  following  results  : 


Ferric-chloride 
reaction. 

Diazo. 

Reactions  disap- 
pear on  boiling 
or  strongly 
acidifying. 

Iodoform 

tCBtS. 

Acetone  in 
distillate 

Extract 
with  ether. 

Ethereal  ex- 
tract gives 
ferric-cTiloride 

Positive. 

Positive. 

Positive. 
(1 

u 
u 

Positive. 

Li 

Positive, 
tt 
a 

Positive. 
It 

(I 

u 

Positive, 
(t 

ti 

<( 

From  the  above-given  cases,  which  responded  in 
every  particular  to  the  tests  for  aceto-acetic  acid,  the 
writers  feel  justified  in  announcing  that  this  body  is 
the  setiological  factor  in  the  production  of  the  diazo  re- 
action in  pathological  urines.  This  acid  probably  occurs, 
in  the  majority  of  instances,  in  combination  with  am- 
monia. 

With  regard  to  the  diagnostic  and  clinical  significance 
of  this  reaction  it  is  evident  that  it  must  be  identical  with 
that  of  the  ferric-chloride  test.  The  following  table  is  elabo- 
rated from  a  series  of  experiments  made  by  Edwards  *  upon 
the  occurrence  of  the  diazo  reaction,  and  illustrates  in  what 
extremely  diverse  processes  aceto-acetic  acid  may  be  pro- 
duced : 


Disease. 


Dl.«EASE. 


Typhoid  fever  

Enteritis:  febricula  

Malaria  

Tuberculosis  

Rheuniatisru  

Nephritis  

Diabetes  mellitus  

Carcinoma  

Syphilis  

Cardiac  lesions  

Lung  (except  tuberculosis) . . 

Plumbism  

Cerebral  ha-morrhage  

Septicirmia  

Chronic  arthritis  

Cirrhosis  of  liver  

Jaundice  (simplex)  

Acute  intestinal  obstruction  . 

Intussusception  

Abscess  of  liver  

Neuritis  

Alcoholic  gastritis  

Purpura  hiemorrhagica. ... 


No.  of 

Reaction 

Reaction 

cases. 

present. 

absent. 

130 

122 

8 

19 

6 

13 

5 

3 

2 

32 

27 

5 

10 

3 

7 

18 

11 

7 

'2 

2 

4 

3 

i 

5 

.  2 

3 

8 

6 

2 

8 

5 

3 

4 

1 

3 

3 

2 

1 

3 

3 

2 

i 

3 

2 

1 

1 

1 

i  , 

1 

1 

i  \ 

1 

1 

Pneumonia  

Pleuritis  

Measles  

Scarlatina  

Erysipelas  

Diphtheria  

Various  suppurative  diseases . 

Typhoid  fever  

Pulmonary  tuberculosis  , 

Tubercular  meningitis  

Pertus.si-i  

Rhachitis  

Chlorosis  

Perityphlitis  

Parotiditis  

Mitral  disease  

Extensive  bum  

Acute  nephritis  

Osteosarcoma  


No.  of 
cases. 


Brouet  f  has  examined  the  urines  of  one  hundred  and 
fifty  children  relative  to  the  reaction  produced  on  the  addi- 
tion of  ferric  chloride,  and  found  that  this  test  could  be  ob- 
tained in  sixty-three  cases. 

Of  these  sixty-three  cases  in  which  a  reaction  could  be 
obtained,  only  three  were  entirely  apyretic.  Brouet  believes 
that  the  ferric-chloride  reaction  is  common  in  childhood, 
does  not  occur  uniformly  in  all  febrile  conditions,  and 
bears  no  relation  in  its  intensity  to  the  intensity  of  the 
pyrexia. 


23 

6 
2f. 
34 
4 
31 
13 
4 
6 
4 
6 
2 
2 
1 
1 
1 
1 
15 
1 


Reaction 
present. 


10 

10 
27 
4 
11 
2 
2 


Reaction 
absent. 


13 

6 
10 

7 

20 

11 
2 
6 
2 
6 
2 
2 

1 
1 

15 


Von  Jaksch  *  finds  the  ferric- chloride  reaction  given  in 
the  following  cases  : 


Disease. 

No.  of 
cases. 

Reaction 
present. 

Reaction 
absent. 

8 

6 

2 

6 

2 

4 

40 

39 

3.T 

33 

1 

Miliarv  tuberculosis  

1 

1 

*  Medical  News,  April  2,  1892. 
\  Romie  medicale  de  la  Suisse  romarule. 
1890. 


Geneva,  September  2( 


Seifert  f  obtained  the  same  reaction  from  the  urine  in 
pericarditis,  in  nine  out  of  fifteen  cases  of  typhoid  fever, 
and  in  twelve  out  of  forty  cases  of  pneumonia.  He  also 
observed  it  in  rotheln,  perityphlitis,  acute  miliarv  tubercu- 
losis, and  phthisis  pulmonalis. 

Tnve.stigations  by  the  writers  as  to  the  occurrence  of  the 
diazo  reaction  have  resulted  as  shown  in  the  following  table. 

From  these  observations,  therefore,  it  would  seem  well 
established  that  the  presence  of  aceto-acetic  acid — as 
determined  by  either  the  ferric  chloride  or  diazo  reactions 
— is  not  associated  with  any  particular  affection,  and,  al- 
though observers  are  not  as  yet  agreed  on  the  question  of 
its  being  an  almost  constant  concomitant  of  typhoid  fever, 
its  very  frequent  occurrence  in  the  urines  of  various  pro- 
cesses would  tend  to  neutralize  anj'  diagnostic  value  which 
it  might  otherwise  possess.    We  are  justified  in  denying 

*  Von  Jaksch.     Ucber  Aceionurie  und  Diaceturie.    Berlin,  1885. 
+  Ueber  Acetonurie.    Verhandhtngcn  d.  physikalisfh-vifd.  GtselLirh. 
in  Wurzburg,  V.  F.  xvii,  Bd.  4. 


130 


THORP:  DIVISION  OF 


THE  TEN  DO  A  CHILLIS. 


[N.  Y.  Med.  Jock., 


Disease. 

No.  of 
cases. 

Hcuction 
present. 

Kcdction 
absent. 

1  o 

i 

PUGUITIOIIKI 

\ 

1 

q 

rj 

(1 

£i 

1 
i 

1 
1 

1 
1 

CcrGlirn,!  softciiiii^j  sypliilitic .... 

A 

o 

L 

1 
1 

1 

i) 

1 

1 

1 
1 

1 

o 

Pleiiriti'^ 

2 

1 

3 

1 

2 

1 

1 

5 

3 

2 

1 

1 

1 

1 

that  the  occurrence  of  aceto-acetic  acid  is  of  greater  diag- 
nostic importance  than  the  excess  of  phosphates  or  the  trace 
of  albumin  with  which  it  is  so  frequently  observed. 

As  to  its  clinical  significance.  Aceto-acetic  acid  is  not 
essentially  a  fever  product.  The  original  idea  that  the  diazo 
reaction  was  a  result  of  high  temperature  is  wrong.  Aceto- 
acetic  acid  in  its  production  bears  no  relation  to  the  tem- 
perature, and  it  is  even  produced  in  the  greatest  quantities 
in  diabetes — a  disease  in  which  the  temperature  is,  if  any- 
thing, subnormal.  It  is  rather  to  be  considered  as  a  prod- 
uct of  incomplete  oxidation  than  of  excessive  catabolism, 
but  upon  what  conditions  this  incomplete  oxidation  depends 
is  as  yet  unexplained.  With  regard  to  the  prognosis  it  will 
be  observed  that  aceto-acetic  acid,  as  a  rule,  is  present  only 
in  the  urines  of  grave  affections.  It  is  in  itself  of  but  in- 
significant importance  in  the  quantities  in  which  it  is  gen- 
erally present  in  fever  urines,  and  it  is  only  when  present 
in  the  extraordinary  quantities  found  in  certain  cases  of  dia- 
betes that  it  becomes  a  factor  of  pathological  importance, 
acting  not  through  any  toxic  properties  in  itself,  but  merely 
by  virtue  of  its  acidity — i.  e.,  its  affinity  for  alkalies,  by 
which  the  sodium  and  potassium  compounds  of  the  body 
are  attacked.  To  an  excessive  blood  acidity  are  without 
doubt  to  be  ascribed  the  cerebral  disturbances  and  neuroses 
of  diabetes  and  possibly  a  few  other  affections  in  which  it 
may  occur  in  quantity,  and  a  recent  treatment  of  diabetic 
coma  by  the  intravenous  injection  of  strong  alkaline  solu- 
tions *  is  based  upon  this  idea  of  an  "  acid  intoxication." 


DIVISION  OF  THE  TENDO  ACHILLIS : 

tsjvorshapiiy. 
By  henry  thorp,  M.  D. 

The  rarity  of  this  accident,  together  with  the  ease  with 
which  an  otherwise  serious  condition  can  be  relieved  and 
an  excellent  result  obtained,  warrant  this  report. 

On  January  9th  M.  G.  was  brought  into  St.  Luke's  Hospital 
from  liis  chib  with  the  history  of  having  been  struck  above  the 
right  lieel  hy  a  piece  of  glass  from  a  burst  soda-water  bottle. 
The  glass  had  cut  through  trousers  and  shoe  and  caused  some 
bleeding,  but  he  did  not  realize  the  injury  until  attempting  mo- 
tion.   He  was  seen  by  a  physician,  who  fastened  the  knee  in 

*  Minkowski.    Deulnch.  med.  Wochenschr.,  May  11,  1889. 


position  of  flexion  and  ankle  in  extension  and  ordered  him  to 
hospital.  Examination  revealed  a  transverse  incised  wound 
two  inches  and  a  half  above  the  heel  and  about  two  inches  in 
length.  Depth  not  ascertained,  it  not  being  thought  advisable 
to  probe.  There  was  a  break  in  tendon  outline  at  point  of  in- 
cision and  the  upper  fragment  could  not  be  felt. 

Temporary  dressing  applied  and  ])atient  ordered  to  operat- 
ing room,  where,  by  the  kind  permis'sion  of  Dr.  Curtis,  to 
wliose  service  the  case  came,  I  operated,  making  an  incision 
upward,  when  a  short  dissection  showed  the  retracted  fragment, 
which  was  dragged  down.  The  tendon  was  sutured  with  one 
heavy  silk  suture  passed  twice  through  each  fragment  about  a 
quarter  of  an  inch  from  divided  edge  and  actmg  as  a  "  retention 
suture,"  and  tlie  edges  approximated  by  several  fine  interrupted 
silk  sutures.  External  wound  closed  and  dressing  with  plaster 
from  toes  to  thigh  applied  to  maintain  position.  Patient  remained 
in  bod  until  January  30th,  when  first  dressing  done ;  primary 
union  throughout.  Power  at  ankle  present.  Starch  bandage 
now  a[)plied  and  [)atient  allowed  crutches,  but  forbidden  to  use 
foot.  On  February  10th  all  dressings  were  removed  and  patient 
allowed  to  walk.    Power  and  motion  perfect. 

Four  months  later,  except  for  the  minute  scar,  it  was  ira- 
poBsible  to  say  which  Itg  had  been  injured. 

41  West  Eighty-second  Street. 


ALOPECIA  PRJ5MATURA: 

ITS  MOST  FREQUENT  CAUSE  ECZEMA  SEBORRHOICUM* 
By  GEORGE  T.  ELLIOT,  M.  D., 

VI8ITINQ  DKRMATOI.OOrST  TO  THK  DEMILT  DISPENSABT  AND 
THE  NEW  TOBK  INFANT  ABTLUM  ; 
ASSISTANT  VI3ITINO  DERMATOLOGIST,  NEW  YORK  SKIN  AND  CANCER  nOSPITAL  ; 
LECTURER  ON  SKIN  DISEASES. 
NEW  YORK  POST-GRADUATE  MEDICAL  SCHOOL,  ETC. 

To  judge  by  my  experience,  the  subject  of  alopecia 
praematura,  or  falling  of  the  hair  in  early  life,  notwithstand- 
ing its  great  importance  and  interest,  receives  little  or  no 
attention  from  physicians  in  general.  The  condition  is  re- 
garded by  them  as  irremediable ;  the  sufferers  are  allowed 
to  lose  their  hair  gradually  and  surely,  or  they  are  relegated 
to  the  extremely  dubious  care  of  hair-dressers,  artists,  or 
whatever  they  wish  to  call  themselves,  who,  alike  ignorant 
of  what  a  skin  or  a  hair  really  is,  of  the  laws  governing  the 
health  of  each,  and  of  the  diseases  which  may  affect  both, 
only  succeed  in  accelerating  the  alopecia  and  in  intensify- 
ing the  already  existing  pathological  state.  Without  doubt, 
the  inattention  paid  to  the  subject  is  due  to  the  fact  that 
alopecia  is  generally  regarded  as  the  outcome  of  some  un- 
known cause  ;  it  is  not  appreciated  that  many  conditions 
favor  or  predispose  to  its  development ;  it  is  not  understood 
that  not  one,  but  a  large  number  of  causes  and  diseases,  dif- 
fering widely  from  each  other,  may  be  its  active  producers ; 
and  in  evidence  of  this  I  would  preface  the  results  of  my  own 
observations  and  studies  by  a  brief  resume  of  the  various 
causes,  etc.,  to  which  it  may  owe  its  origin  and  existence. 

Congenital  and  senile  alopecia  require  only  mention,  the 
former  being  rare  and  due  to  a  scanty  supply  or  to  an  en- 
tire absence  of  hair  bulbs ;  the  latter  being  only  a  part  of 
the  general  atrophy  of  the  skin  occurring  with  advancing 


*  Read  before  the  American  Dermatological  Association,  at  New 
London,  September,  1892. 


Feb.  4,  1893.] 


ELLIOT:  ALOPECIA  PREMATURA. 


131 


age,  and  representing  what  has  been  so  aptly  termed  by  Dr. 
Holmes  "  retrogressive  evolution." 

Alopecia  pnematura,  however,  which  develops  irrespect- 
ive of  age,  is  of  especial  importance,  as  it  constitutes  the 
bulk  of  cases  in  regard  to  which  advice  is  sought.  It  may 
be  idiopathic  in  origin,  no  local  or  general  cause  being  dis- 
coverable, but  there  is  observed  only  an  excess  in  loss 
over  the  regeneration  of  the  hair ;  or  it  may  be  in  some  in- 
stances hereditary ;  again,  the  alopecia  may  depend  upon 
some  morbid  state  of  the  general  system,  constitutional  or 
hygienic,  and  in  the  great  majority  of  cases  upon  some 
purely  local  cause.  As  is  well  known,  alopecia  occurs  in 
an  acute  form  in  the  course  of  or  during  the  convalescence 
after  the  eruptive  fevers — scarlatina,  measles,  variola, 
typhoid — or  it  develops  during  pregnancy  or  after  its  ter- 
mination ;  or  again  it  is  the  result  of  the  reception  of  vio- 
lent nervous  shocks,  or  it  follows  upon  intense  prolonged 
anxiety. 

On  the  other  hand,  the  process  occurs  in  a  more  chronic 
form  owing  to  bad  hygiene  and  injurious  procedures,  or  it 
may  arise  from  debility,  excesses  of  various  kinds,  cares, 
anxieties,  intellectual  work,  etc.  Neuralgic  headaches  appear 
to  exert  also  a  considerable  influence,  according  to  my  ob- 
servations, the  alopecia  frequently  occurring  in  an  acute 
manner  over  the  distribution  of  the  nerve  or  nerves  which 
had  been  the  seat  of  the  pain.  After  such  an  attack  the 
hair  is  usually  regenerated ;  but  if  the  neuralgia  is  of  long 
continuance  or  its  attacks  are  repeated  and  at  short  inter- 
vals, then  the  hair  becomes  more  and  more  thinned  and  a 
large  portion  is  permanently  lost.  I  have  never,  however, 
seen  complete  baldness  result  from  this  cause,  but  in  a  few 
cases  of  long  duration  there  were  areas  on  the  scalp,  situ- 
ated over  a  nerve  branch,  perhaps  half  an  inch  to  an 
inch  in  length  and  a  quarter  to  half  an  inch  broad,  en- 
tirely denuded  of  hair  and  presenting  also  complete  atro- 
phy of  the  skin. 

Alopecia  prsematura  may  also  develop  in  the  course  of 
chronic  intoxications,  such  as  diabetes,  leprosy,  syphilis, 
cancer,  etc.  There  is  not  the  slightest  doubt  but  that  these 
conditions  do  produce  alopecia,  yet,  in  my  opinion,  it  is  a 
matter  open  to  question  whether  they  act  alivays  and  in 
every  case  per  se  and  are  the  sole  and  unique  cause  of  the 
hair  loss,  or  whether  their  role  is  not  frequently  that  of 
favoring  and  predisposing  to  the  development  of  one  or 
another  of  the  local  processes  or  diseases  which  directly 
influence  the  growth  and  health  of  the  hair.  In  other 
words,  patients  may  suffer  from  alopecia  as  the  direct  out- 
come of  these  intoxications,  but  they  may  also  present  the 
same  condition  as  the  result  of  causes  totally  distinct  from 
these  systemic  diseases,  and  I  am  led  to  make  the  state- 
ment owing  to  the  fact  that  I  have  so  frequently  found  local 
disturbances  directly  causative  of  alopecia  present  upon  the 
scalps  of  patients  affected  with  the  general  processes  men- 
tioned. 

The  local  diseases  which  produce  alopecia  are  of  various 
kinds.    Brocq  has  very  happily  and  aptly  put  it  in  stating 
•  that  in  some  the  alopecia  is  only  an  accessory  feature, 
while  in  others  it  constitutes  the  major  symptom.  Among 
the  former  there  may  be  mentioned  such  diseases  as  eczema. 


psoriasis,  dermatitis  exfoliativa,  various  inflammatory,  atro- 
phic, and  ulcerative  processes,  etc.,  while  among  the  latter 
pityriasis  capitis,  so-called  seborrhoea  sicca,  various  condi- 
tions termed  seborrhoea,  keratosis  pilaris,  alopecia  areata, 
tinea  tonsurans,  favus,  etc. 

Allow  me  to  turn  now  to  my  own  personal  observations 
and  study  of  the  subject,  which  may  perhaps  be  of  some 
interest,  as  they  cover  a  period  of  a  number  of  years  and  a 
large  number  of  cases.  There  were  several  questions  sug- 
gested by  these  latter,  and  for  their  elucidation  an  analysis 
of  a  certain  number  has  been  undertaken. 

The  questions  were : 

1.  Whether  in  the  production  of  alopecia  prematura 
local  causes  or  constitutional  and  systemic  influences  and 
factors  were  the  most  frequent  in  operation. 

2.  What  form  of  local  disease  was  most  usually  pro- 
ductive of  the  loss  of  the  hair. 

3.  General  considerations  and  facts  derived  from  and 
suggested  by  my  own  observations. 

The  material  which  I  would  make  use  of  in  this  paper 
I  would  limit  to  those  cases  which  I  have  treated  dur- 
ing the  last  two  years  and  a  half  that  I  have  paid  espe- 
cial attention  to  the  subject.  The  total  number  seen  dur- 
ing that  period  was  512.  Of  these,  234  were  in  private 
practice,  the  remainder  in  my  various  hospital  services. 
My  analysis  and  further  remarks  will,  however,  have  refer- 
ence entirely  to  the  former — the  234 — for  the  reason  that 
from  private  patients  more  accurate  histories  were  ob- 
tainable and  a  more  satisfactory  investigation  and  super- 
vision of  each  was  possible.  From  the  234  there  have  been 
excluded  as  not  germane  to  the  subject  all  instances  of 
tinea  and  favus,  as  well  as  those  alopecias  due  to  atrophic 
or  ulcerative  processes  of  one  kind  and  another. 

Of  the  total  number,  111  were  males  and  123  females. 
The  origin  and  causation  of  the  process  was  found  to  be 
due  to  the  following  factors  : 

Alopecia  areata  (males,  7  ;  females,  1)   8 

Congestion  of  the  brain  (female,  1)   1 

Excessive  intellectual  work  (males,  4)   4 

Syphilis  (males,  2)   2 

Frequent,  severe,  and  prolonged  headaches 

and  neuralgias  (females,  3)   3 

Anaimia,  neurasthenia,  and  debility  (males, 

2  ;  females,  1)   ^ 

Scarlatina,   typhoid    fever   (males,   2 ;  fe- 
males, 2)   ^ 

Idiopathic,  without  apparent  cause  (male,  1  ; 

female,  1)   2 

Alopecia  from  purely  local  processes  (males, 
93;  females,  114)   207 

Total   234 

The  analysis  of  my  cases  thus  shows  that  2,  or  0-85  per 
cent.,  occurred  without  apparent  cause;  25,  or  10-68  per 
cent.,  were  due  to  general  systemic  and  constitutional  con- 
ditions, etc. ;  while  207,  or  88-46  per  cent.,  were  the  result 
of  purely  local  processes  and  disturbances  on  the  scalp. 
According  to  my  own  experience,  therefore,  it  is  those  latter 
I  that  predominate  by  an  immense  majority  in  the  produc- 


132 


ELLIOT:  ALOPECIA  PREMATURA. 


[N.  Y.  Med.  .lonit., 


tion  of  alopecia  prsematura,  while  the  effect  of  the  systemic 
factors  constitutes  a  very  small  proportion  of  the  whole.  It 
appears  to  me,  therefore,  unnecessary  to  discuss  in  detail 
this  minority,  but  rather  to  put  it  aside  and  to  particularly 
consider  the  majority,  as  it  represents  thosp  cases  seeking 
aid ;  it  constitutes  a  class  easily  recognized  and  one  suscep- 
tible of  either  great  improvement  or  of  entire  cure  when 
subjected  to  proper  treatment. 

The  nature  of  the  local  disease  productive  of  the  alo- 
pecia in  every  one  of  my  207  cases  was  some  grade  of  what 
has  lately  come  to  be  designated,  whether  rightly  or  wrong- 
ly does  not  concern  us  here,  eczema  seborrhoicura.  That 
is,  the  clinical  symptoms  were  such  as  were  and  are  still 
known  as  pityriasis  capitis,  alopecia  pityrodes,  seborrhoea 
sicca,  or,  progression  to  a  higher  grade  having  occurred, 
there  were  associated  with  the  phenomena  mentioned  more 
or  less  extensive  areas  and  circumscribed  patclies  of  red- 
ness covered  with  squamfe,  or  crusted,  or  presenting  more 
or  less  evidences  of  weeping.  It  is  unnecessary  to  describe 
in  detail  the  symptomatic  appearances  of  the  phases  of  dis- 
ease mentioned,  they  are  so  well  known,  and  I  have,  more- 
over, already  delineated  them  in  a  previous  article  * ;  but  I 
would  state  that  the  majority  of  the  cases  presented  only 
the  symptoms  belonging  to  alopecia  pityrodes,  while  a 
large  number  would  be  described  as  seborrhoea  sicca.  In 
some  the  incrustation  over  the  scalp  was  yellow,  soft,  and 
greasy  from  the  admixture  of  fat ;  in  others  there  was  a 
complicating  seborrhoea  oleosa.  Besides  these  symptoms 
there  were  also,  in  many  cases,  patches  of  redness  of  vari- 
ous size,  circumscribed,  sharply  defined,  not  elevated, 
which  were  glistening,  or  scaly,  or  crusting,  or  showing  a 
few  points  of  weeping,  or  diffusely  moist.  Subjectively, 
itching  was  frequently  complained  of,  it  being,  however, 
moderate,  coming  on  when  the  patient  was  heated ;  occa- 
sionally it  was  severe  and  distressing.  Nothing  particular 
was  observed  in  connection  with  the  hair  itself  except  that, 
when  there  was  not  a  complicating  seborrhoea  oleosa,  it  was 
dry,  lusterless,  and  in  women,  especially,  split  at  the  ends, 
brittle,  and  easily  broken.  There  was  also  a  tendency  for 
them  to  become  gray  and  even  white. 

The  large  majority  of  these  cases  presented,  in  addition 
to  the  scalp  symptoms,  manifestations  of  the  disease  upon 
some  other  portion  of  the  body — face,  ears,  etc.  They  had 
disregarded  the  scalp  trouble,  they  had  considered  it  as  a 
natural  condition,  they  had  never  associated  the  alopecia 
with  it,  but  looked  upon  the  loss  of  hair  as  an  unfortunate 
but  irremediable  circumstance,  and  it  was  only  this  exten- 
sion of  the  process  to  the  face  which  finally  compelled  them 
to  seek  advice.  Were  it  not  that  the  disease  remains  local- 
ized entirely  upon  the  scalp  in  only  a  small  proportion  of 
the  cases,  there  is  no  question  but  that,  owing  to  the  beliefs 
prevalent  among  the  laity,  a  very  much  smaller  number  of 
instances  of  alopecia  would  have  come  under  my  notice,  but, 
the  opposite  being  the  case,  patients  were  continually  seen 
who  were  losing  their  hair  rapidly,  yet  were  concerned  only 
about  their  faces,  and  as  long  as  the  symptoms  on  these  sur- 
faces were  removed  they  accepted  with  entire  resignation 


*  N.  Y.  Med.  Jonr.,  18!) I. 


advancing  baldness.  The  duration  of  the  disease  upon  the 
scalp  before  the  inception  of  the  alopecia  was  variable.  In 
some  the  local  process  was  acute  in  character,  the  loss  of 
hair  beginning  a  few  weeks  later  ;  in  the  majority  it  began 
in  from  one  to  two  years  after  the  development  of  the  local 
disease,  but  in  some  this  latter  had  existed  five,  ten,  and  even 
more  years  before  causing  any  distinct  or  marked  alopecia. 

Making  an  analysis  of  the  20Y  cases  according  to  sex,  it 
was  found  that  there  were  114  females  and  93  males.  The 
generally  accepted  belief  is  that  men  are  more  subject  to 
alopecia  prsematura  than  women  are,  and  though  the  ques- 
tion is  not  one  of  very  great  importance,  yet  it  is  of  some 
interest  to  find  the  opposite  to  be  the  case,  since  it  shows 
that  the  effects  of  the  same  causes  are  the  same  in  both 
sexes  and  almost  to  an  equal  degree. 

Of  greater  importance  is  the  tabulation  of  the  patients 
according  to  their  ages  : 


Table  op  Ages. 


Males. 

Females. 

Total. 

10 

to 

2 

13 

15 

20 

u 

30  "   

44 

54 

98 

30 

u 

40  "   

34 

32 

66 

40 

50  "   

10 

8 

18 

50 

^^ 

60  "   

3 

6 

9 

60 

70  "   

1 

1 

93 

114 

207 

We  thus  find  that  the  largest  number  of  patients  (98) 
were  between  the  early  ages  of  twenty  to  thirty  years,  and 
the  next  largest  (66)  between  thirty  and  forty  years — that 
is,  in  these  two  decades  there  were  164  cases,  or  79-(-  per 
cent,  of  the  whole  number.  The  occurrence  of  fifteen  cases 
between  ten  and  twenty  years,  of  whom  the  youngest  was 
fourteen  years  of  age,  is  particularly  worthy  of  note,  and 
though  the  ten  between  sixty  and  seventy  years  might  be 
considered  as  due  to  senile  changes,  yet  to  my  personal 
knowledge  these  patients  had  abundant  hair  until  after  the 
development  of  the  local  disease.  The  fact  that  113  cases 
were  below  the  age  of  thirty  years  certainly  tends  to  dem- 
onstrate the  excessive  influence  of  the  local  disease  in  the 
production  of  alopecia,  and  if  we  add  to  the  number  those 
66  occurring  between  thirty  and  forty  years,  we  have  a  sur- 
prising total  of  179  cases  in  207,  which  offered  no  other 
explanation  for  their  existence  except  some  one  grade  of 
eczema  seborrhoicum.  I  would  repeat  that  these  results 
obtained  by  the  analysis  throw  into  the  strongest  possible 
light  the  enormous  role  that  this  local  process  plays  in  the 
causation  of  alopecia  prsematura,  especially  as  in  all  of  these 
cases  every  other  cause  for  the  hair  loss  could  be  and  was 
excluded.  Atrophic  changes,  analogous  to  those  taking 
place  in  old  age,  can  not  be  said  to  occur  in  the  early  ages 
mentioned  ;  systemic  or  constitutional  causes  or  disease  in 
general  could  all  be  excluded,  and,  in  fact,  nothing  could  be 
held  responsible  for  the  alopecia  except  the  local  phenomena 
mentioned,  and  it  may  be  further  stated  as  corroborative 
evidence  that  the  alopecia  would  cease  when  the  local  dis- 
ease was  removed,  but  would  not  be  influenced  by  any  other 
mode  of  treatment. 

There  is  not  very  much  to  say  in  regard  to  the  pathology 


Feb.  4,  1893.] 


ELLIOT:  ALOPECIA  PREMATURA. 


133 


of  this  local  process  on  the  scalp  beyond  stating  that  the 
work  done  by  Dr.  Unna  and  his  colaborers  in  his  laboratory 
has  demonstrated,  if  not  as  yet  absolutely  and  definitely 
proved,  that  micro-organisms  play  a  most  prominent  part 
in  the  production  of  eczema  seborrhoicum,  and  that  the  dis- 
ease is  in  all  probability  a  parasitic  one.  I  have  nothing 
to  add  to  this  mj'self,  not  having  had  the  opportunity  or 
time  for  carrying  out  the  extensive  work  necessitated  by 
this  portion  of  the  subject.  The  pathological  anatomy  of 
the  several  grades  of  the  process  has  been  studied  by  me, 
but  before  referring  to  it  I  would  mention  certain  facts  de- 
rived from  the  study  of  the  aetiology  of  my  cases  which 
have  reference  to  their  causation  and  mode  of  origin. 
Functional  disturbances  of  the  health  did  not  appear  to 
play  any  part  in  the  production  of  the  process.  Many  of 
the  patients  suffered  from  constipation,  or  gastric  or  intes- 
tinal dyspepsia,  or  menstrual  disturbances  of  one  kind  or 
another,  but  neither  their  presence  nor  their  removal  was 
followed  by  the  slightest  change  in  either  the  disease  or  the 
consequent  alopecia.  In  many  instances,  however,  general 
diseases,  which  caused  the  patient  to  be  kept  in  bed  for 
some  time,  parturition,  etc.,  were  apparently  predisposing 
causes — not,  in  my  opinion,  ■per  se,  but  only  in  so  far  as  they 
led  to  neglect  in  the  care  of  the  scalp  and  thus  allowed  the 
process  to  develop.  The  patients  included  in  this  category 
were  able  to  trace  the  inception  of  the  disease  on  the  scalp 
to  such  occurrences,  they  having  previously  been  entirely 
free  from  its  manifestations.  The  effects  of  occupation 
were  likewise  exerted  in  the  line  of  predisposition.  I  have 
found,  in  studying  eczema  seborrhoicum  as  a  whole,  that 
the  immense  majority  of  cases  were  among  those  whose 
work  or  occupation  or  state  in  life  obliged  them  to  be  in 
rooms  which  were  poorly  ventilated  or  dusty  or  overcrowd- 
ed, while  those  who  lived  under  opposite  conditions — that 
is,  more  in  the  open  air — were  infrequently  affected.  The 
effects  of  these  conditions  were  rendered  apparent  by  com- 
paring the  number  of  cases  seen  during  the  cold  months, 
when  poor  ventilation  prevails,  when  windows  and  doors  are 
kept  closed  and  artificial  heat  is  used,  when  there  is  dimin- 
ished frequency  in  bathing,  washing,  etc.,  with  the  number 
presenting  themselves  during  the  warm  months,  when  the 
opposite  conditions  are  in  force.  The  proportion  was  as  4 
is  to  1  in  a  total  of  824  cases  of  seborrhoic  eczema  seen 
during  a  period  of  four  years.  Under  such  circumstances 
it  certainly  seems  to  me  that  the  conditions  named  above 
favor  the  development  of  the  disease. 

In  late  years  it  has  been  frequently  alleged  that  the 
continual  wearing  of  stiff  hats  caused  alopecia,  and  my  pa- 
tients were  carefully  examined  in  regard  to  this  question. 
Among  them  there  were  wearers  of  soft  and  of  hard  stiff 
hats,  but  in  none  could  the  hat  be  accused  as  the  direct 
cause  of  the  alopecia,  for  the  reasons  that  in  every  case 
some  grade  of  seborrhoic  eczema  was  present,  and  in  none 
did  the  falling  of  the  hair  begin  until  that  disease  had  de- 
veloped and  existed  for  some  time.  It  can  not,  moreover, 
be  imagined  upon  what  basis  such  a  theory  could  stand. 
If  the  arterial  supply  of  the  scalp  be  examined  and  the  situ- 
ation of  the  arteries  be  observed,  it  can  not  but  be  a[)par- 
ent  that,  for  the  blood  supply  to  be  interfered  with,  a  man 


would  have  to  wear  a  hat  so  tight  that  the  pain  from  the 
compression  produced  by  it  would  be  unbearable.  Further- 
more, the  occipital  arteries  are  the  most  deeply  seated  and 
least  exposed  to  compression,  and  branches  from  them  sup- 
ply the  crown  of  the  head,  or  that  portion  of  the  scalp 
which,  in  the  majority,  is  first  affected  by  the  alopecia ;  or, 
in  other  words,  the  part  of  the  scalp  least  exposed  to  circu- 
latory disturbances  is  the  first  to  suffer  from  alopecia ! 
What,  then,  becomes  of  this  theory  under  these  circum- 
stances ?  On  the  other  hand,  it  must,  however,  be  granted 
that  the  constant  wearing  of  a  hat  may  act  as  a  predispos- 
ing cause  in  so  far  as  increased  warmth,  moisture,  poor 
ventilation,  etc.,  would  result  from  such  use,  and  produce 
conditions  which  would  favor  the  development  of  local  dis- 
ease. It  appears  to  me  that  in  such  cases  the  same  conditions 
exist  as  have  been  observed  very  frequently  by  me  in  those 
women  who  coil  and  mass  their  hair  over  the  occiput.  The 
heat  of  this  surface  was  always  perceptibly  increased.  It 
was  moist,  and  I  have  invariably  found  here  eczema  sebor- 
rhoicum in  a  severer  grade  than  on  other  portions  of  the 
head,  whereas  it  has  been  most  exceptional  and  only  in 
severe  generalized  cases  that  the  same  surface  was  found 
affected  in  men. 

A  large  number  of  my  patients,  especially  men,  main- 
tained that  their  alopecia  was  hereditary  in  origin,  and  the 
question  received  careful  attention.  Without  wishing  to 
deny  the  possibility  of  such  being  the  case,  I  must  confess 
that,  in  my  experience,  it  must  be  very  exceptional.  In  not 
one  of  my  cases  could  the  statement  be  substantiated,  but,  on 
the  contrary,  every  one  of  those  who  alleged  that  mode  of 
origin  was  a  sufferer  at  the  time  of  consultation  from  sebor- 
rhoic eczema.  Furthermore,  tliey  were  induced,  when  it 
was  possible,  to  bring  their  parents  to  my  office,  and  in 
every  instance  these  were  found  by  personal  examination 
to  have  likewise  had  for  years,  and  to  still  have,  the  same 
scalp  disease  as  their  children  had. 

Frequent  observation  of  such  association  would  natu- 
rally suggest  the  possibility  of  contagion,  and  many  facts 
have  come  under  my  notice  which,  clinically,  strongly  sug- 
gested the  probability  of  the  disease  being,  to  a  certain  de- 
gree, contagious.  The  possibility  of  such  being  the  case 
is  not  advanced  by  me  as  anything  new,  for,  some  years 
ago,  Lassar  claimed  to  have  demonstrated  by  experiment 
that  pityriasis  capitis  and  alopecia  pityrodes  were  conta- 
gious ;  but  I  would  mention  six  of  my  patients  who  devel- 
oped the  disease  after  using  the  hair  brushes  of  friends 
with  whom  they  were  staying  at  the  time  and  who  were 
sufferers  from  the  process.  A  very  frequent  history  also 
furnished  me  was  that  of  two  persons  who  had  been  mar- 
ried a  short  time.  The  one  had  had  the  disease  for  a  long 
time  before  marriage,  the  other  not,  and  yet  at  the  end  of 
a  few  months  the  previously  unaffected  individual  was  also 
a  subject  of  the  process.  Furthermore,  parents,  sufferers 
from  the  disease  for  years,  would  bring  one,  two,  or  more 
of  their  children  who  had  developed  the  same  affection, 
one  after  another.  My  friend  Dr.  Dyer,  of  New  Orleans, 
has  recently  told  me  of  an  instance  of  this  sort  which  came 
under  his  notice,  and  which  I  give  as  evidence  of  the  fre- 
quency of  such  occurrences  when  observed  by  the  trained 


134 


ELLIOT:  ALOPECIA  PREMATURA. 


[N.  Y,  Med.  Jouh., 


dermatologist.  The  father  and  mother  had  eczema  sebor- 
rhoiciira  and  alopecia  of  a  severe  grade  for  several  years- 
They  had  three  children  ;  one,  three  years  and  a  half  of 
age,  had  the  same  disease  generalized  over  the  scalp ;  the 
next,  two  years  of  age,  presented  discrete  patches  here  and 
there ;  the  youngest,  four  months  old,  had  already  devel- 
oped one  patch  on  the  occiput.  It  is  also  interesting  to 
note  that  many  women  traced  the  inception  of  their  trouble 
to  their  first  visit  to  some  one  of  the  many  hair  dressers  in 
existence,  they  having  previously  been  entirely  free  from 
it.  In  my  experience,  hair  dressers  and  barbers  have 
proved  to  be  the  most  prolific  source  of  dissemination  of 
the  disease,  owing  to  their  indiscriminate  use  of  the  same 
brushes,  etc.,  their  want  of  cleanliness,  the  manipulation  by 
them,  one  after  another,  of  healthy  and  diseased  scalps — 
all  conjoined  with  an  absolute  ignorance  of  what  skin  and 
hair  are  and  to  what  diseases  each  is  subject.  Dr.  Dyer 
again  gives  me  a  case  in  point.  He  was  a  subject  of  the 
disease  and  of  alopecia  for  years.  He  was  cured  by  proper 
treatment,  and  remained  well  for  eighteen  months.  While 
in  Paris,  in  July,  1892,  he  went  to  a  barber,  who  used  his 
brushes,  etc.  At  the  end  of  four  days  the  doctor  observed 
the  redevelopment  of  the  process  on  his  scalp.  The  facts 
to  which  I  have  called  attention  are  certainly,  I  confess, 
entirely  clinical,  but  yet  they  appear  to  me  to  be  very  sug- 
gestiA'e  and  to  furnish  some  basis  for  a  belief  in  the  conta- 
giousness of  the  disease. 

A  question  of  more  than  ordinary  interest  in  regard  to 
these  cases  is  that  of  their  prognosis.  What  may  be  ex- 
pected from  their  treatment  ?  Can  regeneration  of  the  hair 
ensue  after  a  cure  of  the  local  disease  has  been  obtained  ? 
Of  course,  the  prognosis  will  vary  according  to  the  condi- 
tions existing  in  each  individual  case,  yet,  to  judge  by  my 
experience,  the  outlook  in  a  large  proportion  of  patients  is 
a  good  one.  If  baldness  even  has  occurred,  but  in  an  acute 
manner — in  a  few  weeks  or  months — regeneration  of  the 
hair  may  be  expected ;  but  if  this  condition  is  the  result  of 
the  disease  running  a  slow  and  chronic  course,  then,  of 
course,  nothing  can  be  obtained.  In  the  great  majority  of 
the  cases  the  process  is  chronic  in  character,  and  the  alo- 
pecia is  gradual  and  slow  in  development.  The  prognosis, 
under  these  circumstances,  will  have  to  vary  according  to 
the  age  of  the  patient,  the  stage  of  the  local  disease,  and 
the  length  of  time  the  alopecia  has  lasted.  The  younger 
the  patient,  the  shorter  the  duration  of  the  process,  the 
better  the  prognosis  will  be,  but,  even  in  full  adult  life,  a 
great  deal  of  aid  can  be  given,  and  I  may  say,  on  the  whole, 
that  removal  of  the  disease  by  proper  treatment  is  almost 
invariably  followed  by  cessation  of  the  alopecia,  and  though 
a  complete  regeneration  of  the  hair  may  not  be  possible, 
still  it  may  be  obtained  in  part,  or,  at  any  rate,  what  still 
remains  may  be  preserved  to  the  patient. 

In  the  first  part  of  my  paper  I  stated  that  the  various 
stages  of  disease  present  in  my  cases — the  pityriasis  capi- 
tis, alopecia  pityrodes,  seborrhoea  sicca,  etc. — represented 
only  grades-and  phases  of  the  process  designated  to- day 
eczema  scborrhoicum.  Without  entering  upon  a  discussion 
of  the  appropriateness  or  inappropriateness  of  the  term,  I 
would  add  here  that  my  conception  has  been  based  not  only 


upon  the  clinical  features  and  course  of  the  process,  but 
also  upon  the  microscopical  study  of  its  lesions.  The 
clinical  portion  of  the  question  has  already  been  treated  of 
by  me  in  a  paper  published  in  1891,  and  1  will  therefore 
confine  myself  here  to  the  anatomical  portion  of  the  sub- 
ject. I  was  fortunate  enough  in  public  practice  to  obtain 
from  the  scalp  portions  of  skin  the  seat  of  pityriasis  capi- 
tis, alopecia  pityrodes,  and  seborrhoea  sicca,  as  well  as 
specimens  from  those  cases  in  which  distinct  eczematous 
symptoms  were  present.  As  we  all  know,  the  question  of 
the  source  of  the  squama?  present  in  the  first  three  clinical 
processes  referred  to,  whether  they  are  from  the  epidermis 
or  from  the  sebaceous  glands,  has  long  been  a  subject  of 
controversy,  and  though  it  has  been  studied  by  many  of 
our  eminent  dermatologists,  yet  a  unanimity  of  opinion  has 
not  even  to-day  been  attained.  As  far  as  my  study  of  the 
literature  of  the  subject  has  been  possible,  it  appears  to  me 
that  the  association  of  the  clinical  symptoms  with  the  se- 
baceous glands  was  first  made  by  Hebra,  Sr.  Before  him, 
the  squamae  were  considered  as  epidermic  in  character,  and 
I  have  not  been  able  to  find  any  mention  of  a  seborrhrea 
sicca  prior  to  his  writings.  His  influence  in  dermatology 
has  been  so  wide-reaching  that  though  his  claims  were 
based  upon  the  examination  of  the  scales  alone  and  the 
demonstration  of  the  presence  of  a  large  amount  of  fat  in 
them,  yet  they  were  immediately  accepted  and  are  still  in 
force,  so  that  our  text-books,  for  the  most  part,  make 
pityriasis  capitis  and  seborrhoea  sicca  more  or  less  synony- 
mous terms  and  a  functional  disease  of  the  glands.  I  do 
not  mean  thereby  to  say  that  the  question  has  not  been 
studied  and  investigated  since  the  time  of  Hebra.  On  the 
contrary,  in  this  country  Piffard  and  others  have  done  so  and 
maintained  that  the  squamae  were  epidermic  in  source  ;  but 
yet  their  investigations  were  limited  to  the  scales  scraped 
from  the  surface  only,  and  for  that  reason  could  not  be  re- 
girded  as  conclusive.  To  myself  it  has  always  seemed  an 
impossibility  to  decide  the  question  by  the  examination  of 
squamae  alone,  and,  according  to  the  shape  of  the  cell  or 
the  degree  of  fat  present,  to  determine  that  they  were  or 
were  not  epidermic  in  origin ;  and  my  investigations  have, 
therefore,  been  made  upon  sections  of  the  entire  affected 
skin. 

The  portions  removed  from  the  scalp  were  in  each  in- 
stance cut  into  two  pieces,  one  of  which  was  hardened  in 
alcohol  and  the  other  in  a  one-per-cent.  osmic-acid  solu- 
tion. The  alcohol  preparations  were  mounted  in  celloidin 
and  the  sections  were  stained  in  borax  carmin  or  with 
hsematoxylin  and  examined  in  balsam.  The  osmic-acid 
specimens  were,  however,  mounted  in  wax,  cut  with  the 
microtome,  wet  with  water,  and  placed  immediately  in 
glycerin,  alcohol  at  no  time  coming  in  contact  with  the  sec- 
tions. For  brevity's  sake,  I  will  give  only  the  principal 
and  important  features  seen  under  the  microscope,  begin- 
ning with  the  alcohol  specimens. 

In  pityriasis  capitis  and  alopecia  pityrodes  substan- 
tially the  same  changes  were  present,  what  differences  ex- 
isted being  of  degree,  not  of  character.  The  horny  layer 
of  the  epidermis  was  somewhat  thickened,  loosely  coherent, 
and  separating  easily  into  layers.    About  and  in  the  fol- 


Feb.  4,  1898.] 


ELLIOT:  ALOPECIA  PRA^MATURA. 


135 


licular  openings  it  was  much  increased,  evidently  hyper- 
plastic, and,  in  the  case  of  the  hair  follicle,  almost  choking 
it  up  with  loosely  adherent  masses.  In  seborrhoea  sicca 
the  changes  were  exaggerated  in  degree,  the  horny  epider- 
mis piled  up,  the  hair  follicle  in  its  upper  third  so  filled  up 
with  the  horny  masses  that  it  was  dilated  to  a  considerable 
extent  and  funnel-shaped,  while  the  hyperplastic  epidermis 
was  wrapped  and  twisted  around  the  projecting  hair  shaft 
for  some  distance  outside  of  the  follicle.  The  rete  in 
pityriasis  and  alopecia  pityrodes  showed  slight  changes, 
there  being  only  a  few  vacuoles  in  the  lower  layers  and 
some  wandering  cells  in  the  intercellular  spaces.  It  was 
not  increased  in  thickness.  In  seborrhoea  sicca  a  few 
more  vacuoles,  a  few  more  wandering  cells,  but  no  other 
difference. 

In  the  cutis  proper,  inflammatory  infiltration  of  smal' 
round  cells  was  seen  about  the  vessels  in  the  papillte  in 
pityriasis,  the  ascending  branches  from  the  subpapillary 
plexus  were  in  addition  and  to  a  slight  extent  similarly 
surrounded  in  alopecia  pityrodes,  while  in  seborrhcea  sicca 
the  inflammation  had  extended  to  the  subpapillary  plexus, 
and  even  a  little  lower.  The  sebaceous  glands  in  all  were 
apparently  perfectly  normal.  In  those  grades  where  de- 
cided eczematous  symptoms  had  been  present — that  is, 
where  redness,  crusting,  or  weeping  had  been  noted — the 
cutis  was  slightly  oedematous  (as  was  seen  in  specimens 
hardened  in  Fleming's  solution) ;  it  was  densely  infiltrated 
in  its  upper  half,  but  in  the  lower  half  th^  masses  of  cells 
were  situated  only  about  the  blood-vessels.  In  the  rete 
there  were  many  vacuoles  and  wandering  cells  and  mito- 
ses. Here  and  there  were  subepidermic  vesicles  of  small 
size,  and  the  epidermis  itself  was  thickened  and  either 
loosely  adherent,  showing  some  number  of  nuclei  still 
staining  well,  or  formed  dark-colored  crusts.  The  seba- 
ceous glands  were  normal  in  appearance,  but  surrounded  by 
the  inflammatory  infiltration,  which  in  many  places  was 
also  seen  about  the  coiled  glands. 

From  these  features  presented  by  my  sections  I  believe 
that  I  am  justified  in  drawing  the  conclusion  that  in  all 
these  various  clinical  processes  examined  we  have  to  deal 
with  an  inflammatory  process  of  the  skin  which  in  its 
lightest  grade — pityriasis — is  slight  and  superficial,  but 
which,  as  it  progresses  into  higher  grades,  becomes  more 
extended  until  it  finally  implicates  more  or  less  the  entire 
cutis.  As  a  result  of  the  inflammation  of  the  cutis,  we  find 
in  all  stages  a  hyperformation  of  horny  epidermis,  espe- 
cially about  and  in  the  follicular  orifices,  a  hyperplasia 
more  or  less  proportionate  to  the  degree  of  inflammation  in 
the  corium. 

When  we  turn  to  the  osmic-acid  preparations — an  acid 
which,  as  is  well  known,  stains  fat  black — we  find  that  in 
the  sections  from  pityriasis  capitis,  alopecia  pityrodes,  and 
T  would  particularly  specify  seborrhoea  sicca,  and  also  in 
the  higher  grades  where  distinct  eczematous  symptoms 
were  present,  the  sebaceous  glands  were  stained  in  their 
entirety  a  deep  uniform  black.  In  proportion  to  the  grade 
of  the  process,  the  same  color  was  present  either  to  a 
marked  extent  between  the  hair  shaft  and  the  masses  of 
epidermis  filling  up  the  follicular  openings,  or  it  was  dimin- 


ished to  a  narrow  line — in  seborrhoea  sicca  immediately 
about  the  hair.  In  the  slightest  grades  the  black  staining 
was  also  found  between  the  masses  of  horny  tissue  filling 
up  the  follicle  and  also  permeated  to  some  extent  the  upper 
layers  of  the  external  epidermis.  In  seborrhoea  sicca,  in 
which  the  horny  masses  filling  up  the  follicle  were  much 
denser  and  more  coherent,  this  fat  infiltration  was  not  seen 
and  the  staining  was  very  slight  on  the  external  surface.  In 
the  higher  grades  substantially  the  same  appearances  were 
noted,  except  that  when  a  seborrhoea  oleosa  complicated 
the  process  the  entire  follicular  opening,  the  horny  epi- 
dermis, and  a  good  part  of  the  rete  showed  the  character- 
istic black  color. 

From  my  microscopical  studies  of  the  various  clinical 
grades  of  disease  included  in  this  paper,  I  believe  I  may 
say  that  on  the  one  hand  we  have  an  inflammation  of  the 
skin  which  varies  in  degree  and  extent  proportionately 
with  the  severity  of  the  objective  symptoms,  and  which 
has  as  a  result  a  hyperproduction,  a  hyperplasia  of  the 
horny  epidermis,  especially  in  and  about  the  follicular  ori- 
fices, which  are  more  or  less  choked  and  filled  up. 

On  the  other  hand,  as  shown  by  the  osmic-acid  sec- 
tions, the  sebaceous  glands  are  filled  with  fat,  which  passes 
through  the  ducts  into  the  follicles,  the  amount  so  passing 
varying  according  to  the  degree  in  which  the  follicles  are 
choked  up  by  the  epidermic  hyperplasia. 

Under  these  circumstances — the  epidermic  hyperforma- 
tion, the  glandular  secretion  unchanged,  but  only  mechanic- 
ally prevented  of  egress — what  other  conclusion  can  be 
arrived  at  but  that  the  squamae  and  scaling  seen  in  the  sev- 
eral clinical  processes  referred  to  owe  their  origin  to  the 
hyperplastic  epidermis  and  in  no  way  to  a  cornification  of 
the  cells  of  the  sebaceous  glands,  or  to  the  fact  that  these 
have  not  undergone  fatty  degeneration  ?  I  do  not  for  my 
part  see  any  other  possible  conclusion,  especially  when 
under  the  microscope  the  loose  coherence  and  the  splitting 
off  of  the  horny  epidermis  between  the  follicular  orifices 
was  easily  and  readily  seen ;  and  when  by  treatment  the 
follicular  plugs  were  removed  and  the  mechanical  interfer- 
ence with  the  egress  of  the  fat  secretion  was  done  away 
with,  it  was  then  clinically  seen  that  the  dry,  lusterless 
hair  became  soft,  glossy,  and  oily,  and  that  occurring  when 
neither  oil,  grease,  nor  fat  of  any  kind  had  been  used. 

From  the  clinical  analysis  of  my  234  cases  of  alopecia 
prajmatura  and  the  microscopical  study  of  the  several  grades 
of  the  local  process  present  in  the  207  particularly  treated 
of  in  my  paper,  I  would  allow  myself  to  draw  the  following 
conclusions : 

1.  Constitutional  and  systemic  conditions  may  be  causa- 
tive of  alopecia  prsematura,  but  only  in  a  great  minority  of 
the  cases  which  come  under  observation. 

2.  The  overwhelming  majority  arc  due  to  the  local  pro- 
cesses which  are  known  as  pityriasis  capitis,  alopecia  pity- 
rodes, seborrhoea  sicca,  and  the  higher  grades  to  which 
these  may  progress  by  increase  in  the  inflammatory  symp- 
toms. 

3.  All  of  these  severally  described  forms  of  disease  are 
merely  stages  and  grades  of  the  process  known  to-day  as 
the  eczema  seborrhoicum  of  Unna. 


136 

4.  The  proof  of  this  is  seen  clinically  *  in  the  progres- 
sion and  transformation  of  the  slighter  grades  into  the 
higher,  the  evolution  of  one  stage  to  another  not  being  ex- 
ceptional, but  almost  always  the  rule  in  any  given  case. 

5.  Microscopically,  it  was  found  that  from  the  lightest 
to  the  highest  grade  the  pathological  phenomena  were 
represented  by  degrees  of  inflammation  of  the  skin,  super- 
ficially situated  in  the  former,  but  extending  more  or  less 
throughout  the  entire  cutis  in  the  latter.  As  a  result  of 
the  inflammatory  process  there  was  a  hyperformation  of 
horny  epidermis. 

6.  The  sebaceous  glands  were  found  unchanged,  the 
diminution  in  the  amount  of  their  secretion  being  due  to 
mechanical  interference  to  its  egress,  not  to  disturbed 
function. 

7.  The  source  of  the  squamte  seen  in  the  various  stages 
is  the  hyperplastic  epidermis,  not  the  sebaceous  glands. 

8.  In  consequence  of  the  processes  being  inflammatory 
in  nature  and  situated  in  the  cutis  and  not  in  the  glands,  in 
consequence  of  the  squamae  being  epidermic  and  not  glandu- 
lar in  origin,  therefore  the  inclusion  of  these  processes 
among  glandular  diseases  of  the  skin  and  the  designation 
of  seborrhoea  attached  to  them  are  manifestly  erroneous. 

7  West  Tiiikty-fir.st  .Street. 


INGUINAL  HERNIA  IN  THE  MALE.f 
By  henry  O.  MARCY,  A.  M.,  M.  D.,  LL.  D., 

BOSTON. 

Until  recently  the  cure  of  inguinal  hernia  in  the  male 
has  been  considered  at  the  best  accidental,  and  even  when 
apparently  effected  generally  doubtful,  and  it  is  still  taught 
that  the  hernia  is  apt  to  return.  The  great  majority  of  sur- 
geons look  upon  an  attempt  at  cure  as  ill-advised,  and  believe 
that  operative  measures  are  not  to  be  undertaken  except  in 
cases  of  strangulation.  There  is  abundant  reason  for  such 
conclusions  when  judged  from  the  earlier  history  of  surgical 
attempts  at  cure.  It  is  impossible  in  the  limit  assigned  me 
to  treat  at  all  in  an  exhaustive  way  this  most  interesting  sub- 
ject. Three  centuries  ago  the  problem  was  mastered  by  the 
surgeons  of  Europe,  but  only  by  the  sacrifice  of  the  testicle 
and  the  removal  of  the  cord.  In  this  way  the  abdominal 
opening  was  closed  and  the  resulting  cicatrix  was  unyield- 
ing. The  demand  for  relief  from  this  burdensome  com- 
plaint was,  however,  so  great,  even  at  this  sacrifice,  braving 
the  suffering  from  surgery  without  anaesthetics,  and  a  slow 
healing  of  a  dangerous,  suppurating  wound,  that  the  opera- 
tion was  forbidden  by  royal  edict,  lest  the  nation  should 
suffer  from  the  lessening  of  the  reproductive  power  of  the 
race. 

It  is  necessary  to  revert  briefly  to  the  anatomical  struc- 
tures involved,  in  order  to  note  the  method  by  which  Na- 
ture permits  the  passage  of  the  cord  through  the  abdominal 
wall  without  pressure,  and  retains  without  inconvenience  or 


*  Eczema  seborrhoicum.    New  York  MedicalJournal,  1891. 
t  Read  before  the  Southern  Surgical  and  GynsECological  Society  at 
its  annual  meeting,  in  Louisville,  November,  1892. 


[  N.  Y.  Mkd.Jottk., 

suffering  the  abdominal  organs.  This  passage  is  normally 
lined  with  perit<jnaeum  loosely  attached  to  the  abdominal 
wall  without,  and  to  the  cord  within,  the  canal.  This  peri- 
tonaeum, owing  largely  to  its  loose  attachment,  presents  a 
slight  infundibuliform  depression  at  the  site  of  the  internal 
ring,  but  never  more  than  to  permit  a  very  limited  move- 
ment of  the  cord  within  the  canal.  The  canal  itself  trav- 
erses the  abdominal  wall  obliquely  from  without  inward 
in  a  direction  so  that  the  intra-abdominal  pressure,  radiat- 
ing from  a  center  represented  by  the  promontory  of  the 
sacrum,  is  distributed  equally  along  the  line  of  the  canal, 
compressing  its  walls  laterally.  The  disposition  of  the  canal 
is  not  unlike  that  of  the  ureter  in  its  entrance  into  the 
bladder,  the  intravesicular  pressure  closing  yet  the  more 
firmly  the  ureter  at  its  orifice. 

The  pathological  changes  incident  to  acquired  hernia 
present,  as  the  first  factors,  an  increase  of  the  infundibu- 
lum  of  the  peritonaeum  about  the  cord  and  a  depression  of 
the  lower  border  of  the  internal  ring.  Thus  is  produced  a 
change,  at  first  slight,  of  the  direction  of  the  intestinal 
wave  impulse,  which  acts  at  times  as  a  wedge  to  open  yet 
more  the  ring.  Little  by  little  the  axis  of  the  canal  changes 
until  at  length  the  intra-abdominal  pressure  is  in  the  line 
of  the  opening  instead  of  at  right  angles  to  it.  These 
changes,  which  culminate  in  a  well-pronounced  hernia  more 
or  less  direct,  have  long  been  recognized,  but  it  of  necessity 
remained  that  a  reconstruction  of  the  canal  to  its  normal 
conditions  could  not  be  rendered  possible  until  aseptic  sur- 
gery established  the  methods  of  primary  repair  of  the  tis- 
sues upon  a  scientific  basis.  The  most  important  factor,  as 
I  shall  presently  demonstrate,  is  the  closure  of  the  deep 
structures  by  means  of  the  buried  animal  suture. 

The  essential  considerations  for  the  cure  of  hernia  are : 

1.  Strict  Aseptic  Conditions. — These  pertain  alike  to  all 
modern  surgical  procedures  and  need  not  be  recapitulated 
to  this  audience. 

2.  A  free  dissection,  in  order  to  lay  bare  the  internal 
ring,  permit  of  the  enucleation  of  the  peritoneal  sac,  and  the 
separation  and  elevation  of  the  cord  out  of  the  wound.  The 
external  epigastric  artery  often  courses  in  the  line  of  the 
incision.  It  is  not  seldom  that  the  size  of  this  vessel  is 
such  that  the  operator  fears  he  may  have  wounded  the 
larger  vessel. 

3.  The  Sac. — The  separation  of  the  sac  to  its  very  base 
before  removal  is  to  be  recommended  as  the  rule.  There 
are  times  when  it  is  not  easy  to  free  the  peritoneal  pouch, 
owing  to  adhesions  to  the  surrounding  tissues  and,  in  large, 
old,  irreducible  hernia,  more  or  less  intimate  fusion  of  the 
contents  to  the  inner  wall  of  the  sac.  It  is  generally  better 
to  open  the  sac  before  ligating  or  sewing  through  its  neck, 
since  by  so  doing  the  condition  at  the  internal  ring  is 
assured,  and  the  operator  is  often  profited  by  such  knowl- 
edge even  when  the  sac  is  completely  empty. 

Not  seldom  the  omentum  is  adherent  at  the  internal 
ring,  and  even  a  constricted  bit  of  intestine  may  escape  ob- 
servation when  it  is  attempted  to  resect  the  sac  unopened. 
Freed  quite  within  the  ring,  tension  is  to  be  made  upon  the 
sac  and  then  the  sutures  are  applied  in  the  line  of  the  long 
diameter  of  the  internal  ring,  and  the  sac  is  resected  near 


MARCY:  INGUINAL  HERNIA  IN  THE  MALE. 


Feb.  4,  1893.J 


MARCY:  INGUINAL  HERNIA  IN  THE  MALE. 


137 


its  base.  The  retraction  sliould  be  sufficient  to  carry  tlie 
resected  peritonajuin  quite  within  the  rincj. 

Mr.  Maceweii  and  his  followers,  who  recognize  the,  of 
necessity,  from  within  outward  funnel-shaped  opening  of 
the  inguinal  ring  after  operation,  make  the  attempt  to  util- 
ize the  freed  sac,  in  whole  or  in  part,  by  puckering  it  up  into 
a  mass  and  with  it  embossing  the  internal  ring,  more  or  less 
tilling  the  open  space  otherwise  left  to  invite  a  lodgment 
of  the  abdominal  contents  and  wedge  open  the  canal,  caus- 
ing a  return  of  the  hernia. 

Having  demonstrated  the  feasibility  of  restoring  the 
obliquity  of  the  inguinal  canal,  it  needs  no  argument  to 
show  the  greater  value  of  such  a  procedure  over  the  sub- 
stitution of  plugging  the  opening  with  pathological  tissues. 

4.  The  Posterior  Border  of  the  Inguinal  Canal. — Having 
freed  the  cord  to  its  point  of  entrance  within  the  abdomi- 
nal cavity  and  lifted  it  to  one  side,  we  are  prepared  to  study 
the  structures  which  may  be  utilized  in  the  reformation  of 
the  internal  ring  and  the  posterior  border  of  the  canal.  Sir 
Astley  Cooper  was  the  first  to  emphasize  the  remarkable 
development  of  the  transversalis  fascia  which  here  is  usu- 
ally found  to  consist  normally  of  a  thick  layer  of  connective- 
tissue  fibers.  A  careful  study  of  the  structures  posterior 
to  the  inguinal  canal,  especially  if  made  upon  the  healthy, 
well-formed  subject,  demonstrates  that  the  muscular  fibers 
of  the  transversalis  make  up  a  part  of  the  posterior  wall. 
In  fact,  it  should  be  considered  that  the  internal  inguinal 
ring  is  formed  by  a  slit  in  the  muscle.  The  pyramidalis 
also  greatly  strengthens  these  structures,  and  it  is  note- 
worthy that  they  rarely  if  ever  yield  unless  acted  upon  by 
a  wedge-like  force  from  above  downward  in  the  line  of  the 
inguinal  canal. 

In  large  hernia  the  lower  border  of  the  internal  ring  has 
often  fallen  quite  on  a  line  with  that  of  the  external  ring — 
direct  hernia — but  it  will  usually  be  found,  even  where  ab- 
normal pressure  of  the  truss  has  produced  absorption,  that 
Nature  made  a  distinct  effort  to  fortify  the  parts,  and  that 
the  lower  margin  of  the  ring  and  the  transversalis  fascia 
have  become  markedly  thickened.  These  structures  are  to 
lie  utilized  in  the  reformation  of  the  posterior  wall  of  the 
canal.  Upon  the  lower  and  outer  border  this  fascia  blends 
with  the  posterior  edge  of  Poupart's  ligament,  while  upon 
the  upper  and  inner  border  it  unites  with  the  lower  edge  of 
the  transversalis  muscle  and  conjoined  tendon.  Often  the 
finger  may  be  introduced  into  the  internal  ring  to  aid  in  the 
guidance  of  the  needle,  which  is  made  to  traverse  from 
side  to  side  the  relaxed  fascia  and  evenly  intrafold  it  with 
a  layer  of  continuous  tendon  sutures.  These  are  continued 
from  below  upward,  until  the  internal  ring  is  closed  upon 
the  cord  at  its  exit  from  the  abdominal  cavity. 

One  unaccustomed  to  the  operation  will  be  surprised  to 
note  the  amount  of  tissue  which  may  be  intrafolded  to  form 
the  posterior  border  of  the  canal.  If,  however,  for  any  rea- 
son the  structures  seem  insufficient,  it  is  easy  to  unite  the 
deeper  edge  of  Poupart's  ligament  to  the  lower  border  of 
tlie  transversalis  muscle  and  thus  strengthen  the  parts.  This 
is  usually  recommended  by  Bassinni,  and  in  this  in  large 
measure  his  method  of  operation  consists. 

Ilalsted,  of  Baltimore,  has  gone  one  step  farther  and  but- 


tresses the  posterior  wall  of  the  canal  by  uniting  all  the  mus- 
cles beneath  the  cord,  forming  an  entirely  new  canal  exter- 
nal to  them.  These  operators  carry  the  methods  which  I 
have  long  used  and  taught  to  extremes  that  I  have  rarely 
found  necessary  ;  very  likely,  in  large  measure,  because  by 
my  method  of  deep  double  suturing,  I  am  enabled  to  coap- 
tate  a  thick  layer  of  firm  resisting  structures  and  reform  the 
posterior  portion  of  the  inguinal  canal  quite  more  closely 
according  to  the  method  of  normal  construction. 

Once  satisfied  that  the  coaptated  structures  are  sufficient, 
the  cord  is  replaced  and  the  uniting  of  the  external  struc- 
tures is  conducted  in  the  same  manner  with  a  deep  double 
layer  of  tendon  sutures,  joining  the  divided  muscular  wall 
of  the  abdomen  and  bringing  into  close  apposition  Pou- 
part's ligament  to  the  conjoined  tendon  quite  upon  the  cord, 
until  the  external  ring  is  reconstructed.  It  is  surprising  to 
note  the  little  interference  which  follows  upon  the  close  ap- 
proximation of  the  structures  upon  the  cord  the  entire  length 
of  the  canal,  as  evinced  by  lack  of  pain,  swelling  of  the  tes- 
ticle, or  even  oedema  of  the  scrotum. 

The  structures  external  to  the  muscles  are  best  approxi- 
mated by  one  or  more  layers  of  single  continuous  sutures, 
taken  by  means  of  a  Hagedorn  needle  introduced  from 
side  to  side.  In  a  similar  manner  the  skin  is  closed  with  a 
continuous  buried  tendon  suture.  The  needle,  straight  or 
curved,  is  best  held  in  the  fingers  and  is  carried  through  the 
deep  layer  of  the  skin,  entering  and  emerging  at  points  ex- 
actly opposite  in  the  sides  of  the  wound.  This  is  impor- 
tant or  the  wound  will  assume  a  wavy  look,  owing  to  a  puck- 
ering of  the  skin  by  drawing  upon  the  suture.  This  I  have 
termed  the  parallel  suture,  since  the  needle  is  carried  through 
the  skin  exactly  parallel  to  the  line  of  the  incision.*  It  will 
be  noted,  however,  when  the  points  of  entrance  and  emer- 
gence are  exactly  opposite,  that  the  suture  lies  in  the  wound 
transversely,  and  if,  for  the  purpose  of  demonstration,  the 
wound  is  allowed  to  remain  only  partially  closed,  the  suture 
lies  in  parallel  lines,  like  the  rounds  of  a  ladder,  at  right 
angles  to  the  long  axis  of  the  wound. 

I  believe  it  is  generally  safer  to  conduct  the  entire  oper- 
ation under  the  irrigation  of  a  weak  sublimate  solution,  and 
often  sponges  are  unnecessary.  It  is  much  better  to  remove 
shreddy  tissue  if  much  tearing  of  the  tissues  has  occurred, 
since  it  is  very  important  to  join  well-vitalized  structures 
in  order  that  primary  union  may  supervene.  I  think  it  also, 
wise  to  dust  the  parts  with  iodoform  before  sealing  with 
collodion.  It  is  well  worth  while  to  take  time  and  pains  to 
dry  the  wound  and  evenly  coaptate  the  edges  of  the  skin, 
sealing,  if  need  be,  only  a  part  of  the  wound  at  a  time. 
This  is  best  effected  by  evenly  spreading  a  few  fibers  of 
absorbent  cotton  upon  a  smooth  surface  and  moistening  it 
with  iodoform  collodion.  This,  gently  laid  upon  the  ap- 
proximated edges  of  the  wound,  soon  dries  and  makes  a 
germ-proof  dressing,  holding,  as  in  a  splint,  the  tissues  in  a 
firm,  sure  grasp.  This  method  of  wound  treatment  is  of 
sufficient  importance  to  be  emphasized  :  aseptic  sutures, 
aseptically  applied  in  an  aseptic  wound,  aseptically  main- 
tained.   This  is  the  sine  qua  non,  without  which  more  or 

*  See  The  Anatomy  and  Stirgical  Treatment  of  Hernia,  pp.  401-412. 
Heniy  O.  Many,  1892. 


138 


MA  ROY:  INQUINAL  HERNIA  IN  THE  MALE. 


[N.  Y.  Mki).  Jour., 


less  of  failure  must  ensue.  Otherwise,  buried  sutures  are 
not  to  be  commended  in  any  wound,  and  must  ever  be  a 
source  of  danger. 

The  advantages  of  the  above  method  of  operation  and 
closure  of  the  structures  as  described  are  obvious.  First, 
by  no  other  means  than  the  deep  closure  of  the  parts  by 
the  use  of  sutures,  to  be  left  in  the  wound  and  not  to  be 
subsequently  removed — buried  sutures — can  the  posterior 
border  of  the  inguinal  canal  be  restored,  the  parts  strength- 
ened and  re-enforced,  or  even  the  neck  of  the  sac  closed  and 
the  redundant  tissue  removed.  To  accomplish  such  a  pur- 
pose the  use  of  silver  wire  or  silkworm  gut  is  not  to  be 
considered,  since,  by  general  consent,  these  structures  must 
act  as  irritants,  and  usually  are  a  source  of  much  annoy- 
ance and  suffering  until  they  are  ultimately  eliminated  as 
foreign  bodies.  Silk  is  used  by  many  operators  for  this 
purpose ;  but  abundant  clinical  and  experimental  studies 
have  demonstrated  that  silk  at  the  best  is  encapsuled,  never 
absorbed.  It  may,  after  months  of  suffering,  be  thrown  off 
by  suppurative  processes. 

A  wound  that  is  closed  aseptically  in  layers  with  the 
tendon  suture  leaves  no  pockets  to  become  distended  by 
blood  or  serum,  and  hence  the  drainage-tube  is  not  required. 
In  aseptic  wounds  the  drainage-tube  is  ever  to  be  consid- 
ered as  a  foreign  body,  positively  harmful,  since  it  separates 
tissues  which  should  be  in  contact,  and,  if  long  maintained, 
this  portion  of  a  wound  must  be  restored  by  secondary  pro- 
cesses instead  of  primary  union.  During  its  retention  it  is 
ever  a  possible  source  of  danger  from  infection,  which  must 
be  guarded  against  by  the  most  careful  of  antiseptic  dress- 
ings. This,  in  the  region  of  the  groin,  is  most  difficult, 
and  the  large  proportion  of  suppurating  wounds  following 
hernia  in  the  hands  of  our  best  operators  shows  the  great 
risk  from  an  open  wound  in  this  portion  of  the  body.  The 
complete  closure  of  the  skin  by  a  line  of  buried  animal 
sutures  has  been  my  daily  practice  for  years,  and  was  de- 
cided upon  in  order  to  prevent  stitch  abscesses  long  before 
the  beautiful  demonstration  showing  their  cause  to  be  from 
the  introduction  of  the  Micrococcus  pyogenes  albus  with  the 
suture — the  normal  habitat  of  the  healthy  skin  aiding  in 
the  destruction  and  proliferation  of  the  dying  and  dead 
epithelium. 

The  iodoform  collodion  seal  is  useful  in  two  ways  : 
First,  it  holds  in  fixation  the  divided  edges  of  the  skin 
which  should  be  carefully  approximated.  Secondly,  it  pre- 
vents the  possibility  of  subsequent  infection.  An  aseptic 
wound  thus  protected  must  remain  aseptic,  and  when  the 
tissues  are  well  vitalized  the  union  must  be  primary. 

If  the  skin  is  in  close  approximation  the  union  is  lin- 
ear, and  often  after  a  few  months  can  scarcely  be  detect- 
ed. In  many  wounds  in  other  parts  of  the  body  this  is 
of  great  value,  especially  so  in  facial  wounds  in  the  fe- 
male. It  is  interesting  to  note  briefly  the  repair  processes 
which  supervene  in  such  a  wound.  Histological  investiga- 
tions upon  animals  show  that  the  tendon  or  animal  suture 
is  little  by  little  invaded  by  leucocytes  which  arc  abundant- 
ly proliferated  to  surround  the  material.  Little  by  little,  de- 
pendent upon  age,  activity  of  developmental  processes,  vi- 
tality of  structures,  etc.,  this  proliferated  material  is  trans- 


formed into  connective-tissue  cells  until  the  suture  is  in 
large  measure  replaced  by  a  band  of  living  tissue.  This  is 
important  in  most  wounds,  but  is  perhaps  never  of  greater 
value  than  in  hernia,  where  the  resistant  power  of  the 
structures  has  long  been  defective.  An  aseptic  wound  thus 
closed  is  rarely  painful,  oedematous,  or  even  tender  to  gen- 
tle touch.  The  new  proliferated  material  can  be  easily  felt 
for  a  considerable  period,  and  is  perhaps  at  its  maximum 
four  to  six  weeks  after  the  operation. 

For  many  reasons  the  tendon  suture  is  greatly  to  be  pre- 
ferred to  catgut — a  subject  of  extreme  interest  and  impor- 
tance, but  one  that  can  receive  here  only  slight  reference. 
The  kangaroo  tendon  has  met  with  universal  approval  by 
nearly  every  operator  who  has  used  it,  and  is  now  in  the 
market  in  quantity  and  in  price  so  that  it  comes  within 
the  reach  of  every  surgeon.  I  am  confident  that  once  used 
by  an  operator,  he  will  not  do  without  it  in  his  surgical 
practice. 

Time  does  not  permit  an  analytical  comparison  of  the 
different  methods  of  operation.  I  have  recently  treated 
this  subject  in  extenso*  The  operation  is  eminently  a  safe 
one.  In  a  table  which  I  have  collated  of  over  three  thou- 
sand cases,  the  proportion  of  deaths  is  less  than  one  per 
cent.,  and  these  are  for  the  most  part  explained  as  result- 
ing from  causes  which  the  authors  state  were  accidental 
and  were  not  due  to  the  operation. 

In  numbers,  Bassinni's  clinic  leads  the  list — 262  opera- 
tions and  only  one  death,  and  that  from  pneumonia; 
Championniere's  clinic,  254  operations,  2  deaths ;  Schede's 
clinic,  165  operations,  2  deaths;  Banks,  106  operations,  no 
deaths;  Park,  115  operations,  no  deaths,  85  reported 
cured;  Marcy,  115  operations,  no  deaths,  Y8  traced,  4  re- 
lapses. Even  the  experience  of  the  late  celebrated  John 
Wood,  of  London,  covering  years  of  labor  before  the  period 
of  antiseptic  regime,  gave  only  seven  deaths  in  339  operations. 

By  estimate,  between  three  and  four  millions  of  the 
people  living  in  the  United  States  are  subject  to  this 
usually  lifelong  progressive  disability,  and  if  the  demon- 
stration is  complete  that  the  risk  of  life  is  less  than  one 
per  cent,  from  operative  procedures  instituted  for  cure, 
and  that  scarcely  more  than  ten  per  cent,  are  subject  to  re- 
lapses, and  these  almost  invariably  remain  in  a  state  improved 
by  the  operation,  the  plea  is  a  strong  one  to  consider  favor- 
ably the  advisability  of  operation  in  a  very  large  majority 
of  all  the  sufferers  from  hernia.  We  are  all  painfully  fa- 
miliar with  the  dangers  of  strangulation  in  neglected  hernia 
and  the  large  percentage  of  mortality  which  results  there- 
from. It  seems  to  me  a  duty  resting  heavily,  not  only 
upon  all  surgeons,  but  also  every  physician  residing  where 
he  can  not  easily  obtain  surgical  assistance,  to  familiarize 
himself  with  all  the  details  of  the  operation  for  hernia,  its 
relief  when  strangulated,  its  cure  when  troublesome,  and 
thus  fit  himself  for  the  discharge  of  a  solemn  obligation 
which  may  at  any  moment  of  his  professional  experience 
be  freighted  with  the  issues  of  life  or  death. 

180  Commonwealth  Avenue. 

*  The  Anatomy  and  Surgical  Treatment  of  Hernia.  By  Henry  0. 
Marcy,  A.  M.,  M.  D.,  LL.  D.,  Boston.  Quarto,  with  66  full-sized  illus- 
trations, some  colored.    New  York  :  D.  Appleton  &  Co. 


Feb.  4,  18!>8.J     BERMINGHAM:   THE  EDISON  CURRENT  AND  THE  OALVANO-CAUTERY. 


139 


THE  ADAPTATION  OF  THE  EDISON  CURRENT 
TO  THE  GALVANO-CAUTERY. 
By  EDWARD  J.  BEPwMINGEIAM,  A.M.,  M.  D., 

SmtOEON  TO  TUE  NEW  TOllK  THBOAT  AND  NOSE  INFIUMART. 

Since  September,  1890,  I  have  been  using  the  Edison 
current  for  nearly  all  galvano-cautery  operations.  The 
method  in  which  this  is  accomplished  I  have  repeatedly 
had  the  pleasure  of  demonstrating  to  visiting  professional 
friends.  As  the  apparatus  is  simple  and  can  be  easily  con- 
structed by  any  ordinary  machinist,  T  propose  to  give  a 
brief  description  of  it. 

The  Rheostat. — The  rheostat  is  made  of  No.  14  iron 
wire  wound  in  the  form  of  a  spring,  forming  a  coil  about 
an  inch  and  a  quarter  in  diameter.  The  length  of  this  coil 
must,  of  course,  vary  according  to  the  maximum  quantity 
of  current  which  it  is  designed  to  carry.  In  the  instrument 
I  use  the  coil  is  about  fifty  feet  in  length.  This  is  arranged 
in  parallel  rows  in  lengths  of  about  two  feet,  care  being 
taken  to  insulate  wherever  there  is  the  slightest  danger  of 
short-circuiting.  I  have  arranged  the  whole  in  a  box  un- 
derneath a  table.  A  switch-board  controls  the  amount  of 
resistance.  The  entire  coil  should  be  in  circuit  at  first ; 
then,  by  moving  the  arm  of  the  switch  successively  from 
post  to  post  of  the  switch-board,  the  amount  of  resistance 
can  be  gradually  lessened  until  the  proper-sized  current 
passes  to  the  knife. 

The  Conductors. — It  is  essential  that  the  conductors 
should  be  large  enough  to  carry  all  the  current  needed  for 
the  largest  knives.  In  the  instrument  which  I  have  now  in 
use  I  employ  No.  8  copper  wire  to  connect  the  rheostat 
with  the  underground  cables  in  the  subways,  and  No.  14  flexi- 
ble cords,  doubled,  for  each  conducting  cord  connecting 
the  cautery  handle  with  the  rheostat.  All  safety  fuses 
should  be  stout  enough  to  resist  the  current  employed. 

The  Cautery  Handle. — A  great  objection  to  the  use  of 
the  Edison  current  in  cautery  work  is  the  production  of  an 
arc  in  the  cautery  handle  in  completing  and  breaking  the 
circuit.  I  have  devised  a  handle  in  which  this  is  obviated. 
It  is  a  closed-circuit  handle.  The  conductors  are  not 
broken,  but  form  one  solid  piece  and  a  closed  circuit  with 
the  knife.  A  spring,  controlled  by  the  operator's  thumb, 
holds  a  piece  of  metal  firmly  across  and  in  contact  with 
both  handle  conductors  so  as  to  form  a  connecting  link  be- 
tween them.  Pressure  with  the  thumb  pushes  the  metal 
from  both  conductors  and  allows  the  current  to  pass  to  the 
knife.  Release  of  the  pressure  permits  the  spring  to  bring 
the  metal  bar  again  in  contact  with  both  conductors,  and 
the  current,  seeking  the  shortest  distance  home,  leaves  the 
knife  and  takes  the  road  acro.ss  the  bar.  There  is  no  arc, 
and  the  handle  works  to  perfection. 

The  conductors  in  the  handle  should  also  be  large 
enough  to  carry  the  requisite  sized  current,  and  thus  ob- 
viate the  resistance  and  accompanying  heat.  No.  8  wire  is 
used  in  my  handle.  The  rheostat  which  I  am  now  using, 
and  which  I  made  two  years  and  a  half  ago,  is  adapted  for 
heating  knives  requiring  from  fifteen  to  sixty  amperes  of 
current.    It  has  always  given  me  complete  satisfaction. 

7  West  Forty-kiktii  Strkbt. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

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


NEW  YORK,  SATURDAY,  FEBRUARY  4,  1893, 


THE  MANAGEMENT  OF  PLACENTA  PRyEVIA. 

Among  the  subjects  of  great  interest  discussed  by  the  Brus- 
sels Congress  of  Gynascology  and  Obstetrics,  in  September  last^ 
was  the  treatment  of  placenta  prfevia.  Dr.  D.  Berry  Hart's  re- 
port on  that  subject  excited  general  interest  and  nioch  com- 
ment. In  his  paper  he  began  by  giving  a  caution  regarrling 
forcible  efforts  at  delivery  before  the  cervix  was  well  dilated. 
All  attempts  to  introduce  the  hand  through  it  for  the  purpose 
of  detaching  the  placenta  or  of  extracting  the  infant,  he  said, 
were  made  at  the  risk  of  a  laceration  or  bruising  of  the  uterus. 
The  avoidance  of  violent  extraction  efforts,  even  when  the  in- 
troduction of  the  hand  into  the  womb  was  not  required,  wai 
essential  to  the  well-being  of  the  infant.  The  operation  offered 
little  chance  of  life  to  the  child  and  was  not  free  from  danger 
to  the  mother ;  hence  a  very  important  indication  was  to  act 
without  precipitation  and  violence.  The  complete  detachment 
of  the  placenta  is  not  always  indi8])ensable  to  the  arrest  of 
blood-loss.  The  first  period  of  the  operation  of  cervical  dilata- 
tion, with  Barnes's  dilators,  should  be  made  as  short  as  possi- 
ble; at  that  time  it  is  that  the  dangers  of  hsemorrhage  during 
the  procedure  must  be  kept  in  view.  If  labor  is  imminent, 
rupture  of  the  membranes  may  suffice  to  excite  uterine  contrac- 
tion and  put  a  stop  to  the  hjemorrhage.  A  temporai-y  employ- 
ment of  the  tampon  may  be  indicated,  the  tamponading  to  be 
done  thoroughly  with  iodoform  gauze. 

Separation  of  that  portion  of  the  adherent  placenta  that 
covers  the  inferior  segment  of  the  womb  may  at  times  be  ac- 
complished by  the  introduction  of  the  index  finger,  when  the 
introduction  of  the  hand  or  total  detachment  of  the  placenta 
is  impracticable  or  dangerous.  This  step  favors  regular  dila- 
tation of  the  internal  orifice  as  well  as  contraction  of  the 
lower  uterine  eegtnent,  and  this,  in  turn,  favors  the  lessening 
of  blood-loss. 

After  dilatation  has  been  effected,  if  the  head  is  the  present- 
ing part,  the  use  of  the  forceps  is  to  be  preferred  to  version,  as 
safer  to  botli  child  and  mother.  The  operation  of  version  is 
not,  as  a  rule,  favorably  viewed  by  Dr.  IJart.  When  version  is 
resorted  to  "in  a  head  presentation,"  he  says,  "we  go  com- 
pletely against  the  course  indicated  by  Nature."  He  is  aware 
that  it  is  maintained  that  by  this  procedure  wo  facilitate  dilata- 
tion of  the  cervix  by  exercising  traction  on  the  legs  and  body 
of  the  child,  and  that  the  head  makes  salutary  pressure  on  the 
surface  that  is  the  seat  of  the  hiemorrhage.  To  this  he  replies 
that  both  these  ends  are  better  subserved  by  the  hydrostatic 
(hhitor  and  then  by  tlio  forceps.  "Version  deniinids  more 
force,  which  docs  hurm  to  the  ]>aticnt  and  diminishes  the 


140 


LEADING  ARTICLES.— MINOR  PARAORAPHS. 


[N.  Y.  Med.  Jodb., 


chances  of  life  to  the  child."  Ills  recent  experience,  especially 
sioce  his  abandonment  of  the  Braxton  Hicks  bimanual  method, 
leads  him  to  the  opinion  that  placenta  prsevia  is  destined  to  he- 
come  progressively  less  fatal  to  infants ;  in  his  later  practice  lie 
has  been  enabled  to  record  thirty-three  per  cent,  of  children 
saved. 

The  value  of  the  use  of  Barnes's  dilators  as  a  relatively  safe 
and  rapid  means  of  obtaining  dilatation  and  tamponage  has 
been  increasingly  made  apparent  to  Dr.  Hart,  both  in  his  earlier 
and  in  his  later  experience.  These  implements,  he  thinks, 
must  be  regarded  as  indispensable  to  the  rational  and  scientific 
management  of  i)lacenta  pra3via. 


SMALL-POX  IN  CENTRAL  AFRICA. 

A  French  pioneer  missionary  to  the  Barotse,  named  Ooil- 
lard,  has  given  in  the  Christian  for  December  29th  an  account 
of  his  efforts  to  contend  with  epidemic  small-pox  in  a  tribe  of 
very  wild  Africans.  Dating  from  the  return  of  a  war  partj* 
that  brought  back  with  them  a  multitude  of  captives,  women 
and  children  chiefly  and  designated  concisely  as  ''slaves,"  the 
whole  valley  in  which  the  missionary  dwelt  became  the  seat  of 
small-pox.  No  adequate  sanitary  precautions  can  he  adopted  in 
the  case  of  a  wild  people  like  these.  The  warriors  and  their 
slaves,  some  of  them  infected,  scattered  themselves  throughout 
the  villages.  Nearly  every  person  sooner  or  later  took  the  dis- 
ease, even  some  who  had  formerly  had  it.  The  deaths  became 
so  frequent  tiiat  the  people  left  off  wailing  for  their  dead  and 
many  of  the  latter  were  not  buried,  but  were  thrown  into  the 
river  or  dragged  off  into  the  fields.  The  missionary  proceeded 
to  inoculate  some  cows,  and,  collecting  the  lymph,  "  vacci- 
nated "  the  people  with  it.  After  many  attempts  he  succeeded 
in  getting  a  protective  lymph.  He  even  instructed  some  intel- 
ligent young  tribesmen  to  inoculate  the  kine  and  to  collect 
lymph  and  apply  it.  The  negro  doctors  tried  to  imitate  his 
methods  and  established  a  keen  competition  for  the  purpose  of 
enriching  themselves,  but  some  of  them  contracted  the  small- 
pox and  died  of  it.  The  people  flocked  to  the  missionary  by 
hundreds,  but  they  could  never  be  induced  to  return  to  the 
mission  to  i)art  with  the  lymph  from  their  own  vaccinations, 
so  that  the  missionary  had  to  go  again  and  again  through 
the  tedious  ordeal  of  im])lanling  the  virus  upon  cows  or  calves. 
A  curious  feature  about  the  transaction  was  the  behavior  of 
the  king  of  the  valley.  He  selfishly  sought  to  limit  the  treat- 
ment to  himself,  his  family,  and  his  attendants,  then  to  his  own 
village,  and  then  to  the  ruling  persons  of  adjoining  villages; 
but  at  last  he  reluctantly  consented  to  its  extension  to  the  na- 
tion at  large.  The  motive  for  this  conduct  seemed  to  be  an 
ambition  to  show  a  kind  of  monopoly  in  the  matter  of  plague 
repression.  The  missionary  was  not  to  be  daunted,  but  con- 
tinued his  lymph  production  sufficiently  to  give  supplies  of 
his  product  to  his  brother-missionaries  among  the  nations  or 
tribes  that  were  liable  to  come  into  contact  with  his  own  in_ 
fected  people. 


MINOR  PARAGRAPHS. 

TUBERCULIN  IN  LUPUS  OF  THE  FACE. 

1)k.  J.  William  White  and  Dr.  Alfred  Wood,  of  the  Uni- 
versity of  Pennsylvania,  have  given  in  the  American  Jour ruil  of 
the  Medical  Sciences  for  January  an  account  of  liifjus  cured  by 
tuberculin.  The  article  is  illustrated  by  two  jihotogravures 
showing  the  left  side  of  the  jjatient's  head  before  and  after 
treatment.  The  disease  occurred  in  a  man,  aged  fifty-nine 
years,  and  had  been  under  observation  for  two  years  and  a  half. 
The  ulcerated  surface,  situated  in  front  of  and  lielow  the  ear, 
measured  four  inclies  and  over  in  its  long  diameter  and  about 
sixteen  square  inches  in  area.  Tlie  lupus  began  as  a  small  scab 
in  front  of  the  ear,  from  which  point  it  extended  steadily  and 
ulcerated  as  it  grew.  The  diagnosis  made  by  the  practitioners 
who  first  saw  the  case  was  that  of  epithelioma,  and  eight  cut- 
ting operations  and  numerous  ap[)lications  had  been  unsuccess- 
fully tried  before  the  use  of  parataloid  was  tried  by  Dr.  White. 
Six  injections  in  the  lumbar  region  were  made  in  three  weeks, 
beginning  with  O'l  milligramme  and  rising  to  0'5  milligramme 
at  each  injection.  A  distinct  reaction  was  obtained,  and  no 
]ocal  treatment  was  emidoyed.  At  the  end  of  three  weeks  the 
healing  was  sufficiently  established  to  allow  the  jjatient  to  re- 
turn home,  and  ten  days  later  the  ulcer  was  entirely  closed. 
Now,  two  years  later,  the  site  of  the  former  ulcer  is  occupied 
by  a  firm  and  sound  scar,  and  the  patient  states  that  at  no  time 
has  there  been  the  slightest  solution  of  continuity  since  the 
time  of  the  healing.  This  long  period  of  sound  condition  after 
the  use  of  parataloid  is  unusual,  and  few  peimanent  cures  of 
lupus  have  been  reported  from  the  use  of  that  substance. 
Oheyne  has  some  cases  of  rapid  healing,  and  the  patients  have 
continued  in  good  condition  for  several  weeks.  But  tlie  case 
we  have  spoken  of  strongly  emphasizes  the  utility  of  the  remedy 
in  some  desperate  cases,  and  indicates  that  more  frequent  trial 
should  be  made  of  it  when  failure  has  followed  a  number  of 
operative  procedures. 


PNEUMOCOCCOUS  MENINGITIS. 

Dr.  Lheritier  de  Chegelle  and  Dr.  G.  Prieur  publish  in  the 
Archives  de  medecene  et  de  pharmacie  militaires  for  December 
1892,  an  account  of  a  case  of  pneumonia,  occurring  in  a  soldier 
aged  twenty-two  years,  that  pursued  a  normal  course,  but  in 
which  the  convalescence  was  slow  and  the  patient  remained 
debilitated.  Almost  four  months  after  the  cessation  of  the  pneu- 
monic symptoms  he  was  seized  with  violent  delirium  and  died 
in  a  few  hours.  A  necropsy  showed  a  yellow  exudate  within 
the  dura  mater,  and  bouillon  and  gelatin  cultures  of  inoculations 
of  this  exudate  proved  that  it  was  caused  by  Fraenkel's  pneu- 
mococeus.  Netter  was  the  first  {Archives  generales  de  medecine, 
1887)  to  demonstrate  that  pneumococcous  meningitis  could  occur 
primarily  without  the  localization  of  the  diplococcus  in  any 
other  organ,  as  was  shown  by  a  pneumococcous  meningitis  with- 
out pneumonia.  Such  cases  are  observed  when  there  is  a  pi'eva- 
leuce  of  that  grave  form  of  pneumonia  that  is  usually  accom- 
panied by  endocarditis,  pericarditis,  or  some  other  extra-pul- 
monary complication,  a  pneumonia  that  differs  from  the  or- 
dinary form  and  to  which  Germain  S6e  has  given  the  name  of 
infecting  pneumonia  (pneumonic  infectante). 


DISEASES  OF  THE  ACCESSORY  NASAL  SINUSES. 

Dr.  Robert  0.  Myles  read  a  paper  on  this  subject  before 
the  Section  in  Laryngology  of  the  New  York  Academy  of  Medi- 
cine on  Wednesday,  January  25th.    The  advantage  of  month 


Feb.  4,  1893.] 


MINOR  PARA  GRA  PES.— ITEMS. 


141 


illumination  by  a  three-  or  four-candle-power  electric  light  in  a 
(lark  room  for  diagnostic  purposes  was  illustrated  on  several 
patients,  though  it  was  not  maintained  to  be  an  absolutely  re- 
liable te'^t.  Polypoid  degeneration  of  the  mucous  membrane, 
in  the  author's  experience,  was  the  most  frequent  cause  of  em- 
pyema of  the  maxillary  antrum,  but  upon  this  point  Dr.  Flar- 
rison  Allen,  of  Philadelphia,  and  Dr.  J.  H.  Bryan,  of  VVashing- 
ton,  disagreed  with  him  and  with  each  other,  the  former  hav- 
ing found  it  in  his  experience  due  to  trouble  in  the  teeth,  and 
the  latter  to  operations  upon  the  teeth.  Absence  of  pain,  it  was 
said,  was  generally  to  be  expected  in  this  disease,  and  the  main 
diagnostic  points  were  the  oozing  of  pus  from  the  oriflce  of  the 
antrum,  a  slight  fullness  upon  the  affected  side,  a  dark  spot  be- 
neath the  eye  seen  with  the  electric-light  test,  and  an  odor  per- 
ceptible by  the  patient  as  well  as  by  others.  The  practitioner 
should  be  on  the  lookout  for  diseases  of  the  accessory  sinuses, 
for  it  is  undoubtedly  true  that  many  cases  go  unrecognized  ex- 
cept as  cases  of  ordinary  rhinitis,  and  that  this  may  be  true 
even  among  nose  and  throat  specialists  is  suggested  by  the  rela- 
tively large  number  seen  by  Dr.  Myles  during  the  past  year. 


THE  ACADEMY  OF  MEDICINE  AND  NATIONAL 
QUARANTINE. 

At  a  special  meeting  of  the  New  York  Academy  of  Medicine 
held  on  Tuesday  evening  the  academy's  special  quarantine  com- 
mittee made  a  report  in  which  it  spoke  of  the  quarantine  estab- 
lishment at  this  port  as  utterly  inadequate,  and  attributed  its 
success  in  excluding  cholera  last  summer  to  a  "  fortunate  com- 
bination of  external  assistance  and  good  luck."  The  report  was 
adopted,  and  a  committee  was  appointed  to  go  to  Washington 
for  the  purposes  of  opposing  the  national  quarantine  bill  now 
before  the  Senate  and  of  secnring  the  passage  of  a  better  one. 
The  committee  first  mentioned  disclaimed  the  intention  of  cast- 
ing blame  upon  individuals.  Its  report  was  decidedly  pessi- 
mistic, but  it  is  to  be  hoped  at  least  (for  we  have  no  great  faith 
in  the  mission  to  Washington)  that  it  will  have  the  good  effect 
of  strengthening  the  hands  of  the  health  officer  of  the  port  in  his 
renewed  attempts  to  obtain  State  legislation  to  enable  him  to 
improve  and  enlarge  his  resources.  On  this  probably  we  shall 
have  to  depend  next  summer,  for  the  prospect  of  satisfactory 
congressional  legislation  this  winter  does  not  seem  bright.  For- 
tunately, there  is  good  reason  to  believe  that  the  State  of  New 
York  will  provide  adequately  for  the  occasion,  and  that  Health 
Officer  Jenkins  will  use  his  more  ample  facilities  judiciou.sly. 


THE  INFLUENCE  OF  THE  MINERAL  CONSTITUENTS  OF 
THE  BODY  UPON  IMMUNITY  FROM  INFECTIOUS  DISEASE. 

Dr.  T.  Lauder  Brunton  and  Mr.  T.  J.  Bokenham  have  been 
engaged  for  some  months  p.ist  in  testing  the  eflect  of  feeding 
animals  with  salts  of  potassium,  calcium,  strontium,  magnesium, 
and  aluminium,  with  the  view  of  ascertaining  whether  animals 
could  be  so  saturated  w  ith  these  salts  that  the  artificial  altera- 
tion in  the  mineral  constituents  of  the  body  would  alter  its  re- 
sistau('e  to  the  attacks  of  an  infectious  disease.  Their  results 
wei-e  reported  in  the  British  Medical  Journal  for  July  18, 1^91, 
and  January  7,  1893.  While  in  no  ease  were  any  ill  effects  pro- 
duced by  the  drugs  themselves,  there  was  no  evidence  that  their 
administration  exercised  any  protective  power. 


PUBLIC  INDIFFERENCE  TO  SANITATION. 

At  the  fortieth  annual  meeting  of  the  American  Society  ot 
Civil  Engineers,  held  recently  in  New  York,  the  committee  on 


impurities  of  public  water  supplies  asked  to  be  discharged  on 
the  ground  that,  after  continued  effort,  it  was  clear  that  the 
committee  could  not  accomplish  any  good  in  the  absence  of  co- 
operation by  persons  in  every  part  of  the  country,  which  co- 
operation could  not  be  obtained.  The  State  boards  of  health 
of  Massachusetts  and  Connecticut  had  taken  up  the  subject,  and 
the  committee  judged  that  such  individual  work  was  the  only 
kind  practicable  in  view  of  its  experience.  The  American  Wa- 
ter Works  Association  had  also  attempted  to  do  similar  work, 
but  had  met  with  no  success.  Those  engaged  in  sanitary  work 
know  how  true  this  statement  is  regarding  public  apathy  in 
such  matters,  but  the  committee  should  not,  we  think,  have 
been  so  easily  discourged,  bnt  rather  have  continued  its  work 
until  it  was  appreciated. 


A  PROPOSED  TREATMENT  OF  ASIATIC  CHOLERA  WITH 
SULPHUR  DIOXIDE. 

Dr.  G.  C.  Purvis  suggests  in  the  British  Medical  Journal 
for  January  7th  that,  as  the  cholera  spirillum  does  not  form 
spores,  the  employment  of  a  solution  of  sulphur  dioxide  by  rectal 
injection,  as  in  Cantani's  method  of  tannin  enteroclysis,  would 
speedily  destroy  that  organism  in  those  portions  of  the  intestinal 
tract  reached  by  the  gas.    lie  bases  his  recommendation  on 

?i  TV 

Professor  Cash's  experiments  that  showed  a  ^  or  —  (where 

n  =  64  grains  to  the  litre)  solution  of  sulphur  dioxide  to  be  al- 
most instantaneously  fatal  to  anthrax  bacilli.  The  sulphur  di- 
oxide may  be  prepared  by  acting  on  crystalline  sodium  sulphite, 
in  water  that  has  been  boiled,  by  either  hydrochloric  or  sul- 
phuric acid. 


POST-GRADUATE  COURSES  AT  THE  HOAGLAND 
LABORATORY,  BROOKLYN. 

Dr.  Sternberg,  director  of  the  laboratory,  has  planned  a 
course  of  twenty-five  demonstrations,  beginning  in  February 
and  extending  into  May,  for  the  benefit  of  graduates.  The  first 
part  of  the  course  will  be  devoted  to  work  in  histology  and  pa- 
thology, under  Dr.  J.  M.  Van  Oott,  and  the  latter  half  will  be 
guided  by  Dr.  Sternberg  himself  into  bacteriological  examina- 
tions. These  studies  are  undertaken  with  the  view  of  enabling 
practitioners  to  make  independent  research  as  to  bacteria  in 
tissues  and  for  the  improvement  of  their  microscopical  work. 
The  fee  for  the  course  will  be  thirty  dollars. 


A  VINE  LEAF  THE  NUCLEUS  OF  A  VESICAL  CALCULUS. 

At  a  recent  meeting  of  the  Societe  des  sciences  medieales 
de  Lyon,  as  we  learn  from  Lyon  medical,  the  debris  of  a  calcu- 
lus that  had  been  removed  from  a  woman,  aged  twenty-eight, 
were  presented.  The  nucleus  of  the  calculus  was  a  vine  leaf 
that  she  had  introduced  into  her  urethra  eight  years  before  the 
operation. 

A  NEW  JOURNAL  OF  MEDICAL  ELECTRICITY. 

The  new  Archives  d^electricite  medicale  experirnentnles  et 
cliniques,  founded  and  edited  by  M.  J.  Bergenia,  the  professor 
of  medical  physics  of  the  Bordeaux  faculty  of  medicine,  bids 
fdir  to  form  a  valuable  addition  to  our  periodical  literature.  An 
excellent  feature  is  its  bibliographical  index. 


ITEMS,  ETC. 

The  American  Electro-therapeutic  Association. — At  tlio  aiiiuinl 
meeting  officers  for  tiie  ensuiug  year  were  elected  as  follows :  Presi- 


142 


ITEMS.— PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jock., 


dent,  Dr.  Augustin  H.  Goelet,  of  New  York ;  vice-presidents,  Dr. 
William  F.  Hutoliinson,  of  Providence,  R.  I.,  and  Dr.  W.  J.  Ilardman, 
of  Ann  Arbor,  Mich. ;  secretary,  Dr.  Margaret  A.  Cleaves,  of  New 
York;  treasurer,  Dr.  K.  J.  Niinn,  of  Savannah,  Ga.  The  next  meeting 
will  be  held  in  Cliicago  on  Sejjtember  12th,  13tli,  and  14tli. 

Dr.  Hammond  on  Organic  Extracts. — In  Dr.  William  A.  Ham- 
mond's ai  ticlc  On  Certain  Organic  E.\tracts :  their  Preparation  and 
Ph3'siological  and  Therapeutical  Effects,  published  in  our  last  issue,  an 
error  occurred  in  the  last  paragraph.  In  the  sixth  line  from  the  con- 
clusion, for  "  uric  acid,"  read  boric  acid. 

The  Bviffalo  Academy  of  Medicine. — At  the  next  meeting  of  the 
Section  in  Surgery,  on  Tuesday  evening,  the  7th  inst.,  Dr.  George  F. 
Cott  will  read  a  pa^er  entitled  Some  Remarks  on  Intubation,  and  offi- 
cers for  the  ensuing  year  will  be  elected. 

The  New  York  Therapeutic  Review  is  the  title  of  a  new  quarterly 
journal  edited  by  Dr.  Paul  Gibier.  The  first  number  for  January, 
1893,  contains  thirty  large  octavo  pages  of  reading  matter. 

The  Metropolitan  Medical  Society  has  elected  officers  as  follows : 
President,  Dr.  Henry  S.  Stark ;  vice-president.  Dr.  S.  Marx ;  recording 
secretary.  Dr.  B.  F.  Ochs ;  corresponding  secretary,  Dr.  E.  Meierhof. 

The  ITniverBal  Medical  Jonmal  is  now  the  title  of  the  Satellite  of 
the  Annual  of  the  Universal  Medical  Sciences,  edited  by  Dr.  Charles  E. 
Sajous  and  Dr.  C.  Sumner  Witherstiue,  of  Philadelphia. 

Changes  of  Address. — Dr.  Henry  0.  Marcy,  to  No.  180  Common- 
wealth Avenue,  Boston ;  Dr.  C.  J.  Mooney,  to  No.  38  East  Sixtieth 
Street. 

The  Death  of  Dr.  Linus  P.  Brockett,  of  Brooklyn,  occurred  on  Janu- 
ary 13th.  He  was  a  native  of  Canton,  Conn.,  and  a  graduate  of  the 
Yale  Medical  School.  He  had  lived  over  thirty  years  in  Brooklyn,  and 
had  given  his  time  largely  to  literary  work.  He  was  the  author  of 
Woman^s  Work  in  the  Civil  War  and  several  other  books.  His  age 
was  seventy- two  years. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  SlcUes 
Army,  from  Januari/  15  to  January  S8,  1893 : 

Raymond,  Thomas  U.,  First  Lieutenant  and  Assistant  Surgeon,  is  re- 
lieved from  further  duty  at  Vancouver  Barracks,  Washington,  and 
will  report  in  person  to  the  commanding  officer.  Fort  Canby,  Wash- 
ington, for  duty  at  that  station,  relieving  Carter,  Edvtard  C,  Cap- 
tain and  Assistant  Surgeon,  who,  on  being  thus  relieved,  will  pro- 
ceed to  Vancouver  Barracks  and  report  in  person  to  the  command- 
ing officer  of  that  post  for  duty  there. 

PoiNDEXTER,  Jefferson  D.,  Captain  and  Assistant  Surgeon,  is  granted 
leave  of  absence  for  four  months. 

Edie,  Goy  L.,  Captain  and  Assistant  Surgeon,  is  relieved  from  duty  at 
Fort  Niobrara,  Nebraska,  and  will  repair  to  New  York  city  and  re- 
port in  person  to  the  attending  surgeon  in  that  city  for  duty  in  his 
office. 

Crampton,  Louis  W.,  Captain  and  Assistant  Surgeon,  now  on  leave  of 
absence  at  Los  Angeles,  California,  will  report  in  person  to  the  com- 
manding general.  Department  of  Arizona,  for  such  temporary  duty 
at  Los  Angeles,  California,  as  may  be  required. 

Walker,  Freeman  V.,  Captain  and  Assistant  Surgeon,  is  granted  leave 
of  absence  for  four  months  on  surgeon's  certificate  of  disability,  on 
condition  that  he  spend  the  period  of  leave  as  a  patient  in  the  Army 
and  Navy  General  Hospital,  Hot  Springs,  Arkansas. 

Naval  Intelligence. — Official  List  of  Changea  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  January  28.  1893 : 
Arxoi-d,  W.  F.,  Passed  Assistant  Surgeon.    Detached  from  the  U.  S. 

Training-ship  Richmond  and  granted  three  weeks'  leave  of  absence. 

Society  Meetings  for  the  Coming  Week : 

Mo.NDAY,  February  Glh :  New  Yoi-k  Academy  of  Sciences  (Section  in 
Biology) ;  German  Medical  Society  of  the  City  of  New  York  ;  Mor- 
I  isania  Medical  Society  (private) ;  Brooklyn  Anatomical  and  Surgical 


Society  (private) ;  Utica  Medical  Library  Association  ;  Corning,  N. 
Y.,  Academy  of  Medicine  ;  Boston  Society  for  Medical  Observation  ; 
St.  Albiins,  Vt.,  Medical  Association ;  Providence,  R.  I.,  Medical 
Association;  Hartford,  ('onn..  Medical  Society;  South  Pittsburghi 
Pa.,  Medical  Society  ;  Chicago  Medical  Society. 
Tuesday,  February  7th:  Medical  Society  of  the  State  of  New  York 
(first  day — Albany);  New  York  Obstetrical  Society  (private) ;  New 
York  Neurological  Society  ;  Elmira  Academy  of  Medicine  ;  Buffalo 
Academy  of  Medicine  (Section  in  Surgery) ;  Buffalo  Medical  and 
Surgical  Association  ;  Ogdensburgh,  N.  Y.,  Medical  Association ; 
Hampden,  Mass.,  District  Medical  Society  (Springfield);  Hudson, 
N.  J.,  (jounty  Medical  Society  (Jer.sey  City) ;  Androscoggin,  Me., 
County  Medical  Association  (annual — Lewiston) ;  Baltimore  Acade- 
my of  Medicine. 

Wednesday,  February  8th :  Medical  Society  of  the  State  of  New  York 
(second  day) ;  New  York  Surgical  Society  ;  New  York  Pathological 
Society  ;  American  Microscopical  Society  of  the  City  of  New  York ; 
Medical  Society  of  the  County  of  Albany ;  Pittsfield,  Mass.,  Medical 
Association  (private) ;  Franklin,  Mass.,  District  Medical  Society 
(quarterly — Greenfield) ;  Philadelphia  County  Medical  Society. 

Thursday,  February  9th :  Medical  Society  of  the  State  of  New  York 
(third  day) ;  New  York  Laryngological  Society ;  New  York  Academy 
of  Medicine  (Section  in  Pa;diatrics) ;  Society  of  Medical  Jurispru- 
dence and  State  Medicine,  New  York ;  Brooklyn  Pathological  So- 
ciety (annual) ;  Medical  Society  of  the  County  of  Cayuga,  N.  Y. ; 
South  Boston,  Mass.,  Medical  Club  (private) ;  Pathological  Society 
of  Philadelphia. 

Friday,  February  10th :  New  York  Academy  of  Medicine  (Section  in 
Neurology) ;  Yorkville  Medical  Association  (private) ;  German  Medi- 
cal Society  of  Brooklyn  ;  Medical  Society  of  the  Town  of  Saugerties, 
N.  Y. 

Saturday,  February  11th :  Obstetrical  Society  of  Boston  (private). 
Answers  to  Correspondents : 

No.  392. — Probably  circumcision  would  be  of  service. 
No.  393. — We  knon  of  no  such  reports. 


IProctciJmgs  of  .Societies. 

NEW  YOEK  SURGICAL  SOCIETY. 
Meeting  of  November  9,  1892. 
The  President,  Dr.  Aepad  G.  Geehtee,  in  the  Chair. 

Thiersch's  Skin-grafting  on  a  Large  Burned  Surface.— 

Dr.  F.  W.  MtJEitAY  presented  a  patient  who  had  been  operated 
upon  by  this  method.  Six  tnonths  before,  the  patient  had  been 
scalded  over  the  abdomen  and  over  the  greater  part  of  both  upper 
extremities.  The  scalds  of  the  abdomen  and  of  the  right  upper 
exircmity  had  healed  quickly  under  the  use  of  dermatol.  On 
the  left  side  there  was  left  a  large  granulating  surface,  beginning 
above  the  wrist,  involving  the  entire  flexor  surface  of  the  fore- 
arm and  elbow,  then  involving  the  entire  inner  hnlf  of  the  arm, 
extending  across  the  axilla  and  ending  in  the  left  pectoral  region, 
Tiie  entire  granulating  surface  was  completely  covered  with 
skin  grafts  at  one  sitting.  All  the  grafts  united,  excepting 
over  a  small  space  in  part  of  the  elbow  ;  but  this  healed  rapidly. 
Wet  dressings  for  seven  days,  then  dry  dressings,  and  the  patient 
was  soon  discharged  entirely  healed  and  with  a  useful  arm. 
There  was  a  slight  contraction  at  tlie  elbow,  but  it  did  not  in- 
crease and  did  not  interfere  with  the  use  of  the  arm.  At  dififer- 
cnt  parts  of  this  grafted  surface  could  now  be  seen  what  ap- 
peared to  be  secondary  formations  of  scar  ti>BUP.  About  the 
edges  of  the  grafts  the  underlying  tissue  was  thickened  and 
elevated  and  the  appearance  was  that  of  false  cheloid.  This 


Feb.  4,  1893.] 


PROCEEDINGS 


OF  SOCIETIES. 


143 


was  the  first  case  which  the  speaker  had  seen  where  such  a  con- 
dition had  followed  Thiersch's  method  of  skin-grafting. 

Dr.  F.  Lanqe  had  noticed  a  like  secondary  formation  of  scar 
tissue  in  several  of  his  cases  after  the  patient  had  been  dis- 
charged with  a  perfectly  healthy  grafted  surface.  He  men- 
tioned one  case  where  he  had  done  the  operation  for  webbed 
fingers  with  good  result.  The  patient  had  been  presented  to 
the  society.  Six  months  later  be  had  seen  him  again.  Appar- 
ently scar  tissue  had  formed  underneath  the  grafts  and  contrac- 
tion to  a  certain  degree  had  been  the  result.  The  same  thing 
he  had  noticed  in  a  lady  from  whose  cheek  he  had  removed  a 
melanosarcoma.  Primarily  the  grafts  had  healed  in  a  faultless 
manner. 

Dr.  F.  Kammeeer  had  had  a  similar  experience  last  summer 
in  a  case  where  he  had  done  Thiersch's  grafting  after  the  sec- 
tion of  some  contracted  tissues  on  the  neck  after  a  burn.  The 
denuded  surface  had  been  quite  a  large  one  and  had  been  im- 
mediately covered  by  the  grafts.  The  result  a  few  weeks  after 
operation  was  apparently  a  very  good  one,  and  the  contraction 
seemed  to  have  been  entirely  overcome.  Several  months  later, 
however,  the  process  of  contraction  had  again  gone  on  beneath 
the  grafts  to  a  considerable  extent. 

Dr.  OnARLEs  MoBurney  desired  to  know  how  long  the  rub- 
ber tissue  had  been  left  on. 

Dr.  Murray  replied,  Seven  days. 

Dr.  MoBuRNEY  thought  that  where  the  rubber  tissue  and 
wet  dressing  had  been  replaced  by  a  dry  dressing  so  early  as 
had  been  specified  by  Dr.  Murray  this  cheloid  condition  would 
be  more  apt  to  develop.  He  thought  the  wet  dressing  should 
be  left  on  at  least  twelve  or  fourteen  days.  However,  the  dis- 
continuance of  the  wet  dressing  at  an  early  period  would  not 
account  for  all  cases  of  cheloid  formation,  for  the  speaker  had 
seen  it  occur  in  several  instances  where  the  wet  dressings  had 
not  been  removed  until  after  the  lapse  of  a  fortnight. 

Dr.  L.  S.  PiLonER  had  noticed  the  cheloid  formation,  but 
bad  been  more  interested  in  another  complication.  In  a  case 
where  he  had  done  grafting  over  an  extensive  burn  everything 
had  gone  well  as  long  as  the  patient  had  remained  in  bed  ;  the 
grafts  had  all  appeared  perfectly  healthy.  In  a  few  hours  after 
the  patient  had  left  his  bed  a  very  extensive  purpuric  condition 
had  developed,  not  only  in  the  new  grafts,  but  also  in  the  surface 
from  which  the  grafts  had  been  taken.  This  purpura  had  gone 
on  to  the  formation  of  blisters  discharging  a  serous  fluid.  Some 
of  the  blisters  had  opened  and  some  had  not.  Upon  the  pa- 
tient's returning  to  bed  the  purpura  bad  diminished  and  the  sur- 
faces had  resumed  a  more  healthy  appearance.  After  his  leaving 
his  bed  the  second  time  the  same  condition  had  developed,  and 
he  had  returned  to  bed  a  third  time,  after  which  the  healthy 
appearance  had  again  been  resumed.  The  patient  was  now  in 
bed. 

Dr.  George  R.  Fowler  expressed  the  opinion  that  the 
cheloid  formation  was  due  to  the  same  cause  that  produced 
the  condition  after  other  operations  than  skin  grafting.  Some 
time  before  lie  had  attempted  to  remove  a  large  vaccination 
scar  which  had  undergone  cheloid  change  from  the  arm  of  a 
child  by  cutting  away  the  scar  and  grafting  the  surface  with 
the  skin  of  a  frog.  Secondary  cheloid  had  developed.  The 
s[)eaker  had  again  attempted  the  operation  by  grafting  the  skin 
from  the  lower  surface  of  a  pigeon's  wing  on  to  the  child's  arm. 
Again  cheloid  had  developed.  The  third  time  the  operation 
had  been  done  the  akin  had  been  taken  from  the  inner  surface 
of  the  patient's  tiiigh,  after  wliich  cheloid  had  developed,  not 
only  in  the  graft,  but  also  at  the  point  from  which  the  graft 
had  been  taken.    Ho  had  not  attempted  a  fourth  operation. 

Dr.  Wyetu  suggested  that  the  contraction  at  the  elbow 
might  be  overcome  by  cutting  the  contracted  tissues  and  sewing 


on  a  flap  of  skin  turned  over  from  the  abdomen.  He  had  suc- 
cessfully treated  two  cases  in  this  way. 

Extensive  Ulceration  of  the  Scalp.— Dr.  Kammerer  pre- 
sented a  patient  showing  this  condition.  The  girl  was  about 
nineteen  or  twenty  years  old,  with  neither  family  nor  personal 
history  beyond  the  fact  that,  about  eight  years  before,  she  had 
noticed  an  ulceration  on  the  outer  side  of  the  left  foot,  which 
had  gradually  increased  in  size  for  about  two  years,  and  had 
then  begun  to  heal  and  had  gone  on  to  perfect  recovery  with- 
out treatment.  Four  years  ago  a  small  ulcer  had  appeared  on 
the  top  of  the  patient's  head,  which  had  gradually  increased  in 
size  until  the  present  time,  when  ft  occupied  almost  the  entire 
scalp.  She  had  entered  St.  Francis's  Hospital  last  summer  in 
abou  the  same  condition  that  she  was  now  in,  except  that  th& 
granulations  had  not  then  been  so  healthy-looking  as  they  now 
were.  The  entire  scalp  and  forehead  were  involved  and  cov- 
ered with  smooth,  flabby,  granulating  tissue.  For  the  first  two 
months  very  large  doses  of  iodide  of  potassium  had  been  given 
three  times  daily.  This  had  done  no  good.  Then  the  patient 
had  been  etherized,  the  borders  of  the  ulcer  excised,  and  the 
ulcer  itself  scraped  and  dressed  with  a  l-to-250  solution  of  sil- 
ver nitrate.  She  had  done  very  well'under  this  treatment  for 
two  months,  but  lately  the  appearance  of  the  granulations  had 
not  been  so  healthy.  During  curetting  the  skull  had  been  de- 
nuded of  its  periosteum  in  several  areas  of  the  size  of  a  twenty- 
five-cent  piece.  These  places  had,  however,  again  been  cov- 
ered by  the  granulations. 

The  speaker  had  been  unable  to  come  to  a  definite  conclu- 
sion regarding  the  nature  of  the  trouble.  He  had,  of  course, 
suspected  syphilis  and  tuberculosis,  the  former  as  the  more 
probable.  The  appearance  of  the  ulcerated  surface  and  the  re- 
sult of  combined  surgical  and  medical  treatment  did  not,  how- 
ever, warrant  such  a  diagnosis.  A  microscopical  examination 
of  the  granulating  tissue  had  not  been  made. 

Dr.  Lange  had  seen  a  few  similar  cases  of  this  smooth  granu- 
lating surface.  In  one  case  almost  the  whole  chest  had  been 
involved.  In  this  case  hypodermics  of  mercuric  bichloride  had 
done  good  work.  Since  some  cases  of  syphilis  did  not  yield  to 
the  iodide  alone,  he  advised  "mixed  treatment"  in  this  case. 
He  did  not  think  the  ulcer  tuberculous;  therefore  it  must  be 
syphilitic,  as  there  was  nothing  else  for  it  to  be.  The  character 
of  the  scar  on  the  foot  made  it  probable  that  there  had  existed 
a  syphilitic  ulceration. 

Dr.  0.  K.  Briddon  had  seen  one  similar  case.  Large  doses 
of  iodide  of  potassium  had  increased  the  disease.  It  had  readi- 
ly yielded  to  "  mixed  treatment."  He  had  thought  both  cases 
syphilitic. 

Dr.  McBuENEY  said  he  would  not  give  a  positive  opinion, 
but  he  believed  the  ulcer  to  be  tuberculous,  from  its  appearance 
and  also  from  the  character  of  the  scar  at  the  ankle.  He  also 
thought  its  growth  was  too  slow  for  syphilis.  He  advised  Dr. 
Kammerer  to  examine  the  ulcer  for  tubercular  bacilli. 

Dr.  Willy  Meyer  thought  the  ulcer  was  due  to  syphilis, 
since  the  evidently  former  extensive  sore  surface  on  the  foot 
had  healed  without  operative  treatment.  According  to  his  ex- 
perience, tuberculous  ulcers  of  such  a  size  never  healed  without 
surgical  interference. 

Dr.  McBoRNEY  differed  with  Dr.  Meyer  in  this  respect.  He 
had  seen  several  turberculous  ulcers  heal  without  operation. 

Dr.  Wyeth  asked  if  it  was  possible  that  the  ulcer  could  have 
been  caused  by  irritants  applied  by  friends  while  the  patient 
had  been  sleeping.    He  had  seen  one  such  case. 

Large  Vesical  Calculi. — The  Presii>ent  showed  specimens 
that  had  been  taken  from  the  body  of  a  peddler,  sixty-two 
years  old,  who  had  presented  himself  at  Mt.  Sinai  Hospital  in  a 
state  of  physical  and  mental  decrepitude.    The  only  history 


144 


BOOK  NOTICES.— NEW  INVENTIONS. 


[N.  Y.  Med.  Johe., 


that  could  be  secured  was  that,  fifteen  years  before,  he  had  suf- 
fered from  retention  of  urine  and  had  been  compelled  to  use  a 
catheter.  This  had  lasted  only  a  short  time,  and  he  had  soon 
become  "  perfectly  well."  Four  months  ago  the  bladder  had 
become  irritated  and  continued  so  when  he  had  come  into  the 
hospital,  on  July  12th.  Upon  the  introduction  of  a  sound  it 
had  immediately  come  in  contact  with  a  calculus.  The  bladder 
seemed  almost  filled  with  calculi.  Only  about  two  ounces  of 
fluid  could  be  forced  into  the  bladder.  A  suprapubic  operation 
was  done  and  the  three  calculi  were  removed.  They  weighed 
4,140  grains.  The  first  one  had  been  the  only  troublesome  one 
to  remove.  Unfortunately,  the  patient  died  of  exhaustion  nine 
days  after  the  operation. 

Neurectomy. — Dr.  Lange  showed  two  specimens  of  nerves 
he  had  taken  from  two  old  men  (one  sixty  years  old  and  the 
other  seventy)  by  Tlnersch's  method  and  forceps.  The  first 
specimen  had  been  from  the  third  division  of  the  fifth  nerve. 
It  had  been  taken  from  just  below  the  foramen  ovale.  About 
an  inch  of  the  main  trunk  had  been  removed.  The  second  spe- 
cimen had  been  a  part  of  the  second  branch,  taken  from  just 
below  the  foramen  rotundum.  In  both  cases  the  neuralgia  had 
been  cured.  In  the  second  case  the  evulsion  was  done  partly 
at  the  point  of  the  exit  from  the  infra-orbital  canal,  and  the 
nerve  was  extracted  far  into  its  finest  ramifications  up  to  about 
the  point  of  entrance  into  the  fissura  orbitalis  inferior.  A  sec- 
ond evulsion  just  below  the  foramen  rotundum  in  the  same  sit- 
ting, after  osteoplastic  resection  of  the  zygoma,  had  yielded  the 
main  trunk,  including,  as  he  thought,  the  ganglion  sphenopala- 
tinum.  In  the  first  case  only  one  branch  of  the  third  nerve 
had  given  way  in  its  smallest  ramifications. 


|ooh  Sottas. 


j^tudes  de  clinique  chirurgicale.    Ann6e  scolaire  1890-1891. 
Par  A.  Lk  Dentu,  professeur  de  clinique  chirurgicale  a  la 
Faculty  de  medecine  de  Paris.    Avec  trente-six  figures  dans 
le  texte.    Paris :  G.  Masson,  1892.    Pp.  xi-312. 
Toe  author  states  that  this  volume  is,  he  trusts,  the  initia- 
tive of  a  series  of  clinical  studies  that  will  be  published  from 
time  to  time  as  circumstances  permit.    In  it  he  has  presented 
the  statistics  of  his  operations  for  a  year,  the  clinical  lectures 
that  he  has  delivered,  and  descriptions  of  the  more  important 
operations  that  he  has  performed.    The  text  is  illustrated,  and 
the  book  is  an  interesting  and  worthy  record  of  a  year's  work 
in  the  n6pital  Necker. 

BOOKS,  ETC.,  RECEIVED. 

The  Anatomy  and  Surgical  Treatment  of  Hernia.  By  Henry 
0.  Marcy,  A.  M.,  M.  I).,  LL.  D.,  of  Boston,  President  of  the 
American  Medical  Association ;  Surgeon  to  the  Hospital  for 
Women,  Cambridge,  etc.  With  Sixty-six  Full-page  Heliotype 
and  Lithographic  Plates,  including  Eight  Colored  Plates  from 
Bougery,  and  Thirty-seven  Illustrations  in  the  Text.  New 
York  :  1).  Appleton  &  Company,  1892.  Pp.  xvii-421.  [Price, 
$15.] 

The  Diseases  of  Children,  Medical  and  Sui-gical.  By  flenry 
Ashby,  M.  D.  Lond.,  F.  R.  C.  P.,  Physician  to  the  Central  Hos- 
pital for  Sick  Oliildren,  Manchester,  and  G.  A.  Wright,  B.  A., 
M.  B.  Oxon.,  F.  R.  C.  S.  Eng.,  Assistant  Surgeon  to  the  Man- 
chester Royal  Infirmary.  Second  Edition.  Edited  for  Ameri- 
can Students  by  William  Perry  Northrnp,  A.  M.,  M.  D.,  Attend- 
ing Physician  to  the  Presbyterian  Hospital,  New  York.  New 


York  and  London  :  Longmans,  Green,  &  Co.,  1893.  Pp.  xxii- 
773.    [Price,  $5.] 

A  Handbook  of  the  Diseases  of  the  Eye  and  their  Treat- 
ment. By  Henry  B.  Swanzey,  A.  M.,  M.  B.,  F.  R.  C.  S.  I.,  Sur- 
geon to  the  National  Eye  and  Ear  Infirmary,  Dublin.  Fourth 
Edition.  With  Illustrations.  Philadelphia:  P.  Blakiston,  Son, 
&  Co.,  1892.    Pp.  xv-518.    [Price,  $3.] 

Handbook  of  Massage.  By  Emil  Kleen,  M.  D.,  Ph.  D.,  Prac- 
ticing Physician  in  Carlsbad,  Bohemia.  Authorized  Translation 
from  the  Swedish.  By  Edward  Mussey  Hartwell,  M.  D.,  Ph.  D., 
Director  of  Physical  Training  in  the  Public  Schools  of  Boston. 
Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1892.  Pp.  xvi-17  to 
316.    [Price,  $2.75.] 

Alcoholism  and  its  Treatment.  By  .1.  E.  Usher,  M.  D., 
Fellow  of  the  Royal  Geographical  Society  of  London,  etc.  New 
York :  G.  P.  Putnam's  Sons.  London :  Bailliere,  Tindall,  & 
Cox,  1892.    Pp.  xii-151.    [Price,  $1.25.] 

The  Coal-tar  Colors,  with  Especial  Reference  to  their  In- 
jurious Qualities  and  the  Restriction  of  their  Use.  A  Sanitary 
and  Medico-legal  Investigation.  By  Theodore  Weyl.  With  a 
Preface  by  Professor  Sell.  Translated,  with  permission  of  the 
Author,  by  Henry  Leffmann,  M.  D.,  Ph.  D.,  Philadelphia.  Phila- 
delphia: P.  Blakiston,  Son,  &  Co.,  1892.  Pp.  xii-17  to  154. 
[Price,  $1.50.] 

Convulsions  and  Malaria.  By  Frederick  Hill  Stanbro,  M.  D., 
Springville,  N.  Y.    [Reprinted  from  the  Medical  News.] 


^eto  Jnbentbixs,  etc. 


A  NEW  INSTRUMENT  FOR  IRRIGATING  THE  UTERUS  IN 
PUERPERAL  SEPTICEMIA. 

By  Russell  Bellamy,  M.  D., 
jrmioB  PHYSICIAN,  belleyuk  hospital. 

Recently,  while  pursuing  one  of  the  most  popular  methods 
of  treating  puerperal  septicaemia,  using  several  of  the  favorite 
irrigators,  I  was  impressed  with  the  great  length  of  time  re- 
quired in  douching  the  uterus,  the  liability  of  injuring  the  soft- 
ened walls  of  this  organ,  the  imperfect  drainage,  the  small  area 
of  the  diseased  endometrium  that  is  attacked  by  the  therapeu- 
tic agent,  and  the  uncertainty  of  the  amount  of  organized  and 
necrosed  tissue  that  is  removed  by  the  bichloride  or  creolin  solu- 
tions. 

Believing  that  the  obstacles  related  above  attending  the 
methods  by  the  use  of  the  instruments  for  intra-uterine  douch- 
ing could  be  easily  overcome,  I  devised  an  irrigator,  which, 
after  having  been  thoroughly  tested,  is  described  as  follows : 


1.  It  consists  of  two  tubes — a  glass  tube,  twelve  inches  long, 
half  an  inch  in  diameter,  with  its  proximal  end  slightly  curved 
and  smooth,  its  distal  end  containing  two  openings,  one  being 
horizontal,  tapering  for  the  introduction  of  the  internal  tube; 
the  other,  opening  at  the  end  of  an  arm  an  inch  and  a  half  long, 
at  an  angle  of  forty-five  degrees,  for  the  outflow  (if  a  Kelly  pad 
or  a  bed  pan  is  not  used)  through  rubber  tubing  to  a  receptacle 
below. 


Feb.  4,  1893.] 


MISCELLANY. 


146 


2.  The  internal  tube  is  composed  of  material  which  renders 
it  firm,  but  sufficiently  elastic  for  all  purposes.  It  is  fourteen 
inches  long,  one  fourth  of  an  inch  in  diameter,  having  twenty 
perforations  at  its  proximal  end ;  to  the  distal  end  is  attached 
the  tubing  of  an  ordinary  fountain  syringe. 

Method  of  Using. — The  glass  tube  is  introduced  well  into 
the  cervix  uteri,  the  index  finger  on  the  os  tineas  being  the 
guide. 

The  second  tube  is  introduced  through  the  glass  tube  until 
the  distal  end  of  the  glass  tube  is  closed  by  the  rubber  tubing, 
which  embraces  the  distal  end  of  the  internal  tube  for  half  an 
inch. 

Advantages. — 1.  A  double  return  flow  is  got,  the  one  com- 
ing back  between  the  tubes  being  especially  advantageous  in 
oases  of  contraction  of  the  os  uteri,  the  space  between  the  tubes 
being  sufficient  to  admit  quite  a  large-sized  slough,  clot,  or  detri- 
tus ;  the  other  returning  on  the  outside  of  the  tube. 

2.  It  saves  time,  a  large  douche  bag  being  emptied  in  three 
minutes,  while  by  other  tubes  fifteen  to  twenty  minutes  were 
consumed,  thereby  causing  the  woman  little  discomfort,  pre- 
venting a  long  strained  position,  and  saving  the  busy  obstetri- 
cian much  valuable  time. 

3.  By  having  a  large  number  of  openings,  small  in  size,  we 
are  enabled  to  secure  more  power  to  attack  a  larger  portion  of 
endometrium  (the  force  of  the  liquid  being  regulated  by  the 
height  of  the  bag),  and  the  certainty  of  removing  all  noxious 
material  being  secured. 

4.  The  moderately  soft  and  pliable  consistence  of  the  inter- 
nal tube,  which  comes  in  contact  with  the  uterine  walls,  does 
away  with  the  possibility  of  injuring  them  seriously,  as  might 
be  the  case  with  the  other  devices  of  glass  and  metal. 

5.  In  cases  of  post-partum  haemorrhage,  or  where  it  is  con- 
sidered advisable  to  rapidly  irrigate  the  uterus  or  vagina,  either 
tube  can  be  attached  to  the  fountain  syringe  and  used  with  great 
advantage. 

6.  It  can  be  kept  aseptic,  boiling  water  and  antiseptic  solu- 
tions not  seriously  afi'ecting  it. 

I  am  greatly  indebted  to  the  "W.  F.  Ford  Surgical  Instrument 
Company,  New  York  city,  for  their  promptness  and  cleverness 
in  carrying  out  my  design. 


The  New  Mesmerism. — Under  this  heading  the  London  Times  for 
•lanuary  10th  publishes  the  following  letter  from  Mr.  Ernest  Hart,  the 
editor  of  the  British  Medical  Journal  : 

"  Having  been  invited  by  the  committee  of  the  Institut  de  France 
to  attend  the  Pasteur  Jubilee,  I  found  myself  in  Paris  at  the  moment 
when  the  first  communication  of  your  correspondent  on  The  New  Mes- 
merism was  published.  In  view  of  the  importance  attaching  to  state- 
ments published  so  prominently  and  with  so  much  detail  in  the  colunms 
of  the  Times,  I  took  the  opportunity  of  communicating  through  a  medi- 
cal friend  with  Dr.  Luys,  and  was  invited  by  him  to  witness  the  demon- 
strations which  your  correspondent  so  picturesquely  describes,  and  which 
carried  such  firm  conviction  to  his  mind.  The  whole  phenomena  which 
he  witnessed  were  actually  reproduced  before  me,  and  many  more,  still 
more  startling  and  dramatic,  of  which  he  makes  no  mention.  JJcing 
deeply  interested  in  performances  which  were,  prima  facie,  so  astound- 
ing, and  which,  if  verified,  would  carry  us  back  to  some  of  the  old 
practices  and  conclusions  of  the  mystics  and  sorcerers  of  the  middle 
ages,  I  thought  it  worth  while  to  spend  a  fortnight  in  the  closest  inves- 
tigation of  the  facts,  and  in  attempting  to  arrive  at  correct  conclusions 
as  to  their  causation, 


"  With  this  object  I  made  repeated  visits  to  La  Charite  hospital, 
and  I  visited  the  Ecole  Polytechnique  by  the  invitation  of  Colonel 
Rochas  d'Aiglun,  the  administrateur  of  the  school,  who  reproduced  be- 
fore me  there,  as  he  had  already  done  in  the  presence  of  Dr.  Luys  at 
La  Charite,  the  performances  described  as  '  externalization  of  the  sen- 
sations '  and  '  transference  of  sensibility  to  inanimate  objects.'  I  was 
able  to  carry  out  at  La  Charite  hospital  itself  some  very  simple  test 
experiments,  which,  at  the  outset,  convinced  me  that  Dr.  Luys  was  the 
victim,  to  some  extent,  of  trickery  and  imposture,  and  that  he  did  not 
take  even  the  elementary  precautions  necessary  to  protect  himself  from 
fraud  on  the  part  of  his  .subjects,  and  from  self-deception.  I  suggest- 
ed to  him  at  once  one  or  two  simple  tests  of  the  good  faith  of  his  pa- 
tients, such  as  the  use  of  an  electro-magnet,  in  which  the  magnetic  cur- 
rent could  easily  be  extinguished  without  the  patient's  knowledge; 
and  again,  in  his  experiments  on  the  influence  or  alleged  influence  of 
medicinal  substances  in  sealed  tubes  placed  in  contact  with  the  skin,  I 
suggested  that  substances  other  than  those  which  the  patient  had  rea- 
son to  believe  were  in  use  should  actually  be  applied.  Both  of  these 
precautions,  however,  he  declined  then  to  take,  alleging  either  that  he 
had  done  so  in  the  past  or  would  in  the  future.  He  could  only  show  me, 
he  said,  his  experiments  in  his  own  way,  and,  if  I  were  not  convinced, 
be  could  only  regret  it.  On  each  of  the  occasions  of  my  visits  I  was 
accompanied  by  independent  and  competent  witnesses,  who  observed 
with  me  that  in  two  instances  in  which  I  employed  very  simple  mag- 
netic tests  of  control,  the  patients  were  uttei-ly  at  fault,  giving  false 
answers,  and  seeing  blue  flames  and  red  flames  issue  from  a  small 
pocket  simili-magnet,  which  was  no  magnet  at  all,  and  making  other 
blunders  which  equally  gave  reason  to  suspect  imposture. 

"  Subsequently  to  this  I  secured  the  attendance  at  my  apartments 
of  five  of  the  persons  on  whom  Dr.  Luys  had  been  accustomed,  and  is 
still  accustomed,  to  give  his  demonstrations  in  the  wards,  and  who  have 
been  the  chief  subjects  of  his  Lemons  cliniques,  of  which  I  have  before 
me  the  printed  volumes,  containing  reports  of  ttie  marvelous  phenome- 
na produced,  with  photographic  representations  of  many  of  them.  I 
had  in  all  nearly  twelve  sittings  with  these  five  subjects,  among  them 
being  the  persons  shown  to  your  correspondent  and  going  through  the 
performances  which  he  describes.  At  all  these  sittings  there  were 
present  medical  and  scientific  witnesses  and  independent  observers  of 
undoubted  competency.  Among  those  who  were  present  at  one  or 
other  of  the  sittings  were  Dr.  Louis  Olivier,  darteur  de.i  sciences,  direc- 
teur  de  la  Revue  generale  des  sciences  ;  Dr.  Lutaud,  editor  of  the  Jour- 
nal de  medecine  de  Paris  ;  Dr.  Sajous,  editor  of  the  American  Annual 
of  Medicine  ;  M.  Cremifere,  of  St.  Petersburg ;  Mr.  B.  F.  C.  Costello,  of 
London,  and  others  whose  names  I  need  not  at  present  mention.  They 
have  signed  the  notes  of  the  various  test  experiments.  These  notes 
are  too  numerous  and  too  detailed  to  permit  me  to  venture  to  burden 
your  columns  with  them ;  I  shall  shortly  publish  them  in  detail.  I  need 
only  say  here  that  the  whole  of  the  phenomena  were  reproduced  with 
sham  magnets,  with  substituted  figures,  with  mi.snamed  medicinal  sub- 
stances, and  with  distilled  water,  and  with  sham  '  suggestion,'  opposite 
suggestion,  or  none  at  all.  Every  one  was  able  to  convince  himself  that 
all  the  results  so  shown  were,  without  exception,  simulated,  fictitious, 
and  fraudulent.  That  some  of  the  patients  were  hypnotic  and  hysteri- 
cal in  a  high  degree  does  not  alter  the  fact  that  from  beginning  to  end 
they  all  showed  themselves  to  be  tricksters  of  the  most  barefaced  kind  ; 
some  of  them  very  clever  actors,  possessing  dramatic  powers  which 
might  have  been  turned  to  better  purposes,  most  of  them  utterly  venal, 
and  some  of  them  confessing  that  they  played  upon  the  credulity  of  Dr. 
Luys  for  their  own  purposes. 

"  I  do  not,  of  course,  ask  your  readers  to  accept  this  statement  as 
final  evidence,  but  the  protocols  of  the  sittings  signed  by  the  witnesses 
present  at  each  of  them  and  the  detail  of  the  methods  employed  will,  I 
think,  convince  even  the  most  credulous  apostles  of  the  new  mesmerism 
that  we  have  here  to  deal  only  with  another  chapter  of  human  folly, 
misled  by  fraud,  a  reproduction  of  the  old  frauds  of  Mesmer,  of  the 
self-deceptions  of  Reichenbach,  and  the  malpractices  of  sham  magi- 
cians of  the  middle  ages  who  have  still  their  ingenious  imitators.  These 
impostures  and  this  self-deception  mask  themselves  now  under  a  new 
nomenclature,  iiiul  avail  themselves  of  recent  developments  of  psycho- 
logical investigation  in  order  to  assume  more  plausible  shapes  and  a 


146 


MISCELLANY. 


[N.  Y.  Med.  Jooe., 


psewrfo-scientific  character.  But  when  the  authentic  details  of  their 
separate  and  combined  simulations  are  read,  it  will  only  remain  to  re- 
gret that  so  much  prominence  has  been  given  to  so  sad  a  page  in  hu- 
man wickedness  and  folly,  and  that  men  of  distinguished  position  and 
good  faith  have  allowed  themselves,  by  carelessness  and  persistent  credu- 
lity, to  be  made  use  of  as  propagators  and  apostles  of  wild  follies  and 
vulgar  deceptions.  There  is  a  still  more  painful  social  and  moral  side 
to  this  matter  to  which  I  can  here  only  distantly  allude,  but  which  con- 
firms me  in  the  belief  that  the  question  is  at  least  as  much  one  of  po- 
lice as  of  science,  and  from  that  point  of  view  deserves  the  attention 
of  the  lay  authorities  of  the  Paris  hospitals  and  of  the  correctional 
tribunals." 

Intrathoracic  Auscultation. — The  last  number  of  the  A.sclepiad 
contains'  a  paper  on  this  .subject,  read  before  the  Medical  Society  of 
London  on  October  31,  1892,  by  Dr.  B.  W.  Richardson,  in  which  he 
says : 

"I  call  the  present  essay  a  study  of  Intrathoracic  Auscultation,  a 
New  Departure  in  Physical  Diagnosis,  and  I  can  not  introduce  it  to  your 
notice  better  than  by  relating  how  it  came  into  my  mind  and  practice. 
A  few  months  ago  a  patient  consulted  me  who  was  suffering  from  seri- 
ous and  obscure  symptoms  refei'able,  by  the  process  of  exclusion  in 
diagnosis,  to  the  upper  portion  of  the  alimentary  canal.  He  had  lost 
flesh  to  an  extreme  degree,  was  very  feeble,  had  often  a  difficulty  in 
swallowing  food,  at  times  retained  food  of  a  fluid  or  semi-fluid  kind  in 
the  stomach  for  long  periods,  and  then,  after  suffering  severe  pain,  vom- 
ited it  with  difficulty,  returning  it  in  a  partially  digested  state.  I  looked 
upon  the  symptoms  with  suspicion  as  possibly  indicating  malignant  dis- 
ease of  the  lower  part  of  the  oesophagus ;  but  as  I  found  he  had  been 
following  an  imprudent  dietary,  I  was  content  at  the  moment  to  regu- 
late diet  carefully  and  to  prescribe  a  mixture  of  dilute  hydrochloric  acid 
and  pepsin.  He  left  me,  to  return  in  two  months,  reporting  himself 
in  every  respect  better.  He  had  gained  in  flesh,  he  retained  food,  was 
free  from  acute  pain,  had  improved  in  strength,  and  had  lost  a  sense  of 
weariness  of  mind  as  well  as  body,  which  had  been  most  oppressive. 
He  had  determined  to  take  a  holiday,  and  I  agreed  with  him  that  the 
change  he  suggested  would  be  advantageous.  I  did  not  see  this  patient 
again  for  three  months,  when  he  consulted  me  once  more  in  conse- 
quence of  a  sudden  return  of  his  worst  symptoms,  to  which  were  added 
others  pointing  more  decisiyely  to  (esophageal  mischief  low  down  in  the 
tube.  With  difficulty  he  had  partaken  of  a  rather  too  copious  meal  one 
day  previously,  and  soon  afterward  had  been  seized  with  acute  pain, 
which  lasted  until  the  undigested  mass  had  been  vomited,  with  free 
secretion  of  the  gum-like  mucus  characteristic  of  stricture.  He  was 
again  greatly  emaciated,  presented  a  condition  of  circulation  so  feeble 
that  I  could  scarcely  detect  the  radial  pulse,  and  the  heart  was  so  weak 
that  it  was  difficult  to  distinguish  clearly  the  two  sounds. 

"  I  tried  in  this  case  what  I  have  called  the  water-gurgle  test  for  the 
diagnosis  of  stricture,  as  described  in  the  Asdepiad,  vol.  vii,  p.  332 ; 
that  is  to  say,  I  got  the  patient  to  attempt  to  swallow  fluid  while  I  aus- 
cultated in  the  line  of  the  oesophagus  anteriorly  and  posteriorly.  When- 
ever there  is  true  stricture  of  the  organic  class  I  have  usually  found  by 
this  method  a  point  where  there  is  heard  a  loud  gurgling  sound  on  at- 
tempts to  swallow,  followed  by  a  sharp  noise  as  of  a  passing  current  of 
fluid  through  a  constricted  passage,  and  I  think  there  are  few  more 
characteristic  points  of  diagnosis  of  stricture  existing  in  the  lower  third 
of  the  tube.  There  was  no  response  to  this  test  in  the  present  instance, 
and  the  patient  expressed  to  me  that  the  tumbler  of  milk  and  water 
which  he  had  swallowed  went  down  without  his  being  conscious  this 
time  of  obstruction.  1  turned,  therefore,  naturally  to  the  use  of  the 
oesophageal  tube — an  operation  which  led  me  to  the  new  facts  I  have 
to  record.  I  passed  along  the  oBSophagus  a  medium-sized  tube  and  ran 
it  without  difficulty  down  to  the  stomach.  There  was  no  serious  ob- 
struction at  any  part,  but  I  thought  I  experienced  some  sense  of 
friction  of  a  very  slight  kind.  While  endeavoring  to  be  certain  on  this 
matter  an  idea  which  I  had  once  before  had  in  my  mind,  but  had  not 
before  acted  upon,  suddenly  occurred  to  me.  Why  not  auscultate 
through  the  ex])loring  tube  V  At  once  I  sliced  off'  a  portion  of  the  free 
end  of  the  tube  obliquely,  slii)ped  over  this  sliced  end  the  terminal  part 
of  the  double  8tethoscoi)C,  and  made  in  this  fashion  the  exploring  tube 


a  continuous  stethoscope.  The  effect  of  auscultating  in  this  way  was 
most  interesting  and  satisfactory.  I  could  hear  soft  friction  of  the 
tube  against  the  walls  of  the  oesophagus,  and  was  made  quite  sure  that 
the  friction  was  uniform  throughout  and  that  there  was  no  special  con- 
striction or  induration  in  any  portion  of  the  tube.  When  I  passed  the 
tube  into  the  cavity  of  the  stomach  itself  I  obtained  a  sound  new  to  me, 
like  a  gentle  seething  as  of  air  or  gas  agitated  in  a  thickish  fluid,  and 
at  times  a  gurgling  sound  of  gas,  with  another  sound  probably  due  to 
muscular  contraction  of  the  stomach  itself.  As  the  patient  experienced 
no  trouble  or  inconvenience  during  examination,  I  had  ample  time  for 
inquiry  ;  and  I  leisurely  withdrew  the  tube,  noting  the  sounds  audible 
in  the  course  of  the  movement.  In  the  tube  at  this  time  there  were 
only  two  openings,  and  those  at  the  extreme  end.  I  succeeded  there- 
fore in  catching  sounds  at  such  points  only  as  were  in  apposition  to  the 
openings.  I  withdrew  the  tube  until  the  opening  on  the  left  side  came 
in  contact  with  that  portion  of  the  oesophagus  that  lies  in  immediate 
proximity  with  the  heart.  By  previous  auscultation  of  the  heart  over 
the  thoracic  wall  I  had  failed  to  detect  clearly  the  two  cardiac  soundf 
owing  to  the  feebleness  of  the  cardiac  action,  but  now  both  sounds 
were  as  distinct  as  they  would  have  been  from  a  normal  heart.  They 
were  not,  however,  the  same  precisely  as  the  sounds  we  hear  through 
the  thoracic  wall ;  they  were  duller  in  character,  as  if  they  wanted  the 
resonance  which  is  probably  produced  by  the  pleura  stretched  over  the 
thoracic  cavity.  At  the  same  time  they  were  loud  and  were  singularly 
distinct.  By  moving  the  tube  gently  up  and  down  I  could  get  the  sec- 
ond sound  separately  from  the  first,  and  vice  versa  ;  but  when  I  had 
the  opening  of  the  tube  midway  so  as  to  compass  both  sounds,  there 
was  not  so  much  difference  between  the  first  and  second  sounds  as  is 
distinguishable  under  ordinary  aust  iltation.  •  I  was  quite  prepared  for 
all  these  modifications  of  phenomena ;  they  corresponded  precisely 
with  what  I  had  learned  many  years  ago  when,  in  combination  with  the 
late  Dr.  Baly  and  Dr.  Sibson,  I  had  seen  Dr.  Halford  demonstrate 
Brien's  valvular  theory  of  the  cause  of  the  two  sounds.  We  listened 
at  that  time  directly  to  the  sounds  from  an  opening  in  the  chest  wall  of 
a  lower  animal  under  aneesthesia,  and  detected  that  with  such  immedi- 
ate auscultation  the  sounds  were  deficient  in  sharp  resonance,  and  were 
more  equable  in  tone  than  was  common  from  ordinary  auscultation.  It 
was  the  same  now.  I  counted  the  beats  of  the  heart  very  deliber- 
ately from  the  inside  of  the  thorax,  seventy  beats  per  minute,  the 
sounds  and  the  pause  in  proper  order  and  the  action  perfectly  regu- 
lar. I  expected  that  ou  withdrawing  the  tube  further  out  of  the 
oesophagus  it  would  be  possible  to  hear  a  loud  sibilant  or  vesicular  mur- 
mur in  respiration.  In  this  I  was  disappointed  to  a  certain  extent.  It 
was  impossible  to  catch  a  murmur,  even  on  a  deep  inspiration,  so  dis- 
tinct as  the  murmur  heard  from  the  chest  wall  outside. 

"  From  these  observations  I  have  been  led  to  the  new  departure  in 
physical  diagnosis  in  which  I  am  anxious  others  should  take  part,  and 
I  have  devoted  some  time  to  certain  preliminary  steps  in  its  develop- 
ment. Briefly  it  is  a  means  for  auscultating  on  an  extensive  scale  the 
organs  of  the  body  from  within  the  body.  I  shall  occupy  most  usefully 
the  short  remaining  time  at  my  command  by  indicating,  first,  the  lines 
of  research  in  which  the  plan  promises  to  be  most  useful;  secondly,  the 
limitations  of  the  plan  and,  if  I  may  so  express  myself,  the  objections 
to  it ;  and  thirdly,  the  modes  by  which  it  may  be  improved  from  this 
its  original  start,  so  as  to  make  it  ready,  safe,  and  in  its  broadest  sense 
useful. 

"  Touching  the  first  of  these  points,  the  method  promises  to  be  use 
ful — I  hope  very  useful — in  the  diagnosis  for  which  I  first  applied  it. 
It  proved  of  service  to  me  ;  at  the  moment  it  told  me  distinctl}',  in  the 
case  I  have  referred  to,  that  there  was  no  constriction,  no  induration,  at 
any  part  of  the  oesophagus,  so  that  the  hearing  confirmed  the  touch,  or, 
rather,  corrected  it  in  a  manner  that  could  not  have  been  more  satisfac- 
tory. The  advantage  will  be  that  stricture  may  be  detected  in  its  very 
earliest  stage — the  stage  in  which,  according  to  my  experience  (unfortu- 
nately, an  experience  specially  large  in  this  disease),  there  is  the  only 
chance  of  doing  good  by  dilatation.  The  new  auscultation  may  prove 
also  an  aid  to  diagnosis  in  diseased  conditions  of  the  stomach  itself.  It 
is  certain,  from  the  sound  I  heard  from  within  the  cavity  of  the  stomach, 
that  there  arc  going  on  there  changes  of  a  physico-chemical  kind,  lead- 
ing to  a  sort  of  effervescence  that  is  distinctive  in  character.    It  is  most 


Feb.  4,  1893.] 


MISCELLANY. 


147 


probable  there  are  differences  of  sounds  connected  with  special  fermen- 
tations, and  that  by  study  and  experience  these  differences  may  become 
detectable  at  once  by  auscultation.  Here  there  is  an  open  field  for  re- 
search into  which  I  have  been  unable  as  yet  to  enter.  Again,  as  bear- 
ing on  the  stomach,  the  motions  of  that  organ  evidently  produce  sound 
that  will  admit  of  interpretation.  A  healthy  stomach  may  possibly  give 
forth  no  sound,  or  it  may  give  forth  a  definite  sound  when  full  of  food, 
with  other  sounds  during  various  stages  of  digestion.  These  are  points 
to  be  inquired  into  and  will  be  of  curious  interest.  Still  it  is  certain 
that  iu  diseased  conditions  of  the  stomach  a  whole  series  of  diagnostic 
symptoms  will  be  learned,  bearing  not  only  on  the  fermentative  action 
in  progress,  but  on  alterations  in  the  walls,  and  on  contractile  functions. 
The  stomach,  in  short,  will  admit  of  being  sounded  like  the  chest.  Scir- 
rhus  affecting  the  stomach  should  easily  be  diagnosticated  by  ausculta- 
tion. Through  the  stomach  it  may  also  be  possible  to  diagnosticate 
physically  and  more  correctly  than  we  now  diagnosticate  the  nature  of 
some  pulsating  abdominal  tumors  which  are,  as  they  have  been  since  the 
time  of  William  Harvey  himself,  a  constant  source  of  disagreement 
among  physicians.  With  the  terminal  of  a  full-sized  oesophageal  stetho- 
scope in  the  stomachic  cavity  a  loud  murmur  from  an  arterial  source 
will  be  detected  without  the  interposition  of  pressure,  and  an  important 
difficulty  in  diagnosis  removed.  A  third  service  that  may  be  rendered 
by  intrathoracic  auscultation  is  forecast  in  the  observation  I  have  al- 
ready made  respecting  the  detection  of  the  cardiac  sounds  in  conditions 
when  those  sounds  are  inaudible  under  the  usual  method  owing  to  ex- 
treme feebleness  of  the  circulation.  We  are  called  sometimes  to  per- 
sons in  such  entire  collapse  that  it  is  doubtful  whether  they  are  alive  or 
dead.  The  sounds  of  the  heart  are  imperceptible  to  the  ear  through  the 
thoracic  walls.  Here,  then,  is  an  instant  and  ready  method  of  deciding 
whether  the  action  of  the  heart  is  still  in  progress.  We  have  a  new 
proof  either  of  absolute  death  or  of  continued  life.  In  acute  collapse, 
as  after  death  from  chloroform,  we  not  only  can  institute  a  good  diag- 
nosis in  the  same  manner,  but  we  are  half  way,  by  our  manipulation, 
toward  assisting  to  restore  life.  Through  the  oesophageal  tube,  after 
disconnecting  the  stethoscopic  tubes,  we  could  inject  a  free  quantity  of 
heated  water  or  water  with  oxygen  peroxide  into  the  stomach  ;  or,  if  we 
had  learned  the  practice  correctly,  we  could  direct  an  electrical  current 
upon  the  heart  itself,  so  as  to  excite  contraction  of  the  right  side. 

"  The  use  of  the  intrathoracic  method  may  be  turned  to  account  in 
diagnosis  of  heart  disease  and  of  aneurysm  of  the  large  thoracic  arterial 
trunks.  Stricture  of  the  oesophagus  arising  from  aneurysmal  pressure 
would  be  instantly  diagnosticated.  These  cases  are  often  most  per- 
plexing. The  pressure  causing  the  obstruction  varies,  and  no  sufficient 
sign  of  aneurysmal  murmur  in  the  early  stages  reaches  the  ear  at  all 
times.  One  auscultator  fortunately  catches  the  murmur,  another  does 
not,  and  so  contradiction  upon  contradiction  among  the  best  diagnos- 
ticians occurs.  By  the  process  of  intrathoracic  auscultation  this  diffi- 
culty would  be  immediately  met,  the  pulsation  would  come  under  direct 
observation,  and  the  precise  seat  of  the  pressure  would  be  descended 
upon.  We  should  hear  a  pulsating  stricture.  In  heart  disease  itself 
the  intrathoracic  mode  of  examination  should  be  of  service.  By  it  we 
ought  to  be  able,  in  cases  of  enlargement,  to  distinguish  between  dila- 
tation and  hypertrophy.  The  diagnosis  of  clot  on  the  right  side  might 
be  made  clear  by  this  plan,  and  the  differential  diagnosis  of  valvular 
affection  on  the  right  or  left  cavity  ought  to  be  rendered  absolute, 
when  we  have  learned  sufficient  of  uisophageal  auscultation  to  discover 
the  new  distinctions  of  sound  that  will  have  to  be  made,  in  some  cases 
*t  least,  between  the  tone  of  the  first  and  the  second  sounds,  and  have 
defined  all  new  lines  of  distinction  between  these  sounds  as  heard  from 
within  and  from  without  the  exterior  walls  of  the  chest.  The  clearest 
definition  by  this  test  should  be  obtainable  also  as  between  pericardial 
and  endocardial  friction  sound  and  between  pericardial  as  distinct  from 
pleural  friction. 

"As  this  is  only  a  preliminary  note,  I  must  leave  untouched  the  sub- 
ject of  pulmonary  auscultation  by  the  intrathoracic  method  and  also 
that  of  pharyngeal  exploration.  The  pharynx  is  within  such  ea.sy 
reach,  it  should  admit  of  more  frequent  auscultation  than  lower  parts 
of  the  oesophageal  canal.  Its  size,  too,  renders  it  more  accessible. 
From  it  we  should  be  able  to  reach  the  apices  of  the  lung  and  the 
greater  part  of  the  air  passages  from  the  larynx  down  to  the  bifurca- 


tion of  the  bronchi.  Exploration  of  these  parts  will  be  easy  when  a 
set  of  appropriate  and  convenient  exploring  instruments  has  been  con- 
structed, and  will  afford  help  to  diagnosis  of  changes  incident  to  the 
apices  of  the  lungs  in  subclavian,  innominate,  and  carotid  murmurs, 
and  in  thickenings  and  obstructions  of  the  trachea  and  larynx. 

"  Having  given  an  outline  of  what  may  be  gained  by  intrathoracic 
auscultation,  I  shall  now  refer  to  the  limitations  of  the  plan  and  to  the 
objections  which  may  be  taken  to  it.  I  assume  at  once  that  this  mode 
of  research  is  not  callcl  for  when  by  the  ordinary  auscultation  diagno- 
sis is  clear.  It  may  come  in  usefully  in  all  cases  where  the  oesophageal 
tube  is  used  for  exploration,  but  it  vvill  not  be  always  applicable  in  in- 
stances where  it  might  be  useful,  owing  to  the  circumstance  that  many 
patients  are  unable  to  bear  the  introduction  of  the  tube,  and  that  it 
may  sometimes  be  unadvisable  to  subject  them  to  it.  I  met  with  a  pa- 
tient last  week  suffering  from  probable  thoracic  aneurysm,  in  whose 
case  the  exploration  would  have  been  most  valuable ;  but  the  introduc- 
tion of  the  tube  caused  so  much  retching  and  straining,  I  was  obliged 
to  withdraw  the  tube  before  I  had  explored  as  fully  as  I  could  have 
wished,  although  what  was  effected  was  sufficient  to  inform  me  of  the 
existence  of  aneurysmal  murmur  from  the  left  carotid  or  subclavian. 
The  explorations  might  also  be  objectionable  in  cases  of  irritable 
stomach,  or  where  there  was  severe  cough  or  cough  with  haemorrhage. 
I  need  not  dwell  any  longer  on  particular  points  of  this  kind,  since  the 
whole  is  summed  up  in  a  sentence  :  whenever  the  practitioner  feels  he 
can  safely  and  prudently  pass  a  tube  into  the  stomach,  he  can  practice 
intrathoracic  auscultation. 

"  The  third  point,  the  modes  in  which  this  method  may  be  improved 
by  mechanical  means,  opens  up  a  very  wide  field  of  inquiry.  I  com- 
menced my  work  with  the  ordinary  flexible  tube,  and  up  to  the  present 
time  I  have  found  nothing  better  than  a  good-sized  tube  with  a  large 
lateral  aperture  at  the  extreme  end.  I  have  used  another  tube 
charged  with  several  apertures  an  inch  from  each  other,  and  this  an- 
swers fairly  well.  Apertures  are  essential  in  these  tubes ;  if  they  are 
not  made  there  is  little  or  no  conduction  of  sound.  Messrs.  Krohne  & 
Sesemann  have  been  making  tubes  for  me  of  different  materials,  and 
one  of  metal  of  malleable  nature  is  good  in  many  ways ;  but  I  have  not 
yet  obtained  what  is  precisely  wanted.  The  best  tube  at  this  moment 
is  the  long  oesophageal  flexible  tube  with  the  stethoscope  attached  to  it. 

"  I  leave  now  this  contribution  in  the  hands  of  a  society  to  which  it 
has  been  my  high  privilege  to  communicate  many  of  my  first  thoughts 
from  the  very  opening  of  my  long  career.  I  would  not  on  any  account 
attach  an  undue  importance  to  the  effort,  or  look  upon  it  as  anything 
more  than  an  extension  of  the  simple  act  of  the  illustrious  Laennec, 
when,  in  the  Necker  Hospital,  one  day  in  1816,  he  improvised  a  stetho- 
scope out  of  a  roll  of  paper  and  projected  thereon  a  new  science  to 
which  there  seems  to  be  no  end." 

Urethrectomy,  Partial  or  Complete,  as  a  Method  for  the  Badical 
Treatment  of  Eupture  of  the  Urethra,  Fistula,  or  Organic  Stricture. 

— Dr.  Thomas  H.  Manley  recently  read  a  paper  with  this  title  before 
the  Section  in  Genito  urinary  Surgery  of  the  New  York  Academy  of 
Medicine,  the  concluding  portion  of  which  (here  printed  from  advance 
sheets  of  the  Annals  of  Surgery)  was  as  follows : 

It  is  almost  needless  to  say  that,  for  many  obvious  reasons,  these 
operations  were  undertaken  with  some  hesitency  and  trepidation,  as  I 
have  always  believed  that  serious  surgical  operations  should  have  some- 
thing more  to  commend  or  justify  their  performance  than  their  unique- 
ness or  novelty,  however  skillfully  performed.  But  having  carefully 
studied  the  anatoraico-physiological  qualities  of  tlie  normal  urethra  and 
considered  just  what  constitutes  the  pathological  foundation  of  all 
traumatic  or  organic  strictures  or  fistul*,  I  could  conceive  of  no  serious 
objection  to  total  resection  of  the  entire  caliber  of  the  urethra  with  an 
immediate  homologous  urethrorrhaphy  in  old  fistula;  or  tramnatic  rup- 
ture ;  nor  to  external  urethrotomy,  partial  linear  resection  of  the  calloused 
mass,  and  immediate  reconstrtu-lion  of  the  urethral  floor  with  the  cellu- 
lar tissues.  It  might  be  said  that  the  membranous  urethra,  in  its  long 
as  well  an  in  its  lateral  diameters,  is  lax,  elastic,  and  very  distensible. 

Dr.  Otis  was  the  first  to  demonstrate  Its  enormous  lateral  distensile 
properties,  thereby  opening  the  way  to  successful  litlioUity. 

I  am  not  acquainted  with  any  author  who  has  called  attention  to 


148 


MISCELLANY. 


[N.  Y,  Med.  Jora. 


this  property  of  elongation  possessed  by  that  segment  of  the  urethra 
wholly  enveloped  by  the  perineal  muscles.  It  also  may  be  added  that 
the  principles  of  this  operation  are  precisely  the  same  as  those  em- 
ployed in  the  management  of  all  organic  strictures. 

Through  a  certain  course  of  pathological  changes  generally  conse- 
quent on  gonorrhoea,  the  male  urethral  mucous  membrane  undergoes 
degenerative  changes,  resulting  in  a  destruction  of  its  epithelium  layers 
and  a  fibrosis  of  its  outerlying  tissues.  That  this  is  clearly  understood 
is  evident  by  the  measiires  commonly  instituted  for  the  relief  of  a  con- 
dition which  art  is  powerless  to  perfectly  cure.  We  may  widen  a  nar- 
rowed, strictured  passage  by  immediate  or  gradual  dilatation,  split  it 
with  a  blade  from  within  or  without,  burn  an  opening  through  it  by 
potash  or  electrolysis,  yet,  with  all,  complete  retrogressive  changes  to  the 
normal  state  can  not  be  said  to  ever  occur,  though  the  immediate  in- 
convenience which  it  occasions  usually  disappears. 

It  might  be  argued  that  a  urethral  floor  composed  of  cellular  ele- 
ments will  never  assimilate  to  mucous  membrane,  and  a  contracted  con- 
dition must  follow  this  operation,  worse  than  that  we  have  endeavored 
to  relieve. 

John  Hunter,  Earon  Dupuytren,  Laennec,  and  Villume  long  ago 
called  attention  to  the  close  resemblance  of  the  membrane  investing  a 
urinary  fistula  and  a  mucous  one.  Cruveilhier  and  Chassier  admit  the 
possibility  of  the  reproduction  of  mucous  membranes  after  they  have 
suffered  loss  of  substance.  Andral  claimed  that  in  all  these  cases  the 
reproduced  mucous  membrane  was  the  result  of  transformation  of  the 
cellular  elements. 

Dieffenbach  in  his  time  demonstrated  by  the  Taliscotian  method, 
which  has  been  recently  revived,  that  he  succeeded  in  curing  a  large 
number  of  perineal  fistuhc  of  urethra,  though  in  those  days  nothing  was 
known  of  anaesthetics  or  antiseptics.  Thus  it  appears  that  the  funda- 
mental objections  can  not  stand  against  this  autoplastic  procedure  in 
the  surgery  of  the  urethra. 

Happily,  since  the  two  cases  here  recorded  were  dismissed  from  the 
hospital,  I  have  read  with  much  satisfaction  Guyou's  essay,  which  ap- 
peared in  the  Gazette  hehdomaditire,  May  14,  1892,  entitled  Resection 
Partial  of  the  Perineal  Urethra,  followed  by  Restoration  Entire  and 
Complete. 

It  may  not  be  amiss  here  to  give  the  substance  of  his  article,  as  it 
has  a  direct  bearing  on  the  subject  under  consideration,  and  is  in  many 
particulars  a  peculiarly  unique  production. 

In  the  beginning  he  says  that  partial  resection  of  the  urethra  has 
occupied  a  very  moderate  rank  until  very  recently ;  that  Roqu6s,  one  of 
his  internes,  has  been  able  to  collect  but  sixty-four  cases  from  all 
sources.  Forty-nine  of  these  were  complete  and  fifteen  incomplete. 
After  describing  the  precise  manual  for  operation,  he  tells  us  that 
Championnifere  treated  a  case  of  complete  traumatic  rupture  of  the 
urethra  by  perineal  section  and  immediate  approximation  with  entire 
success.  There  were  nine  cases  of  lesions  of  the  peiineal  urethra 
treated  in  his  own  wards ;  six  by  himself.  In  all  these  cases  operation 
was  resorted  to  only  when  the  passage  of  instruments  was  quite  impos- 
sible. Four  were  traumatic  and  two  blennorrhagic.  In  two  there  were 
tistulse.  In  all,  the  entire  calloused  mass  was  removed  and  prompt 
union  followed.  Patients'  ages  were  from  fourteen  to  fifty  years.  The 
youngest  leaving  the  servi  3e  could  pass  a  No.  30  sound  (French),  and 
the  adults  from  No.  50  to  60. 

In  no  instance  bad  there  been  any  troublesome  relapses,  though  he 
admits  that  he  advised  them  to  pass  a  sound  on  themselves  from  time 
to  time. 

Resume. — (a)  It  seems,  then,  from  the  foregoing,  that  in  all  ca.ses  of 
traumatic  rupture  of  the  perineal  urethra  the  tissues  should  be  laid  open 
at  as  early  a  date  as  possible,  and  the  continuity  of  the  lumen  of  the 
urethra  should  be  then  entirely  restored  by  a  urethrorrhaphy. 

(ft)  In  those  urethral,  perineal  fistulip  which  l  esist  dilatation  or  other 
tentative  measures,  regardless  as  to  whether  they  are  of  a  traumatic  or 
blennorihagic  origin,  they  should  be  resected  and  continuity  restored 
in  the  passage  by  homologous  approximation  of  the  separated  edges, 
the  hiatus  remaining  being  obliterated  through  linear  elongation  of  the 
fibers  of  the  muscular  coat. 

(c)  With  those  strictures  rebellious  to  tentative  methods,  not  ap- 
propriate for  internal  urethrotomy  or  divulsion,  when  they  are  divided 


by  an  external  incision  the  occasion  should  be  utilized  to  hew  a  gutter 
through  the  cicatricial  tissues,  and  to  reconstruct  tlie  floor  of  the  canal 
with  the  adjacent  connective  tissues. 

{d)  In  all  cases  the  most  rigoi'ous  asepsis  should  be  employed,  and 
the  aim  in  every  case  should  be  to  secure  non-suppurative,  primary 
union. 

The  New  York  Academy  of  Medicine. — For  the  meeting  of  Thurs. 
day  evening,  the  2d  inst.,  a  memorial  address  on  the  late  Dr.  James  R. 
Learning,  by  Dr.  J.  Leonard  Corning,  was  announced;  also  a  paper  on 
A  New  Method  of  Artificial  Respiration  in  Asphyxia  Neonatorum,  by 
Dr.  J.  Harvey  Dew. 

At  the  next  meeting  of  the  Section  in  Pasdiatrics,  on  Thursday  even- 
ing, the  9th  inst..  Dr.  F.  W.  Lester  will  open  a  discussion  on  Pineapple 
Juice  as  an  Application  to  Dii)hthoritic  Pseudo-membrane  ;  a  member 
whose  name  is  not  announced  will  read  a  paper  on  Differential  Diagno- 
sis in  Cases  of  Dyspnoja ;  and  Dr.  T.  H.  Manley  will  read  one  on  Surgi- 
cal Measures  of  Relief  in  Stenosis  of  the  Air-passages. 

At  the  next  meeting  of  the  Section  in  Genito-urinary  Surgery,  on 
Tuesday  evening,  the  14th  inst..  Dr.  W.  K.  Otis  will  read  a  paper  on 
The  Treatment  of  Supi)urating  Buboes  by  Injection  of  Iodoform. 


IPo  Contributors  and  Correspondenta. —  The  attention  of  all  wJw  purpoit 

favoring  ua  with  communications  is  respectfully  called  lo  llie  follow- 
ing : 

Authors  of  nrtulcs  intended  for  puhlication  nuder  the  Ivead  of  originon 
contrihuliims  "  are  respectfully  informed  tltat,  in  accepting  such  art) 
cles,  we  always  do  so  with  the  understanding  that  the  following  condi 
lions  are  to  be  ohse7-ved:  (i)  when  a  matiuscript  is  sent  to  this  jour 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notifed 
of  the  fact  at  the  time  the  article  is  sent  to  its  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revinon,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  isttie  ;  (3)  any 
conditions  which  an  author  wishes  compjlied  with  must  be  distincth 
stated  in  a  communication  accompanying  the  manuscript,  and  n< 
new  conditions  can  be  considered  after  the  manuscript  has  been  pm 
into  the  typesetters'  hands.  We  are  oftai  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  aulJiors,  are 
not  suitable  for  publication  in  thii  journal,  either  because  they  are 
too  long,  or  are  loaded  xcith  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
)  at  large.  We  can  not  enter  bUo  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  puhlication  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  lo  each  cor- 
respondent informing  him  under  what  number  the  an.m<er  to  hit  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  partiadar  cases  or  recommend  indi- 
vidual practitioners. 

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

Kewspo.pers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mentr- 
hers  of  the  profession  v  ho  send  us  information  o  f  matters  of  iiderest 
to  our  readers  will  be  considered  as  doing  them  and  ics  a  javor,  and, 
if  the  space  at  our  command  admits  of  it,  wc  shall  take  pleasure  in 
'  inserting  the  sub.itance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 

in  care  of  the  publishers, 
ill  communications  relating  to  the  business  of  the  journal  should  be  ad- 
dressed to  the  publishers. 


THE  'NEW  YORK  MEDICAL  JOURl^AL,  EEBRrAEY  11,  1893. 


MEDICAL  SOCIETY  OF  THE  STATE  OF  NEW  YORK. 

THE  PRESIDENT'S  INAUGURAL  ADDRESS, 
DELIVERED  AT  THE  EIGHTY-SEVENTH  ANNUAL  MEETINf!, 
February  7,  1893. 
By  lewis  S.  PILOHER,  M.  D., 

BROOKLYN. 

Members  of  the  Medical  Society  of  the  State  of 
New  York  :  The  duty  which  your  by-laws  impose  upon  the 
president  of  inaugurating  the  annual  meeting  by  communi- 
cating to  the  society  the  condition  of  the  medical  profes- 
sion in  the  State  at  the  current  date  is  a  pleasing  task  at 
this  time  by  reason  of  the  encouraging  report  which  the 
facts  warrant.    It  is  especially  fitting  that  such  a  review 
should  be  required  of  your  presiding  officer  on  account  of 
the  very  important  relations  to  the  medical  profession  of 
the  State  which  this  society  sustains.    The  people  of  this 
commonwealth,  by  the  act  of  their  representatives  in  the 
Legislature  of  1806,  constituted  this  society  the  legal  repre- 
sentative of  the  medical  profession  of  the  State,  provided 
for  the  organization  of  the  practitioners  of  the  State  into 
county  medical  societies,  and  by  a  later  enactment  made  it 
the  duty  of  every  physician  to  join  the  medical  society  of 
his  county.    To  these  societies  were  committed  important 
functions  pertaining  to  the  licensing  of  medical  practition- 
ers and  to  the  regulation  of  the  practice  of  physic  and  sur- 
gery while  they  were  affiliated  with  and  subordinated  to 
the  State  Medical  Society.    With  the  lapse  of  years  the  de- 
velopment of  new  conditions  of  society,  of  education,  and  of 
practice  brought  from  time  to  time  modifications  in  the 
duties  presumably  required  of  these  medical  corporations ; 
the  function  of  supervising  the  qualifications  of  those  who 
should  desire  to  practice  physic  and  surgery  in  the  State  of 
New  York  was  virtually  abrogated  by  the  law  of  1844, 
which  threw  open  the  privileges  of  medical  practice  to  all 
men  who  could  protect  themselves  from  suits  for  damages  due 
to  malpractice,  from  ignorance  or  immoral  conduct  in  their 
practice.     The  Legislature  of  1857  gave  legal  status  to 
practitioners  of  homoeopathic  medicine  by  incorporating 
them  into  State  and  county  societies,  and  likewise,  in  1865, 
the  eclectic  practitioners  were  given  a  similar  legal  status. 
In  1874,  1880,  and  1887  statutes  were  enacted  by  the  sev- 
eral Legislatures  of  those  years,  regulating  and  defining  the 
status  of  the  medical  practitioners  in  the  State  by  -which 
the  prerogatives  of  the  State  and  county  medical  societies 
were  less  prominently  acknowledged  and  the  importance  of 
chartered  medical  colleges  was  more  clearly  recognized. 
Nevertheless,  throughout  the  whole  of  this  long  period  of 
eighty-seven  years,  the  State  of  New  York  has  never  ceased 
to  recognize  the  dignity  and  importance  of  the  medical  so- 
ciety which  it  created  in  1806  as  the  proper  representative 
and  exponent  of  rational  medicine  within  its  borders.  This 
society  has  ever  been  unceasing  in  its  efforts  for  the  public 
welfare,  for  raising  the  standard  of  medical  education,  and 
for  promoting  a  higher  ideal  of  medical  character.   By  vir- 


tue of  its  representative  character,  of  the  loftiness  of  its 
aims,  and  the  personal  dignity  and  worth  of  its  members, 
its  influence  for  good  in  this  commonwealth  has  never  been 
measured  or  restricted  by  the  legal  regulations  or  stipula- 
tions that  may  have  bound  it  at  any  period  of  its  history. 
It  has  furthermore  continually  used  its  influence  to  elevate 
the  status  of  medical  education  and  practice  throughout  the 
country  at  large ;  during  the  early  years  of  its  history  it 
was  active  in  securing  common  action  among  the  medical 
colleges  of  the  United  States  in  improving  the  character 
and  extent  of  the  teaching  in  those  institutions ;  later  it  in- 
augurated and  carried  to  a  successful  issue  the  movement 
for  organizing  an  American  medical  association,  and  in  the 
more  recent  past  it  did  not  hesitate  to  declare  that  the 
changing  conditions  of  knowledge,  of  education,  of  legisla- 
tive enactments,  and  of  social  conditions  made  it  desirable 
that  the  medical  profession  should  emancipate  itself  from 
certain  paternal  restrictions  that  it  had  inherited  from  the 
conditions  of  a  previous  generation,  and  to  formally  take 
action  giving  a  large  liberty  of  personal  judgment  upon 
ethical  questions  to  all  who  acknowledged  its  authority.  It 
thus  placed  itself  again  in  the  forefront  of  a  reform  the  ef- 
fects of  which  have  spread  far  beyond  the  limits  of  the 
State  within  which  this  society  has  any  jurisdiction. 

In  the  immediate  present  the  commonwealth  has  again 
intrusted  to  this  society  the  important  duty  of  supervising 
the  qualifications  of  all  who  may  hereafter  desire  to  prac- 
tice rational  physic  or  surgery  within  the  State  of  New 
York,  by  the  recent  law  constituting  a  medical  board  of 
examiners,  whose  members  shall  be  nominated  by  this  so- 
ciety and  to  whom,  thus  rejjresenting  this  society  and  being 
accountable  to  it  for  their  work,  is  committed  the  preroga- 
tive of  fixing  the  standard  of  educational  qualifications  to 
which  every  future  practitioner  of  rational  medicine  in  this 
State  shall  attain  before  receiving  license  to  practice. 

Your  president  has  taken  some  pains  during  the  past 
year  to  acquaint  himself  with  the  condition  of  the  medical 
profession  throughout  the  State.  The  estimated  number  of 
practitioners  is  10,000;  the  estimated  population  is  6,000,- 
000,  or  1  physician  to  every  600  of  population ;  of  these 
10,000,  about  8,000  are  practitioners  of  rational  medicine, 
1,300  of  homoeopathic  medicine,  400  of  vegetable  medicine, 
and  the  remaining  300  represent  many  kinds  of  medical 
theories. 

The  number  of  schools  devoted  to  undergraduate  in- 
struction in  rational  medicine  is  9  ;  of  these,  2  are  in  the 
city  of  Buffalo,  1  in  the  city  of  Syracuse,  1  in  Albany,  1  in 
Brooklyn,  and  4  in  New  York  city ;  2,096  students  are  at 
the  present  time  under  instruction  in  these  schools — 128  in 
Buffalo,  58  in  Syracuse,  170  in  Albany,  201  in  Brooklyn, 
and  1,539  in  New  York  city. 

The  number  of  schools  in  the  State  of  New  York  de- 
voted to  post-graduate  instruction  is  two,  both  in  New  York 
city.  During  the  past  year  the  number  of  matriculants  at 
these  two  schools  has  aggregated  819. 

The  number  of  students  in  the  medical  schools  in  this 
State  is  especially  significant  from  the  fact  that  the  entrance 
into  these  schools  is  guarded  by  a  preliminary  examioation 


160 


PILGRER:  INAUGURAL  ADDRESS. 


[N.  Y.  Mbd.  Jouh., 


prescribed  by  the  State,  and  conducted  not  by  the  officials 
of  the  schools  but  by  the  Board  of  Regents  of  the  Univer- 
Bity  of  the  State,  an  examination  which  is  not  a  mere  form 
but  is  sufficient  to  insure  that  intending  students  of  medi- 
cine shall  already  possess  a  fair  general  education  before  be- 
ginning their  technical  studies.  It  is  still  more  significant 
by  the  fact  that  the  diplomas  of  these  schools  no  longer  con- 
fer the  right  to  practice  medicine  in  the  State  of  New  York, 
and  have  a  value  only  as  the  thoroughness  and  comprehen- 
siveness of  the  instruction  to  which  they  testify  is  acknowl- 
edged by  public  opinion.  The  laws  of  the  State  further  re- 
quire that  all  who  hereafter  enter  upon  the  practice  of  physic 
or  surgery  in  this  State  shall  have  attended  three  full  courses 
of  lectures,  and  all  the  medical  schools  of  the  State  now  re- 
quire the  same  amount  of  attendance  upon  lectures  before 
the  granting  of  a  diploma,  while  the  general  influence  of 
these  teaching  bodies  is  to  encourage  their  students  to  ex- 
tend periods  of  lecture  attendance  to  four  years.  The  influ- 
ence of  the  present  conditions  that  attend  medical  education 
in  this  State  is  very  healthful,  in  that  every  teaching  corpo- 
ration is  directly  stimulated  to  improve  its  methods  and  fa- 
cilities for  teaching,  that  thereby  students  may  be  attracted 
to  its  halls.  An  examination  of  the  curriculum  and  the  pub- 
lished statements  of  each  of  the  schools  of  this  State,  sup- 
plemented in  some  instances  by  additional  statements  from 
the  dean,  shows  that  much  has  been  done  already  and  more 
is  contemplated  in  the  immediate  future  toward  securing 
proper  gradation  of  studies,  division  of  students  into  small 
sections  under  tutorial  supervision,  systematic  text-books 
and  laboratory  drill,  and  adequate  personal  contact  of  the 
students  with  patients  in  dispensary  and  hospital  classes. 
The  present  law  of  the  State  with  regard  to  the  supply  of 
anatomical  material  is  fairly  liberal,  and  an  enlightened  pub- 
lic opinion  has  sustained  its  practical  application  whenever 
it  has  been  brought  into  question.  Laboratories  of  histology 
and  pathology  have  been  furnished  and  equipped  in  connec- 
tion with  all  the  schools,  and  in  New  York  city  and  Brook- 
lyn elaborately  planned  and  fully  endowed  institutions  for 
these  departments  of  instruction  exist,  in  which  not  only 
the  instruction  of  students  is  provided  for,  but  every  facil- 
ity and  encouragement  for  original  work  is  furnished  not 
only  to  their  staff  of  instructors,  but  to  any  member  of  the 
medical  profession.  The  department  of  practical  obstetrics 
presents  conditions  of  special  difficulty  in  American  com- 
munities for  organization  so  as  to  give  the  needed  amount 
of  practical  demonstrative  teaching  to  students.  Appreci- 
ating this  and  thinking  that  this  one  department  might  be 
taken  as  a  fair  index  of  the  average  character  of  the  instruc- 
tion that  was  being  given  in  the  medical  schools  of  the  State, 
I  addressed  to  each  of  them  an  inquiry  as  to  the  amount  of 
practical  experience  in  midwifery  required  by  each  of  a  stu- 
dent before  graduation,  stating  that  I  intended  to  present 
the  information  thus  obtained  to  this  society.  The  follow- 
ing are  the  answers  received  : 

Medical  Department  of  Niagara  University. — Each  stu- 
dent attends  from  five  to  ten  cases  before  graduation. 

Medical  Department  of  the  University  of  Buffalo. — Each 
student  is  required  to  attend  at  least  two  cases. 

Medical  Department,   Syracuse   University. — At  least 


one  case  must  be  attended ;  usually  from  two  to  four  are 
given. 

Albany  Medical  College. — Provision  is  made  to  enable 
members  of  the  senior  class  to  attend  one  or  more  cases  of 
obstetrics. 

Long  Island  College  Hospital. — All  obstetrical  cases  in 
this  hospital  and  in  the  Kings  County  Hospital  used  for 
clinical  instruction.  Six  students  in  the  former  and  three 
in  the  latter  attend  each  labor.  The  average  number  of 
labors  attended  by  each  student  has  varied  from  five  to 
fifteen. 

Woman'' s  Medical  College  of  the  New  York  Infirmary. 
— Each  student  is  required  to  attend  ten  cases. 

Bellevue  Hospital  Medical  College. — Each  student  is  rec- 
ommended to  have  a  two-week.s'  course  at  the  midwifery 
dispensary,  during  which  each  student  attends  at  least  six 
cases  of  labor,  but  this  is  not  obligatory. 

Medical  Department,  Columbia  College. — Every  student 
required  to  attend  the  Sloane  Maternity  for  one  week,  day 
and  night ;  examine  all  cases  and  be  present  at  all  confine- 
ments. 

Medical  Department,  University  of  the  City  of  New  York. 
— Students  who  desire  it  may  secure  attendance  in  the 
lying-in  service  of  the  midwifery  dispensary  for  periods  of 
two  weeks  or  more.    Not  obligatory. 

From  these  replies  it  is  evident  that  much  progress  is 
being  made  in  this  most  important  department  of  medical 
instruction.  It  appears,  however,  that  in  at  least  two  of  the 
largest  schools  in  this  State  it  is  still  possible  for  students 
to  receive  the  degree  of  Doctor  of  Medicine  without  ever 
having  seen  a  case  of  labor.  I  know  that  it  is  the  desire  of 
the  authorities  of  these  schools  that  at  the  earliest  practica- 
ble moment  this  reproach  should  be  removed,  and  I  submit 
that  it  is  a  proper  thing  for  the  Medical  Society  of  the  State 
of  New  York  to  use  its  influence  in  promoting  this  end.  For 
this  purpose  I  would  recommend  that  this  society  formally 
request  the  Regents  of  the  University  of  the  State  to  decree 
that  an  essential  requirement  for  admission  to  examination 
in  obstetrics  by  the  State  Board  of  Medical  Examiners  shall 
be  that  the  candidate  certify  to  having  attended  at  least 
three  cases  of  labor. 

Time  does  not  permit  me  to  further  analyze  the  methods 
of  medical  education  now  prevalent  in  this  State.  I  think, 
however,  that  all  the  facts  warrant  the  statement  that  posi- 
tive improvement  in  every  direction  is  constantly  being  ef- 
fected, that  it  has  already  attained  a  breadth  and  thorough- 
ness and  practical  value  that  compels  the  confidence  of  an 
enlightened  public,  and  that  wherever  deficiencies  or  occa- 
sions for  adverse  criticism  still  exist,  that  will  gradually  be 
removed  with  the  lapse  of  time  ;  they  are  the  faults  of  youth, 
the  results  of  the  absence  of  governmental  control  and  en- 
dowment, the  effects  of  the  spirit  of  individualism  which  is 
at  once  our  pride  and  our  weakness.  It  will  ever  remain 
the  duty  of  this  society  to  point  out  the  way  of  improve- 
ment and  to  give  form  to  the  public  and  professional  opin- 
ion which  must  always  precede  each  advance  step. 

The  State  Board  of  Medical  Examiners. — The  work  of 
this  board  may  now  be  considered  as  fully  inaugurated. 
The  time  during  which  any  persons  desiring  to  practice 


Feb.  11,  1893.] 


PILCEER: 


INAUGURAL  ADDRESS. 


151 


medicine  in  tliis  State  were  exempt  from  examination  b}' 
this  board  has  now  elapsed,  and  at  the  present  time  the 
only  gateway  to  the  legal  practice  of  medicine  in  this  State 
is  examination  by  this  board.  I  am  not  aware  that  the  two 
years  of  testing  to  which  tliis  law  has  been  subjected  has 
shown  it  to  possess  any  objectionable  features,  while  its  in- 
fluence is  acknowledged  by  all  to  have  been  beneficent.  Up 
to  the  1st  of  December  last,  ninety  candidates  had  been  ex- 
amined by  the  board  representing  this  society,  of  whom 
eighty  had  been  accepted ;  ten  by  the  board  representing 
the  Homoeopathic  Medical  State  Society,  of  whom  five  were 
accepted ;  and  five  by  the  board  representing  the  Eclectic 
State  Medical  Society,  of  whom  two  were  accepted.  When 
it  is  remembered  that  these  were  all  subjected  to  the  same 
examination,  except  in  the  department  of  therapeutics,  it 
illustrates  the  direct  effect  of  the  bill  on  the  public  welfare, 
since,  while  it  caused  the  rejection  of  eleven  per  cent,  of 
the  candidates  from  schools  of  rational  medicine,  it  caused 
the  rejection  of  fifty  per  cent,  and  sixty  per  cent,  of  the 
candidates  from  schools  of  sectarian  medicine.  The  inevi- 
table result  of  the  continuance  of  the  work  of  this  board 
will  be  to  greatly  improve  the  general  standard  of  medical 
education  in  this  State.  It  is  certain  also  to  excite  the  an- 
tagonism of  those  whose  pretensions  are  put  in  so  bad  a  light 
by  its  workings.  It  behooves  every  intelligent  and  public- 
spirited  citizen  to  protest  on  every  proper  occasion  against 
any  modification  of  the  existing  law  which  shall  weaken  its 
force  or  efficiency  in  any  way.  It  would  be  proper  for  this 
society  at  this  time  to  adopt  a  resolution  expressing  satis- 
faction with  the  law  as  it  now  stands,  and  requesting  that 
the  Legislature  decline  to  permit  any  modification  of  its 
provisions  for  the  present  at  least,  and  instricting  its  com- 
mittee on  legislation  to  be  vigilant  in  guarding  this  law 
against  amendment  or  attack.  I  accordingly  recommend 
such  action  to  the  society.  The  society  will  be  called  upon 
at  this  meeting  to  nominate  four  candidates,  from  which 
shall  be  chosen  by  the  Board  of  Regents  two  persons  to  fill 
vacancies  that  will  occur  in  this  Board  of  Examiners  dur- 
ing the  present  year.  Such  nominations  will  have  to  be 
made  hereafter  at  each  meeting  of  the  society.  Hitherto 
a  special  committee  to  select  these  names  has  been  appoint- 
ed by  the  president.  It  is  evident  that  this  places  in  the 
hand  of  the  president  a  responsibility  which  ought  not  to 
attach  to  that  office,  and  practically  makes  the  Board  of 
Examiners  to  represent  the  presidents  of  the  society  rather 
than  the  society  as  a  whole.  The  suggestion  was  made  in 
the  president's  inaugural  address  of  last  year  that  the  an- 
nual duty  of  selecting  names  to  fill  these  regularly  recurring 
\  acancies  be  delegated  to  the  regular  nominating  committee 
of  this  society — a  suggestion  which  seems  eminently  proper 
in  view  of  the  thoroughly  representative  character  of  the 
committee.  I  desire  to  renew  the  suggestion  at  this  time, 
.  and  to  recommend  its  adoption  as  the  settled  policy  of  the 
society. 

Necrology. — Before  proceeding  further  with  suggestion 
of  special  matters  that  may  properly  be  brouglit  to  the  at- 
tention of  the  society,  I  desire  to  pause  while  a  merited 
tribute  is  paid  to  the  memory  of  those  of  our  number  who 
have  died  during  the  past  year. 


Dr.  Thompson  Burton,  permanent  member,  died  at  Ful- 
tonville,  May  5,  1892,  aged  eiglity  years. 

Dr.  Abiathar  Pollard,  permanent  member,  died  at  Port 
Henry,  April,  1892,  aged  ninety-one  years. 

Dr.  F.  L.  R.  Chapin,  permanent  member,  died  at  Glen's 
Falls,  April  10,  1892. 

Dr.  Charles  E.  De  la  Vergne,  permanent  member,  died 
at  Brooklyn,  June  4,  1892,  aged  thirty-four  years. 

Dr.  James  R.  Learning,  permanent  member,  died  at  New 
York,  December  5,  1892,  aged  seventy-two  years. 

The  advanced  age  to  which  most  of  those  named  had 
attained  will  attract  attention.  These,  our  fathers  in  medi- 
cine, passed  to  their  rest  full  of  years,  attended  by  the  re- 
grets and  the  love  of  the  communities  among  which  they 
labored.  Dr.  De  la  Vergne  was  stricken  in  the  full  vigor 
of  his  manhood  by  a  virulent  diphtheria  contracted  by  him 
while  ministering  to  a  patient  suffering  from  a  similar  dis- 
ease. His  name  is  to  be  added  to  those  who  have  died  in 
the  field,  and  swells  the  unnumbered  host  of  physicians  who 
are  martyrs  to  duty. 

The  Merritt  H.  Cash  Fund. — Permit  me  to  invite  the 
attention  of  the  society  to  this  fund  of  $500  which  has 
been  in  the  treasury  of  the  society  since  1862.  It  is  a 
legacy  left  without  restriction  by  the  late  Dr.  Merritt  II. 
Cash,  of  Orange  County,  a  member  of  this  society  who  died 
in  1861.  By  vote  of  the  society  it  has  been  invested, 
and  the  income  from  it  is,  from  time  to  time,  offered  as  a 
prize  to  be  competed  for.  It  has  been  awarded  eight  times. 
Vaccination,  Acupressure,  Artery  Constriction,  School  Hy- 
giene, Fractures  of  the  Lower  Extremity  of  the  Radius, 
Phosphorus  and  the  Hypophosphites,  The  Sanitation  of 
School  Life  and  Schoolhouses,  and  The  Caisson  Disease 
have  severally  been  the  subjects  which  have  engaged  the 
attention  of  the  prize  essayists.  It  perhaps  may  be  ques- 
tioned whether  the  use  of  the  fund  for  the  purpose  of 
stimulating  original  work  and  valuable  contributions  to 
knowledge  has  been  altogether  successful.  But  few  com- 
petitors have  striven  for  the  prize  at  any  time,  and  in  some 
instances  no  essay  that  was  deemed  worthy  of  securing  the 
prize  has  been  offered.  It  is  undeniable  that  the  temper  of 
modern  scientific  work  is  not  favorable  to  such  prize  com- 
petitions. Even  if  it  were,  the  amount  which  this  society 
has  at  intervals  offered  as  a  prize  (llOO)  is  entirely  too  small 
to.  serve  as  an  inducement  for  extensive  reseai'ch  or  labori- 
ous experiment  in  the  preparation  of  an  essay,  while  the 
honor  attaching  to  it  has  not  been  sufficiently  great  to  com- 
pensate for  the  meagerness  of  the  money  element.  I  would 
ask  the  society  to  consider  whether  a  better  use  of  this 
money  may  not  be  made  in  the  future.  The  fund,  in  the 
first  place,  should  be  increased.  The  interest  should  be 
allowed  to  accrue  and  be  added  to  the  principal  until  the 
fund  is  at  least  $1,000,  while  the  society  should  take  meas- 
ures to  add  another  |1,000  to  it,  so  that  an  annual  income 
of  at  least  $100  should  bo  at  the  disposition  of  the  society. 
With  this  sum  an  annual  lectureship  could  be  maintained  ; 
the  lecturer  could  be  selected  from  among  the  most  capa- 
ble men  of  the  medical  profession  in  the  country,  who 
should  ])resent  to  the  society  the  results  of  his  own  obser- 
vation in  the  fields  in  which  he  was  confessedly  eminent. 


152 


PILGHER:  INAUGURAL  ADDRESS. 


[N.  Y.  Med.  Joub., 


Thus  the  vaUie  of  the  annual  meeting  would  be  greatly  en- 
hanced, and  the  attendance  of  an  increased  number  of  the 
profession  would  be  attracted  and  rewarded.  Such  a  lecture 
naturally  would  occupy  one  of  the  evenings  of  the  session. 

Time  of  holdimj  Annual  Meetings  of  County  Societies. — 
By  previous  presidents  attention  has  been  called  to  the  de- 
sirability of  the  adoption  of  a  uniform  period  of  the  year 
at  which  the  annual  meetings  of  all  the  county  societies 
should  be  held,  in  order  that  the  directory  of  officers  and 
members  of  each  society  in  the  transactions  of  the  State 
society  may  be  an  accurate  record  for  the  current  year.  Of 
more  importance,  however,  is  the  fact  that  often  there  are 
communications  to  be  made  from  the  State  society  to  the 
county  societies,  requiring  action  by  them  at  their  annual 
meetings.  If  such  annual  meetings  occurred  at  some  time 
during  the  spring  following  the  meeting  of  the  State  society 
it  would  make  such  communications  more  direct,  and 
would  tend  to  promote  a  more  intimate  relation  between 
the  State  and  county  organizations.  At  the  present  time 
eleven  county  societies  have  their  annual  meetings  in  Jan- 
uary, one  in  April,  eleven  in  May,  twenty-five  in  June,  six 
in  July,  one  in  September,  four  in  October,  and  one  in  No- 
vember. The  reasons  above  given  would  make  the  month 
of  May  the  latest  period  to  which  the  holding  of  the  county 
annual  meetings  should  be  deferred.  I  respectfully  sug- 
gest that  this  society  adopt  a  resolution  urging  its  constitu- 
ent county  societies  to  appoint  this  month  for  their  annual 
meetings. 

Attendance  of  Delegates  from  the  County  Societies  at  the 
Meetings  of  the  State  Society. — The  average  attendance  of 
delegates  and  permanent  members  of  the  society  at  its  an- 
nual meetings  for  the  years  1890,  1891,  and  1892  has  been 
186.  The  average  attendance  for  the  three  years  1880, 
1881,  and  1882  was  173.  The  steadiness  with  which  the 
work  of  this  society  has  been  maintained  is  worthy  of 
special  remark  in  consequence  of  the  well-known  fact  that 
most  persistent  efforts  were  made  for  a  number  of  years  to 
alienate  both  individual  members  and  whole  county  socie- 
ties from  their  allegiance  to  this  society.  It  is  a  subject 
for  congratulation  that  with  the  lapse  of  time  the  feelings 
which  prompted  this  action  have  been  largely  overcome  by 
the  manifest  absence  of  the  abuses  or  tendencies  which 
were  feared  and  prognosticated  by  some  and  by  the  steady 
improvement  in  every  element  of  professional  character  and 
work  as  fostered  by  the  society.  Year  by  year  county  so- 
cieties which  at  first,  after  the  change  in  the  code  of  ethics 
in  this  society,  declined  to  send  delegates,  have  renewed 
their  representation  until  at  the  present  time  there  are  very 
few  which  are  not  in  full  fellowship  with  this  society,  so 
that  practically  now  the  whole  profession  of  this  State 
has  become  unified  under  the  leadership  of  the  State  Medi- 
cal Society.  It  is  my  pleasure  to  announce  that  at  this 
present  session  the  County  of  Queens,  which  has  not  been 
represented  for  some  years,  is  again  represented  by  its 
delegates,  and  that  the  claims  of  the  State  society  against  it 
for  back  dues  have  been  adjusted  in  accordance  with  the 
plan  previously  ordered  by  this  society. 

The  American  Medical  Association. — I  have  the  pleasure 
of  presenting  to  this  society  at  this  time  a  communication 


from  Dr.  William  B.  Atkinson,  permanent  secretary  of  the 
American  Medical  Association,  transmitting  a  resolutioD 
adopted  by  that  association  at  its  session  held  in  Detroit  in 
June,  1892,  appointing  a  committee  of  five,  instructed  to 
meet  a  like  committee  from  the  State  Medical  Society  of 
New  York  and  the  State  Medical  Association  of  New  York 
for  the  purpose  of  adjusting  all  questions  of  eligibility  of 
members  of  the  State  Medical  Society  of  New  York  to 
membership  in  that  association,  and  notifying  this  society 
that  the  committee  in  question  had  been  appointed,  con- 
sisting of  Dr.  N.  S.  Davis  and  Dr.  John  II.  Ranch,  of  Illi- 
nois; Dr.^William  T.  Briggs,  of  Tennessee;  Dr.  Dudley  S. 
Reynolds,  of  Kentucky ;  and  Dr.  Willis  P.  King,  of  Mis- 
souri. 

The  evident  intention  of  this  resolution  was  to  request 
that  this  society  appoint  a  similar  committee  to  confer  with 
the  committee  named,  although  the  resolution  as  transmit- 
ted does  not  say  so.  It  is  difficult  to  see  what  purpose 
such  a  conference  as  is  proposed  could  serve.  The  Ameri- 
can Medical  Association  is  very  properly  its  own  judge  of 
what  shall  be  the  qualifications  required  of  its  members. 
It  is  a  voluntary  association,  responsible  to  no  one,  and 
may  change  its  standard  for  admission  at  its  will.  At  its 
session  at  St.  Paul,  in  June,  1882,  it  voted  that  the  Medi- 
cal Society  of  the  State  of  New  York  was  not  entitled  to 
representation  in  it  because  the  code  of  ethics  adopted  by 
that  society  essentially  differed  from  and  was  in  conflict 
with  the  code  of  ethics  of  the  American  Medical  Associa- 
tion. The  status  of  affairs  to-day  differs  in  no  respect  from 
what  prevailed  in  1882,  save  that  a  year  or  two  later  the 
American  Medical  Association  adopted  an  explanatory 
declaration  which  practically  interpreted  its  own  code  to 
mean  the  same  as  the  code  already  adopted  by  the  Medical 
Society  of  the  State  of  New  York.  It  did  not,  however, 
rescind  the  vote  of  disfellowship  adopted  in  1882,  but,  on 
the  contrary,  at  the  recent  meeting  in  Detroit,  renewed  it, 
and  extended  it  to  embrace  not  only  this  society  as  an  or- 
ganization, but  also  all  persons  who  affiliated  with  it.  At 
this  same  meeting  also  it  appointed  a  committee  to  report 
upon  the  revision  of  its  own  code  of  ethics.  There  is, 
therefore,  no  certainty  as  to  what  the  future  code  of  ethics 
of  the  American  Medical  Association  will  be.  It  would  be 
highly  improper  for  the  Medical  Society  of  the  State  of 
New  York  to  assume  in  any  way  to  dictate  to,  or  even  sug- 
gest to,  any  organization  not  subordinate  to  it  what  ethical 
standard,  if  any,  such  an  organization  should  adopt.  It 
must  content  itself  with  regulating  its  own  standards,  as  it 
now  does,  suggesting,  in  turn,  that  it  is  equally  indelicate 
for  organizations  which  have  no  supervising  relation  to  it 
to  extend  advice  as  to  its  internal  affairs.  Practically,  the 
relations  of  the  Medical  Society  of  the  State  of  New  York 
to  the  American  Medical  Association  are  the  same  as  those 
which  it  sustains  to  the  British  Medical  Association,  the 
Canadian  and  Ontario  Medical  Associations,  and  to  the 
medical  societies  of  the  various  adjacent  States  to  which  it 
is  in  the  habit  of  sending  delegates  annually — viz.,  the  re- 
lations of  courtesy  and  comity.  All  these  medical  organi- 
zations named  continue  to  receive  with  due  honor  and  re- 
spect the  delegates  appointed  by  this  society,  and  doubtless 


Feb.  11,  1893.] 


PILGHER:  INAUGURAL  ADDRESS. 


153 


whenever  the  American  Medical  Association  shall  signify 
its  desire  that  this  society  shall  again  send  delegates  to  its 
meetings  such  delegates  will  be  sent.  The  Medical  Society 
of  the  State  of  New  York,  however,  must  meanwhile  be 
content  to  do  its  own  work  in  its  own  way,  awaiting  the 
pleasure  of  the  association  in  question.  Nevertheless, 
since  a  failure  by  this  society  to  appoint  such  a  committee 
as  is  contemplated  in  the  communication  from  the  Ameri- 
can Medical  Association  would  doubtless  be  construed  by 
many  who  are  still  ignorant  of  the  real  relations  which  ex- 
ist between  the  two  organizations  as  displaying  a  factious 
and  quarrelsome  spirit,  and  as  a  matter  of  simple  profes- 
sional comity,  I  would  advise  that  a  committee  of  five  be 
appointed  by  this  society  to  meet  the  committee  of  the 
American  Medical  Association  as  requested. 

The  Code  of  Ethics. — In  the  course  of  the  discussions 
which  have  been  provoked  by  the  action  of  the  American 
Medical  Association  just  alluded  to,  it  has  come  to  the 
knowledge  of  your  president  that  many  of  the  physicians  of 
this  State  are  convinced  that,  in  view  of  the  present  state  of 
general  enlightenment  prevailing  throughout  the  State  of 
New  York,  and  the  safeguards  which  by  legal  enactments 
are  thrown  about  the  entrance  into  the  medical  profession, 
it  would  comport  more  with  the  dignity  of  the  medical  pro- 
fession, and  would  enhance  the  respect  in  which  it  is  held 
by  the  general  public,  if  all  specific  rules  of  ethical  conduct 
were  elided  from  the  by-laws  of  the  State  Medical  Society, 
and  if  the  regulation  of  such  matters  were  hereafter  left  to 
the  judgment  of  individual  practitioners  influenced  by  the 
well-known  consensus  of  professional  opinion  and  local  cus- 
tom in  the  places  where  the  work  of  each  is  being  carried 
on.  Among  a  large  number  of  representative  physicians 
from  all  portions  of  the  State  with  whom  I  have  conferred 
on  this  point,  I  have  found  a  singular  unanimity  of  feeling 
on  this  subject.  The  only  hesitancy  which  any  have  ex- 
pressed has  been  as  to  whether  it  would  be  wise,  since  prac- 
tically this  is  already  the  present  status  of  the  profession 
in  this  State,  to  make  any  movement  looking  to  a  formal 
elision  of  a  code  from  our  by-laws,  lest  it  should  revive 
acrimonious  discussion,  and  reawaken  strife  that  would  be 
detrimental  to  the  higher  interests  of  the  profession  in  this 
State.  By  far  the  greater  weight  of  the  opinions  which  I 
have  been  able  to  elicit  has,  however,  been  that  no  such  re- 
sult would  follow,  but  that,  on  the  contrary,  such  action 
would  tend  still  more  to  heal  old  differences  and  bring  to- 
gether all  the  elements  of  the  medical  profession  in  this 
State.  Such  is  also  my  own  mature  opinion,  and,  further,  it 
has  seemed  to  me  that  at  present,  when  there  is  a  general 
revival  of  interest  in  the  matter  of  professional  ethics,  as  is 
evidenced  by  the  discussions  which  are  now  going  on  in  the 
medical  journals  of  the  country,  and  when  this  question  of 
code  is  again  unavoidably  brought  to  the  attention  of  this 
society,  it  is  a  specially  favorable  moment  for  taking  this 
final  step.  At  the  present  time  the  only  allusion  in  the  by- 
laws of  this  society  to  a  system  of  medical  ethics  is  the  very 
brief  Section  8  of  Chapter  VI,  which  merely  says  : 

'*  The  system  of  medical  ethics  adopted  by  this  society, 
February  7,  1882,  shall  be  considered  authoritative  to  gov- 
ern the  medical  profession  in  the  State  of  New  York." 


I  would  recommend  that  this  section  be  dropped  in 
toto.  The  effect  of  such  action  would  be  to  leave  this 
State  Society  without  any  formulated  code  of  ethics,  and 
to  relegate  the  code  of  1882,  together  with  that  of  1847 
and  1823,  to  the  domain  of  history,  though  ever  remaining 
of  interest  and  value  to  the  student  of  the  development  of 
ethical  standards  in  the  medical  profession  of  this  State. 

A  National  Quarantine. — Prominent  in  the  thoughts  of 
both  physicians  and  people  at  this  time  are  considerations 
as  to  safeguards  against  the  invasion  of  this  country  by 
cholera,  the  danger  of  which  all  the  lessons  of  the  past 
warn  us  is  imminent.  Action  has  already  been  taken  by 
many  of  the  county  societies  of  this  State  urging  upon  Con- 
gress the  enactment  of  comprehensive  laws  establishing  the 
national  regulation  of  quarantine.  Doubtless  at  an  early 
period  in  this  meeting  this  subject  will  engage  the  atten- 
tion of  this  society,  and  will  receive  thorough  consideration 
at  your  hands. 

It  is  to  be  hoped  that  Congress  will  not  be  satisfied 
with  hasty  legislation  intended  only  to  meet  a  present 
emergency,  but  that  it  will  forthwith  institute  a  committee 
of  inquiry  that  shall  thoroughly  investigate  and  consider 
all  matters  pertaining  to  national  sanitation,  which  shall 
mature  a  report  which  shall  result  in  the  enactment  of 
permanent  and  comprehensive  laws  in  this  department  of 
the  public  welfare. 

The  Programme  for  Scientific  Work. — It  is  now  my 
privilege  to  submit  to  you  the  most  important  of  the  mat- 
ters which  can  engage  the  attention  of  this  society — viz., 
the  programme  for  scientific  work,  which  has  been  arranged 
by  the  business  committee.  This  committee  was  appointed 
soon  after  the  adjournment  of  the  last  meeting  of  the  so- 
ciety, and  at  once  set  about  perfecting  such  arrangements 
for  scientific  contributions  as  it  believed  would  be  to  the 
interest  of  the  society.  Being  persuaded  that  a  systematic 
arrangement  of  topics  for  discussion  would  be  desirable, 
for  the  present  meeting  at  least,  they  secured  the  co-opera- 
tion of  gentlemen  especially  qualified  to  advise  them  in 
special  fields  of  medical  work,  to  whom  they  committed 
choice  of  topics  and  essayists  in  their  special  departments. 
They  omitted  to  send  out  the  general  circular  inviting  con- 
tributions, which  has  been  customary  in  the  past,  for  the 
reason  that  the  brevity  of  the  session  of  the  society  would 
not  make  possible  the  presentation  to  it  of  any  large  num- 
ber of  miscellaneous  papers  if  the  selected  topics  were  to 
be  discussed  as  was  planned.  The  committee  were  assisted 
by  Dr.  William  Browning,  of  Brooklyn,  who  arranged  for  the 
discussion  for  the  morning  of  the  first  day  upon  Epilepsy  ; 
by  Dr.  Egbert  K.  Grandin,  of  New  York  city,  in  arranging  for 
the  discussion  on  the  Relative  Value  of  Certain  Obstetrical 
Operations ;  by  Dr.  V.  P.  Gibney,  of  New  York  city,  in  ar- 
ranging for  the  discussion  upon  the  Management  of  Suppu- 
ration complicating  Tuberculous  Disease  of  the  Bones  and 
Joints ;  and  by  Dr.  H.  L.  Eisner,  of  Syracuse,  the  vice- 
president,  in  arranging  for  the  discussion  upon  Newer  Meth- 
ods of  Diagnosis  and  Treatment  of  Stomach  and  Intestinal 
Diseases.  The  programme  as  completed  is  already  in  your 
hands.  It  is  obvious  that,  for  the  successful  and  easy 
carrying  of  it  out,  the  division  of  time  arranged  by  the 


154 


FREUDENTHAL :  ASEPSIS  OR  ANTISEPSIS  III  NASAL  SURGERY.     [N.  Y.  Med.  Jodk., 


committee  must  be  rigidly  adhered  to.  I  would  recom- 
mend that  the  society,  immediately  upon  the  close  of  this 
address,  formally  accept  the  order  of  business  as  presented 
in  the  programme  submitted  by  the  Business  Committee, 
and  direct  its  presiding  officer  to  strictly  enforce  it. 

A  large  number  of  gentlemen  appear  here  as  delegates 
this  morning  for  the  first  time.  It  is  with  sincere  pleasure 
that  I  welcome  them  to  the  privileges  of  this  society,  and 
urge  that  they  will  freely  take  part  in  all  its  business  and 
discussions.  With  equal  pleasure  do  I  tender  the  privileges 
of  this  meeting  to  those  invited  guests  who  have  consented 
to  add  their  presence  and  scientific  contributions  to  the  work 
of  the  session. 

I  now  declare  this  the  eighty-seventh  annual  meeting 
of  the  Medical  Society  of  the  State  of  New  York  open  for 
the  transaction  of  business. 


dPrisinal  Commxtniratimts. 


ASEPSIS  OR  ANTISEPSIS  IN  NASAL  SURGERY  ?  * 
By  W.  FREUDENTHAL,  M.  D., 

ATTENDING  I.ARYNGOLOOIST  TO  THE  GERMAN  POLIKLINIK  ; 
VISITING  LARYNGOLOGIST  TO  ST.  MARK'S  HOSPITAL  AND  THE  MONTEPIORE  HOHE. 

As  antiseptic  wound  treatment  in  general  surgery  pro- 
gressed, antiseptic  treatment  in  operations  of  the  nose  grew 
more  popular,  and  especially  of  late  years  has  been  favored 
by  many  voices. 

But  the  variety  of  methods  proposed  for  this  purpose 
gives  evidence  of  a  very  undecided  manner  of  applying  an- 
tiseptics in  the  nose,  as  some  emphatically  speak  in  favor 
of  the  open-wound  treatment,  while  others  recommend  the 
nose  to  be  "  hermetically  "  closed.  And  the  therapeutic 
methods  used  by  each  side  are  naturally  in  accordance. 

To  arrive  at  a  clear  conclusion  we  must  decide  the  fol- 
lowing questions : 

L  Is  a  strict  antisepsis  joossiJZe  in  nasal  surgery  ? 

2.  Is  it  a  necessity  ? 

The  difficulty  in  treating  antiseptically  a  cavity  opening 
in  all  directions,  with  its  intricate  accessory  channels,  is  be- 
yond a  doubt.  The  peculiar  formation  of  some  nasal  sajpta 
or  turbinated  bodies  is  at  times  so  unfavorable  for  our  pur- 
poses that,  for  instance,  relatively  large  masses  of  secretion 
could  be  stemmed  behind  a  deviated  sjeptum,  and,  through 
decomposition,  might  produce  putrefaction.  Drainage, 
therefore,  is  impossible.  The  question  now  arises,  In  which 
way  do  the  present  methods  reach  their  final  purpose  of  a 
quick  and  good  recovery  ?  Or,  at  least,  how  can  the  meth- 
ods of  nasal  antisepsis  now  in  vogue  be  brought  in  accord 
with  our  theoretical  and  practical  experience  ? 

Just  on  account  of  the  novelty  of  nasal  surgery,  only 
little  on  this  subject  has  been  published,  and  these  com- 
paratively few  articles  have  been  published  mainly  by 
American  laryngologists.    Dr.  Rice,  f  in  a  worthy  article, 

*  Read  before  the  Section  in  Laryngology  and  Rhinology  of  the  New 
York  Academy  of  Medicine,  November  23,  1892. 

t  Antiseptic  Nasal  Surgery.   New  York  Med.  Jour.,  March  2,  1889. 


recommends  the  following  modus  operandi :  "  Some  days 
before  the  operation"  he  syringes  the  nose  with  an  anti- 
septic solution  twice  daily.  As  he  uses  one  to  two  quarts 
of  fluid  each  time,  he  recommends  beginning  with  a  saline 
water,  and  after  this  sublimate  (l  to  4,000)  in  a  lesser 
quantity.  Or  he  uses  a  weaker  solution  of  sublimate  (1  to 
10,000)  alone,  syringing  the  nose  with  this  through  the  re- 
tropharynx.  As  excellent  as  his  mode  appears  at  first  sight, 
we  must  stop  to  consider  whether  we  thus  can  accomplish 
the  desired  end.  Referring  to  the  preliminary  disinfection, 
what  is  gained  by  it  ?  Should  pus  have  gathered  at  any 
point,  it  will  return  of  an  evening  if  syringed  in  the  morn- 
ing, or  in  the  morning  if  syringed  in  the  evening,  unless  the 
primary  cause  has  been  removed,  so  that  disinfecting  di- 
rectly before  the  operation  will  be  as  absolute  a  necessity 
as  though  no  antiseptic  had  been  used  at  all.  Should  there 
be  any  other  detrimental  factor,  the  result  would  be  the 
same.  A  disinfection  begun  some  days  prior  to  the  opera- 
tion will  be,  to  say  the  least,  useless. 

And  if  asked  whether  this  same  antiseptic  syringing  be 
expedient,  even  directly  before  the  operation,  I  should  also 
emphatically  disapprove  of  it.  My  reasons  for  this  are  the 
following :  Gentlemen,  you  all  know  the  many  different 
kinds  of  bacteria  which  are  inhaled  and  remain  in  the  nose. 
And  in  connection  with  this  I  quote  these  lines  from  the 
interesting  observations  of  Dr.  Jonathan  Wright  *  :  "  Ten 
litres  of  laboratory  air,"  he  says,  "  contained  four  molds 
and  one  hundred  and  twenty-five  bacteria.  Ten  litres  of 
laboratory  air  after  passing  through  the  nose  contained  one 
mold  and  twenty-four  bacteria."  Although  these  data 
vary,  as  Wright  already  mentions,  they  prove  the  large 
amount  of  living  bacteria  deposited  in  the  nose.  And  now 
think  of  the  effect  of  antiseptic  measures  against  these.  Do 
you  for  an  instant  believe  that  a  few  minutes'  spray  of  a 
weak  antiseptic  solution  could  kill  those  bacilli  which  have 
to  lie  for  hours  in  concentrated  antiseptic  solutions  before 
they  die  off  ?  Granted  they  are  not  killed,  but,  by  the  force 
of  the  spray,  are  removed  from  the  nose,  which  is  not  plausi- 
ble, considering  the  depth  of  intricate  chambers  lined  with 
mucous  membranes  in  which  they  lie — even  then  little  is 
gained.  To  verify  this,  I  cite  Miquel,  who  has  found  that 
in  the  ordinary  atmosphere  of  a  large  city  "  there  are  two 
thousand  bacteria  to  the  cubic  yard,  the  air  of  a  room  or  an 
old  house  in  winter  showing  forty-five  thousand  to  the 
cubic  yard,  while  the  wards  of  a  long-used  hospital  show 
ninety  thousand  germs  in  the  same  space.  ...  Of  course, 
all  these  micro-organisms  are  not  infectious,  and  ...  it 
has  been  shown  that  there  are  probably  a  few  species  which 
are  chiefly  active  in  producing  septic  diseases  and  suppura- 
tion, notably  Staphylococcus  pyogenes  aureus  and  albus,  the 
streptococcus  of  erysipelas,  etc." 

Therefore,  after  freeing  the  nostrils  of  all  germs,  the 
next  inspiration  will  refill  every  chamber  with  fresh  para- 
sites, and,  by  the  time  the  spray  is  laid  aside  and  the  in- 
struments taken  in  hand,  the  condition  of  the  nose  is  al- 
most as  bad  as  at  first.    A  reply  would  be  that  this  theory 


*  Nasal  Bacteria  in  Health.  Jour,  of  the  Am.  Med.  Assoc.,  Sept. 
21,  1889. 


Feb.  11,  1893.]  FREUDENTEAL:  ASEPSIS  OR  ANTISEPSIS  IN  NASAL  SURGERY. 


155 


would  have  like  effect  in  operations  upon  the  extremities  or 
any  part  of  the  body,  which  is  not  true,  because,  firstly, 
you  can  irrigate  the  same  continuously,  and,  secondly,  there 
does  not  exist  the  inspiratory  action  which  we  have  in  the 
nose.  The  air  with  its  contents  passes  through  the  nose, 
even  when  we  try  to  inhale  through  the  mouth  only.  The 
normal  condition  of  a  healthy  body  rids  itself  of  most  of  these 
germs,  but  those  remaining  are  the  important  ones,  which 
are  surely  not  killed  by  our  present  methods. 

That  the  operation  itself  should  be  performed  with  ab- 
solutely clean  {i.  e.,  sterilized)  instruments,  that  the  oper- 
ator himself  must  have  clean  {i.  e.,  aseptic)  hands — about 
this  there  is  no  question  at  the  present  day,  and  I  am  not 
going  to  dwell  upon  this  subject  any  longer. 

What,  however,  should  the  mode  of  after-treai?nent  be 
which  we  now  begin  to  discuss  ?  In  that  the  authors  do  not 
as  yet  agree.  To  me  it  appears  that  occlusion  of  the  nos- 
trils is  favored  at  present  by  the  majority.  For  different 
reasons  I  have  to  speak  against  it.  First,  I  consider  an  ab- 
solutely hermetically  closed  nostril,  as  Roe*  wants  it,  an 
impossibility ;  whether  we  use  flexible  metal  and  wrap  it  in 
cotton,  or  cotton  alone,  or  iodoform  gauze,  or  the  kind,  it 
still  remains  an  impossibility.  No  matter  how  closely  we 
pack  the  material,  it  will  not  prevent  air  from  passing 
through  the  retropharynx,  or  the  accessory  cavities  of  the 
nose,  to  the  operated  spot,  and  this  air  is  not  always  fil- 
tered, as  there  is  generally  some  hidden  space  which  the 
tamponing  has  not  fully  occluded,  allowing  the  unfiltered 
air  to  pass  through.  A  packing  applied  to  exclude  all  air, 
if  at  all  possible,  would  have  such  bad  general  effects  that 
one  would  desist  fi'om  using  it  again.  Think  merely  of  the 
consequences  following  the  damming  back  of  air  into  the 
accessory  cavities ;  furthermore,  the  congestion  caused  by 
strong  pressure  upon  the  blood-vessels  and  its  effects  upon 
the  tissues  of  the  face,  and  you  will  easily  conceive  that  a 
"hermetic"  occlusion  is  out  of  the  question. 

Where,  however,  the  tamponade — I  do  not  mean  "  her- 
metic "  occlusion  of  the  nose — is  used  for  the  purpose  of 
further  disinfecting  as  an  antiseptic  tamponade,  there,  even 
in  a  good  course,  we  can  not  speak  of  a  prima  intentio,  ac- 
cording to  the  opinion  of  Tavel,f  but  only  of  a  norma] 
aseptic  course.  Tavel  reserves  the  prima  intentio  only  for 
those  cases  in  which  healing  takes  place  without  any  fur- 
ther post-operative  antiseptic  procedures. 

That,  furthermore,  all  these  dressings  are  foreign  bodies, 
which  generally  produce  local  irritation  and  sometimes 
oedema  which  reaches  the  forehead.  These  are  my  per- 
sonal observations,  made  repeatedly,  which  caused  me  to  do 
away  with  a  firm  dressing  whenever  possible. 

Finally,  it  is  too  well  known  that  these  dressings,  due 
to  irritation  of  the  glands,  cause  a  flow  of  their  secretion, 
or,  in  other  words,  give  rise  to  humidity.  And  in  just 
such  humid  states  do  micro-organisms  thrive  best.  Thus, 
in  removing  these  dressings,  we  always  see  a  large  amount 

*  The  Aseptic  Method  as  applied  to  Intra-nasal  Surgery.  Vcrhand- 
lungcn  des  X.  intcrnaiion.  niedicin.  Congresaes.    Bd.  iv,  p.  90. 

\  Die  Sterilitat  der  antiseptiseh  behandelten  Wunden  iinter  dein 
antiseptisclien  Verbande.  Correspondenzbl.  f,  schweizer  Acrzte,  Nos.  13 
and  14,  1892. 


of  pus  and  decomposed  fluid.  We  have  artificially  pro- 
duced the  best  nutritive  power  for  the  development  of  the 
bacilli.  Were  we,  however,  to  deprive  the  bacilli  of  this 
nutritious  element — the  element  of  moisture — we  would 
stunt  the  growth  of  the  micro-organisms.  And  if  we  were 
to  provide  that  blood,  pus,  and  other  secretions  of  the  wound 
dry  up,  we  would  then  absolutely  prevent  the  development 
of  lower  bacteria. 

We  have,  therefore,  to  return  to  the  open  after-treat- 
ment recommended  some  years  ago  by  Dr.  Rice.  That  in 
this  case  strict  antisepsis  does  not  at  all  exist  is  beyond 
question. 

Thus,  after  having  seen  that  neither  before  nor  after  the 
operation  absolute  antisepsis  is  possible,  we  come  to  the 
second  very  important  question.  Is,  in  nasal  operations,  an- 
tisepsis at  all  necessary  ? 

Permit  me  to  attract  your  attention  to  a  few  side  re- 
marks somewhat  foreign  to  our  present  topic,  but  where  we 
have  reason  to  expect  the  greatest  results  from  asepsis — 
namely,  obstetrics  and  gynaecology.    "  When  Lawson  Tail 
published  his  first  successful  operations,"  says  I.  Veit,* 
"  not  a  few  physicians  were  at  first  incredulous.    Only  to  a 
small  degree  did  the  first  thousand  of  his  laparotomies  re- 
move their  antagonistic  views ;  the  second  thousand  left 
only  few  who  still  doubted  the  truth  of  his  results,  so  that 
the  third  thousand,  which  will  be  shortly  published,  can  do 
little  more  than  corroborate  and  confirm  the  now  generally 
adopted  views.    The  fundamental  principles  of  Tait's  asep- 
sis have  proved  to  be  correct.    This  remains  a  truth,  whether 
or  not  it  be  recognized  by  this  or  that  surgeon.    We  know 
that  the  results  of  gynaecological  laparotomies  depend  essen- 
tially upon  how  minutely  and  thoroughly  the  principles  of 
asepsis  are  carried  out  in  all  its  details.    In  gynaecology  as 
well  as  in  surgery  asepsis  is  potential."    In  speaking  of  the 
different  stages  of  a  confinement,  Veit  comes  to  the  follow- 
ing conclusions,  which  are  interesting  to  us :  1.  An  internal 
disinfection — i.  e.,  of  the  genitals — is  never  indicated  under 
normal  circumstances.    2.  A  disinfection  after  the  birth  in 
normal  cases  is  not  indicated  either  externally  or  internally. 

Now,  if  we  compare  the  possibility  of  infection  that 
is  so  very  great  in  a  confinement  with  those  relatively  sim- 
ple procedures  in  operations  of  the  nose,  we  must  declare 
that  when  we  have  given  up  antisepsis  in  obstetrics  we 
will  find  it  much  easier  and  our  results  more  successful  in 
nasal  operative  work.  Gentlemen,  it  is  bold  to  express 
views  to  you  against  antisepsis — you  who,  so  to  speak,  have 
grown  up  with  the  antiseptic  period,  to  whom  the  antisep- 
tic methods  have  gone  in  succum  et  sanffuitiem  ;  to  you  who 
have  had  ample  occasion  to  see  the  immense  advantages 
which  antisepsis  has  brought  to  thousands  and  thousands 
of  people  ;  but,  gentlemen,  thinking  asepsis  so  far  superior 
to  antisepsis,  I  hope  the  time  not  too  distant  when  we  can 
say  that  antisepsis  was  only  a  herald  to  asepsis.  And  now 
to  go  into  details. 

Independent  of  the  fact  that  artificial  means  (antisep- 
tics) seem  to  be  uncalled  for  in  a  natural  process  like  chilu 


*  Aseptik  der  Geburtshiilfe.  Berlin,  klin.  Wockenschr.,  May  16 
1892. 


156 


FREUDENTHAL:  ASEPSIS  OR  ANTISEPSIS  IN  NASAL  SURGERY.     [N.  Y.  Med.  Joue., 


birth,  we  yet  acknowledge  tliat  through  the  act  of  birth  the 
whole  genital  canal  becomes  an  open  wound,  truly  gives 
freest  scope  to  infection.  But  with  what  ease  do  all  these 
parts  heal  in  most  cases  without  any  aid  save  Nature, 
which  teaches  us  that  she  does  her  work  best  when  not  in- 
terfered with  !  And  so  obstetrics  has  made  its  first  rule : 
nihil  nocere.  Why  not  transfer  this  powerful  law  to  rhino- 
logical  operations  ?  Do  not  harm  your  patient  with  antisep- 
tics or  any  other  harmful  means  where  a  simple  method 
like  asepsis  will  fulfill  every  indication. 

There  are  few  organs  in  the  human  body  which  are  as 
susceptible  to  all  manipulations  as  the  mucous  membrane 
of  the  nose,  and  therefore  the  less  we  manipulate  it  the 
better  it  is.  And  when  such  extensive  lesions  in  the  uterus 
and  vagina  usually  heal  per  primam  without  our  doing  any- 
thing for  them,  why  should  not  this  be  possible  in  the 
nose  ?  When  Lawson  Tait  has  successfully  performed 
thousands  of  laparotomies  in  an  aseptic  manner  pure  and 
simple,  why  should  we  not  succeed  with  this  method  in 
much  smaller  operations  ? 

Besides,  when  we  apply  antiseptics  in  the  abdominal 
cavity  we  at  least  know  that,  to  a  degree,  we  do  no  harm. 
In  the  nasal  cavity,  however,  it  is  quite  different.  Mercury, 
salicylic  acid,  and  carbolic  acid  have  a  decided  noxious  in- 
fluence upon  the  physiological  function  of  the  raucous  mem- 
brane of  the  nose — an  influence  certainly  not  noticeable  at 
once,  but  appearing  after  the  operation  is  a  thing  of  the  past. 
Have  you  not  had  patients  come  to  you  having  had  a 
piece  of  bone  or  the  like  removed  by  some  other  specialist, 
claiming  they  could  breathe  better,  but  were  still  very  un- 
comfortable ?  Such  patients  are  now  suffering  from  a  dry 
catarrh  or  the  like,  due  to  the  result  of  our  antiseptic  reme- 
dies, which  affected  badly  the  physiological  function  of  the 
mucous  membrane  of  their  nose.  And  it  is  just  this 
physiological  action  of  the  mucous  membrane  which  is  de- 
stroyed by  our  operative  antisepsis,  and  nothing  has  been 
more  pernicious  in  my  experience  than  the  use  of  mercury. 
This  idea  is  confirmed  by  experiments  made  by  Dr.  Wal- 
thard,  of  Bern,*  which  prove  that  it  is  mainly  the  subli- 
mate which  destroys  the  physiological  function  of  the 
mucous  membranes.  Therefore  I  would  emphatically  ap- 
prove of  doing  away  with  all  antiseptics,  especially  mer- 
cury, as  long  as  feasible. 

It  is  peculiar  that  the  nose,  and  especially  the  naso- 
pharynx, are  almost  inaccessible  to  antiseptic  methods,  yet, 
strange  to  say,  these  parts  heal,  as  a  rule,  quicker  than  all 
others.  Since  I  began  in  Berlin  operating  on  adenoid 
vegetations  until  this  day  I  have  performed  about  six  hun- 
dred such  operations.  At  first  I  used  Meyer's  knife,  and 
since  three  years  Gottstein's  curette — instruments  when 
used  usually  cause  some  bleeding,  but  not  much.  I  have 
never  applied  antiseptics,  either  before  or  after  the  opera- 
tion. Without  any  preliminary  manipulations,  I  attacked  the 
pharynx  with  clean — i.  e.,  sterilized — instruments,  scraped 
away  the  vegetations,  and  did  nothing  further.  As  a  mat- 
ter of  course,  I  always  prescribed  a  weak  gargle — as  boric 
acid  or  hypermanganate  of  potassium — but  more  as  a  pla- 

*  Corr&ipondenzlb,  /.  schweizer  Aerzte,  loc.  cit,  1892. 


cebo  than  for  any  other  reason  ;  and  never  have  I  seen  any 
infection  as  a  result  of  my  operative  interference.  Never  a 
case  of  sepsis  occurred,  and  yet  no  antiseptics  were  ever  ap- 
plied. 

Now,  how  were  all  these  cures  brought  about  ?  It 
seems  that  the  healing  power  of  Nature  is  now  more  and 
more  recognized.  Herbert  J.  Waterhouse,*  of  Edinburgb, 
through  experiments  and  clinical  observations,  has  demon- 
strated the  anti-bacteric  power  of  the  peritonaium.  Bou- 
chard and  others  have  observed  the  destruction  of  bacilli  by 
the  spleen  and  their  elimination  by  the  kidneys,  as  in  ty- 
phoid fever.  Finally,  Buchner  f  has  proved,  only  latelyi 
the  bactericidal  effect  of  the  blood  serum.  He  has  shown 
that  every  species  of  serum  is  capable  only  of  killing  a 
limited  number  of  certain  kinds  of  bacteria,  and  has  found 
that  there  are  certain  albuminous  bodies  of  the  serum 
which  possess  this  bactericidal  effect.  For  these  latter  he 
proposes  the  international  name  of  alexines.  Thus  we  se« 
that  the  body  takes  care  of  itself  and  defends  its  own  im- 
munity against  bacteria.  "  We  have  abundant  reason, 
therefore,"  says  White,  J  "  to  believe  in  a  general  antago- 
nism between  the  body-cells  and  the  micro-organisms  of 
disease,  even  if  we  consider  the  question  of  phagocytosis  as 
still  an  open  one.  It  follows  that  the  theoretical  propriety 
of  non-interference  with  these  tissues  can  not  be  doubted  ;  * 
and  Lister  has  recently  admitted  and  accepted  this  view, 
remarking  that  the  floating  particles  of  the  air  having 
been  shown  to  be  less  harmful  than  was  supposed,  '  we 
may  possibly  dispense  with  antiseptic  washing  and  irriga- 
tion,' provided,  always,  that  we  can  trust  ourselves  and  our 
assistants  to  avoid  the  introduction  into  the  wound  of  septic 
defilement  from  other  than  atmospheric  sources.^''  * 

From  this  standpoint  we  will  be  able  to  understand  why 
most  of  the  operations  in  the  nose  heal  so  readily,  and  we 
comprehend  just  why  the  adenoid  vegetations  must  heal  so 
quickly,  even  where  the  asepsis  is  but  used  as  a  cleansing 
means  for  hands  and  instruments.  As  long  as  we  do  not 
carry  micro-organisms  into  the  field  of  operation,  they  heal 
undisturbed. 

For  this  reason,  I  think,  we  should  have  ideal  results 
in  healing  in  the  nose,  if  the  patients  would  not  become  in- 
fected afterward.  And  this  after-infection,  as  you  know, 
is  not  rare.  As  an  illustration  let  me  cite  a  case  that  oc- 
curred last  year  in  my  practice.  A  colleague  sent  a  patient 
with  hypertrophied  turbinated  bodies  for  treatment,  re- 
marking that  the  patient  had  been  galvano-cauterized  al- 
ready by  a  specialist,  but  the  reaction  had  always  been 
extraordinarily  severe  (high  fever,  swelling  of  the  tonsils, 
headache,  etc.).  He  thinks,  the  doctor  continued,  that  the 
specialist  in  question  had  not  used  clean  instruments  and 
hoped  to  see  better  results  from  my  treatment.  Although 
I  was  more  careful  regarding  the  asepsis  than  I  usually  am, 
I  am  sorry  to  say  that  my  experience  was  no  better  than 

*  Virchow's  Archiv,  Bd.  cxix,  p.  342. 

f  Ueber  die  Schutzstoffe  des  Serums.  £<y>-l.  klin.  Wochcnschr.,  No. 
19,  1892. 

\  I.  William  White.  Antisep.sis  and  Asepsis,  in  Hare's  System  of 
Practical  7'herapeutics. 

*  Italics  mine. 


Feb.  11,  1893.]  FREUDENTEAL:  ASEPSIS  OR  ANTISEPSIS  IN  NASAL  SURGERY. 


157 


the  first.  The  patient  showing  the  same  reaction,  I  had  to 
use  every  power  of  persuasion  to  cauterize  her  nose  a  sec- 
ond time.  This  time  I  applied  every  antiseptic  precaution 
to  satisfy  myself.  I  applied  the  antiseptic  solutions  and 
dressings  recommended,  but  I  was  not  a  little  surprised 
to  find  even  this  time  high  fever,  amygdalitis,  and  all  the 
other  symptoms  following  as  before.  After  a  careful  ex- 
amination I  found  that  factor  which  is  the  cause  in  many 
similar  cases.  In  the  patient's  home,  while  under  treat- 
ment, one  or  the  other  of  her  four  children  were  sick  with 
angina  follicularis,  which  infected  the  mother.  The  infec- 
tion happened,  therefore,  entirely  independent  of  the  opera- 
tion through  contact  with  a  patient  suffering  from  an  infec- 
tious disease.  In  a  closely  inhabited  city  like  New  York, 
where  such  diseases  exist  throughout  the  year,  this  is  not 
surprising. 

Last  winter  I  made  inquiries  of  the  surroundings  and 
circumstances  of  a  series  of  patients  and  found — I  will  not  de- 
tain you  with  more  details  of  this  tiresome  work — that  about 
forty  per  cent,  of  all  reactions  after  an  operation  could  be 
traced  to  an  infection  at  the  home  of  the  patient,  either 
through  angina,  diphtheria,  scarlet  fever,  measles,  or  other 
infectious  disease.  At  times  where  the  patient  lived  in  a 
large  tenement  house,  although  suspecting  the  cause,  I 
could  not  prove  this  fact,  as  the  patient  did  not  know  his 
neighbors.  I  have,  therefore,  gained  the  conviction  that 
almost  ajl  the  cases  of  our  nasal  operations  which  have  been 
strictly  aseptically  performed  and  nevertheless  show  strong 
reaction,  have  been  infected  in  the  above  manner,  and  I 
have  now  made  it  a  custom  every  time  before  operating  to 
ask  whether  there  is  an  infectious  disease  in  the  house  of 
the  patient. 

That,  in  spite  of  the  greatest  precaution,  severe  diseasse 
of  the  brain,  etc.,  may  happen,  demonstrates  the  case  of 
Dr.  Quinlan,  as  well  as  a  case  lately  published  by  R.  Wag- 
ner, in  which  last  case  a  fatal  meningitis  occurred  after 
galvano-cauterization  of  a  middle  turbinated  body.  Wag- 
ner believes  that  it  is  impossible,  in  spite  of  the  greatest 
care,  to  render  the  nose  entirely  antiseptic — a  view  which  is 
upheld  by  Professor  Schech,  the  reporter  of  this  article  in 
the  Internationale  Centralblatt  fur  Laryngologie,  page  9, 
1892. 

From  the  theoretical  deductions  given  you  this  evening 
results  my  mode  of  practicing.  I  leave  out  all  antiseptic 
sprayings  and  washings.  When  I  want  to  remove  secre- 
tions from  the  nose,  I  spray  gently  with  lukewarm  sterilized 
water.  After  applying  a  clean  solution  of  cocaine,  I  ask 
the  patient  to  blow  his  nose  not  too  gently.  The  purpose 
of  this  blowing  is  to  irrigate  the  whole  field  of  operation 
with  the  glandular  secretions  of  the  mucous  membrane, 
which  is  of  course  aseptic.  By  these  means  I  have  made 
the  field  of  operation  for  our  purposes  sufficiently  aseptic, 
and  thus  all  preparations  for  the  operation  are  finished. 
The  latter  is  performed  in  the  usual  way.  Professor 
Tavel,*  of  Bern,  reconmiciids  to  keep  the  wounds  humid 
with  the  solution  of  salt  and  soda  used  in  Bern.  This  lat- 
ter consists  of  the  physiological  solution  of  salt,  seven  and 

*  Lor.  cit. 


a  half  per  cent.,  and  caustic  soda,  two  and  a  half  per  cent. 
I  think  this  solution  ought  to  prove  satisfactory  where  there 
is  a  preliminary  cleaning  necessary.  It  possesses  the  alka- 
linity of  the  blood  and  is  not  destructive  to  the  physiologi- 
cal function  of  the  mucous  membrane.  I  have  been  using 
it  for  about  three  months  to  my  satisfaction.  It  is  always 
good,  if  we  can,  to  stop  the  bleeding  while  the  patient  is  in 
our  office.  A  thick  layer  of  blood  covers  the  whole  wound, 
and  the  protective  qualities  of  the  blood  serum  prevent  any 
infection  for  the  time  being:.  The  blood  soon  coamilates 
and  we  get  a  protective  that  keeps  away  all  infective  germs. 
Frequently,  however,  this  natural  protection  falls  off  after- 
ward or  is  removed  by  strong  blowing  of  the  nose  or  new 
bleeding,  and,  if  the  patient  then  enters  an  infectious  atmos- 
phere, he  can  easily  be  infected.  Now,  to  preserve  the  origi- 
nal protection  I  use  collodium  especially  thickly  prepared, 
which  I  spread  over  the  whole  wound  with  cotton.  Former- 
ly I  experimented  for  the  same  purpose  with  the  collodium 
commonly  used  and  with  colophony  without  getting  sat- 
isfactory results.  Now,  after  having  coated  the  wound 
with  a  thick  layer  of  collodium,  I  introduce  a  small  plug  of 
cotton  just  within  the  nasal  entrance,  instructing  the  pa- 
tient to  remove  it  as  soon  as  he  comes  home.  This  is 
done  for  the  purpose  of  protecting  the  wound  from  the 
cold  air.  In  the  beginning  I  found  it  good  to  apply  the 
collodium  daily.  The  after-treatment  is  of  course  an  open 
one.  E.  Aronsohn,*  of  Ems,  has  of  late  recommended 
dermatol  for  this  purpose,  but  I  have  no  experience  with  it. 
Pyoctanin  is  very  much  lauded  by  Bresgen.f  In  another 
article  J  I  have  spoken  at  length  about  the  use  of  trichlor- 
acetic acid.  I  can  not  recommend  it.  The  only  thing  I 
use,  if  necessary,  is  lukewarm  water,  to  which  I  add  now 
Tavel's  solution.  With  these  simple  procedures  I  think 
just  as  good  results  can  be  reached  as  with  a  complicated 
mass  of  antiseptics.  I  even  believe  our  after- results  will  be 
much  better  when  we  take  care  of  the  physiological  func- 
tions of  the  tissues,  which  so  far  have  been  entirely  neg- 
lected. 

It  is  my  simple  belief  and  conviction  that  patients  who 
are  healthy  do  not  harbor  pathogenic  germs.  For  this  rea- 
son I  earnestly  recommend  and  ask  of  you  to  give  the  aseptic 
treatment  a  fair  trial.  If  your  results  give  you  as  favora- 
ble healings  as  mine,  I  shall  feel  more  than  repaid  by  this 
contribution. 

1054  Lexington  Avenue. 


Bellevue  Hospital. — Dr.  John  Winters  Branuaa  ha.-?  been  appointed 
a  vi>;iting  physician  to  tlie  hospital. 

The  Death  of  Dr.  George  Jackson  Fisher,  of  Sing  Sing,  N.  Y.,  is 

announced  as  having  taken  place  on  the  3d  inst.  The  deceased,  who 
was  sixty-eight  years  old,  had  been  a  well-known  practitioner  for  many 
years,  and  was  noted  as  having  collected  a  very  extensive  and  valuable 
medical  library,  particularly  rich  in  books  on  the  history  of  medicine 
and  on  teratology.  He  had  been  president  of  the  Medical  Society  of 
the  County  of  Westchester  and  of  the  Modioal  Society  of  the  State  of 
New  York. 

*  Deutsche  medicin.  Wochcnschrift,  Nos.  29  and  30,  1892. 
f  Die  Vorwcndiuig  dea  Pyoktaiiins  in  Nasc  und  Hals.   Deutsche  med. 
Work.,  No.  24,  1890. 

\  New  Yorker  medieln.  Momihsr/ir.,  .lauuary,  ls;>2. 


158 


RUSBY:   VEGETABLE  MEDICINES  OF  THE  IPECAC  CLASS.         [N.  Y.  Meu.  Johk., 


VEGETABLE  MEDICINES  OF  THE  IPECAC  CLASS* 
By  H.  H.  RUSBY,  M.  D., 

PROFESSOR  OF  BOTANY  AND  MATERIA  MEDICA  IN  THE 
NEW  YORK  COLLEGE  OF  PHARMACY. 

The  group  of  medicines  here  considered  is  a  very  large 
one,  its  development  liaving  resulted  partly  from  the  medi- 
cal practices  of  aborigines,  and  partly  from  those  of  edu- 
cated physicians.  Every  physician  whose  practice  extends 
among  the  lower  classes  will  appreciate  the  fact  that  savages 
are  deeply  impressed  with  the  importance  of  emetics  and 
cathartics.  To  these  they  assign  simple  names  which  indi- 
cate such  properties, f  and  in  dilTerent  sections  where  the 
same  or  similar  languages  are  used,  different  articles  come 
to  be  designated  by  the  same  or  similar  names.  While 
agreeing  in  the  production  of  this  one  effect,  these  medi- 
cines may  be  as  unlike  in  physiological  action  and  thera- 
peutic application  as  their  plants  are  in  botanical  structure. 
They  may  but  present  symptomatic  analogies.  Upon  the 
introduction  of  a  member  of  such  a  group  to  civilization,  if 
it  chance  to  "  take,"  the  others  are  quickly  brought  for- 
ward. Ipecac  was  thus  introduced  during  the  seventeenth 
century,  and,  although  proposed  as  an  antidysenteric,  its 
powerful  emetic  properties  made  a  deep  impression  upon 
the  medical  practitioners  of  that  early  period,  so  that  from 
the  very  first  it  occupied  a  very  prominent  position,  and 
soon  became  a  sort  of  a  type,  around  which  were  grouped 
not  only  the  other  varieties  of  ipecac  which  were  sought 
out  and  brought  to  Europe,  but  all  drugs  possessing  proper- 
ties at  all  like  it.  This  position  ipecac  has  maintained,  as 
its  usefulness  and  importance  have  grown  almost  steadily 
during  two  hundred  years,  and  its  group  has  received  con- 
stant accessions  up  io  the  immediate  present.  So  large 
indeed  has  it  become  that  several  special  works  in  different 
languages  have  Deen  devoted  to  the  enumeration  and  de- 
scription of  its  members,  the  most  recent  being  the  Etude 
des  ipecacuaiias,  by  Edouard  Jacquemet,  published  in  Paris 
in  1890.  As  a  matter  of  mere  historical  interest,  it  would, 
perhaps,  be  not  worth  while  to  occupy  your  time  with  a 
consideration  of  these  medicines.  It  is  the  practical  fea- 
tures of  the  case  to  which  I  wish  to  direct  your  attention. 
Not  only  is  it  desirable,  in  the  case  of  such  important 
agents,  to  discriminate  clearly  between  their  several  special 
fields  of  application,  but  it  is  no  small  matter  to  know 
where  and  how  to  search  intelligently  for  a  satisfactory 
substitute  in  case  of  emergency.  The  recent  and  present 
scarcity  and  costliness  of  ipecac,  with  its  consequent  in- 
creased tendency  toward  adulteration  and  inferiority,  almost 
constitute  an  emergency,  or  are  liable  at  any  time  to  do  so.  J 

My  purpose  is,  therefore,  to  classify  this  great  group, 
separating  those  members  which  exhibit  mere  resemblances 
to  ipecac  from  those  which  are  really  like  it  in  physiologi- 
cal action,  the  only  sound  basis  of  therapeutic  application. 
For  such  comparison  I  first  present  an  analysis  of  the 
properties  of  ipecac  itself. 

*  Read  before  the  Practitioners'  Club  of  Newarli,  New  Jersey, 
f  As,  ipe-ka(ji-yaena  —  a  creeping  plant  which  will  cause  vomiting. 
\  Since  this  was  ijenned,  accounts  of  extensive  adulteration  of  ijie 
cac  have  ajipeared. 


The  action  of  ipecac  lies  in  two  entirely  distinct  and 
fully  understood  directions,  besides  producing  certain  other 
as  yet  imperfectly  understood  effects.  The  first  is  its  local 
irritation  ;  the  second,  its  effects,  after  absorption,  upon  the 
vagi.  Its  imperfectly  understood  effects  are  the  expectorant, 
cutaneous,  and  hepatic. 

Its  locally  irritant  effects  are  very  simple  and  exhibited 
both  externally  and  internally — externally,  in  the  hyperae- 
mia,  pustulations,  and  even  ulcerations  produced  in  direct 
experiment  and  in  collecting  and  working  with  the  drug  ; 
internally,  in  the  sneezing  and  asthmatic  seizures  depend- 
ent upon  inhalation,  as  well  as  in  the  nature  of  its  effects 
upon  the  digestive  mucous  membrane.  We  find  that 
stomach  administration  produces  emesis  much  more  quickly 
than  other  modes.  That  this  difference  is  due  to  local 
irritation  is  shown  by  the  fact  that  agents  which  tend  to 
mollify  .«uch  irritation,  like  bismuth  and  hydrocyanic  acid, 
postpone  the  emesis.  Direct  observation  has  shown,  more- 
over, that  there  is  hyper;emia  and  increased  temperature  of 
the  intestinal  mucous  membrane,  and  often  purging,  after 
contact  of  the  ipecac  or  during  its  elimination  by  that 
tissue. 

Its  effect  upon  the  vagi  is  indicated  by  the  occurrence 
during  intense  poisoning  of  symptoms  corresponding  to 
those  caused  by  section  of  the  vagi — namely,  sudden  im- 
peding of  the  lungs.  When  death  occurs  as  the  result  of 
ipecac  [loisoning,  it  is  usually  in  the  form  of  respiratory 
paralysis.  Moreover,  if  the  vagi  be  first  severed,  the  hypo- 
dermic administration  of  the  active  constituent  of  ipecac — 
emetine — will  not  produce  emesis. 

Some  of  the  effects  of  ipecac,  notably  vomiting,  are  ex- 
plained by  these  two  properties.  The  vomiting  is  doubt- 
less due  more  especially  to  the  central  action  of  the  drug, 
because  it  is  of  slow  action,  as  though  the  local  effects 
were  not  sufficient  until  after  the  central  action  had  come 
to  their  aid.  Sometimes  repeated  doses  will  fail  to  pro- 
duce emesis  and  the  subject  will  become  narcotized. 

Cerebral  congestion  is  found  to  be  entirely  indirect,  due 
to  the  strain  in  vomiting. 

The  evacuation  of  bile,  both  by  stomach  and  bowels, 
is  partly  explained  by  the  nature  of  the  vomiting,  in  which 
the  diaphragm  is  fixed  from  above,  and  the  stomach,  liver, 
and  gall-bladder  are  squeezed  between  it  and  the  abdomi- 
nal walls.  But,  in  addition  to  this  mechanical  evacuation 
and  stimulation,  it  appears  that  the  liver  must  be  affected 
in  some  other  way,  for  the  bilious  stools  are  even  more 
pronounced  after  toleration  is  established  and  all  tendency 
to  emesis  is  absent. 

We  do  not  understand,  or  at  least  are  not  agreed  as  to, 
the  expectorant  action  of  ipecac,  especially  upon  the 
bronchial  lining,  its  diaphoretic  action,  or  its  occasional  re- 
duction of  cutaneous  temperature.  In  its  expectorant 
action  it  increases  the  secretion  of  the  parotid  glands  and 
of  the  mucous  membranes  of  the  mouth,  nose,  pharynx,  and 
bronchial  tubes.  Its  action  upon  the  broncliial  tubes  is 
especially  marked  in  children,  and  is  powerfully  accentuated 
by  combining  with  it  some  synergist,  the  result  being 
greater  than  would  be  accounted  for  by  the  result  of  the 
one  plus  that  of  the  other.    The  same  may  be  said  of  its 


Feb.  11,  1893.] 


BUSBY:   VEGETABLE  MEDICINES  OF  THE  IPECAC  CLASS. 


159 


action  upon  the  skin,  and  it  is  important  to  note  that  this 
action  is  not  strong,  regular,  or  certain. 

Ipecac  exerts  no  action  upon  the  pulse,  blood-pressure, 
and  general  temperature,  in  most  cases. 

Although  not  accepted  by  most  physiologists,  it  would 
appear  as  though  ipecac  must  relax  the  muscles  of  the 
arterioles  by  peripheral  paralysis  of.  the  vaso-motor  nerves, 
at  least  in  certain  parts. 

For  therapeutical  purposes,  and  especially  in  estimating 
the  comparative  value  of  any  similar  agent,  the  important 
points  to  note  are  that  the  effects  of  ipecac  are  diverse ; 
that  usually  only  a  part  of  them  are  desired,  the  others  being 
often  very  undesirable,  or  even  intolerable,  and  that  its 
most  useful  action  is  usually  the  most  difficult  to  secure, 
except  by  combining  something  with  it.  According  as 
these  disadvantages  are  shared  by  its  associates,  their  de- 
grees of  usefulness  and  value  should  be  accorded. 

With  these  facts  in  mind  we  are  prepared  to  briefly 
consider  the  numerous  claimants  of  ipecac-like  properties. 
A  great  many  of  these,  it  must  be  remembered,  have  never 
been  investigated.  All  that  we  have  to  guide  us  in  esti- 
mating them  is  their  domestic  repute,  some  hints  as  to 
composition,  and  their  botanical  relationship  to  plants 
whose  action  is  well  known. 

Those  which  we  shall  first  consider  may  be  regarded  as 
the  really  ipecac-like  group.  In  their  domestic  use,  and 
both  in  their  symptoms  and  mode  of  action,  they  are  strik- 
ingly like  ipecac,  and  almost  any  of  them  would  make  a 
good  substitute.  If  ipecac  were  to  become  lost  to  the  world 
and  we  were  obliged  to  study  this  group  for  the  best  article 
to  replace  it,  it  is  doubtful  if  therapeutics  would  not  be  a 
gainer  by  this  disclosure  of  her  riches,  and  by  finding  the 
enforced  substitutes  superior  to  the  standard  which  they 
replaced. 

Apomorphine  is  too  well  known  to  call  for  description. 
It  may  better  be  classed  as  an  alternative  than  as  a  substi- 
tute for  ipecac,  for,  while  in  many  cases  it  is  inferior,  in 
other  cases  it  is  superior.  Unlike  ipecac,  it  has  no  local 
action. 

Among  the  near  botanical  relatives  of  ipecac  we  find  a 
number  of  similar  agents.  Randia  dumetorum  yields  a  fruit 
a  portion  of  the  pulp  of  which  seems  to  act  in  a  manner 
identical  with  that  drug.  But  in  a  pure  form — for  it  must 
be  carefully  separated  from  the  remainder  of  the  fruit — it 
is  hardly  as  accessible  as  ipecac. 

Although  ipecac  is  commonly  called  a  Cepkaelis,  it  is 
doubtful  if  it  should  be  held  separate  from  the  very  large 
genus  psychotria,  many  of  whose  species  apparently  possess 
properties  similar  to  those  of  our  own  drug,  and  which,  it  is 
fair  to  assume,  contain  the  same  active  constituent.  Their 
comparative  value  would  therefore  depend  upon  their  per- 
centage of  active  constituent  and  their  freedom  from  unde- 
sirable constituents  and  properties.  Among  them  the  Psi/- 
chotria  tomentosa  is  prominent,  and  has  been  used  as  an 
adulterant.  The  similar  adulterant  yielded  by  Psychotria 
emetica  is  called  the  violet-striped  ipecac.  The  black-striped 
ipecac  perhaps  comes  from  the  same  species.  The  Psycho- 
tria undata  yields  a  similar  drug,  and  the  large-ringed  ipe- 
cac is  yielded  by  Uragoga  granatanensis.    Richardia  scabra 


yields  the  small-ringed  ipecac.  But,  while  all  these  are  so 
similar  to  ipecac  that  they  are  in  reality  forms  of  it,  the 
difficulty  is  that  they  are  equally  inaccessible,  being  small 
roots,  growing  in  the  same  general  part  of  the  world,  and 
equally  difficult  to  collect.  Still  their  availability  must 
never  be  lost  sight  of. 

The  violet  family  also  presents  a  rich  field  of  search  for 
ipecac  drugs.  The  emetic  properties  of  some  common  vio- 
lets have  long  been  known  and  extensively  utilized.  Their 
similarity  to  ipecac  is  attested  by  the  nature  of  the  active 
constituent  violin,  so  much  like  emetine  as  to  have  long 
supported  the  claim  that  it  was  an  impure  form  of  that 
alkaloid.  This  view  has  now  been  abandoned,  though  the 
precise  nature  of  the  body  is  yet  undetermined.  Besides 
the  proper  violets —  V,  tricolor  and  V.  odorata — the  ionidi- 
ums  in  this  family  possess  in  a  marked  degree  the  same 
properties.  The  lonidium  ipecacuanha,  Vent.,  contains  five 
per  cent,  of  the  violin,  and  is  not  only  ipecac-like  in  prop- 
erties, but,  because  of  its  close  resemblance,  it  has  been 
used  as  an  adulterant,  its  root  being  known  as  white  ipecac. 
The  lonidium  parviflorum,  I.  itouba,  I.  atropurpureum,  I. 
poaya,  and  /.  marcutii,  all  share  more  or  less  the  same 
properties  and  uses.  Should  it  ever  be  found  necessary, 
practitioners  would  doubtless  find  themselves  very  well  con- 
tented to  rely  upon  a  plentiful  and  good  stock  of  lonidium 
root  for  at  least  most  of  the  purposes  for  which  ipecac  is 
now  used. 

Last  of  this  group  we  consider  the  family  which  appar- 
ently takes  highest  rank  among  those  which  we  are  consid- 
ering— namely,  the  Meliacece,  not  represented  with  us  ex- 
cept by  the  Melia  azedarach,  the  pride  of  India  or  flower 
of  Paris,  cultivated  in  the  open  air  of  our  Southern  States. 
Some  of  the  members  of  this  family  are  too  violent,  like 
the  Walsura  piscidia,  a  fish  poison  of  India,  described  as 
"  a  dangerous  emmenagogue  and  violent  emetic."  But  most 
of  them  are  mild  and  efficient.  The  JVaregamia  alata  of 
India  is  known  commonly  as  Goanese  ipecac,  because  in  the 
province  indicated  it  is  generally  used  in  that  wa}'.  It  has 
been  considerably  tried  in  hospital  practice,  and  the  reports 
say  that,  as  an  emetic  and  expectorant,  it  has  given  "  re- 
sults similar  to  those  obtained  from  ipecacuanha  given  in 
equal  doses."  Its  active  principle  is  a  crystallizable  alka- 
loid. Various  plants  of  this  family  possess  names  indica- 
tive of  their  properties,  as  Trichelia  emetica  of  Arabia,  and 
Guarea  emetica  and  Guarea  purgans  of  South  America. 
Guarea  Aubletii  of  Colombia  is  there  considered  "  an  excel- 
lent substitute  for  ipecac."  The  drug  of  this  family  which 
has  been  the  most  thoroughly  studied  and  proved  is  the 
bark  of  one  of  these  guareas,  probably  undescribed  and 
commonly  known  as  cocillana.  All  things  considered,  it 
is  the  most  available  and  desirable  of  all  the  ipecac  sub- 
stitutes. As  its  properties  are  typical  of  its  relatives  in  the 
family  and  of  the  class  in  general,  I  introduce  a  condensed 
sketch  of  its  nature  and  uses.  Professor  David  D.  Stewart, 
of  the  Jefferson  Medical  College,  was  the  first  to  give  it  an 
extended  clinical  trial,  and  he  concluded  that,  "  as  regards 
the  sphere  of  infiuence  of  the  two  drugs  on  the  respiratory 
organs,  the  effects  are  not  unlike  those  of  ipecac,  and  that 
it  possesses  therapeutic  properties  which  render  it  even  su- 


160 


RUSBT:   VEGETABLE  MEDICINES  01  THE  IPECAC  CLASS.         [N.  Y.  Mkd.  Jotjk., 


perior  to  ipecac  in  certain  diseases  of  the  air  passages  in 
which  the  latter  is  often  used."  These  are  specified  as 
bronchial  catarrh,  especially  the  subacute  and  chronic  forms, 
when  accompanied  by  scanty  or  moderately  profuse  secre- 
tion, whether  the  cough  be  tight  or  loose.  The  cough  be- 
comes less  frequent  and  difficult,  and  the  secretion  less  vis- 
cid and  more  easily  expectorated.  At  the  same  time  loss 
of  appetite  is  markedly  corrected.  Some  time  later  Dr.  R. 
W.  Wilcox,  of  the  New  York  Post-graduate  Medical  School, 
made  an  extremely  careful  series  of  studies,  taking  cases 
as  nearly  as  possible  alike,  and  treating  one  set  with  ipe- 
cac, another  with  apomorphine,  and  a  third  with  cocillana. 
He  concluded  that  cocillana  acts  more  upon  the  glands,  and 
is  preferable  in  acute  bronchitis  in  those  cases  first  seen 
after  forty- eight  hours.  Its  effect  is  long  continued,  so  that 
doses  need  not  be  given  at  such  short  intervals.  In  cases 
seen  earlier  he  found  it  best  to  start  expectoration  with  apo- 
morphine, and  keep  it  up  with  concillana.  In  subacute  and 
chronic  bronchitis  the  cocillana  was  especially  serviceable. 
Its  effects  are  surer  than  those  of  either  ipecac  or  apomor- 
phine. It  is  mildly  laxative.  It  is  to  be  avoided  in  senile  bron- 
chitis. In  chronic  diseases  of  pulmonary  tissue,  cough  and 
expectoration  diminish,  and  night-sweats,  inappetence,  and 
constipation  are  relieved.  He  says,  finally,  that  it  is  superior 
to  ipecac  and  can  with  propriety  entirely  supersede  it,  and 
that  it  is  superior  to  apomorphine,  except  in  the  early  stages 
of  acute  bronchitis.  The  last  investigator  to  present  a  com- 
plete report  upon  this  drug  was  Dr.  J.  W.  Eckfeldt,  pro- 
fessor of  materia  medica  and  therapeutics  in  the  Medico- 
chirurgical  College  of  Philadelphia,  who  spent  two  years 
in  systematically  studying  it  before  presenting  his  report. 
His  conclusions  are  the  same  as  those  given  above,  except 
that  he  does  not  find  it  counter-indicated  in  senile  bron- 
chitis. He  has  found  it  serviceable  in  pneumonia  and  hay 
asthma.  He  indorses  it  as  one  of  the  finest  modern  acqui- 
sitions to  materia  medica,  and  believes  it  superior  to  ipecac 
for  all  the  purposes  for  which  that  drug  is  used. 

During  the  recent  epidemic  of  influenza  or  grip,  lead- 
ing German  practitioners  claim  to  have  met  with  excellent 
results  from  the  cocillana  treatment. 

The  second  group  to  be  considered  is  one  in  which  the 
resemblance  to  ipecac  is  strong — things  which  might,  under 
stress,  be  used  in  place  of  it,  but  which  no  one  would  claim 
as  approaching  it  in  efficacy  or  desirability.  The  most  pro- 
nounced of  this  class  are  from  plants  with  milky  juices, 
though  of  diverse  botanical  relationship.  Among  them  are 
some  of  the  Euphorbiacece,  notably  the  E.  ipecacuanha  and 
E.  corollata.  The  name  of  the  former  is  sufficient  to  indi- 
cate its  supposed  relation  to  ipecac.  But  while  they  de- 
termine eraesis,  expectoration,  and  diaphoresis,  they  show 
their  relation  to  castor  oil  by  combining  a  strongly  ca- 
thartic tendency.  If  given  in  small  doses  their  ipecac  ac- 
tion is  by  no  means  certain,  while  if  we  increase  it  we  get 
a  very  indefinite  amount  of  purging;  in  some  cases  uncon- 
trollable and  dangerous.  After  long  and  persistent  trial 
their  use  has  been  mostly  abandoned.  The  natural  order 
AHclepiadacece  furnishes  a  number  of  milky-juiced  plants 
which  belong  in  this  group,  of  which  the  officinal  asclepias 
or  pleurisy-root  may  be  taken  as  the  type  medicinally.  Its 


use  is  not  admissible  as  an  emetic,  but  it  is  both  expecto- 
rant and  diaj)horetic.  It  seems  strange  that  authors  do 
not  agree  as  to  the  mode  of  action  of  so  old,  important,  and 
much-used  a  drug,  but  by  some — and  probably  correctly — 
it  is  put  into  the  stimulant  or  irritant  class,  while  by  others 
this  view  is  disputed.  Certainly  it  reduces  the  heart's  ac- 
tion and  the  blood-pressure.  If  given  to  th«  point  of 
emesis  it  is  also  liable  to  purge.  The  ancient  and  cele- 
brated madar  or  mudar,  of  Asia  and  Africa,  is  a  root  bark 
from  Calatropis  procera  and  C.  gigantea,  related  to  our 
asclepias.  These  have  been  freely  urged  in  substitute  for 
ipecac,  but  their  active  constituent  seems  to  be  very  dis- 
similar and  they  act  entirely  through  local  irritation.  The 
original  use  of  this,  like  ipecac,  as  an  antidysenteric,  un- 
fortunately sheds  little  light  upon  its  properties,  because  of 
the  very  indefinite  application  of  the  term  "  dysentery." 
Both  the  roots  and  leaves  of  the  related  plant  Tylophora 
asthmatica,  of  India,  have  been  urged  in  exactly  the  same 
way.  Except  in  its  tendency  to  purge,  clinical  reports  show 
a  marked  similarity  of  this  drug  to  ipecac.  Tylophora  fasci- 
culate, Dcemia  extensa,  and  Dregia  voluhilis,  all  fall  more  or 
less  clearly  into  this  group.  Most  of  you  have  probably 
seen  our  little  plant  Asarum  canadense,  or  Canada  snake- 
root,  which  has  been  so  strongly  urged  for  introduction  to 
the  pharmacopoeia.  As  its  common  name  indicates,  it  is  an 
aromatic  stimulant.  It  seems  a  little  strange  that  the  very 
similar  Asarum  europceum  should  have  been  lauded  as  an 
ipecac  drug,  and  largely  used  as  its  substitute  in  some  parts 
of  Europe.  I  have  not  been  able  to  find  any  information 
concerning  its  physiological  action  to  support  this  view. 
Gillenia  yields  two  species  of  beautiful  North  American 
plants,  somewhat  related  to  the  strawberry  and  blackberry, 
but  emetico- cathartic  rather  than  astringent  like  those 
plants.  The  external  resemblance  of  the  root  of  Gillenia 
trifoliata  to  ipecac  has  caused  it  to  be  used  as  an  adulter- 
ant, and,  strangely  enough,  its  properties  also  have  been 
found  similar.  But  it  is  much  less  effective,  and  its  com- 
mon name  of  Indian  physic  indicates  an  important  differ- 
ence in  action.  There  is  no  doubt,  however,  that  this 
would  serve  as  a  fair  substitute  in  the  absence  of  anything 
better. 

The  third  group  we  may  call  the  tobacco  group.  Should 
one  attempt  to  use  tobacco  to  secure  emesis  he  would  find 
almost  the  maximum  of  distress  accompanying  the  mini- 
mum of  emesis,  whereas  he  should  seek  exactly  the  oppo- 
site combination.  Great  nausea  and  extreme  depression 
would  precede  the  vomiting.  If  he  used  it  as  an  expecto- 
rant, he  would  find  that  while  it  increased  the  supply  of 
mucus  there  would  be  no  stimulus  to  carry  this  away.  On 
the  contrary,  it  acts  strongly  toward  paralysis  of  the  re- 
spiratory apparatus.  Its  perspiration  is  a  cold  one,  accom- 
panying an  unhealthy  condition  of  the  skin.  Lobelia  is  a 
drug  of  the  same  general  type,  though  much  less  objection- 
able. Although  its  expectorant  action  can  be  secured  with- 
out an  extreme  degree  of  disorder,  it  weakens  both  the  cir- 
culation and  respiration  preceding  its  emetic  action.  In 
tropical  America  we  find  a  considerable  number  of  related 
plants,  some  Lobelias,  some  Tupas,  and  some  in  the  genus 
Siphocampglos,  which  the  natives  use  to  produce  tobacco- 


Feb.  11,  1893.] 


RUSBT:   VEGETABLE  MEDICINES  OF  THE  IPECAC  CLASS. 


161 


like  or  lobelia- like  eifects,  on  account  of  which  they  have 
been  compared  to  ipecac.  The  natural  order  Acanthacece 
yields  various  plants,  as  Adhatoda,  Ruellia,  and  Gendarussai 
whose  physiological  action  has  not  been  well  established, 
but  which  apparently  belong  to  the  tobacco  group.  The 
same  may  be  said  of  some  bignoniads. 

Group  4  are  essentially  nervines.  Their  action  upon  the 
nervous  system  may  be  immediate  or  it  may  be  through  cir- 
culatory disarrangements,  but  in  some  way  the  prominent 
effect  is  a  great  modification  of  the  nervous  functions.  The 
distinctively  cardiant  division  of  this  group  contains  the  three 
Veratrums — viride,  album,  and  nigrum — cevadiila,  scilla, 
Crinum  toxicarium,  and  some  other  related  monocotyledo- 
nous  plants.  The  powerful  depresso-motor  effects  of  these 
plants  are  well  typified  by  the  almost  uncontrollable  vomit- 
ing of  Veratrum  viride.  The  vomiting  depends  clearly  upon 
derangements  of  the  cerebral  circulation.  Various  species 
of  narcissus  would  appear  at  first  thought  to  pertain  to  this 
group,  but  there  is  evidence  to  show  that  the  resemblance 
of  their  action  to  that  of  ipecac  may  be  much  more  real. 
Very  similar  in  action  to  these  monocotyledons  are  a  num- 
ber of  poisonous  Leguminosce — namely,  laburnum,  baptisia, 
sophora  of  various  species,  Clitoria  ternatea,  broom,  etc. 
Plants  whose  action  is  not  well  determined,  but  which  ap- 
pear to  belong  here,  are  Datisca  cannabina,  Atriplex  hor ten- 
sis,  and  several  species  of  Boerhaavia. 

The  "  harsh  "  emetics  may  stand  as  our  fifth  group.  In 
kind  they  are  very  similar  to  group  6,  but  differ  so  greatly 
in  degree  as  to  introduce  a  different  feature  into  the  effects 
— namely,  the  possible  production  of  so  great  an  irritation 
or  inflammation  as  to  cause  prostration  or  collapse.  That 
is,  they  are  irritant  poisons  and  pseudo-narcotics.  It  will 
at  once  occur  to  you  that  these  characters  will  admit  a  large 
number  of  drugs,  for  so  many  of  our  powerful  medicines 
are  capable  of  producing  this  form  of  emesis.  But  I  am 
here  restricting  myself  to  those  things  in  which  the  effects 
for  which  ipecac  is  used  are  so  conspicuous  among  the  other 
properties,  that  the  articlevs  have  been  proposed  as  substi- 
tutes for  that  agent.  Even  thus  the  group  is  large  enough 
and  varied  enough  to  be  properly  subdivided.  Some  of  the 
members,  in  moderate  doses,  effect  no  conspicuous  action 
upon  the  bowels  sufficient  to  stamp  them  as  cathartics.  To 
this  subdivision  may  be  referred  the  powerful  irritant  meze- 
reum,  some  plants  of  the  buttercup  family,  perhaps  the 
WucJcstroemia  Forsteri  of  Tahiti  (related  to  the  tea  plant), 
and  some  irritant  poisons  of  the  natural  order  Menisperma- 
ceoe.  In  the  other  subdivision  the  primary  tendency  is  to- 
ward catharsis,  the  emesis  postponed  until  after  catharsis 
has  failed  to  be  excited  or  to  relieve.  This  group  includes 
the  drastics,  gamboge,  podophyllum,  elaterium,  bryony  and 
melon-root.  Cyclamen  europaum,  and  others  of  the  primrose 
family  (not  the  evening  primrose  family  or  Onagrarice),  and 
perhaps  Calophijlhim  inophi/llum  and  the  gratiolas.  The 
Vandellia  diffusa  seems  to  be  in  some  respects  like  these, 
in  others  like  the  tobacco  group.  Croton  oil,  curcas  seeds, 
Hura  crepitans,  etc.,  of  the  natural  order  Euphorbiacea;,  ap- 
pear to  belong  here,  while  others  of  this  large  family  must 
be  ranked,  as  previously  stated,  much  nearer  the  ipecac  in 
properties  and  mode  of  action.    Attention  is  called  to  the 


fact  that  none  of  these  harsh  emetics  are  true  nervines.  As 
I  have  said,  they  may  be  pseudo- narcotics,  but  the  nervous 
effects  are  reflex  and  secondary,  resulting  from  the  severe 
irritation.  Iris  versicolor  and  colchicum  might  be  placed 
here,  though  they  would  require  special  characterization, 
especially  colchicum.  The  profound  disturbances  which  are 
a  prerequisite  for  emesis  by  these  plants  render  them  all  not 
commendable  as  ipecac  substitutes. 

Group  6  are  also  irritant  emetics,  though  they  can  not 
properly  be  called  harsh.  They  are  those  of  the  mustard 
type,  act  only  when  introduced  by  the  stomach,  and  then  not 
through  absorption.  They  are,  like  the  next  group,  more 
efficient  when  administered  in  bulky  form,  but  differ  from 
that  group  in  their  specific  irritant  properties.  The  term 
"  reflex  emetics  "  has  been  applied  to  them,  as  well  as  to 
the  last.  Besides  the  mustards,  the  group  includes  various 
plants  of  the  Capparidea;,  the  family  yielding  our  capers, 
and  the  Stanleya  pinnatifida,  which  vomited  a  party  of  early 
explorers  under  the  botanist  Nuttall,  they  having  eaten  it 
for  its  large  cabbage- like  leaves. 

Another  group,  more  distinctly  irritant  than  these,  yet 
not  so  irritant  as  the  harsh  emetics,  may  be  laxative,  but 
this  property  is  slight  and  incidental.  They  act  as  emetics 
through  their  direct  effect  upon  the  gastric  nerves.  Their 
stimulant-expectorant  powers  are  marked.  The  best  known 
of  them  contain  saponin  in  considerable  quantity.  Here  we 
place  senega,  saponaria,  quillaia  or  soap-bark,  sarsaparilla, 
(in  part),  and  the  horse-chestnut.  Besides  our  official  Pohj- 
gala  senega,  a  large  number  of  species  of  polygala  are  used 
in  various  parts  of  the  world  in  the  same  way.  Most  nota- 
ble is  the  P.  poaya,  of  Brazil. 

The  last  group  to  be  considered  is  the  most  distant  of 
all  from  the  true  ipecac.  It  is  well  illustrated  by  the  Eupa- 
torium  perfoliatum,  the  old-fashioned  boneset  or  thorough- 
wort,  which,  taken  in  the  form  of  extract  or  fluid  extract, 
produces  none  of  its  sudorific  or  expectorant  effects,  except 
slightly,  through  general  stimulus,  and  gives  no  hint  toward 
emesis.  These  results  come  from  administering  it  in  large 
quantities  of  water,  whereas  a  minute  portion  of  the  active 
principle  of  ipecac — emetine — given  hypodermically,  is  effi- 
cient. 

With  boneset  go  all  the  many  species  of  eupatorium 
used  here  and  in  other  countries,  the  related  senecios,  elder 
flowers,  linden  flowers,  and  most  of  the  old-fashioned  herbs 
used  in  the  same  manner  and  for  the  same  purpose.  Here 
also  probably  belongs  the  Ilex  vomitoria,  or  Southern  holly, 
yielding  the  black  drink  of  the  Southern  aborigines,  con- 
cerning which  plant  a  book  has  recently  been  written. 
Other  species  of  ilex  fall  within  the  same  group.  This 
group  is  represented  in  the  practice  of  almost  all  uncivilized 
classes. 

We  must  conclude  from  this  study  that  ipecac,  even 
when  strictly  considered,  is  not  a  unique  remedy  ;  that 
while  the  very  great  majority  of  drugs  which  have  been  as- 
sociated with  it  are  not  really  of  the  same  type,  a  number 
of  them  arc  and  could,  in  emergency,  yield  products  equal- 
ly satisfactory  ;  and  that  one  of  them  at  least  is  already 
proved  to  be  capable  of  immediately  superseding  it  with  ad- 
vantage. 


162 


CURRIER:  CONSTIPATION. 


[N.  Y.  Med.  Joue., 


CONSTIPATIOIS", 

ESPECIALLY  IN  ITS  RELATIONS  TO 
THE  DISEASES  PECULIAR  TO  WOMEN.* 
By  ANDREW  F.  OURRIER,  M.  D. 

That  so  large  a  portion  of  the  human  race  is  afflicted 
witli  constipation  is  a  fact  of  great  interest  from  which  im- 
portant deductions  can  be  drawn.  Assuming,  as  we  fairly 
may  without  argument,  that  the  intestinal  canal  is  not  in- 
tended as  a  reservoir  for  the  storage  of  excrementitious  mat- 
ter, ordinary  clinical  experience  informs  us  that  of  the  great 
multitude  of  individuals  in  whom  occur  this  unnatural 
storage  and  the  other  elements  wliich  constitute  constipa- 
tion, the  condition  is  the  expression  of  disease  with  some, 
while  with  others  it  is  an  expression  of  neglect — partly  due 
to  ignorance  and  partly  to  indolence.  This  leads  naturally 
to  the  observation  that  the  far-reaching  influence  and  sig- 
nificance of  constipation  are  not  appreciated  by  a  very  con- 
siderable portion  of  the  community.  For  this  situation  the 
medical  profession  is  largely  to  blame,  for  it  includes  the 
instructors  in  hygiene  to  individuals  and  to  families  which 
make  up  the  community.  This  arraignment  must  extend 
to  many  of  our  clinical  teachers,  and  especially  to  that 
system  of  teaching  in  which  diseases  are  classified  and  con- 
formed to  rigid  rules  as  if  pathology  were  one  of  the  exact 
sciences.  Thus  the  student  goes  forth  to  his  practical 
work  with  his  head  crammed  with  theories  and  notions  to 
which  he  vainly  endeavors  to  conform  the  phenomena 
which  he  witnesses.  This  is  no  disparagement  to  the 
scientific  grouping  of  symptoms,  but  rather  an  appeal  that 
induction,  and  not  deduction,  is  the  proper  method  of  con- 
sidering the  morbid  states  of  the  body. 

In  human  beings  it  may  fairly  be  said  that  constipation 
is  omnipresent.  We  witness  it  in  the  convulsions  of  the 
new-born  infant  with  an  inactive  and  overloaded  bowel, 
and  in  the  coma  sometimes  terminating  in  death  in  the 
aged  from  the  same  cause,  and  in  the  intervening  period  it 
presents  phenomena  of  every  degree  of  intensity  and  va- 
riety. It  is  the  result  of  habits  and  occupations,  climate 
and  diet ;  it  is  caused  by  conditions  of  exactly  opposite 
character,  by  fasting  or  full  eating,  by  watching  or  sleep- 
ing, by  exercise  or  indolence,  in  those  who  are  anaemic  and 
those  who  are  plethoric,  the  idle  and  the  industrious,  the 
temperate  and  the  dissipated.  1  have  seen  two  people  who 
sat  at  the  same  table,  did  the  same  amount  of  work,  in  fact, 
experienced  conditions  which  were  practically  identical,  and 
who  were  in  good  physical  condition  when  brought  to  this 
similarity  of  experience,  develop  diarrhoea  in  the  one  case 
and  constipation  in  the  other.  I  am  aware  that  this  is  a 
common  observation,  and  it  is  mentioned  simply  as  an 
illustration  of  the  infinite  variety  of  causes  which  result  in 
constipation.  It  is  often  said  that  women  are  more  frequently 
constipated  then  men,  and  that  this  is  to  be  explained  by 
their  indoor  and  sedentary  life  ;  but  this  is  an  unsatisfactory 
explanation,  for  many  men  who  lead  an  indoor  life  are 
constipated,  and    many   women   are    constipated  whose 

*  Read  before  the  Section  in  General  Medicine  of  the  New  York 
Academy  of  Medicine,  October,  1892, 


lives  are  not  sedentary,  but  very  active.  Here,  again,  we  are 
confronted  with  the  protean  character  which  distinguislies 
constipation.  The  reciprocal  influence  of  constipation  and 
pelvic  disease  in  women  must  be  apparent  to  every  one 
who  is  brought  in  contact  with  the  morbid  conditions 
which  are  grouped  under  the  latter  comprehensive  term  ; 
indeed,  it  has  seemed  to  me  that  the  structure  and  func- 
tions of  the  pelvic  organs  in  the  female  have  more  to  do 
with  the  cause  and  continuance  of  constipation  than  any 
other  factor.  A  study  of  the  histories  of  one  hundred  con- 
secutive cases  in  the  records  of  ray  private  practice  showed 
that  in  sixty-five  there  was  manifest  and  annoying  consti- 
pation. It  must  be  remembered,  moreover,  that  the  term 
constipation,  with  women  more  than  with  men,  is  a  relative 
one,  and  that  if  the  statements  of  all  of  the  one  hundred 
women  in  question  had  been  based  upon  the  same  physio- 
logical and  psychological  standard,  more  than  sixty-five 
would  have  admitted  the  existence  of  constipation.  But  if 
we  limit  our  argument  to  the  statements  of  these  individu- 
als as  they  were  given,  these  one  hundred  women  may  be 
considered  an  average  representative  of  women  who  suffer 
with  pelvic  disease,  for  all  of  them  consulted  me  with  refer- 
ence to  such  disease,  either  complicated  or  uncomplicated 
with  disease  of  other  parts  of  the  body,  and  the  diagnosis 
included  almost  every  recognized  form  of  disease  or  lesion 
of  the  pelvic  organs.* 

The  fact  that  nearly  two  thirds  of  these  women  were 
constipated  to  an  annoying  extent  is  a  proof,  to  my  mind 
at  least,  of  the  correctness  of  the  statement  which  was 
made — of  the  very  great  importance  of  the  symptom  con- 
stipation in  its  relation  to  pelvic  disease  in  women. 

It  may  seem  presumptuous  to  offer  a  definition  of  con- 
stipation, but  it  is  not  improper  when  we  take  into  consid- 
eration the  fact  that  there  is  much  latitude  of  opinion  upon 
this  matter,  simple  even  to  transparency  though  it  may  ap- 
pear at  first  thought.  We  can  always  progress  more  fa- 
vorably and  satisfactorily  upon  any  subject  when  our  eyes 
are  fixed  upon  it  from  a  common  standpoint.  I  shall  at- 
tempt no  refinements  of  statement,  but  would  consider  con- 
stipation as  simply  that  condition  in  which  the  intestine 
fails  to  readily  expel  the  excrementitious  matter  which  it 
contains  at  intervals  sufficiently  frequent  and  in  a  mass  of 
suitable  consistence  to  insure  the  individual  against  detri- 
ment from  waste  and  decomposing  material. 

This  definition  takes  into  consideration  the  injury  that 
may  result  from  hardened  fseces,  the  intoxication  which 
may  result  from  the  bacteria  of  the  intestine  and  their 
ptomaines,  and  is  in  harmony  with  the  fact  that  the  act  of 
defecation  is  the  resultant  of  mechanical  forces  generated 
by  the  voluntary  muscles  of  the  abdomen  and  the  involun- 
tary muscle  of  the  intestine.  This  act  is  dependent  to  a 
certain  degree  upon  the  exercise  of  the  will ;  but,  on  the 

*  The  sixty-five  cases  were  distributed  as  follows :  Atresia  vaginae 
cum  cardiopathia,  1  ;  anajmia,  3 ;  anteflexio  uteri,  1 ;  carcinoma  uteri, 
2  ;  cystitis  (from  hairpin  in  bladder),  1  ;  endometritis,  1 1  ;  gonorrhoea  cum 
cystitide  et  peritonitide,  1 ;  haimorrhoidte,  2 ;  hyperplasia  uteri  et  pro- 
lapsus vagime,  1  ;  myoma  uteri,  6  ;  neurasthenia,  1  ;  obesitas  et  innutritio 
uteri,  1;  parametritis,  2;  pyosalpinx,  11;  ruptura  cerv.  et  perin.,  1; 
retroflexio  aut  retroversio  uteri,  6  ;  sarcoma  uteri,  1 ;  septicsemia  post 
abort.,  2  ;  sterilitaa,  2  ;  syphilis,  1  ;  tumor  ovarii,  3  ;  utero-gestatio,  5. 


Feb.  11,  1893.] 


CURRIER:  CONSTIPATION. 


163 


other  hand,  the  will  may  be  sufficiently  strong,  while  the 
I    muscles  do  not  co-ordinate  with  it,  defecation  taking  place 
^    in  spite  of  the  inhibition  of  the  will.    It  may  take  place 
I    without  the  participation  of  the  will,  as  in  sleep,  in  paral- 
ysis of  spinal  origin,  or  insufficiency  of  the  sphincter  mus- 
cles.   The  will  may  be  active  and  defecation  may  be  at- 
tempted, but  prove  a  failure  from  weakness  of  the  abdom- 
inal muscles,  as  in  women  with  very  fat,  relaxed,  or  pendu- 
lous abdomens,  or  the  muscular  force  of  the  intestine  may 
be  insufficient  to  propel  the  faecal  mass  onward,  or  a  me- 
1    chanical  obstruction  outside  the  intestine  may  bar  the  way. 
I   Consequently  any  cause  which  impairs  the  activity  of  the 
i   voluntary  or  involuntary  muscles  concerned  in  the  act  of 
defecation  will  tend  to  produce  constipation.    Such  causes 
may  be  removable  or  unremovable  ;  they  may  consist  in 
neglect,  in  disease  within  the  intestine  or  without  the  intes- 
i   tine ;  they  may  be  mechanical,  neurotic,  or  vascular.  Some 
'   of  them  are  predisposing  and  others  are  inevitable.  Trau- 
matism and  neoplasm  may  play  a  conspicuous  part.  In 
short,  when  we  reflect  upon  the  many  ways  in  which  this 
nicely  adjusted  mechanism  which  controls  the  act  of  defe- 
cation may  get  out  of  order,  we  begin  to  understand  why  it 
gets  out  of  order  so  frequently. 

I  CAUSES   OF  CONSTIPATION. 

i        Neglect. — Of  all  the  preventable  or  removable  causes 
j  from  which  constipation  in  women  originates,  neglect  or 
!  indolence  is  the  most  common.    It  is  most  noticeable  in 
,  girls  and  young  women ;  it  is  less  noteworthy  in  mature 
j  women,  perhaps  because  they  have  learned  better,  perhaps 
j  because  it  has  brought  on  other  evils  for  which  they  have 
i  sought  relief ;  it  is  least  apparent  in  the  aged.    The  care- 
lessness of  young  girls,  especially  schoolgirls,  in  the  mat- 
ter of  evacuating  the  bowels  is  proverbial,  and  the  resulting 
I  ■constipation  is  the  foundation  of  so  many  physical  evils  that 
it  would  be  far  better  for  these  individuals  and  for  society 
if  their  intellectual  culture  were  curtailed,  and  the  time  de- 
-  voted  to  physical  exercise  or  to  any  means  of  activity  where- 
by the  evils  in  question  could  be  anticipated  and  prevented. 

Morbid  Conditions  within  the  Intestine. — Under  ordinary 
conditions  the  inclination  to  evacuate  the  bowels  is  caused 
I   by  the  deposit  of  faecal  matter  within  the  rectum,  the  mu- 
[  cous  membrane  being  excited  or  irritated  by  its  presence. 
I   Hence  there  is  reason  in  the  statement  which  is  to  be  found 
in  the  text-books  on  physiology  that  the  rectum  is  usually 
empty.    But  the  sensitiveness  of  the  rectal  mucous  mem- 
brane varies  greatly  in  different  individuals,  and  in  women 
it  seems  to  be  less  acute  than  in  men.    In  my  experience 
the  rectum  of  women  is  rarely  free  from  faecal  matter  ex- 
j  cept  after  particular  preparation,  and  the  insensitiveness 
'  which  accompanies  it  has  much  to  do  with  the  constipated 
habit.    Constipation  in  both  sexes  is  a  common  occurrence 
f  as  the  result  of  disease  of  the  intestine  above  the  pelvis,  but 
\  certain  forms  of  such  disease  occur  much  more  frequently 
j  in  women  than  in  men.    Peritonitis  may  serve  as  an  illus- 
tration which  is  especially  common  after  abdominal  opera- 
tions and  with  disease  of  the  pelvic  viscera.    The  paralysis 
of  the  bowel  and  retention  of  excrementitious  matter  which 
characterize  it  are  often  the  prelude  to  a  fatal  issue.  Pro- 


longed retention  of  faecal  matter  within  the  large  bowel, 
even  leading  to  the  formation  of  a  large  abdominal  tumor 
and  complete  paralysis  of  the  bowel,  is  by  no  means  unusual 
in  women.  Constipation  may  also  be  effectually  produced 
by  infiltration  of  the  bowel  structure  with  malignant  or 
syphilitic  disease  or  by  polypi  in  its  interior. 

Morbid  Conditions  within  the  Rectum,  Medical  and  Sur- 
ffical.— The  causes  which  are  operative  in  the  production  of 
paralysis  of  the  bowel  above  the  pelvis  are  similarly  opera- 
tive and  to  a  much  greater  extent  on  that  portion  which  is 
within  the  pelvis.  These  causes  may  be  considered  with 
reference  to  the  treatment  which  is  usually  employed  for 
their  relief — that  is,  from  a  medical  and  a  surgical  standpoint. 
In  the  former  are  to  be  included  the  thickenings  and  new 
formations  of  syphilitic  origin,  the  dilatation  and  muscular 
weakness  accompanying  prolonged  inattention  to  the  accu- 
mulation of  fa3cal  matter,  as  in  certain  cerebral  and  spinal 
diseases,  congestion  and  engorgement  of  the  venous  system 
of  the  rectum  associated  with  menstruation,  pregnancy,  or 
obstruction  in  the  portal  circulation. 

From  the  surgical  standpoint  causative  conditions  are  to 
be  found  in  fissures,  ulcers,  and  haemorrhoids,  polypi,  infil- 
tration of  the  tissue  with  malignant  or  inflammatory  disease, 
dilatation  and  weakness  due  to  prolapse  of  the  vagina,  or 
rupture  of  the  perinaeum,  or  both. 

Medical  Conditions. — Of  those  conditions  in  which  medi- 
cal measures  are  indicated  for  their  relief,  syphilitic  disease 
of  the  rectum  is  sometimes  eminently  amenable  to  such  re- 
lief, but  a  diagnosis  of  syphilitic  stricture  of  the  rectum  in 
women  is  not  always  easily  made,  and  the  condition  may  be 
treated  surgically  and  ineffectually  because  of  such  an  error. 
The  constipation  which  is  associated  with  cerebral  disease 
as  effect  must  be  distinguished  from  constipation  which 
is  the  cause  of  such  disease.  I  have  seen  a  case  within  a 
few  months  in  which  a  life  was  nearly  lost  through  want  of 
such  discrimination.  Probably  the  case  would  have  been 
fatal  if  the  accumulation  of  faecal  matter  had  not  been  re- 
moved. The  constipation  which  accompanies  dilatation  of 
the  rectum  and  in  which  there  is  functional  trouble  alone  is 
usually  remediable,  but  the  task  is  a  severe  one,  for  the  pro- 
longed and  systematic  use  of  medicaments  by  persons  who 
have  carelessly  allowed  a  constipated  habit  to  creep  upon 
them  is  with  difficulty  enforced.  If  constipation  is  due  to 
spinal  lesions,  it  is,  of  course,  irremediable,  excepting  in  the 
few  cases  which  are  susceptible  of  surgical  treatment.  When 
associated  with  pregnancy  it  may  be  as  a  new  condition  re- 
sulting from  vascular  engorgement,  or  pressure  due  to  dis- 
placement, or  it  may  be  merely  the  intensification  of  prece- 
dent constipation.  Cases  of  this  character  are  too  often 
examined  and  treated  with  insufficient  care,  especially  in  view 
of  the  important  relations  subsisting  between  open  bowels 
and  the  parturient  and  puerperal  states.  The  use  of  cathar- 
tics in  a  thoughtless  manner  is  responsible  for  the  prema- 
ture termination  of  pregnancy  in  any  number  of  cases,  and 
the  aid  which  they  render  the  criminal  abortionist  is  well 
known. 

The  periodical  occurrence  of  constipation  with  the  men- 
strual flow  is  a  result  of  venous  congestion,  and  is  remova- 
ble by  medical  means.    The  same  may  be  true  if  the  rectal 


164 


CURRIER :   GONSTIPA  TIOK. 


fN.  Y.  Meu.  Jodh., 


congestion  is  associated  with  an  obstructed  portal  circula- 
tion. These  are  all  important  points  but  can  not  now  be 
discussed. 

Surfjical  Conditions. — In  constipation  due  to  surgical 
conditions  of  the  rectum  the  trouble  is  irremediable  in  far- 
advanced  malignant  disease,  especiallj'  if  it  has  extended 
from  the  uterus.  If  there  is  rectal  dilatation  as  an  accom- 
paniment of  prolapse  of  the  vagina  or  rupture  of  the  peri- 
naeum,  the  indication  is  clear.  The  results  in  such  cases 
are  not  always  satisfactory,  especially  with  very  fat  women, 
with  those  whose  muscles  are  relaxed  from  many  pregnan- 
cies, and  with  the  aged,  in  whom  the  muscular  tissue  of 
the  intestine  and  the  genital  organs  has  mostly  disappeared. 
Of  the  other  surgical  conditions  which  have  been  men- 
tioned in  this  connection,  their  removal  is  usually  follovved 
by  the  removal  of  the  constipation.  This  statement  has 
been  verified  many  times  in  the  treatment  of  hiemorrlioids, 
ulcers,  fissures,  and  strictures. 

Morbid  Conditions  External  to  the  Rectum. — The  dispo- 
sition of  the  viscera  in  the  female  pelvis  is  such  as  to  make 
constipation  possible  if  the  normal  arrangement  is  but 
slightly  disturbed.  Constipation  under  such  conditions  is 
due  primarily  to  a  mechanical  obstruction,  which,  as  a  rule, 
will  require  surgical  means  of  some  character  for  its  re- 
moval. If  left  to  Nature,  the  result  may  be  a  very  trying 
one,  though  it  is  by  no  means  the  fact  that  a  cure  never 
results  spontaneously.  Such  cases  frequently  illustrate  the 
marvelous  accommodative  powers  of  Nature  under  adverse 
circumstances.  The  rectum  is  closely  united  to  the  uterus 
for  a  portion  of  its  course  ;  consequently,  anything  which 
materially  disturbs  the  position  or  surroundings  of  the  uterus 
must  disturb,  to  a  greater  or  less  degree,  the  rectum  also. 
This  disturbance,  if  serious  enough,  must  also  cause  dis- 
turbance of  function,  and  thus  we  can  rationally  explain 
many  of  the  cases  of  constipation  which  attend  uterine  dis- 
orders. 

There  are  at  least  two  ways  in  which  a  mechanical  ob- 
struction external  to  the  rectum  may  act  upon  it — (1)  as  a 
mass  pressing  upon  a  certain  portion  of  it  and  retarding  its 
contractions  or  making  them  irregular,  or  (2)  as  an  im- 
bedding mass  in  which  the  rectum  is  more  or  less  firmly 
fixed  and  more  or  less  paralyzed.  The  longer  the  rectum 
is  subjected  to  either  of  these  forms  of  obstruction  the 
more  persistent  will  be  the  resulting  constipation ;  not  only 
is  the  muscular  coat  of  the  rectum  paralyzed,  but  there  is 
paralysis  of  sensation  in  the  mucous  membrane  as  well. 
The  accumulation  of  faical  matter  goes  on  unheeded  for 
considerable  periods,  and  when  a  sufiicient  stimulus  does 
occur,  which  leads  to  the  emptying  of  the  bowel,  it  is  ac- 
companied with  much  pain  and  straining  and  often  with 
loss  of  blood.  As  examples  of  obstructive  conditions  of 
the  first  kind  may  be  mentioned  posterior  displacements  of 
the  uterus,  whether  the  latter  be  impregnated  or  unimpreg- 
nated,  and  tumors  of  the  uterus  or  its  appendages.  As 
long  as  these  masses  are  movable,  their  obstructive  effect 
may  not  be  of  serious  importance.  A  retroflexed  uterus, 
whether  gravid  or  not,  may  be  replaced,  and  the  rectal 
trouble  which  it  was  causing  may  disappear.  But  if  adhe- 
sion takes  place  between  the  rectum  and  the  overlying  mass, 


an  event  which  usually  occurs  if  the  apposition  continues 
suflSciently  long,  the  function  of  the  rectum  will  be  materi- 
ally disturbed,  the  condition  then  merging  into  that  of  the 
second  class,  in  which  the  rectum  is  more  or  less  imbedded 
or  surrounded  by  a  mass  from  which  it  can  not  free  itself, 
and  in  which  muscular  contraction  is  restrained  or  prevent- 
ed. This  condition  is  often  caused  by  pelvic  inflammations 
with  effusions  of  pus,  blood,  or  serum,  and  by  the  effusions 
of  malignant  and  tubercular  disease.  Even  though  the  fluid 
elements  of  these  deposits  be  absorbed,  bands  and  bridges 
of  adhesion  material  will  remain,  and  as  these  contract  the 
rectum  is  the  more  tightly  bound  in  their  embrace,  whicJi, 
of  course,  does  not  tend  to  the  relief  of  its  disturbed  func- 
tion. 

Consequences  of  Constipation,  Near  and  Remote,  in  the 
Conditions  mentioned. — Constipation  may  therefore  exist  as 
cause  and  as  result ;  it  may  be  due  entirely  to  neglect  or  to 
conditions  over  which  the  individual  has  absolutely  no  con- 
trol. In  either  case  it  is  interesting  to  note  its  consequences, 
and  this  may  be  done  by  considering  the  subject  in  three 
groups,  the  first  of  which  shall  include  those  individuals  in 
whom  constipation  results  from  inattention,  neglect,  or  any 
other  cause  outside  the  pelvis.  In  this  group  the  com- 
plaint arising  from  the  constipation  is  principally  inconven- 
ience. The  second  group  will  include  those  in  whom  there 
has  been  neglect  and  also  more  or  less  pelvic  disease,  but 
with  whom  the  predominant  symptom  relates  to  the  retained 
excrementitious  matter.  In  other  words,  the  predominant 
symptom  in  this  group  is  sepsis. 

The  third  group  includes  those  in  whom  pelvic  disease 
is  so  pronounced  that  constipation  would  be  inevitable 
whether  there  had  been  neglect  or  not.  In  this  group  the 
predominant  symptom  is  pain.  In  the  mild  cases,  which  are 
included  in  the  first  group,  little  harm  is  caused  aside  from 
the  inconvenience,  especially  with  women  who  are  not  very 
sensitively  organized.  They  may  be  able  to  attend  to  their 
ordinary  occupations  without  much  interruption.  Defeca- 
tion may  be  painful,  the  straining  and  loss  of  blood  may 
be  troublesome,  and  there  will  certainly  be  an  absence  of 
that  sense  of  relief  which  a  normal  movement  of  the  bowels 
always  gives.  The  faeces  are  extruded  in  hard  lumps,  their 
fluid  elements  having  been  absorbed  during  their  retention 
in  the  bowel.  There  may  be  fermentation  and  decomposi- 
tion, with  the  expulsion  of  foul-smelling  gases,  but  there  is 
very  little  evidence  of  septic  absorption,  and  there  may  be 
all  the  outward  appearances  of  good  health. 

In  the  second  group  of  cases,  in  which  the  fsecal  matter 
accumulates  in  the  rectum,  distending  it,  and  also  in  the  folds 
of  the  large  bowel,  a  thorough  evacuation  is  impossible. 
The  pelvic  disease  in  these  cases  may  have  preceded  the 
constipation  or  may  have  followed  as  the  result  of  the  vas- 
cular disturbance  which  has  been  developed  ;  or  coinci- 
dently  with  the  constipation  there  may  have  existed  a  dis- 
placement of  the  uterus,  inflammatory  disease  of  the  ap- 
pendages, relaxation  of  the  vagina  and  perinJEum,  or  lesions 
resulting  from  parturition  or  the  puerperiura.  The  consti- 
tutional symptoms  in  these  cases  are  marked,  and  I  do  not 
refer  to  the  symptoms  which  are  characteristic  of  the 
severer  forms  of  pelvic  disease,  but  to  those  which  proceed 


Feb.  11,  1893.] 


CURRIER :   GONSTIPA  TION. 


165 


I  principally  from  the  constipation.    There  is  a  marked  want 

I  of  animation  in  the  performance  of  duties,  drowsiness,  head- 
ache, backache,  a  muddy  complexion,  a  furred  tongue,  cold 
extremities,  and  loss  of  appetite.  Such  cases  are  frequently 
treated  for  malaria.    Tympanites  is  troublesome,  for  de- 

,  composition  and  septic  absorption  are  constantly  present. 

I  The  influence  of  the  bacteria  of  the  large  intestine,  the  de- 
velopment and  distribution  of  ptomaines,  the  saprsemia,  the 
development  of  diarrhoea  with  vile-smelling  passages,  are 
all  characteristic  of  this  group.  There  may  also  be  a 
clouded  mental  condition,  with  gloom  and  melancholy. 

j  This  form  of  constipation  obtains  with  many  insane  women, 
both  within  and  without  the  hospitals.    It  is  in  this  group 

I  that  we  meet  with  fiscal  tumors,  and  with  these  also  there 
may  be  disturbance  of  the  portal  circulation  and  of  the 
functional  activity  of  the  liver.  In  short,  the  characteristic 
sepsis  is  plainly  apparent  in  the  cases  which  are  included 
in  this  group. 

In  the  third  group  the  cause  of  the  constipation  is 
located  essentially  in  the  pelvis,  and  whatever  the  previous 
condition  may  have  been  it  would  seem  that  constipation 
was  now  inevitable.  The  rectum  may  be  occluded  by 
stricture  or  polypus,  infiltrated  with  inflammatory  or  neo- 
plastic elements,  or  impinged  upon  and  surrounded  by  effu- 
sions or  dislocated  viscera,  and  its  muscular  contractions 
are  either  greatly  restrained  or  entirely  prevented.  Venous 
congestion  is  a  necessary  and  continuous  consequence  of 
the  foregoing  conditions.  Faecal  matter  accumulates  in 
the  rectum  and  colon,  but  it  is  not  impacted,  as  in  the 
cases  in  the  second  group,  nor  is  there  stercoral  intoxica- 
tion, as  in  those.  This  may  be  due  to  the  fact  that  the 
women  of  this  group  are  constant  sufferers — in  fact,  pain 
is  the  predominating  symptom — and  hence  require  constant 
professional  care.  The  relief,  more  or  less,  to  the  con- 
stipation is  incidental,  and  it  is  possible  that  the  drugs 
which  are  constantly  taken  prevent  the  septic  phenomena 
which  are  so  common  with  women  of  the  second  group. 
The  effect  of  the  pain  in  these  cases  is  the  effect  of  pain 
everywhere — a  general  lowering  of  the  vitality  and  loss  of 
flesh  and  strength.  Unless  they  are  relieved  by  surgical 
measures  they  become  bedridden  and  easy  victims  to  inter- 
current disease.  In  addition  to  the  acute  pain  in  the  rec- 
tum, which  is  especially  acute  with  every  effort  at  defeca- 
tion, there  is  the  pain  of  the  monthly  period,  backache, 
tympanites,  indigestion,  and  many  other  ills,  which,  taken 
together,  make  the  burden  of  life  for  them  a  heavy  one. 

TREATMENT. 

The  recommendation  of  methods  of  treatment,  whether 
medical  or  surgical,  is  to  my  mind  one  of  the  most  unsatis- 
factory features  of  the  work  of  a  teacher  or  writer.  It  is 
so  easy  for  opinions  to  differ  with  regard  to  a  given  condi- 
tion, that  at  the  very  outset  a  writer  is  confronted  with  a 
disadvantage  in  the  fact  that  his  meaning  may  be  misap- 
prehended or  his  directions  misapplied  even  where  there  is 
the  utmost  candor  and  good  intention  in  carrying  them 
out.  In  any  case,  if  the  results  are  not  those  which  were 
promised  and  anticipated,  there  is  disappointment  and  also 
loss  of  confidence  in  the  ability  and  integrity  of  the  writer. 


Therapeutics,  therefore,  should  deal  with  principles  rather 
than  with  rules  and  formulae,  though  I  can  not  deny  that 
the  latter  are  sometimes  very  convenient.  If  the  principle 
is  firmly  grasped  the  application  will  usually  follow. 

The  treatment  of  constipation,  associated  as  this  condi- 
tion is  with  a  great  variety  of  morbid  states,  offers  a  wide 
latitude  for  the  application  of  therapeutic  principles.  It 
must  include  both  medical  and  surgical  measures,  and  it  is 
unnecessary  to  say  that  it  is  useless  to  attempt  to  cure  the 
constipation  without  removing  its  cause.  The  following 
measures  would  certainly  be  indicated  in  more  or  fewer 
cases:  (1)  cutting  operations,  (2)  electricity,  (3)  massage, 
(4)  cathartics  and  aperients,  (5)  injections  and  applications 
in  vagina  and  rectum,  (6)  tonics. 

Cutting  Operations. — It  is  becoming  more  and  more 
recognized  that  certain  diseased  conditions  of  the  pelvis 
which  long  occupied  debatable  ground  are  not  amenable  to 
medical  treatment,  but  to  surgical  only,  or  to  surgical  and 
medical  combined.  This  has  involved  a  period  of  education 
in  which  many  mistakes  have  been  made  by  those  who  be- 
lieved and  those  who  did  not  believe  in  radical  surgical  meas- 
ures for  this  portion  of  the  body.  But  without  wandering^ 
too  far  into  this  bypath,  the  concrete  application  of  the  prop- 
osition is  that  when  constipation  is  associated  with  a  rectum 
which  is  firmly  bound  by  adhesions  or  imbedded  in  exu- 
date, the  chances  of  relief  are  not  one  in  a  thousand,  unless 
the  offending  and  obstructing  matter  is  removed  by  a  sur- 
gical operation.  When  the  rectum  and  vagina  are  dilated, 
the  perinaeum  torn,  and  the  conditions  which  favor  muscu- 
lar contraction  wanting,  the  constipation  will  probably  go 
unrelieved  until  a  surgical  operation  has  been  performed. 
Pressure  of  a  displaced  uterus  upon  the  rectum  may  often 
be  relieved  by  mechanical  appliances,  but  if  these  fail  more 
radical  measures  will  be  indicated  in  order  to  allow  the 
rectum  to  perform  its  work.  The  cutting  operation  may 
not  be  all  that  is  necessary  to  cure  the  constipation  in  these 
cases,  but  it  will  often  be  found  an  indispensable  factor  in 
the  treatment. 

Electricity. — In  cases  in  which  there  is  no  serious  lesion 
in  the  pelvis  or  elsewhere  which  causes  the  constipation, 
the  condition  being  only  functional,  and,  in  particular,  due 
to  muscular  inactivity,  the  use  of  electricity  will  be  rational 
and  effective.  A  mild  faradaic  current  producing  contrac- 
tions of  successive  portions  of  the  intestine,  or  a  mild  gal- 
vanic current  with  the  negative  electrode  in  the  rectum  and 
the  positive  upon  the  abdomen,  repeated  at  sufficiently  fre- 
quent intervals,  has  been  found  very  useful  in  many  re- 
corded cases. 

Massage. — For  the  same  class  of  cases  as  the  preceding, 
and  also  in  the  relaxed  cases,  the  cases  in  which  both  the 
involuntary  and  the  voluntary  muscles  concerned  in  the  act 
of  defecation  are  involved,  the  judicious  use  of  massage  is 
of  great  benefit.  A  skillful  rubber  is  one  of  the  most  valu- 
able assistants  which  a  physician  can  have  in  cases  of  this 
character. 

Cathartics  and  Aperients. — The  field  occupied  by  cathar- 
tics and  aperients  is  a  large  one,  and  I  can  not  pretend  to 
do  justice  to  the  subject  in  the  brief  allusion  which  will  be 
made  to  it.    The  use  of  the  aperient  mineral  waters,  of 


106 


DUNLAP:   RUPTURE  OF  INTESTINE  BY  TAPEWORM. 


[N.  Y,  Mkd.  Joub,, 


which  so  many  really  valuable  ones  are  now  available,  will 
be  found  very  efficient  in  many  of  the  cases  in  which  the 
trouble  is  purely  functional,  and  in  others  in  which  they 
will  be  required  both  before  and  after  the  performance  of 
surgical  operations.  A  long  course  of  such  treatment  sys- 
tematically and  patiently  carried  out  will  often  relieve  the 
most  obstinate  cases.  The  list  of  approved  remedies  in 
addition  to  the  mineral  waters  for  persistent  and  careful 
use  is  a  long  one — too  long  to  be  detailed  here.  One  need 
only  mention  the  preparations  in  which  cascara,  aloin, 
podophyllin,  calomel,  and  senna  are  the  active  ingredients. 
For  surgical  cases  nothing  can  surpass  the  usefulness  of  the 
salines,  which  are  now  so  extensively  used  both  before  and 
after  operations.  Their  function  in  depleting  the  circula- 
tion and  relieving  congestion  has  undoubtedly  saved  many 
lives  which  would  have  succumbed  to  peritonitis  or  sepsis 
after  the  performance  of  severe  abdominal  operations. 

Injections  and  Applications  in  the  Vacjina  and  Rectum. — 
The  use  of  glycerin  and  salines  in  the  vagina  and  rectum, 
injections  of  ox  gall,  and  the  oils  has  played  a  most  useful 
part  both  in  surgical  and  medical  cases.  As  they  are  all 
free  from  poisonous  properties,  they  should  be  used  fear- 
lessly and  in  large  quantities.  They  are  frequently  eifect- 
ive  when  life  seems  to  hang  by  a  thread,  and  their  value 
in  these  desperate  cases  is  not  yet  fully  appreciated  by  the 
profession  at  large. 

Tonics. — There  are  few  cases  in  which  constipation  has 
persisted  for  any  length  of  time  in  which  tonics  with  other 
measures  are  not  proper.  Quinine,  malt,  iron,  arsenic, 
strychnine — all  have  their  appropriate  place  in  this  connec- 
tion. Constipation  is  certainly  debilitating  ;  it  may  re- 
(juire  this  form  of  treatment  or  it  may  require  that,  and 
in  all  cases  it  should  be  our  aim,  to  borrow  a  comparison 
from  comic  opera,  "  to  make  the  punishment  fit  the  crime." 
85  Madison  Avenue. 


RESECTION  OF  THE  SMALL  INTESTINE 
FOR  RUPTURE  CAUSED  BY  TAPEWORM. 

RECOVERY. 
By  FAYETTE  DUNLAP,  M.  D., 

DANVILLE,  KT. 

On  the  morning  of  September  12th  Mrs.  L.,  aged  thirty-one, 
was  attacked  by  violent  pains  in  the  left  iliac  region.  The  onset 
was  without  i>remonition  and  prostration  rapidly  followed. 
When  first  called  there  were  no  symptoms  of  shock,  and,  sup- 
posing the  pain  due  to  the  re-establishment  of  menstruation  after 
eighteen  montbs'  lactation,  I  gave  morphine  hypodermically. 
About  three  hours  thereafter,  the  pains  recurring,  I  repeated 
the  morphine.  In  another  hour  a  messenger  announced  that 
the  patient  was  again  in  distress,  and  at  this  visit  the  signs  of 
shock  and  haemorrhage  were  unmistakable  and  my  suspicion 
that  there  was  an  ectopic  gestation  with  ruptured  sac  seemed 
now  confirmed. 

Eighteen  months  prior  to  tliis  she  had  borne  a  child,  and 
twelve  months  thereafter  menstruation  appeared  but  once. 
From  May  to  September  she  did  not  menstruate,  but  gave  no 
signs  of  pregnancy.  There  was  a  boggy  mass  to  be  felt  now  by 
bimanual  examination,  and  this,  with  frequent  syncopic  attacks, 
satisfied  me  that  hoemorrhage  was  going  on  in  the  abdomen.  I 
sent  at  once  for  assistance  and  a  nurse  and  began  an  exploratory 
cujliotoray,  expecting  to  find  a  ruptured  tubal  pregnancy.  The 


pelvis  was  filled  with  recent  blood-clot  and  the  uterus,  ovaries, 
and  tubes  were  perfectly  normal. 

I  searched  for  an  aneurysm  and  none  was  found.  In  flood- 
ing the  cavity  to  free  it  of  clots  there  floated  to  the  surface  a 
long  tapeworm.  Following  this  lead  it  was  found  protruding 
from  a  large  ragged  rupture  in  the  small  intestine.  There  were 
two  bleeding  points  and  these  were  secured  and  the  attempt  to 
dislodge  the  worm  entire  was  unsuccessful.  It  had  fastened 
about  twelve  inches  above  tlie  rupture.  About  two  thirds  of 
the  lumen  of  the  intestine  was  gone,  and  possibly  the  length  of 
the  opening  was  an  inch  and  a  half.  The  edges  were  ragged 
and  gangrenous,  but  it  was  quite  evident  tliat  there  had  been  no 
previous  ulceration. 

It  was  impossible,  from  the  great  loss  of  tissue,  to  unite  the 
edges  without  so  narrowing  the  gut  as  to  produce  constriction, 
so  a  resection  of  the  damaged  parts  was  done  and  the  ends  wt  i 
united  by  the  continuous  suture  after  the  manner  of  Lembert. 
Owing  to  the  extreme  prostration  the  operation  was  completed 
in  a  remarkably  short  time — less  than  thirty  minutes — aud  the 
patient  ])ut  to  bed  pulseless.  Vomiting  was  continuous  for 
thirty  hours  and  only  ceased  after  a  large  enema  of  an  ounce 
each  of  glycerin  and  sulphate  of  magnesium  and  a  quart  of  hot 
water.  From  this  time  forth  the  recovery  was  prompt  and  sat- 
isfactory. From  the  abdomen  there  was  removed  about  eight 
feet  of  live  tapeworm,  and  with  the  enema  there  came  away 
seventeen  feet  more.  There  were  no  antiseptics  used ;  only 
boiled  cistern  water.  The  surroundings  were  as  unfavorable  as 
could  be  imagined  for  abdominal  section,  but  there  was  no  evi- 
dence of  sepsis  in  the  progress  of  the  case. 

The  interesting  feature  of  this  case  is  the  cause  of  the 
intestinal  rupture,  the  ragged  gangrenous  margins  of  the 
wound  inclining  me  to  the  idea  of  pressure  gangrene.  The 
worm  had  evidently  become  entangled  and,  in  the  effort  to 
free  itself,  so  eroded  the  wall  as  to  cause  the  rupture.  Col- 
lections of  lumbricoids  are  frequently  the  means  of  intes- 
tinal obstruction  in  children,  but  in  the  whole  range  of  my 
reading  or  observation  this  is  the  first  instance  of  escape  of 
an  intestinal  parasite  into  the  peritoneal  cavity.  Lumbri- 
coids have  been  found  in  a  ruptured  appendix,  but  it  was 
not  safe  to  say  that  they  were  the  cause  of  the  rupture. 

This  indeed  is  another  marked  illustration  of  the  uncer- 
tainty that  is  always  before  the  abdominal  surgeon  as  to  the 
nature  of  what  he  may  find  in  the  cavity.  It  was  my  belief 
and  that  of  Dr.  James  W.  Guest,  Dr.  Montfort,  and  Dr. 
Kincaid  that  a  ruptured  tubal-gestation  sac  was  producing 
the  symptoms,  and  how  far  wrong  we  were,  but  how  strik- 
ingly similar  were  these  symptoms,  the  foregoing  recital 
testifies.  At  this  writing  the  patient  is  in  perfect  health 
and  is  allowed  to  partake  of  whatsoever  character  of  food 
her  taste  calls  for. 


The  Death  of  Dr.  Spencer  Core  Devan,  Passed  Assistant  Surgeon  in 
the  United  States  Marine-Hospital  Service,  occurred  at  Philadelphia  on 
Friday,  the  3d  inst.  Dr.  Devan  was  born  in  New  York  city  in  185(5, 
and  entered  the  Marine-Hospital  Service  from  Missouri  in  October,  1881. 
He  was  on  duty  at  San  Francisco,  served  as  medical  officer  of  the  steam- 
ship Corwin  during  her  cruises  in  the  Arctic  Ocean  in  1882  and  1883, 
was  on  duty  at  Portland  (Oregon),  St.  Louis,  Port  Townsend,  Washing- 
ton, Buffalo,  Portland  (Maine),  and  Norfolk.  While  on  duty  at  the 
latter  station  he  had  an  attack  of  pneumonia,  and  on  recovering  his 
health  was  ordered  to  command  the  quarantine  station  at  Delaware 
Breakwater.  But  his  health  broke  down  in  consequence  of  the  arduous 
duties,  he  was  obliged  to  go  on  sick  leave,  and  his  death  occurred  while 
he  was  oil  leave. 


I  Feb.  11,  1893.J 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


167 


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,  FEBRUARY  11,  1893. 


CHOLERA  AND  THE  PILGRmAGES  TO  MECCA. 

In  an  exhaustive  pamphlet  on  the  cholera  in  Egy])t,  just 
publislied  by  Dr.  F.  M.  Sandwith,  of  Cairo,  tliore  is  an  interest- 
inji  account  of  the  sanitary  conditions  of  Mecca  and  its  pilgrims. 
Mecca  has  110,000  inhabitants.  Tlie  holy  season  is  early  in 
raidsuniraer,  and  the  number  of  pilgrims  then  entering  the  city 
varies  from  80,000  to  100,000.  The  town  is  so  crowded  that 
$15  to  $20  must  be  paid  for  a  night's  lodging,  and  thirty  peojile 
crowd  into  a  small  room  in  order  to  divide  the  expense.  The 
houses  have  cesspools  wliich  are  seldom  or  never  emptied,  and 
the  latrines  are  too  foul  to  be  used.  The  drinking  supply 
comes  from  the  Ain  Zebaida  and  runs  into  an  open  reservoir 
about  three  hundred  feet  in  diameter.  This  reservoir  is  never 
cleaned  out.  It  is  so  contaminated  by  neighboring  cesspools 
that  the  water  stinks.  It  is  unprotected,  so  that  people  throw 
in  whatever  they  wish.  Mecca  stands  in  a  winding  valley  shut 
in  by  rocky  hills  that  fiercely  reflect  the  August  lieat.  Mina  is 
a  village  three  miles  from  Mecca,  and  Arafat  a  mountain 
twelve  miles  away.  The  pilgrims  before  the  sacred  rites  run 
seven  times  between  the  hills  of  Mecca,  and  throng  during  the 
day  the  Kaaba  with  its  horrible  air.  On  the  first  holy  day 
they  go  through  Mina  to  Mount  Arafat,  where  they  remain  all 
night,  with  prayers  for  three  hours  before  daybreak.  Then, 
almost  naked,  exhausted  with  fatigue,  fasting,  and  emotion,  the 
pilgrims  crowd  toward  Mina  in  a  confusion  and  chaos  that  lasts 
most  of  the  second  night.  The  third  day  is  ushered  in  by  prayers 
at  dawn,  and  then  some  rush  headlong  toward  Mecca,  while 
others  gather  in  a  seething  mass  in  a  narrow  pass  to  stone  the 
Devil's  Pillars.  Then  some  six  thousand  sheep  and  cattle  are 
sacrificed  in  the  village  of  Mina,  no  provision  of  any  kind  exist- 
ing for  sanitary  slaughtering.  The  air  becomes  pestilential  and 
prevents  sleep  at  night.  Every  one  suffers  from  the  heat,  stench, 
blood-soaked  earth,  vermin,  kites,  and  vultures.  The  water  at 
Mina  comes  from  the  Mecca  fountain  and  is  kept  in  large  cis- 
terns never  cleaned  and  full  of  entozoa.  Many  pilgrims  fly  at 
once  to  Mecca  to  escape  the  horrors  of  Mina,  but  numbers  are 
detained  by  religious  scruples  or  other  reasons  for  three  days. 
This  state  of  affairs  is  quite  enough  to  produce  any  pest,  and 
the  mortality  from  diarrhcca  alone  is  very  great  among  the  pil- 
grims. Immediately  after  Holy  Week  the  faithful  arc  enjoined 
by  their  religion  to  disperse  from  Mecca,  carrying  with  them 
the  germs  of  diseases  iis  well  as  any  number  of  internal  and 
external  animal  parasites.  Besides  this,  those  who  can  aflbrd 
to  do  so  bring  back  for  their  friends  and  for  home  consumption 
bottles  of  the  precious  Zem  Zem  water,  which  acts  as  a  purge 
and  tastes  and  smells  horribly.     An  analysis  of  this  holy  water 


made  in  London  some  years  ago  showed  that  it  was  danger- 
ously contaminated  with  sewage. 

The  Mecca  lulgrimages  are  a  source  of  great  ])eril  to  many 
Eastern  countries  as  regards  cholera.  Most  of  the  Egyptian 
epidemics  have  had  their  origin  there,  although  a  quarantine 
has  been  enforced  against  returning  ])ilgrim?.  In  1890  Mecca's 
cliolera  mortality  while  the  pilgrims  were  carrying  on  their  de- 
votions to  Mohammed  was  four  hundred  to  five  hundred  daily.. 
In  1891  the  cholera  mortality  in  the  holy  city  during  the  per- 
formance of  the  sacred  ceremonies  by  the  pilgrims  readied  four 
hundred  a  day.  During  the  last  thirty-two  years  cholera  lias 
infested  Arabia  sixteen  times.  Egypt  has  suffered  only  three- 
times  in  the  same  period,  probably  because  the  pilgrimage  is  so 
long  that  the  disease  dies  out  before  the  pilgrims  return.  From 
a  study  of  these  facts  and  all  the  points  in  relation  to  India,  it 
would  seem  that  there  is  no  tendency  among  the  picturesquely 
filthy  Orientals  to  sanitary  reform  of  any  kind,  and  it  becomes 
the  duty  of  Western  governments  regnant  there  to  protect  the 
civilized  world  from  these  barbaric  Oriental  nests  of  pestilence.. 


MEN  OR  PARAGRAPHS. 

THE  MEDICAL  CORPS  OF  THE  NATIONAL  GUARD. 

The  adjutant-general  of  the  National  Guard  of  the  State  ot 
New  York,  in  his  annual  report  for  1892,  says  that  he  concurs 
in  the  statement  and  recommendation  made  by  Surgeon-Gen-  * 
eral  .loseph  D.  Bryant  that  the  organization  of  the  medical  de- 
partment of  the  National  Guard  should  be  made  in  a  more 
permanent  manner,  and  modeled  after  the  organization  of  the 
medical  corps  of  the  United  States  army.  It  may  surprise  many 
of  our  readers  to  know  that  the  commission  of  a  medical  officer 
is  virtually  held  during  the  pleasure  of  the  commanding  officer 
of  his  regiment  for  the  time  being.  In  other  words,  if  a  new 
commanding  officer  is  elected,  the  medical  officers,  as  jiart  of 
his  official  staff,  are  expected  to  tender  their  resignations.  They 
are  not,  however,  usually  accepted.  This  arrangement  subordi- 
nates the  medical  corps  to  an  unwarranted  degree,  and  seems  to 
us  to  be  most  prejudicial  to  the  best  interests  of  the  service. 
The  medical  officers  of  a  regiment  should  be  as  independent  in 
the  tenure  of  their  commissions,  and  of  the  line  in  general,  as 
the  medical  officers  of  the  army,  and  it  is  to  be  hoped  that  Dr. 
l^ryant's  recommendation  will  be  acted  on.  The  evil  that  we 
have  referred  to  does  not  exist  in  New  York  alone,  but  in  many 
other  States  as  well ;  and  it  is  a  part  of  the  absurd  system  of 
appointment  by  official  favor  in  the  creation  of  a  staff  of  carpet 
officers  by  each  new  Governor.  The  incompetency  th.it  is  se- 
cured by  this  method  was  satisfactorily  demonstrated  by  certain 
of  the  staff  corps  in  the  trouble  at  Buffalo  last  summer.  The 
Association  of  Medical  Officers  of  the  National  Guard  should 
take  this  matter  in  hand  and  secure  proper  laws  regarding  the 
medical  corps  of  the  guard  of  each  State. 


INFANTICIDE  BY  MEANS  OF  SPONGE. 

PiiOFF.ssoR  Paul  Cazkneuvk  rejjorts  in  Lyon  medical  for 
December  4,  1892,  a  case  in  which  a  healthy  infant  of  five 
months  died  very  suddenly.  Seven  tnonths  afterward,  on  ac- 
count of  popular  suspicion,  an  examination  was  made  of  the 
I)utrid  and  anatomically  unrecogniziible  masses  constituting  the 
head  and  the  abdomen.  In  making  an  examination  for  arsenic, 
M.  Cazeneuve  noticed  tour  rounded  liodies,  ot  the  size  of  beans, 


168 


MINOR  PARAORAPES.— ITEMS. 


[N.  Y.  Med.  Joub., 


that  were  elastic,  and  oa  further  examination  these  proved  to 
be  pieces  of  sponge).  On  further  search,  three  more  pieces  of 
sponge  were  found.  Clietiiical  tests  failed  to  reveal  the  pres- 
ence of  any  metallic  poison  in  the  remains,  and  no  examination 
was  made  for  alkaloidal  poisons,  on  account  of  the  putridity  of 
the  tissues.  Professor  Oazeneuve  considered  that  the  sponge 
had  been  administered  to  cause  death,  for  in  certain  localities 
dogs  and  cats  are  killed  by  giving  tliem  sponge  fried  in  oil. 
The  sponge  swells  in  the  intestinal  fluids,  resists  their  action, 
and  produces  intestinal  obstruction  with  vomiting  and  convid- 
^  sions.  It  did  not  seem  that  the  pieces  of  sponge  had  been  swal- 
lowed by  accident,  as  they  were  too  numerous,  and  there  is  no 
domestic  use  for  snch  small  bits  of  sponge;  they  were  probably 
administered  in  sou])  or  milk  with  criminal  intent.  The  author 
states  that  a  method  of  infanticide  in  England  is  to  stuff  the 
pharynx  of  the  new-born  child  with  sponge  held  by  a  thread 
that  permits  of  the  removal  of  that  substance  after  suffocation 
is  produced.  But  he  believes  his  case  is  unique  in  jurisprudence. 
The  person  accused  of  giving  the  sponge  was  found  guilty  and 
sentenced  to  hard  labor  for  life. 


THE  BELLEVUE  HOSPITAL  ALUMNI  SOCIETY. 

The  Society  of  the  Alumni  of  Bellevue  Hospital  held  its  third 
reunion  at  the  Hotel  Brunswick  on  Wednesday  evening,  the  1st 
Inst.  About  a  hundred  and  twenty-five  pei'sons,  including  the 
invited  guests,  sat  down  to  dinner.  The  tables  were  beautifully 
decorated  with  choice  cut  flowers  and  the  menu  cards  were 
very  artistic.  The  opening  address  was  made  by  the  president. 
Dr.  W.  R.  Townsend,  who  acted  as  toastmaster,  and  responses 
were  made  to  the  following  toasts :  The  Commissioners,  by  the 
Hon.  W.  W.  Porter ;  Old  Bellevue,  by  General  James  G.  Wil- 
son; The  Medical  Board,  by  Dr.  Joseph  T).  Bryant;  The  Alumni, 
by  Dr.  Charles  McBurney  ;  Medical  and  Other  Kinds  of  Doctors, 
by  Frederick  Taylor,  Esq. ;  Our  Sister  Societies,  by  Dr.  W.  L. 
Carr;  The  Patient,  by  Charles  0.  Beaman,  Esq.  The  society 
was  organized  in  1887,  and  now  has  a  membership  of  more  than 
a  hundred  and  fifty,  two  thirds  of  whom  are  residents  of  New 
York  city.  Within  a  few  weeks  the  society  will  publish  a  cata- 
logue containingthe  names  and  addresses  of  all  of  the  ex-internes 
of  Bellevue  Hospital  and  a  complete  history  of  the  institution 
since  its  organization.  The  book  will  be  profusely  illustrated 
with  views  of  the  hospital  pavilion  and  wards,  and  with  por- 
traits of  many  noted  physicians  and  surgeons. 


A  SECOND  DANIEL. 

One  Dr.  Steinbrecher,  who  is  said  to  have  "  a  brother-in- 
law  in  Europe,"  is  represented  as  ultra-pessimistic  about  the 
New  York  quarantine.  The  Detroit  Trihitne  reports  him  as 
saying:  "  Tammany  is  opposed  to  the  prohibition  of  immigra- 
tion because  it  will  throw  a  lot  of  inspectors  who  are  Tanmiany 
appointees  out  of  a  job  at  New  York.  Health  Officer  Jenkins, 
of  New  York  city,  is  himself  a  Tammany  appointee.  He  is  a 
young  physician,  only  a  couple  of  years  out  of  college,  and 
owes  his  appointment  to  the  fact  that  he  is  a  brother-in-law  of 
Croker,  the  sanitary  chief."  Thus  does  Dr.  Steinbrecher,  if 
the  Tribune  is  to  be  believed,  betray  equal  ignorance  of  New 
York  sanitation  and  of  New  York  jjolitics. 


THE  NEW  YORK  STATE  SOCIETY. 

At  the  meeting  of  the  Medical  Society  of  the  State  of  New 
York  held  this  week  tiie  general  indorsement  of  the  recommen- 
dations contained  in  tlie  president's  inaugural  address  was  fol- 
lowed by  specific  action  by  which  the  society's  code  of  ethics 


was  extinguished.  This,  of  course,  freed  the  society  from  any 
obligation  to  delegate  a  committee  of  conference  to  meet  the 
American  Medical  Association's  special  committee  appointed  to 
consider  ways  and  means  of  re-establishing  relations  between 
the  two  organizations.  The  situation  seems  tlierelbre  to  be 
somewhat  improved ;  the  State  society  has  no  code  of  ethics, 
and  consequently  isTess  at  variance  with  the  American  Medical 
Association  than  when  it  had  a  code  that  positively  clashed  with 
the  association's  code.  It  remains  to  be  seen,  however,  whether 
other  relations  between  the  two  bodies  than  those  of  "  comity  " 
will  again  come  into  existence. 


THE  YELLOW  ABOVE  THE  BLACK. 

In  a  Question  of  Diplomacy ^  a  short  story  by  Dr.  Conan 
Doyle,  the  Prime  Minister  and  another  minister  of  Great  Britain 
have  a  conference  in  the  sick-room  of  the  latter,  who  is  laid  up 
with  the  gout.  Says  the  sick  man :  "  My  head  is  clouded ; 
sometimes  1  think  it  is  the  gout,  and  sometimes  I  put  it  down 
to  the  colchicum."  "  What  will  Sir  William  say  to  that? "  (Sir 
William  is  the  physician  in  the  case).  "  You  are  so  irreverent. 
With  a  bishop  you  may  feel  at  your  ease — bishops  are  not  be- 
yond the  reach  of  argument.  But  a  doctor,  with  his  stetho- 
scope and  thermometer,  is  a  thing  apart.  Your  reading  does 
not  impinge  upon  him.  He  is  serenely  above  you.  And  then, 
of  course,  he  takes  you  at  a  disadvantage.  With  health  and 
strength  one  miglit  cope  with  him."  The  time  for  argument 
has  passed  when  the  doctor  is  in  the  house — then  is  the  time 
for  obedience,  if  not  contrition. 


TUBERCULOUS  MILK  IN  SAN  FRANCISCO. 

The  newspapers  state  that  a  certain  morning  paper  of  San 
Francisco,  having  been  informed  by  a  well-known  physician 
and  ex-member  of  the  board  of  health  of  that  city  that  a  large 
part  of  the  milk  supplied  to  consumers  there  was  taken  from 
tuberculous  cows,  caused  samples  of  milk  to  be  bought  in  six 
places.  These  samples  were  submitted  to  an  expert  chemist 
a"d  bacteriologist,  who  found  tubercle  bacilli  in  two  of  the  sam- 
ples. The  physician  that  suggested  the  experiment  stated  that 
during  his  official  career  he  had  found  that  more  than  fifty  per 
cent,  of  the  milk  supplied  to  the  city  and  county  hospital  con- 
tained the  tubercle  bacillus. 


THE  LONDON  POST-GRADUATE  COURSE. 

The  prospectus  of  this  school  for  the  spring  of  1893  shows 
that  Sir  Joseph  Lister  has  been  added  to  the  teaching  corps. 
His  subject  is  antiseptic  dressings.  Sir  George  Johnson  and  Dr. 
Bristowe  are  also  among  the  latest  acquisitions.  The  composi- 
tion fee  for  the  whole  course  is  about  eighty  dollars.  There  are 
fully  a  hundred  and  twenty  demonstrations  and  lectures  on  the 
schedule,  at  twelve  different  hospitals  or  museums. 


THE  SHEFFIELD  MEDICAL  JOURNAL. 

This  is  the  title  of  a  new  quarterly  journal  published  in 
Sheffield,  England,  and  edited  by  Mr.  Simeon  Snell.  The  sec- 
ond number,  for  January,  1893,  contains  96  pages  of  reading 
matter,  and  is  illustrated  with  a  number  of  excellent  engravings. 

ITEMS,  ETC. 

An  Army  Medical  Board  will  be  in  session  in  Nevr  York  city  during 
April,  1893,  for  the  exaraniation  of  candidates  for  appointment  to  the 
medical  corps  of  the  United  States  army,  to  fill  existing  vacancies.  Per- 


\ 


Feb.  11,  1893.] 


ITEMS.— PROCEEDINGS  01  SOCIETIES 


169 


sons  desiring  to  present  themselves  for  examination  by  the  board  will 
make  application  to  the  secretary  of  war,  before  March  15,  1893,  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  shoidd  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  aud  twenty-eight  yeai'S  of  age  and  a  graduate  from  a  regu- 
lar medical  college,  as  evidence  of  which  his  diploma  must  be  submitted 
to  the  board.  Further  information  regarding  the  examinations  may  be 
obtained  by  addressing  the  surgeon-general,  U.  S.  army,  Washing- 
ton, D.  C. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
And  deaths  reported  during  the  two  weeks  ending  February  7,  1893 : 


DISEASES. 

Week  ending  Jan.  31. 

Week  ending  Feb.  7. 

Cases. 

Deaths. 

Cases. 

Deaths. 

54 

4 

28 

21 

12 

2 

8 

3 

164 

12 

198 

17 

Cerebro-spinal  meningitis. . . . 

10 

5 

5 

1 

71 

8 

86 

6 

120 

39 

121 

43 

4 

1 

3 

1 

The  Society  of  Medical  Jurisprudence. — At  the  next  meeting,  on 
Monday  evening,  the  13th  inst.,  Mr.  S.  B.  Livingston,  of  the  New 
York  bar,  is  to  read  a  paper  on  Suicide  and  Recent  Reactionary  Legis- 
lation. 


The  Index-Catalogue. — Two  weeks  ago  we  spoke  with  regret  of  the 
omission  of  the  usual  appropriation  for  continuing  the  publication  of 
this  great  work.  We  are  glad  to  learn  that  the  omitted  item  has  been 
restored,  and  that  it  is  probable  that  there  will  be  no  further  obstacle 
to  the  necessary  legislation. 

Society  Meetings  for  the  Coming  Week : 

Monday,  Febniary  ISih :  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) ;  Society  of  Medical 
Jurisprudence,  New  York ;  Boston  Society  for  Medical  Improvement ; 
Gynaecological  Society  of  Boston ;  Burlington,  Vt.,  Medical  and  Sur- 
gical Club ;  Norwalk,  Conn.,  Medical  Society  (private) ;  Baltimore 
Medical  Association. 

Tuesday,  February  l^Jh ."  New  York  Academy  of  Medicine  (Section  in 
Genito-urinary  Surgery) ;  New  York  Medical  Union  (private) ;  Kings 
County,  N.  Y.,  Medical  Association  ;  Medical  Societies  of  the  Counties 
of  Delaware  (semi-annual)  and  Rensselaer,  N.  Y. ;  Newark,  N.  J., 
and  Trenton  (private),  N.  J.,  Medical  Associations ;  Baltimore  Gynae- 
cological and  Obstetrical  Society  ;  Northwestern  Medical  Society  of 
Philadelphia. 

Wednesday,  February  15th :  New  York  Academy  of  Medicine  (Section 
in  Public  Health  and  Hygiene) ;  Northwestern  Medical  and  Surgical 
Society  of  New  York  (private) ;  Medico-legal  Society ;  Harlem  Medi- 
cal Association  of  the  City  of  New  York;  New  Jersey  Academy  of 
Medicine  (Newark). 

Thursday,  February  IGth :  New  York  Academy  of  Medicine ;  Brooklyn 
Surgical  Society  ;  New  Bedford,  Mass.,  Society  for  Medical  Improve- 
ment (private). 

Friday,  February  17th :  New  York  Academy  of  Medicine  (Section  in 
Orthopaedic  Surgery);  Baltimore  Clinical  Society;  Chicago  Gynae- 
cological Society. 

Saturday,  February  18th  :  Clinical  Society  of  the  New  York  Post-gradu 
ate  Medical  School  and  Hospital. 


Answers  to  Correspondents : 

No.  394. — The  operator  was  Dr.  Robert  F.  Weir. 

No.  395. — The  micro-organism  does  not  thrive  in  a  solution  of  the 
substance  mentioned,  but  a  solution  strong  enough  to  kill  it  would  not 
be  tolerated  by  the  tissues  of  the  body. 


IProxeib'mgs  of  Socieths. 

MEDICAL  SOCIETY  OF  THE  STATE  OF  NEW  YORK. 

Eighty -seventh  Annual  Meeting,  held  in  Albany  on  ]Tuesday, 
Wednesday,  and  Thursday,  February  7,  8,  and  9,  1893. 

The  President,  Dr.  Lewis  S.  Pilchee,  of  Brooklyn,  in  the  Chair. 

The  President's  Inaugural  Address  having  been  delivered 
(see  page  149),  the  recommendations  contained  in  it  were,  on 
motion,  unanimously  approved. 

A  Contribution  to  the  Study  of  the  Treatment  of  Tra- 
choma and  Vascular  Keratitis  by  means  of  Jequirity,  with 
Cases,  was  the  title  of  a  paper  read  by  Dr.  J.  B.  Emerson,  of 
New  York.  This  drug  had  not  accomplished  what  enthusiasts 
had  hoped  for  it,  but  had  certainly  been  beneficial  in  cases  in 
which  there  was  superficial  vascularity  of  the  cornea  from 
trachoma  or  in  the  fibrous  conditions  which  followed  it.  It  was 
desirable  that  patients  remain  in  hospital  while  this  treatment 
was  being  carried  out,  aud  the  powdered  leaves  should  be  used 
in  preference  to  the  tincture.  The  longer  the  disease  had 
lasted  the  less  severe  was  the  reaction  from  the  treatment. 
The  inflammation  which  resulted  from  the  application  of  the 
drug  was  at  its  height  at  the  end  of  the  third  day.  Pain  was 
to  be  relieved  by  the  use  of  atropine  and  ice-cold  cloths.  The 
membrane  which  formed  as  the  result  of  the  inflammation  usu- 
ally came  away  on  the  fifth  day.  The  drug  was  certainly  a 
valuable  one  and  could  be  depended  upon  to  give  benefit  in 
suitable  cases. 

A  Discussion  on  Epilepsy.— The  Epileptic  Interval ;  its 
Phenomena  and  their  Importance  as  a  Guide  to  Treatment,  was 
the  title  of  a  paper  by  Dr.  William  Beowning,  of  Brooklyn. 
Differences  in  the  pupils  of  the  eyes  in  epilepsy  were  not  com- 
mon, but  occasional ;  oscillation  of  the  pupils  was  of  very  com- 
mon occurrence,  both  contraction  and  dilatation  being  noticeable. 
In  many  cases  it  was  observed  that  it  was  impossible  to  keep 
the  gaze  fixed.  Oscillation  was  less  marked  on  dull  or  cloudy 
days.  In  patients  who  were  physically  degenerate  there  was 
thickening  of  the  iris,  the  condition  being  bilateral.  Other  ocu- 
lar defects  or  deficiencies  were  to  be  regarded  as  results  rather 
than  as  symptoms  of  the  disease.  Peculiarities  of  the  pulse 
were  very  frequent,  including  variations  in  rhythm,  change  in 
the  rapidity  of  the  beats,  and  great  irregularity  which  might 
come  on  suddenly.  The  childish  heart  with  palpitation  was 
especially  noteworthy  in  adult  women.  The  question  was 
pertinent  whether  these  irregularities  were  due  to  heart  strain 
or  to  faults  of  innervation.  Oardio-va=cu!ar  troubles  might  be 
secondary,  but  were  always  of  importance. 

Respiratory  troubles  were  often  marked,  patients  becoming 
fatigued  after  slight  exertion. 

The  appetite  of  epileptics  was  usually  large,  but  there  were 
occasionally  cases  in  which  it  was  deficient. 

Digestive  disorders  frequently  occurred,  and  often  arose 
from  imperfect  mastication  and  hasty  eating. 

Amenorrh(Ea  and  menstrual  irregularities  were  common. 
In  some  cases  epileptic  convulsions  were  absent  during  the 
menstrual  epoch,  in  others  they  were  increased  at  that  time. 

Cold  hands  and  feet  were  a  common  symptom,  and  wero 


170 


BOOK  NOTICES. 


[N.  Y.  Med.  Jode., 


usually  attributable  to  excessive  sweating.  Pruritus  universa- 
lis and  other  skin  affections  were  of  common  occurrence. 

Wakefulness  was  a  common  symptom,  quiet,  dreamless 
sleep  being  rare.  Restlessness  during  sleep  was  common,  also 
tlie  Labit  of  holding  tlie  head  very  high  or  very  low  while 
sleeping;  this  would  affect  the  circulation  of  the  brain  in  some 
cases.  Cervical  adenopatliies  were  common,  also  ear  troubles 
and  nasopharyngeal  difficulties.  The  relation  of  epilepsy  to 
chorea  was  seen  in  the  general  uneasiness  of  patients,  also 
paresis  as  a  residuum  of  convulsions.  Headaches  and  impair- 
ment of  the  tendon  reflexes  were  also  noteworthy. 

(To  be  conlinutd.) 


Mineral  Springs  and  Health  Resorts  of  California,  with  a  Com- 
plete Chemical  Analysis  of  Every  Important  Mineral  Water 
in  the  World.  Illustrated.  A  Prize  Essay.  Annual  Prize 
of  the  Medical  Society  of  the  State  of  California,  awarded 
April  20,  1889.  By  Winslow  Anderson,  M.  D.,  M.  R.  C.  P. 
Lond.,  M.  R.  C.  S.  Eng.,  etc..  Joint  Editor  and  Publisher  of 
the  Pacific  Medical  Journal,  etc.  San  Francisco  :  The  Ban- 
croft Company,  1892.    Pp.  xxx-384. 

This  is  not  a  mere  collection  of  analyses  of  mineral  waters, 
geographical  and  topographic.il  data,  and  therapeutical  allega- 
tions. It  appears  to  us  to  be  discriminative  and  conservative  in 
its  statements,  and  to  have  been  founded  largely  on  the  author's 
personal  observation.  It  covers  more  ground  than  the  title- 
page  sets  forth,  for  nearly  a  hundred  of  the  earlier  pages  are 
devoted  to  mineral  springs  and  to  balneology  in  general.  The 
author's  style  of  writing  is  pleasing,  and  what  he  says  can 
readily  be  understood  by  persons  who  have  no  special  knowl- 
edge of  medicine.  We  can  not  speak  highly  of  the  pictures, 
which  are  numerous;  many  of  them  have  no  particular  bearing 
upon  the  text,  being  mere  scenes,  and  almost  all  of  them  are 
badly  executed.  They  are  quite  unworthy  of  the  book,  and  had 
better  have  been  omitted. 

Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications 
and  Modes  of  Administration.    By  David  Ceena,  M.  D., 
Ph.D.,  Demonstrator  of  Physiology  in  the  Medical  Depart- 
ment of  the  University  of  Texas,  Galveston.  Philadelphia: 
W.  B.  Saunders,  1893.    Pp.  viii-17  to  177.    [Price,  $1.25.] 
Tins  little  book  is  interesting  and  valuable  to  those  who 
wish  to  familiarize  themselves  with  the  newer  and,  in  the  main, 
little-employed  products  of  the  therapeutical  laboratory.  The 
essential  points  are  clearly  and  succinctly  stated.    Thus  we  are 
informed  that  orthine  is  a  body  derived  from  phenylhydrazine, 
its  chemical  name  being  orthohydrazinparaoxybenzoic  acid. 

Physical  Properties. — The  drug  in  a  free  state  is  unstable, 
but  the  hydrochlorate  is  a  good  and  stable  preparation. 
Soliihility. — Orthine  is  soluble  in  water. 
Therapeutic  Applications. — The  remedy  has  been  found  to 
be  a  very  decided  antipyretic,  and  as  such  it  has  been  employed 
with  success  in  typhoid  fever,  acute  articular  rheumatism, 
pneumonia,  and  other  febrile  disorders. 

Administration. — Orthine  is  given  in  doses  of  from  five  to 
eight  grains  (0-30  to  0-50  gramme). 

The  list  of  remedies,  however,  is  not  restricted  to  the  most 
recent  productions,  for  we  note  articles  upon  amyl  nitrite, 
apiol,  bromoform,  carbon  disulphide,  chrysarobin,  salol,  and 
quinine,  as  well  as  many  other  drugs  that  are  more  or  less 
familiar  to  medical  men.    There  is  a  very  complete  index. 


Materia  Medica,  Pharmacy,  Pharmacology,  and  Therapeutics. 
By  W.  Hale  White,  M.  D.,  F.  R.  C.  P.,  Physician  to  and 
Lecturer  on  Materia  Medica  and  Therapeutics  at  Guy's  Hos- 
pital, London.  Edited  by  Reynold  W.  Wilcox,  M.  A.,  M.  D., 
LL.  D.,  Professor  of  Clinical  Medicine  at  the  New  York 
Post-graduate  Medical  School  and  Hospital,  etc.  Philadel- 
phia: P.  Blakiston,  Son,  &  Co.,  1892.  Pp.  8-9  to  607. 
[Price,  $8.] 

TiiEHE  can  be  no  just  ground  for  a  complaint  of  any  dearth 
of  works  on  materia  medica  and  tlierapeutics,  for  no  sooner 
does  one  pass  from  our  table  than  another  is  at  hand  to  take  it& 
place. 

This  last  aspirant  for  professional  favor  gives  no  raison 
d''etre,  and  it  seems  to  us  it  has  been  unfortunate  in  following 
the  materia  medica  of  the  British  Pharmacoi)ceia  and  of  the 
United  States  Dispensatory  that  has  rendered  necessary  more 
or  less  notice  of  many  useless  articles. 

The  therapeutic  action  of  aconitine,  aloin,  and  caffeine  ci- 
trate is  not  specified  in  the  sections  on  these  preparations,  and 
the  text  does  not  state  that  this  may  be  learned  elsewhere  in 
the  volume.  The  section  on  caffeine  states  that  it  is  not  so  use- 
ful in  treating  migraine  as  antipyrine  or  exalgine,  though  in  the 
sections  on  these  latter  drugs  no  mention  is  made  of  their 
utility  in  treating  that  disease.  No  mention  is  made  of  the  use- 
fulness of  acetanilide  or  antipyrine  in  epilepsy,  chorea,  and 
dysmenorrhcea. 

By  oversight,  it  is  stated  that  boric  acid  is  not  employed  in- 
ternally in  medicine;  and  an  error  has  also  been  made  in  the 
statement  that  ouabain  is  isolated  from  strophanthus. 

The  scope  of  the  employment  of  a  medicament  is  sometiraea 
meagerly  stated,  as  in  the  case  of  nitroglycerin,  of  saccharin, 
and  of  hydrogen  peroxide.  No  therapeutic  use  of  sulphocarbo- 
late  of  zinc  is  mentioned. 

While  the  custom  of  certain  clinicians  is  followed  in  recom- 
mending the  administration  of  the  lithium  salts  in  the  treat- 
ment of  gout,  the  fact,  to  which  Sir  William  Roberts  and  others 
have  called  attention,  is  overlooked,  that,  while  these  salts  have 
a  high  solvent  power  on  free  uric  acid,  there  is  but  slight  evi- 
dence that  they  tend  to  prevent  the  formation  of  uratic  de- 
posits. 

The  book  is  compact,  though  its  usefulness  would  be  ex- 
tended if  useless  articles  in  the  materia  medica  had  been  omitted 
and  the  space  saved  devoted  to  the  action  of  drugs.  The  phar- 
macology is  quite  meager. 


The  Modern  Antipyretics ;  their  Action  in  Health  and  Disease. 

By  Isaac  Ott,  M.  D.,  Easton,  Pa.    Second  Edition,  revised 

and  enlarged.    Easton  :  E.  D.  Vogel,  1892.    Pp.  5  to  124. 

This  little  work  is  one  of  the  most  useful  that  can  fall  into 
the  hands  of  the  student  of  therapeutics,  for  nowhere  else  can 
he  find  collected  together  so  much  information  regarding  the 
physiology  and  pathology  of  heat  production  and  the  influence 
that  antipyretics  exercise  upon  it. 

The  author  explains  the  method  of  heat  production  and 
the  manner  of  determining  the  quantity  of  heat  by  calori- 
metry. 

He  considers  that  the  most  recent  experimental  and  clinical 
observations  indicate  that  the  thermotaxic  centers  are  located 
as  follows : 

f  Cortex,  thermo-inhibitory  centers  :  (1)  cruciate, 

(2)  Sylvian. 

J  Base,  thermogenic  centers :  (1)  caudate  nucleus, 
Fore-  rain.  ^^^^  matter  of  s!Bi)tum  lucidum  (white), 

(3)  gray  matter  in  front  of  and  beneath  the 
caudate  nucleus. 


Feb.  11,  1893.] 


BOOK  NOTICES. 


171 


r  Thermogenic  center  in  the  tuber  cinereum. 
Inter-brain.  I  Polj'pnoeic  and  vaso-tonic  centers  in  the  tuber  ci- 

l        nereuin,  connected  with  thermolysis. 
After-brain.    Thermoljtic  centers,  respiratory  and  vaso-motor. 
Spinal  cord.    Tliermolytic,  sudorific,  and  thermogenic  centers. 

He  has  found  that  puncture,  like  fever-poison,  excites  the 
therraotaxic  centers,  and  that  antipyretics  reduce  their  excita- 
I    bility.    Experiments  made  with  the  injection  of  either  albumose 
I    or  peptone  in  a  curarized  animal  show  that  there  is  not,  as  a 
rule,  the  peptone  or  albumose  fever  that  usually  follows  inocu- 
j   lation  of  a  healthy^animal  with  these  substances. 

Dr.  Ott  believes  that  fever  is  either  an  autochthonous  or  het- 
erochthonous  process,  the  basal  tbermotaxic  centers  playing  the 
most  important  part  in  the  temperature  phenomena.  He  further 
believes  that  the  fact  that  antipyretics  have  but  little  action  upon 
man  in  health,  but  a  decided  one  in  fever,  is  a  strong  argument 
for  their  action  upon  nerve  centers  that  are  known  to  be  disor- 
dered by  the  poison  of  fever. 

The  action  of  the  different  antipyretics  is  described,  often 
from  personal  experiments  in  their  employment,  and  that  sec- 
tion completes  this  very  useful  brochure. 


Fermentation,  Infection,  and  Immunity,  a  New  Theory  of  these 
Processes.  By  J.  W.  MoLaughlin,  M.  D.  Austin,  Texas  : 
Eugene  von  Boeckmann,  1892. 

The  author's  purpose  is  to  demonstrate  that  the  intimate 
cause  of  fermentation  rests  in  molecular  physics.  He  believes 
that  ferments  are  organic  substances,  having  an  atomic  and 
molecular  structure  that  gives  them  power  to  drive  apart  the 
molecules  of  other  organic  (fermentable)  substances  when  these 
are  brought  into  solution  or  placed  in  other  suitable  conditions. 
The  differences  in  physical,  chemical,  and  physiological  proper- 
ties of  the  products  of  fermentation  are  caused  by  differences 
in  the  molecular  structure  of  the  ferments  on  the  one  side  and 
of  tbe  fermentable  substance  on  the  other ;  in  other  words, 
there  is  a  definite  relationship  existing  between  the  ferment,  the 
fermentable  substance,  and  the  products  of  every  fermentation 
that  is  caused  by  the  molecular  structure  of  the  substances 
named.  Analogous  to  the  wave  motion  of  water,  light,  and 
sound,  the  author  believes  is  the  wave  motion  (vibration)  of  the 
constituent  molecules  of  ferments,  of  which  the  specific  action 
is  accounted  for  by  specific  vibrations.  He  considei-s  that  im- 
munity is  the  consequence  of  a  change  in  the  molecular  group- 
ing of  an  albuminoid  molecule  that  produces  a  corresponding 
change  in  its  wave  motions,  with  the  result  that  it  is  no  longer 
vulnerable  to  the  molecular  attack  of  the  bacterium. 

There  is  an  extensive  review  of  the  literature  of  fermenta- 
tion, infection,  and  immunity.  We  can  not  say  that  we  are 
prepared  to  accept  the  author's  deductions,  based  as  they  are  on 
analogy,  especially  as  t!ie  complexity  of  many  organic  products 
hae  still  eluded  analysis  by  any  method  known  to  science. 


Mother  and  Child.  Part  I — Mother.  By  Edward  P.  Davis, 
A.  M.,  M.  D.  Part  H— Child.  By  John  M.  Keating,  M.  D., 
LL.  D.  Philadelphia:  J.  B.  Lippincott  Company,  1893. 
Pp.  vi-9  to  472.    [Price,  $2.50.] 

The  authors  state  in  the  preface  that  they  have  endeavored 
to  make  this  manual  both  instructive  and  readable,  not  wishing 
to  supplant  the  physician,  but  to  supplement  the  advice  that  ho 
may  give  and  render  it  intelligible. 

In  the  chapter  on  girlhood  Dr.  Davis  urges  exercise  in  dis- 
cretion, condemns  tea,  coffee,  and  other  stimulants,  and  recom- 
mends plenty  of  sleep  and  daily  bathing.  From  this  he  i)a8ses 
jto  the  consideration  of  puberty,  womanhood,  conception,  and 
pregnancy.    The  advice  given  on  the  hygiene  of  pregnancy  is 


well  considered  and  judicious ;  the  preparation  of  appliances 
for  the  mother  and  for  the  child  is  described ;  and  there  is  a 
short  description  of  the  mechanism  of  labor  and  of  puerperal 
fever. 

In  the  second  part  of  the  volume  Dr.  Keating  describes  the 
care  of  the  new-born  infant,  its  nursing;  and  in  the  chapter  on 
sterilizing  and  sterilizers,  while  referring  to  the  condemnation 
that  that  treatment  of  milk  has  received,  he  holds  that  if  the 
infant  thrives  upon  its  bottles  of  steam-sterilized  milk,  that  is  all 
that  is  needed. 

The  methods  of  preparing  milk  for  infant  feeding  are  ex- 
plained in  a  manner  that  would  do  credit  to  a  technical  work 
on  the  subject. 

There  is  an  elaborate  chapter  on  school  hygiene,  and  there  , 
are  chapters  on  the  various  diseases  that  affect  children,  with 
recommendations  of  the  course  the  parent  should  pursue  while 
awaiting  a  physician. 

The  volume  is  one  that  may  be  recommended  to  young 
mothers  as  a  most  useful  work. 

BOOKS,  ETC.,  RECEIVED. 

On  Peripheral  Neuritis.  A  Treatise.  By  James  Ross,  M.  D., 
LL.  D.  (Aberd.),  F.  B.C.  P.,  Late  Physician  to  the  Manchester 
Royal  Infirmary,  and  Judson  S.  Bury,  M.  D.  (Lond.),  M.  R.  C.  P., 
Senior  Assistant  Physician  to  the  Manchester  Royal  Infirmary. 
With  Illustrations.  London  :  Charles  Grifiin  &  Company,  1893. 
Pp.  vii-424. 

Mineral  Springs  and  Health  Resorts  of  California,  with  a 
Complete  Chemical  Analysis  of  every  Important  Mineral  Water 
in  the  World.  Illustrated.  A  Prize  Essay,  Annual  Prize  of  the 
Medical  Society  of  the  State  of  California,  awarded  April  20, 
1889.  By  Winslow  Anderson,  M.  D.,  M.  R.  C.  P.  (Lond.). 
M.  R.  C.  S.  (Eng.),  etc.  The  Bancroft  Company  :  San  Fran- 
cisco, 1892.    Pp.  xxx-3  to  384. 

Influenza:  its  Pathology,  Symptoms,  Complications,  and 
Sequels ;  its  Origin  and  Mode  of  Spreading ;  and  its  Diagnosis, 
Prognosis,  and  Treatment.  By  Julius  Althans,  M.  D.,  M.  R.  0.  P. 
Lond.,  Senior  Physician  to  the  Hospital  for  Epilepsy  and  Pa- 
ralysis, Regent's  Park.  Second  Edition,  much  enlarged.  Lon- 
don: Longmans  &  Co.,  1892.    Pp.  xii-407. 

The  Chronic  Disorders  of  tlie  Digestive  Tube.  By  W.  W. 
Van  Valzah,  A.  M.,  M.  D.  New  York  :  J.  H.  Vail  &  Co.,  1893, 
Pp.  iv-151. 

A  Practical  Guide  for  Beginners  to  the  Dissection  of  the 
Human  Body,  By  Irving  S.  Haynes,  Ph.  B.,  M.  D.,  Demon- 
strator of  Anatomy  in  the  Medical  Department  of  the  Univer- 
sity of  the  City  of  New  York,  etc.  New  York :  E.  B.  Treat, 
1893.    Pp.  7  to  128. 

Bryce's  Pocket  Practice.  A  Complete  and  Condensed  Work 
on  the  Practice  of  Medicine  for  Physicians  and  Students.  By 
Clarence  A.  Bryce,  M.  D.,  Richmond,  Va.  Richmond:  The 
Southern  Clinic,  1893.    Pp.  5  to  17G. 

A  Study  of  Flat-foot:  with  Special  Attention  to  the  De- 
velopment of  the  Arch  of  the  Foot.  By  John  Dane,  A.  B., 
Boston.  [Reprinted  from  the  Boston  Medical  and  Surgical 
Journal.^ 

Endometritis  considered  clinically.  By  Charles  P.  Noble, 
M.  D.  [Reprinted  from  the  Annals  of  Gynecology  and  Pcedi- 
atry.] 

A  Year's  Work  in  Minor  Surgical  Gynascology  at  the  Ken- 
sington Hospital  for  Women.  By  Charles  P.  Noble,  M.  D.  [Re- 
])rinted  from  the  Transactions  of  the  Philadelphia  County 
Medical  Society.] 

Points  in  Office  Practice  in  the  Treatment  of  the  Diseases  of 
Women.  By  Charles  P.  Noble,  M.  D.  [Reprinted  from  the 
Transactions  of  the  Philadelphia  County  Medical  Society. '\ 


172 


REPORTS  ON  TEE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Joub  , 


Certain  Aspects  of  Gonorrhoea  in  Women.  By  Charles  P. 
Noble,  M.  D.  [Reprinted  from  the  Transaciiom  0/ the  Ameri- 
can GynoBcological  Society.^ 

Quarantine  Control.  State  or  National?  The  Question.  A 
Speech  delivered  before  the  Chamber  of  Commerce  and  Indus- 
try of  Louisiana,  New  Orleans,  January  11,  1893,  and  respect- 
fully submitted  to  the  Honorable  the  Senate  and  House  of  Rep- 
resentatives of  the  United  States  in  Congress  a^^sembled.  By 
•Joseph  Holt,  M.  D.,  of  New  Orleans,  La. 

The  Middlesex  Hospital.  Reports  of  the  Medical,  Surgical, 
and  Pathological  Registrars,  for  the  Year  1891.  London:  H. 
K.  Lewis,  1892. 

Fourth  Annual  Report  of  the  Health  Department  of  the  City 
of  Mansfield,  Ohio,  for  the  Year  commencing  March  1,  1891, 
and  ending  February  29,  1892.  By  R.  Harvey  Reed,  M.  D., 
Health  Officer. 

Annual  Report  of  the  Board  of  Managers  of  the  Maryland 
Hospital  for  the  Insane,  near  Catonsville,  Baltimore  County,  to 
his  Excellency,  the  Governor  of  Maryland,  November,  1892. 


jl^ports  on  i\t  ^rogrtss  of  ^e&ichic. 

PEDIATRICS. 

Bt  FLOYD  M.  CRANDALL,  M.  D. 

Instruction  in  Paediatrics.— Dr.  Marshall  {Lancet,  July  30, 
1892),  in  a  recent  address  upon  diseases  of  children,  referred  to 
the  need  of  more  systematic  instruction  upon  this  subject.  It 
does  not  receive  the  attention  in  the  medical  schools  that  its 
importance  deserves.  The  young  practitioner  when  he  has  to 
face  these  cases  readily  yields  himself  up  and  feebly  remarks 
that  women  know  more  about  babies  than  we  do.  To  some 
physicians  the  diseases  of  children  all  seem  to  be  included  in 
worms,  water  on  the  brain,  and  constipation.  The  first  step  in 
treating  children  satisfactorily  is  tact.  This  is  sometimes  natu- 
ral; more  frequently  it  is  acquired.  The  proper  methods  of 
managing  children  are  not  learned  in  the  class-room,  but  can 
only  come  to  those  who  seek  to  obtain  it  by  constant  asso- 
ciation with  sick  children.  The  numerous  details  connected 
with  diet,  dressing,  and  care  of  children  are  not  above  the  at- 
tention of  the  physician,  who  is  not  justified  in  sizing  the  value 
of  the  patient  by  his  length  or  weight.  A  knowledge  of  these 
matters,  which  may  be  included  under  the  heading  of  Nursery 
Hygiene,  should  be  learned  by  the  medical  student,  who  should 
not  be  required  to  learn  them  at  the  expense  of  his  early  pa- 
tients.   It  too  often  happens  that  he  never  learns  them. 

The  iEtiology  of  Aphthous  Stomatitis.— OUivier  {Rev. 
mens,  des  mal.  d.  Venf.,  June,  1892)  presents  considerable  new 
evidence  in  support  of  the  proposition  that  the  milk  of  cows 
affected  by  aphthous  fever  may  cause  aphthous  stomatitis  in 
persons  who  drink  it.  The  idea  was  first  suggested  by  Sagar, 
in  1765,  who  recorded  observations  of  an  epidemic  of  the  disease 
among  monks  who  used  milk  obtained  from  a  herd  of  cows  that 
showed  evidence  of  the  disease.  The  author,  while  he  believes 
that  the  disease  may  originate  in  this  manner,  also  believes  that 
it  may  result  from  local  irritation.  Frankel  has  demonstrated 
the  presence  of  certain  stapliylococci,  but  docs  not  profess  to 
have  discovered  a  specific  germ. 

The  Action  of  Atropine  on  the  Eyes  of  Infants.— Carpen- 
ter (Zance^,  Aug.  G,  1892)  reports  a  number  of  interesting  investi- 
gations upon  this  subject.  It  is  a  well-known  fact  that  children 
bear  largo  doses  of  belladonna  better  than  adults  without  per- 
ceptible physiological  reaction.    Dilatation  of  the  pupil,  which 


is  so  distinctive  a  symptom  in  later  life,  according  to  Ringer, 
rarely  occurs  in  infants.  With  this  the  author  agrees,  and  be  has 
rarely  seen  a  marked  drying  of  the  throat.  In  making  ophthal- 
mic examinations,  he  concludes  that  the  pupil  in  infants  fre- 
quently remains  for  a  long  time  undilated.  When  that  result 
does  occur,  it  is  sometimes  very  tardy,  being  delayed  for  sev- 
eral hours.  When  atropine  is  used  in  the  eye,  general  symptoms 
not  infrequently  occur  even  when  the  pupil  is  not  affected. 

The  Contagiousness  of  Measles. — Bard  {Revue  d'hygUne 
et  de  police  sanitaire,  August,  1892),  in  an  article  upon  this  sub- 
ject, affirms  that  the  contagium  of  measles  does  not  remain  long 
in  a  locality  after  those  suffering  from  the  disease  are  removed. 
Disinfection  of  rooms,  bedding,  and  furniture  is  therefore  not 
necessary.  The  germs  may  be  conveyed  though  the  air,  but 
the  disease  is  usually  directly  contagious.  The  contagious  ele- 
ment i3  active  and  susceptibility  is  common.  Contagion  is  pos- 
sible for  several  days  before  the  eruption  appears. 

Laparotomy  in  Tuhercular  Peritonitis  of  Children.— 

Hartraan  and  Aldibert  {Annales  de  gyuecologie  et  d'ohstetrique, 
June,  1892)  affirm  that  the  first  cases  of  laparotomy  for  tuber- 
cular peritonitis  were  performed  through  error  in  diagnosis. 
The  first  operation  of  this  character  was  performed  by  Petri. 
He  operated  on  a  girl  of  fourteen,  who  was  supposed  to  suffer 
from  an  ovarian  cyst.  The  efiusion  returned  a  year  later,  and 
there  were  lesions  of  the  bone  and  glands,  but  the  patient  was 
living  twelve  years  later.  The  authors  report  three  cases  in 
their  own  practice.  The  diagnosis  of  tuberculosis  was  confirmed 
by  inoculation  in  two  cases.  The  first  of  these  cases  was  a  boy 
of  twelve  years,  who  suffered  from  night-sweats,  dyspepsia,  ab- 
dominal pains  and  diarrhcea,  tympanites,  and  ascites.  The  tem- 
perature became  intermittent  and  vomiting  was  persistent. 
Laparotomy  was  performed.  The  abdominal  cavity  was  flushed 
with  warm  boric  solution,  and  a  drainage-tube  was  introduced. 
The  symptoms  disappeared  and  a  good  recovery  was  made. 
Tubercular  ulceration  of  the  cicatrix  was  developed,  but  dur- 
ing the  year  in  which  the  child  was  under  observation  no  symp- 
toms of  peritonitis  appeared. 

The  second  patient  was  nine  years  old  and  was  suff"ering 
from  a  tubercular,  suppurating,  encysted  peritonitis.  An  in- 
cision was  made,  pus  was  evacuated,  and  tl/e  cavity  was  irri- 
gated by  a  boric-acid  solution.  The  patient  was  emaciated, 
suffered  from  severe  pain,  and  had  a  high  intermitting  tem- 
perature. Eight  months  later  the  abdomen  was  normal  in  ap- 
pearance and  feeling,  and  the  child  had  no  pain  and  was  strong 
and  hearty. 

The  third  patient  was  six  years  of  age.  Typical  symptoms 
of  peritonitis  having  developed,  an  incision  was  made  and  a 
small  quantity  of  fluid  was  evacuated.  The  cavity  was  irrigated, 
as  in  other  cases,  and  the  child  recovered. 

Forty-eight  cases  of  laparotomy  for  tubercular  peritonitis 
in  children  are  reported  by  the  authors.  Only  two  of  the  pa- 
tients were  known  to  have  died,  but  several  were  not  under  ob- 
servation after  the  incision  closed.  In  eighteen  cases  bacterio- 
logical examinations  were  made.  Six  patients  were  positively 
cured;  all  tlie  remainder  recovered  at  least  from  the  operation. 
The  authors  believe  that  many  children  suffering  from  tubercu- 
lar peritonitis  may  be  cured  by  laparotomy.  Only  those  cases 
should  be  subjected  to  the  operation  in  which  the  peritoneal 
lesions  are  the  principal  ones. 

A  Study  of  the  Etiology  of  Melsena  of  the  New-born.— 

Pomorsi  {Arch.f.  Kinder/i.,  xiv,  1892)  publishes  a  case  of  me- 
laena,  with  vomiting  of  blood,  in  a  child  of  four  days.  The  for- 
ceps had  been  used  in  the  delivery.  The  illness  lasted  two  days, 
when  the  child  died.  The  autopsy  showed  ulceration  of  the 
mucous  membrane  of  the  stomach  and  great  congestion  of  all 
the  organs,  especially  the  lungs.    A  thin  clot  was  found  over 


Feb.  11,  1893.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


173 


the  surface  of  the  right  hemisphere  of  the  brain,  and  there  was 
also  clotted  blood  in  the  fourth  ventricle.  The  right  hemisphere 
was  softened  and  contained  two  hsemorrhagic  spots.  After  a 
review  of  the  various  theories  of  the  {etiology  of  this  condition, 
the  author  concludes  that  none  fully  account  for  all  its  peculiar 
symptoms.  Numerous  facts  have  been  established  by  recent 
observation,  which  seem  to  show  that  certain  brain  lesions  may 
cause  congestion  of  the  viscera  and  ulceration  of  the  mucous 
membrane  of  the  stomach.  There  is  reason  to  believe  that 
some  such  condition  may  account  for  melsena  of  the  new-born. 
To  test  this  the  author  performed  a  series  of  experiments  on 
rabbits,  and  was  able,  by  destruction  of  certain  portions  of  the 
yaso-niotor  centers,  to  produce  circulatory  disorders  of  the  lungs 
and  stomach.  These  consisted  of  hypersemia,  with  hajmorrhages 
and  grave  ulcerous  processes. 

The  .Etiology  of  Primary  Croup  of  the  Larynx.— E. 
Frankel  (^Deut.  med.  Woch.,  2-1,  1892)  reports  four  cases  of  pri- 
mary croup  upon  which  extensive  bacteriological  examination 
was  made  by  microscop*,  culture,  and  inoculation  of  animals. 
The  specific  germ  was  found  in  the  membrane  of  the  larynx. 
In  every  case  this  was  positively  proved  to  be  the  true  bacillus 
of  Klebs. 

Dyspnoea  after  the  Removal  of  a  Tracheotomy  Tube.— 

Clarkson  {Edinburgh  Med.  Jour.,  November,  1892)  records  a  case 
slilFering  from  a  peculiar  complication.  The  patient  was  a, boy 
eight  years  of  age.  Five  days  after  the  operation  the  first  at- 
tempt was  made  at  breathing  through  the  larynx,  but  it  was  five 
days  later  before  respiration  was  free  with  the  tube  corked. 
After  the  child  had  been  breathing  through  the  larynx  eighteen 
hours  the  tube  was  removed.  Eight  hours  later,  as  the  child 
did  not  seem  to  be  using  the  glottis,  the  incision  was  closed 
with  a  dressing ;  respiration  was  immediately  arrested ;  the 
tube  was  reinserted,  and  artificial  respiration  was  performed. 
This  sudden  obstruction  to  respiration  was  supposed  to  be  due 
to  spasm  of  the  glottis.  A  mixture  of  chloral  and  potassium 
bromide  was  i)rescribed,  but  the  child  was  unable  to  breathe 
with  the  tube  corked.  Respiration  would  for  a  time  be  natural, 
but  would  then  become  strident,  cyanosis  would  develop,  and 
the  cork  would  have  to  be  removed.  This  condition  continued 
for  five  months  in  spite  of  treatment.  Examination  under  chlo- 
roform at  length  revealed  a  mass  of  granulation  tissue  flapping 
in  and  out  of  the  wound  when  the  tube  was  removed.  It  was 
about  as  large  as  a  pea,  and  was  adherent  to  the  upper  angle  of 
the  tracheal  incision.  This  was  removed,  and  at  the  same  time 
adenoid  growths  on  the  posterior  wall  of  the  pharynx  were  re- 
moved. On  the  following  day  the  tube  was  corked,  and  the 
patient  breathed  without  trouble  for  two  days.  The  tube  was 
removed,  and  in  four  days  the  incision  had  closed.  He  was  un- 
der observation  for  six  weeks  longer,  and  remained  perfectly 
healthy  during  that  time. 

Typhoid  Fever  in  Children.— Moussous  {Arch.  din.  de 
Bordeaux,  i,  4,  1892)  reports  fifty  cases  of  typhoid  fever  in  chil- 
dren under  fifteen  years.  Thirty-eight  of  these  were  hospital 
patients.  There  was  a  mortality  of  six  per  cent.  Quinine  was 
freely  employed,  and  a  laxative  was  administered  every  sec- 
ond day  during  the  first  twelve  days.  A  sponge  bath  was 
given  morning  and  night.  The  diet  consisted  exclusively  of 
milk,  and  was  given  in  as  large  quantities  as  the  patient  would 
take.  Numerous  peculiarities  were  noticed  in  the  evolution  and 
progress  of  the  disease.  One  patient,  a  little  girl  of  four  years, 
in  perfect  health,  was  seized  suddenly  with  vomiting,  followed 
by  a  rapid  rise  of  temperature.  At  the  end  of  three  days  the 
symptoms  of  typhoid  fever  were  completely  establii-hed.  In 
two  instances  vomiting  persisted  for  ten  days;  in  other  cases 
loss  of  appetite  was  the  only  gastric  symptom.  A  cold  sponge 
bath  given  on  the  fifteenth  day  was  followed  by  syncope  in  one 


case.  In  another,  repeated  attacks  of  syncope  occurred  between 
the  seventeenth  and  twentieth  days.  One  child  died  suddenly 
on  the  twentieth  day  while  raising  herself  to  take  a  glass  of  milk. 
A  carefully  conducted  autopsy  gave  no  explanation  whatever  for 
such  a  result.  Relapses  due  to  too  early  return  to  general  diet 
occurred  in  five  cases.  The  author  concludes  that  typhoid  fever 
in  children  is  marked  by  less  violent  symptoms  than  in  the 
adult,  and  that  complications  are  not  so  common.  The  fever, 
however,  frecjuently  ranges  high. 

The  Use  of  Creasote  in  Scrofula.— Sommerbodt  {Berlin, 
klinisch.  Wochenschr.,  xxvi,  1892)  has  written  favorably  con- 
cerning the  use  of  creasote  in  tuberculosis.  In  this  paper  he 
speaks  of  its  favorable  action  in  scrofula.  Full  doses  are  ne- 
cessary, small  doses  being  of  no  avail.  To  a  child  of  seven 
years  he  gives  one  gramme  per  day.  It  may  be  given  in 
capsules,  if  the  child  can  take  it  in  that  form.  Otherwise  it  is 
given  in  wine  or  milk.  The  initial  dose  should  be  very  much 
smaller  than  this,  the  amount  being  increased  gradually  during 
a  period  of  about  ten  days  to  the  maximum.  It  is  sometimes 
poorly  tolerated  by  the  stomach.  To  avoid  this  it  should  be  ad- 
ministered immediately  after  meals. 

The  Internal  Use  of  Resorcin.— Menche  {Jahrb.  f. 
Kinderh.,  xxxiii,  1892)  reports  favorably  upon  the  use  of  resor- 
cin in  diarrhoea  of  children.  It  is  chiefly  indicated  to  arrest 
fermentation.  In  this  disease  its  use  should  be  preceded  by 
calomel  in  divided  doses.  If  the  child  is  in  collapse  or  is  very 
feeble,  calomel  should  be  omitted.  Its  effect  in  checking  fer- 
mentation has,  in  his  experience,  been  decided.  The  stools 
have  become  less  frequent.  In  gastritis  his  results  have  been 
favorable. 

Rheumatic  Carditis  in  Childhood. — Octavius  Sturges 
{Lancet,  August  27,  1892)  regards  endopericarditis  associated 
with  rheumatism  in  children  as  by  far  the  commonest  of  all 
cardiac  affections  of  early  life.  Pericarditis  ranks  next  in  fre- 
quency. Heart  affections  in  children  are  cast  in  two  great  di- 
visions—one, peri-endocarditis,  which  is  rheumatic;  the  other, 
pericarditis,  resulting  from  a  variety  of  causes.  Recent  endo- 
carditis alone  is  very  rare.  Heart  disease  in  the  strictest  sense 
is  almost  always  rheumatic  in  the  child.  If  diseases  of  the 
heart's  investments  are  included,  several  other  conditions  must 
be  recognized  as  causative  agents.  The  author  reports  one 
hundred  cases  of  heart  disease  examined  post  mortem  during 
eleven  years.  Of  these,  fifty-four  cases  were  rheumatic — 
twenty-two  in  boys,  thirty-two  in  girls;  and  forty-six  were  non- 
rheumatic — twenty-two  in  boys,  twenty-four  in  girls.  Of  the 
rheumatic  patients,  two  were  between  two  and  four  years,  four 
between  four  and  six  years,  six  at  six  years,  and  forty-two  be- 
tween six  and  twelve  years.  Of  the  non-rheumatic  patients, 
thirty-two  were  four  years  and  under,  and  only  eight  were  over 
six  years.  Hence,  of  the  non-rheumatic  a  great  majority  were 
infants.  Of  the  rheumatic,  the  greater  number  were  between 
six  and  twelve  years.  The  preponderance  of  girls  was  wholly 
in  the  rheumatic  division.  The  great  liability  of  females  to 
rheumatism  is  generally  admitted.  Of  the  non-rheumatic  case.s, 
eleven  were  due  to  empyema,  ten  to  tuberculosis,  four  to  diph- 
theria, and  three  to  pneumonia.  The  rest  were  associated  with 
nephritis,  meningitis,  and  sejjticaamia.  After  a  very  careful 
study  of  pericarditis  and  pericardial  adhesions',  and  the  physical 
signs  observed  in  each,  the  author  concludes,  first,  that  peri- 
cardial adhesion  does  not  prevent  exocardial  rubbing;  and, 
second,  that  the  presence  of  such  adhesion  in  fatal  cases  is 
much  more  common  than  would  be  suj)posed,  judging  from 
physical  signs  alone.  Post-mortem  observation,  however,  does 
not  always  reflect  the  ways  of  life.  What  is  true  of  those  who 
died  is  not  necessarily  true  of  those  who  recovered.  Pericar- 
dial adhesion  Tnay  bo  of  more  serious  consequence  than  wo 


174 


MISCELLANY. 


[N.  Y.  Med.  Jodr., 


suppose,  making  sometimes  the  difference  between  living  and 
dying. 

Exalgine  in  the  Treatment  of  Chorea.— Lowentlial  {Ber- 
lin. kliniKch.  Wochensnhr.,  v,  1892)  reports  thirty-five  cases  of 
chorea  treated  by  exalgine.  Tlio  dose  was  usually  about  three 
grains  a  day.  Occasionally  fifteen  grains  a  day  were  taken. 
The  shortest  duration  of  disease  was  eight  dayft.  Tlie  effect  of 
the  drug  was  niuch  more  distinct  and  favorable  when  its  ad- 
ministration was  begun  early  in  the  disease.  In  most  cases  the 
disease  continued  five  or  six  weeks,  but  the  symptoms  were  re- 
duced in  severity.  The  unpleasant  symptoms  were  chiefly 
nausea,  vomiting,  headache,  vertigo,  and  cyanosis.  Jaundice 
appeared  in  three  cases.  The  author  does  not  regard  exalgine 
as  a  specific  in  chorea. 

The  Period  of  Incubation  of  Mumps.— Jessop  {Brit.  Med. 
Jour.,  June  4,  1892)  reports  a  case  of  a  boy  who  was  brought 
in  contact  with  a  person  recovering  from  mumps  on  March  17th- 
On  April  19th,  having  been  in  perfectly  good  health  during  the 
interval,  he  developed  a  typical  attack  of  mumps ;  no  other  ex- 
posure was  known.  On  the  day  of  the  onset  of  his  disease — 
April  19th — his  two  sisters  kissed  him.  They  were  then  removed 
and  did  not  see  him  again.  Twenty-one  days  later — on  May  10th 
— they  also  were  attacked  with  mumps.  This  places  the  period 
of  incubation  in  these  cases  definitely  at  three  weeks.  All  the 
children  were  perfectly  well  during  the  interval  between  the 
exposure  and  the  development  of  the  disease. 

A  Contribution  to  the  Study  of  the  Spleen  in  Children. 

— Paul  Gastou  and  Charles  NaWke  {Rev.  mens.des  mal.de  ren/., 
September,  1892)  report  an  extensive  series  of  observations  upon 
the  spleen  in  children.  Hypertrophy  of  that  organ  is  so  frequent 
in  early  life  that  they  believe  that  more  exact  knowledge  of  the 
spleen  should  be  obtained.  In  ojjening  the  abdomen  the  spleen 
is  not  visible,  for  it  is  covered  by  the  colon  and  stomach  and  also 
by  the  liver,  which  is  abnormally  large  in  children.  The  spleen 
is  found  resting  upon  the  anterior  lateral  face  of  the  first  and 
second  lumbar  vertebrae.  The  weight  and  form  vary  consid- 
erably even  in  health.  The  following  conclusions  are  drawn 
from  eighty  autopsies  made  by  Frerichs :  1.  The  weight  and 
dimensions  of  the  spleen  under  normal  conditions  vary  with  the 
weight  and  dimensions  of  the  body.  2.  The  maximum  weight 
of  the  spleen  compared  with  the  body  weight  occurs  at  eight 
years.  3.  The  weight  of  the  spleen  at  one  year  is  about  thirty- 
two  grammes ;  it  increases  ten  grammes  a  year  up  to  eight  years. 
4.  The  weight  of  the  spleen  increases  with  age  more  than  that 
of  the  other  organs.  5.  The  elasticity  of  the  spleen  accounts 
for  its  frequent  and  extreme  changes  of  volume. 

The  physiology  is  uncertain.  The  organ  seems  to  take  some 
part  in  digestion,  in  the  formation  of  the  blood,  and  perha])s 
in  the  destruction  of  bacteria.  It  has  been  proved  that  after 
removal  of  the  sjjleen  animals  are  much  more  susceptible  to 
infection,  and  pathologic  germs  appear  in  the  blood  in  greater 
numbers. 

The  spleen  may  be  normal  or  a  little  less  in  weight  in  tuber- 
culosis, broncho-pneumonia,  measles,  and  athrepsia.  Hyper- 
trophy of  the  spleen  is  the  general  rule  in  acute  infectious  dis- 
eases, typhoid  fever,  meningitis,  endocarditis,  syphilis,  rickets, 
leuca)mia,  and  tuberculosis. 

Examination  of  the  spleen  by  percussion  is  very  uncertain 
and  misleading.  Diagnosis  must  be  made  by  i)alpation.  The 
condition  of  the  liver,  stomach,  and  colon  afi'ects  its  apparent 
size.  In  determining  the  edges  of  the  spleen,  percussion  should 
be  made  in  a  vertical  line  from  the  axilla  to  the  anterior  superior 
spinous  process  of  the  ilium.  The  lateral  borders  are  deter- 
mined by  percussing  horizontally  from  the  nipple  to  the  spine. 
Errors  are  often  made  by  percussion  and  no  spleen  can  be  posi- 
tively said  to  be  enlarged  unless  it  can  be  felt  by  the  fingers  be- 


neath the  false  ribs.  The  patient  should  lie  upon  the  back  with 
the  knees  flexed,  the  head  brought  forward,  and  the  musc^les  lax. 
Two  general  conclusions  are  drawn  by  the  authors:  1.  An  en- 
larged spleen  mdicates  bad  nutrition  or  an  infectious  disease. 
2.  Continued  enlargement  of  the  spleen  is  of  more  value  for 
prognosis  than  for  diagnosis. 

Congenital  Wryneck. — Murray  {Med.-Ch irurg.  J<??«-.,  July, 
1892)  believes  that  tliis  disease  is  analogous  with  talipes  etpiino- 
varus  for  the  following  reasons:  1.  They  ai-e  congenital  dis- 
eases and  usually  occur  in  otiierwise  healthy  children.  2.  The 
deformity  is  maintained  by  shortening  of  the  flexor  muscles  and 
fascia.  3.  The  skin  and  subcutaneous  tissues  are  stunted  in  the 
flexor  region.  4.  The  appearance  of  the  diseased  parts  is  not 
that  of  hypertrophy,  but  a  stunted  growth.  5.  The  reaction  of 
the  muscles  to  electricity  is  normal.  C.  The  deformity  increases 
with  the  growth  of  the  child.  7.  Paresis  is  absent  and  the  limi- 
tation of  motion  is  due  entirely  to  the  condition  of  the  tissues. 


^  i  s  c  £  1 1  a  n  g . 


"  Seedy  Toe  "  in  Horses. — The  February  nuiiil)er  of  the  American 
VctQrirMry  Rcvievj  contains  the  following  paper,  by  Mr.  W.  Bryden, 
V.  S.,  of  Boston,  read  before  the  Massachusetts  Veterinary  Association  : 

"  About  fifteen  months  ago  I  was  called  to  examine  a  lame  horse, 
one  of  a  handsome  pair  of  grays,  used  on  the  engine  of  the  fire  depart- 
ment at  Medford,  a  pleasant  town  situated  some  five  miles  from  Bos- 
ton. They  were  a  well-matched,  nicely  trained  span  of  strong,  speedy 
horses,  some  ten  or  eleven  jears  old,  fifteen  hands  three  inches  hi^h, 
and  weighing  about  fourteen  hundred  pounds  each.  Being  general 
favorites,  it  was  ill  news  for  the  boys  when  they  learned  that  one  of 
their  splendid  gray  fire  team  was  seriously  lame. 

"  On  examination  of  the  derelict  foot  (the  off  fore  one),  the  disease 
was  found  to  be  what  is  generally  known  as  '  seedy  toe.'  It  had  evi- 
dently been  affected  for  many  months,  gradually  showing  greater  brit- 
tleness  of  the  lower  part  of  the  wall  and  of  the  sole  in  front.  Indeed, 
the  characteristic  retrograde  changes  in  the  horn  at  the  coronet  in  front, 
and  its  separation  and  projection  neaier  the  toe,  proclaimed  the  foot  a 
victim  of  hoof  depravity  of  many  months'  existence ;  and  the  stage  it 
had  arrived  at,  one  which  Nature  with  all  the  assistance  art  could  give 
her,  would  require  months  to  repair,  unless  a  ]ob  of  patchwork  .should 
be  attempted  and  prove  satisfactory  to  the  owner. 

"The  near  foot  was  also  imperfect,  but  from  a  different  combina- 
tion of  circumstances.    The  wall  had  general  contraction,  but  it  did  not 
become  short  and  brittle  at  the  lower  margin  of  each  side  of  the  hoof, 
nor  was  the  growth  at  the  coronet  in  front  almost  entirely  arrested,  as 
shown  by  the  other  foot — two  features  of  great  interest  and  significance 
in  the  pathology  of  the  horse's  feet  and  limbs.    Another  point  worthy 
of  note  suggested  by  the  case  is  that  (1)  laminitis  followed  by  seedy  toe 
may  possibly  be  quite  a  different  pathological  condition — only  one  foot 
being  usually  affected ;  and  (2)  laminitis  followed  by  chronic  founder, 
in  which  two  fore  feet,  two  hind  feet,  or  all  four  feet,  are  simultaneously  \ 
and  similarly  affected.    As  both  are  curable  conditions  up  to  an  ad-i 
vanced  stage,  and  the  treatment  much  alike,  the  importance  of  being  ■ 
able  to  discriminate  between  these  two  conditions  is  robbed  of  some  of 
its  practical  value,  but  not  of  its  scientific  interest — i.  e.,  whether  one 
has  an  element  of  constitutional  trouble  which  is  wanting  in  the  other. 

"In  studies  of  this  subject  it  is  well  to  bear  in  mind  that  the  hoofs 
of  horses  vary  greatly  in  form,  size,  and  quality  in  individuals,  even  of 
the  same  family ;  and  that  domestication,  with  the  restraints  incident 
thereto,  subjects  them  to  many  unfavorable  experiences  and  adverse- 
changes  which  still  further  predispose  them  to  unsymmetrical  growths, 
perhaps  to  diseases  of  the  limbs,  especially  those  peculiar  to  their- ' 
species.  For  example,  hoofs  sometimes  do  not  grow  alike — i.  e.,  it  is 
not  unusual  to  find  the  two  fore  feet  mismated,  or  the  two  hind  ones  ' 
either;  indeed,  all  four  feet  may  be  different.    Other  circumstances, 


Feb.  11,  1893.J 


MISCELLANY. 


175 


such  as  want  of  tear  and  wear,  unsuitable  noil  and  climate,  accidents 
and  exposures,  especially  during  colthood,  when  the  hoofs  are  growing, 
or  rather  developing,  often  incline  them  to  defective  formj  and  quali- 
ties at  maturity,  which  are  readily  excited  to  disease  when  the  animal 
happens  to  be  assigned  to  labor  and  surroundings  unfavorable  to  its 
limbs.  Seedy  toe  is  oftenest  found  affecting  a  fore  foot,  and  predispo- 
sition to  this  family  of  diseases  may  be  the  result  either  of  heredity  or 
of  some  peculiarity  acquired  after  birth. 

"  There  are  many  different  degrees  of  such  hoof  depravity,  as  well 
as  stages  of  degeneration,  and  it  is  in  their  repair,  rather  than  in  their 
•  early  history,  where  their  greatest  resemblance  is  often  seen. 

"  1.  One  case  may  be  nothing  more  than  a  small  discolored  area  of 
8ole  where  a  nail  has  been  driven  too  deep  into  a  part  where  the  vital- 
ity of  the  tissues  has  become  so  much  impaired  that  they  are  unable  to 
contribute  their  share  either  to  their  own  nourishment  or  in  repairing 
the  injury. 

"  2.  Another  case  may  be  a  foot  with  its  hoof  so  warped  and  de- 
formed that  it  resembles  a  clubfoot ;  a  frequent  exciting  cause  of  this 
is  when  the  coronet  is  crushed  from  a  loaded  team  passing  over  it. 

"  3.  Another  case  may  be  one  where  the  secreting  structures  at  the 
pyramidal  process  are  so  crowded  that  the  wall  in  front  stops  growing, 
and  so  do  the  laminis  extending  to  the  toe.  When  these  laminis  give 
way,  the  toe  of  the  coiBn  bone  is  forced  down  and  back  till  it  rests  on 
the  sole  just  in  front  of  the  frog  ;  here  it  soon  becomes  bruised,  then 
thin,  and  finally  convex ;  the  space  between  the  coffin  bone  and  the  wall 
in  front  becomes  filled  with  debris  ;  the  wall  between  the  coronet  and 
toe  settles  down,  while  the  hoof  at  the  heels  grows  vigorously,  forcing 
the  wings  of  the  coffin  bone  upward  and  the  pyramidal  process  forward 
against  the  defectively  nourished  wall  in  front,  the  toe  of  the  coffin  bone 
beiBg  held  back  by  the  perforatus  tendon  inserted  in  its  sole.  This  va- 
riety has  usually  been  described  as  an  example  of  chronic  founder  of 
one  foot ;  it  is  the  form  from  which  '  Mortimer '  suffered  when  Mr. 
Lorillard  imported  him  from  France.  The  following  gives  an  outline 
of  a  case  frequently  met  with — viz. : 

"  When  the  sole  has  been  dressed  with  a  rasp,  the  zone  between  the 
sole  margin  and  the  wall,  which  ought  to  be  white,  is  found  to  be  red. 
At  next  shoeing  it  will  be  a  brown  color ;  next  it  will  be  still  browner, 
and  so  on  till  the  wall  and  sole  are  entirely  separated  and  crumbling. 
A  gradual  destructive  change  takes  place  within  the  foot  where  the  cir- 
culation and  other  vital  functions  have  been  gradually  becoming  more 
disturbed  and  interfered  with,  perhaps  for  months.  Accidents,  such  as 
burning  with  a  hot  shoe,  must  not  be  mistaken  for  this  disease  in  its 
earliest  stages.  As  the  coronet  gradually  tightens  it  exerts  mechanical 
pressure  on  the  coronary  cushion  and  laminoe  ;  the  circulation  is  dimin- 
ished in  force  and  volume,  and  the  wall  shortens  more  and  more  from 
the  extremities  of  its  horn  fibers  crumbling  faster  than  it  grows,  till  it 
,can  not  be  reached  by  the  nails.  When  the  foot  is  without  protection 
from  either  horn  or  shoe  it  is  unfit  for  work  until  Nature  has  restored 
the  part  sufficiently  to  secure  the  shoe  with  nails. 

"  The  stage  at  which  this  disease  has  arrived  indicates  with  consid- 
erable exactness  both  its  age  and  the  time  required  for  its  repair.  As 
already  stated,  cases  vary  accordingly  as  they  reveal  a  history  of  gradual 
invasion,  or  evidence  of  having  been  hastened  by  some  coincident,  such 
as  an  accident,  or  from  harsh  or  improper  treatment. 

"  With  your  permission  I  will  now  illustrate  my  remarks  by  describ- 
ing the  treatment  of  the  Medford  horse.  It  was  my  good  fortune  to 
find  the  superintendent,  Mr.  Arthur  Symms,  a  gentleman  of  more  than 
ordinary  judgment  in  matters  pertaining  to  the  horse's  feet  and  limbs. 
He  did  not  expect  me  to  perform  a  miracle,  or  to  cure  the  beast  in  one 
or  two  times'  shoeing.  After  examining  the  case  carefully,  I  assured 
him  that  complete  recovery  was  possible,  but  that  it  would  take  at  least 
eight  months  before  he  could  again  be  used  on  the  engine,  as  it  would 
require  that  length  of  time  before  the  hoof  could  grow  down  sufficiently 
for  a  shoe  to  be  fastened  so  as  to  be  equal  to  the  quick,  heavy  work 
demanded  in  such  a  place.  During  most  of  the  time,  I  further  a.^sured 
him,  the  horse  could  do  enough  slow,  light  work  to  pay  for  his  keep, 
and  as  I  would  only  retpiire  to  see  him  about  once  a  month  it  would  pay 
well  to  treat  him  rather  than  sacrifice  a  good  animal  by  sellmg  him  for 
about  $25,  which  was  all  any  one  would  be  likely  to  give  for  him  with 
hardly  ihrce  legs  to  stand  on. 


"  It  was  decided  immediately  to  let  me  take  charge  of  the  case,  so 
he  was  led  into  the  shoeing  shop,  where  I  had  the  hoof  trimmed  as  fol- 
lows :  From  the  coronet  about  half  way  to  the  toe  the  horn  grew  in 
narrow  circles,  gradually  increasing  toward  the  heels ;  below  this  at  the 
toe  the  horn  projected  away  from  the  coffin  bone,  the  toe  of  which  had 
crumbled  away.  The  circles  at  the  coronet  in  front,  and  the  projecting 
horn  lower  down,  were  all  rasped  and  cut  away  till  the  part  looked 
more  like  its  natural  shape.  This  left  the  heels  high  and  the  coffin 
bone  in  the  position  of  an  upright  wedge,  the  diseased  toe  pointing  to 
the  sole  in  front  of  the  frog  where  the  part  was  settled  down.  To  cor- 
rect this  position  of  the  coffin  bone  the  commissures  were  pared  out 
and  the  heels  opened  and  lowered ;  after  this  the  wall  was  thinned  at 
the  heels  and  wherever  else  it  could  be  done  without  interfering  with 
the  nailing  on  of  the  shoe  as  early  as  possible.  Above  the  nail  holes  a 
saw  was  used  to  cut  the  wall  in  line  with  the  horn  fibers ;  this  instantly 
freed  and  limbered  the  crowding  wall,  and  yet  left  enough  hoof  to  nail 
to,  which  the  rasp  would  have  taken  away.  The  saw  is  the  same  for- 
merly used  for  '  diamonding '  the  wall  in  cases  of  ringbone,  side  bones, 
enlarged  cartilages,  etc.,  cases  where  the  hoof  is  always  contracted. 
After  carefully  adjusting  the  hoof  so  as  to  set  the  coffin  bone  at  an 
angle  which  would  relieve  the  crowding  of  the  pyramidal  process  and 
adjacent  coffin  bone  against  the  horn  in  front  by  allowing  the  wings  of 
the  coffin  bone  to  settle  between  the  hoof  heels,  a  shoe  was  fitted  aa 
follows : 

"  A  plain,  light  shoe  with  a  fairly  wide  web  was  taken,  and  from 
the  toe  to  the  second  nail  holes  was  hammered  out  thin,  and  then  rolled 
up  in  front  of  the  foot  to  protect  the  part  which  the  disease  had  de- 
nuded of  its  horny  protection  from  coming  accidentally  in  contact  with 
the  ground.  Side  lips  or  clips  were  turned  up  at  each  side  to  relieve 
some  of  the  strain  from  the  nails,  and  the  nail  holes  were  punched  so 
as  to  be  in  line  with  and  reach  the  wall  which  was  strongest.  Two 
heel-corks  were  then  turned  up  about  one  third  of  an  inch  high,  and 
two  more  the  same  height,  one  on  each  side,  set  back  from  the  toe 
about  two  inches ;  when  the  shoe  was  applied  he  still  walked  lame  on 
it,  but  after  poulticing  it  for  about  three  weeks  every  night  with  oil 
meal  and  five-per-cent.  solution  of  carbolic  acid,  the  hoof  began  to  start 
growing,  the  sore  spots  to  become  less  tender,  and  he  was  able  to  per- 
form daily  errands  and  glow,  light  work. 

"  As  the  department  buildings  are  near  the  marshy  banks  of  Mystic 
River,  he  was  allowed  to  stand  in  an  open  pen  of  fresh  peat  bog  every 
day  for  an  hour  or  two  when  not  in  poultices.  The  hoof  was  reduced 
every  time  he  was  shod,  the  wall  grew  down  with  perfect  regularity 
until,  at  the  conclusion  of  eight  months,  he  was  returned  to  his  old 
place  on  the  engine  as  sound  as  ever.  Twelve  months  after  my  treat- 
ment commenced  there  was  no  trace  of  the  disease  excepting  a  hollow 
place  or  dent  in  the  toe,  showing  where  the  point  of  the  coffin  bone  had 
crumbled  away  from  necrosis." 

The  International  Congress  of  Charities,  Correction,  and  Philan- 
thropy.— One  of  the  series  of  international  congresses  to  be  held  in  Chi- 
cago in  1893  is  to  be  devoted  to  the  subjects  of  charities,  correction, 
and  philanthropy,  and  the  fourth  section  of  this  is  to  consider  all  mat- 
ters relating  to  the  hospital  care  of  the  sick,  the  training  of  nurses, 
dispensary  work,  and  first  aid  to  the  injured.  The  committee  of  organi- 
zation of  the  congress  has  appointed  Dr.  John  S.  Billings,  surgeon,  U. 
S.  Army,  as  chairman  of  this  section,  and  Dr.  Henry  M.  Hurd,  superin- 
tendent of  the  Johns  Hopkins  Hospital  in  Baltimore,  as  its  secretary, 
and  has  authorized  and  requested  them  to  complete  its  organization,  to 
extend  invitations,  and  to  prepare  a  programme  for  its  work.  Miss 
Isabel  A.  Hampton,  superintendent  of  the  Training  School  for  Nurses 
of  the  Johns  Hopkins  Hospital,  has  been  appointed  chairman  of  that 
part  of  the  work  of  the  section  which  relates  to  the  training  of  nurses. 

This  section  will  hold  five  meetings  of  about  two  hours  each,  com- 
mencing June  12th,  and  will  also  have  charge  of  one  of  the  general  ses- 
sions of  the  congress — viz.,  that  held  on  the  morning  of  June  14th. 

It  is  desired  that  this  shall  be  a  truly  international  gathering  for 
conference  on  the  subjects  allotted  to  this  section,  and  all  who  are  in- 
terested in  hospitals,  in  training  of  nurses,  in  dispensaries,  or  in  first 
aid  to  the  injured  are  cordially  invited  to  be  present,  to  contribute 
papers,  and  to  take  part  in  the  discussions. 


176 


MISCELLANY. 


[N.  Y.  Med.  Joub. 


The  papers  and  proceedings  will  probably  be  printed  as  a  separate 
yolurne,  and  it  is  hoped  that  this  will  represent  the  best  methods 
and  the  best  work  in  each  of  these  departments  in  all  parts  of  the 
world. 

The  following  are  suggested  as  subjects  for  special  consideration  in 
papers  to  be  prepared : 

1.  Hospital  organization ;  governing  bodies;  relations  of  the  medi- 
cal staff  and  of  nurses'  training  schools. 

2.  Hospital  finances  ;  means  of  support ;  mode  of  keeping  accounts ; 
cost. 

3.  Plan  and  construction  of  recently  built  general  hospitals,  em- 
bodying the  latest  improvements. 

4.  Relations  of  hospitals  to  increase  of  knowledge,  to  medical 
education,  and  to  the  medical  profession ;  hospital  records,  statistics, 
and  reports. 

5.  Pay  patients  in  hospitals. 

6.  Isolating  wards  and  hospitals  for  contagious  diseases. 

7.  Hospital  diets,  dietaries,  kitchens,  etc. 

8.  Hospital  amphitheatres  and  operating  rooms. 

9.  Hospital  laundries  and  disinfecting  establishments. 

10.  Army  and  navy  hospitals ;  emergency  hospitals  in  time  of  epi- 
demics ;  temporary  and  movable  hospitals. 

11.  Small  and  special  hospitals,  cottage  hospitals,  school  hospitals, 
private  hospitals,  sanatoriums,  etc.  ;  convalescent  hospitals,  and  what 
to  do  with  incurables. 

12.  History  and  present  condition  of  hospitals  in  the  large  cities. 

13.  Training  schools  for  nurses. 

14.  Dispensaries;  relations  to  the  public  and  to  the  medical  profes- 
Bion ;  dispensary  records. 

15.  First  aid  to  the  injured ;  associations  for  best  means  of  popular 
instruction  in  and  its  place  in  general  education. 

Persons  desiring  to  present  papers  or  to  share  in  the  discussions  of 
this  section  are  requested  to  communicate  with  the  secretary  at  once. 
The  period  of  time  allotted  for  the  preparation  of  the  programme  is 
necessarily  brief,  and  it  is  essential  that  all  who  are  willing  to  assist  in 
this  work  should  act  promptly. 

Nurses  will  take  part  in  the  general  session  and  in  two  sectional 
meetings,  and  will  hold  in  addition  three  separate  meetings — June  13th, 
14th,  and  17th. 

For  these  three  separate  meetings  papers  on  subjects  of  special  in- 
terest to  nurses  will  be  prepared  and  discussed.  The  following  are 
suggested  as  subjects  to  select  from  : 

Training  schools  in  England  and  America;  the  proper  organiza- 
tion of  training  schools  ;  nursing  in  infirmaries  and  almshouses  ;  nurs- 
ing of  the  insane ;  obstetric  nursing ;  nursing  of  infectious  diseases ; 
nursing  in  sanatoriums  and  home  hospitals ;  private  nursing ;  nurs- 
ing by  religious  orders  ;  the  work  of  graduate  nurses. 

All  communications  relating  to  this  portion  of  the  work  of  the  sec- 
tion should  be  addressed  to  Miss  Isabel  A.  Hampton,  chairman,  the 
Johns  Hopkins  Hospital,  Baltimore. 

The  Pan-American  Medical  Congress. — The  following  preliminary 
manifesto  of  the  Section  in  Diseases  of  the  Mind  and  Nervous  System 
has  been  issued : 

Honorary  Presidents :  Dr.  Jorge  Diaz  Albertina,  Havana,  Cuba ; 
Dr.  Juan  C.  Castillo,  Lima,  Peru ;  Dr.  C.  G.  Comegys,  Cincinnati ;  Dr. 
F.  X.  Dercum,  Philadelphia ;  Dr.  J.  T.  Eskridge,  Denver,  Col. ;  Dr.  Or- 
pheus Everts,  College  Hill,  Ohio ;  Dr.  Juan  M.  Covantes,  Mexico, 
Mexico ;  Dr.  Allan  McLane  Hamilton,  New  York ;  Dr.  W.  A.  Ham- 
mond, Washington ;  Dr.  P.  O.  Hooper,  Little  Rock,  Ark. ;  Dr.  Henry 
M.  Uurd,  Baltimore ;  Dr.  J.  G.  Kiernan,  Chicago ;  Dr.  J.  A.  McBride, 
Wauwatosa,  Wis. ;  Dr.  Charles  K.  Mills,  Philadelphia ;  Dr.  Moncorvo, 
Kio  de  Janeiro,  U.  S.  of  Brazil ;  Dr.  Putnam,  Boston ;  Dr.  E.  C.  Seguin, 
New  York ;  Dr.  E.  C.  Spitzka,  New  York ;  Dr.  G.  Isaac  Ugarte,  Santi- 
ago, Chile ;  Dr.  Samuel  Webber,  Boston  ;  Dr.  Joseph  Workman,  To- 
ronto, Canada, 

Executive  President :  Dr.  C.  H.  Hughes,  500  N.  Jefferson  Avenue, 
St.  Louis. 

Secretaries :  Dr.  A.  B.  Richardson  (English-speaking),  Columbus, 
Ohio ;  Dr.  M.  G.  Echeverria  (Spanish-speaking),  Key  West,  Fla. ;  Dr. 


Melendez  y  Caorea  (Hospicio  San  Buenaventura),  Buenas  Ayres,  Argen- 
tine  Republic ;  Dr.  Nicolas  Hortiz,  La  Paz,  Bolivia ;  Dr.  Carlos  Eiree, 
Rio  de  Janeiro,  U.  S.  of  Brazil ;  Dr.  Stephen  Lett,  Guelph,  Canada ; 
Dr.  Plaloo,  Kingston,  Jamaica ;  Dr.  Paolo  (Jarcia  Medina  (Carrera  8, 
No.  277),  Bogota,  Colombia;  Dr.  Emillano  Nunez  (Galiano,  19),  Havana, 
Cuba;  Dr.  Jose  Azurdia,  Guatemala,  Guatemala;  Dr.  George  Herbert, 
Wailuku  Maui,  Hawaii ;  Dr.  Secundino  E.  Sosa  (Hospital  de  Mujeres 
Dementes),  Mexico,  Mexico ;  Dr.  Pellais,  Leon,  Nicaragua ;  Dr.  Fran- 
cisco Soca  (Florida,  90),  Montevideo,  Uruguay ;  Dr.  Hemiterio  Forraez, 
Merida,  Venezuela. 

"  Every  effort,"  says  the  circular,  "  is  being  made  to  make  the 
meetings  of  the  Section  in  Diseases  of  the  Mind  and  Nervous  System 
both  scientifically  profitable  and  socially  pleasant.  Papers  of  distin- 
guished merit  from  neurological  students  and  physicians  eminent  in 
psychiatry  have  been  promised.  Every  physician  on  this  continent  of 
America,  North  or  South,  is  hereby  cordially  solicited  and  welcomed  to 
join  in  the  meetings  of  this  important  section  of  the  approaching 
Pan-American  Medical  Congress  ;  and  it  is  hoped,  by  unity  of  effort 
and  cordial  co-operation,  to  make  the  Section  in  Nervous  and  Mental 
Diseases  second  to  none  in  the  congress  in  fruitful  results." 


lo  Contributors  and  Correspondents. —  The  attention  of  all  who  ptirpoM 

favoring  lis  with  communications  is  respectfully  called  to  the  follow- 
ing: 

Authors  of  articles  intended  for  publication  binder  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  tlie  article  is  sent  to  us  ;  (S)  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 
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staled  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  pui 
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  hito  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
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respondents asking  for  information  that  we  are  capable  of  giving, 
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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- 
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inserting  the  substance  of  sxich  communications. 

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All  communications  relating  to  the  business  of  the  journal  should  be  ad- 
dressed to  the  publishers. 


DrTaylors  Article  on  the  Pigmentary  Syphilide. 


TPIE  KEW  YORK  MEDICAL  JOURNAL,  FEBErAKY  18,  189 3. 


CS^rigimU  Contmuniattrons. 


THE  PIGMENTARY  SYPHILIDE  * 
By  R.  W.  TAYLOR,  M.  D., 

CLINICAL  PROPESSlOR  OP  TBNEREAL  DISEASES 
AT  THE  COLLEGE  OP  PHYSICIANS  AND  SUKGEONS,  NEW  YORK. 

The  history  of  the  pigmentary  syphilide  is  a  most  pe- 
culiar one.  It  is  an  affection  which  at  first  was  clearly 
and  sharply  described,  but  which  in  the  course  of  time  has 
been  rendered  so  obscure  that  to-day  very  few  have  clear 
and  precise  ideas  as  to  its  course  and  its  nature.  In  the 
whole  range  of  syphilography  there  is  not  a  like  instance 
in  which  the  knowledge  of  a  manifestation  of  syphilis  has 
become  so  progressively  obscure  and  in  which  so  much 
confusion  has  been  interjected  by  reason  of  the  successive 
additions  to  its  literature  by  many  writers.  In  the  sixties 
we  knew  what  the  pigmentary  syphilide  was  as  a  result  of 
the  writings  of  Hardy,  Fournier,  Pillon,  and  Tanturri.  To- 
day this  well-marked  and  peculiarly  characteristic  affection 
is  so  little  understood  that  it  is  confounded  with  the  pig- 
mentations and  the  leucodermatous  conditions  left  as  a  result 
of  previous  syphilitic  processes.  The  writings  of  Neisser, 
Riehl,  Ehrmann,  Poelchen,  and  Szadeck  have  had  much  to 
do  with  the  obscuration  of  this  question,  for  these  authors 
regard  any  pigmentation  or  leucodermatous  condition  pri- 
mary or  secondary  to  a  previous  syphilitic  process  as  ex- 
amples of  the  pigmentary  syphilide. 

We  can  not  too  strongly  insist  upon  the  necessity  of 
holding  fast  to  the  postulate  that  the  pigmentary  syphilide 
is  a  unique,  well-marked  affection,  having  a  sharply  defined 
pathological  basis  and  a  course  attended  by  well-demon- 
strated morphological  changes.  As  a  corollary  of  this,  I 
may  add  that  secondary  pigmentations  and  leucodermatous 
conditions  occurring  in  the  course  of  syphilis,  as  relics  or 
sequelae  of  lesions  chiefly  secondary,  are  in  no  sense  exam- 
ples of  the  pigmentary  syphilide  ;  they  are  simply  dischro- 
matous  accidents  and  not  sharply  defined  essential  affec- 
tions. 

The  reasons  why  this  confusion  has  been  induced  are 
many,  and  the  chief  ones  are  the  following : 

1.  Many  of  the  writers  have  had  little  experience  in  the 
study  of  syphilis,  and  have  written  in  a  dogmatic  manner 
from  the  observation  (and  that  usually  very  limited  as  to 
time)  of  one  or  perhaps  two  cases. 

2.  Conclusions  have  been  drawn  from  clinical  appear- 
ances presented  at  various  stages  in  the  progress  of  the  af- 
fection, which,  being  of  long  duration  and  presenting  at  dif- 
ferent periods  varying  pictures,  can  not  be  well  understood 
by  any  one  unless  he  has  had  his  case  or  cases  under  his 
observation  during  the  whole  period  of  development,  evo- 
lution, and  involution  of  the  affection. 

3.  With  one  exception  (Maieff),  authors  have  studied 
the  question  from  a  histo-pathological  basis  in  a  hap- 
hazard way,  but  have  been  none  the  less  dogmatic  in  their 


*  Read  before  the  American  Association  of  Genito-urinary  Surgeons, 
June  21,  1892. 


conclusions.  Thus  no  observer  until  Maieff's  time  studied 
the  disease  microscopically  step  by  step  in  accordance  with 
its  natural  evolution.  On  the  contrary,  sections  of  skin 
were  made  indiscriminately  in  cases  of  secondary  pigmenta- 
tions and  leucodermatous  conditions,  and  perhaps  in  cases 
of  the  true  pigmentary  syphilide.  In  no  instance  is  any 
distinction  observed.  In  this  way  discrepancies  have  been 
produced,  and  flat  contradictions  and  anomalies  have  re- 
sulted. 

4.  Every  pigmentation  in  a  syphilitic,  recent  or  old,  is 
called  the  pigmentary  syphilide,  and  the  latter  is  thus  de- 
prived of  its  essential  character. 

For  many  years  I  have  carefully  studied  the  affection 
upon  a  large  number  of  patients,  in  many  instances  during 
its  whole  course,  and  I  venture  to  present  my  conclusions, 
now  feeling  confident  that  they  are  correct  and  with  the 
hope  that  the  light  on  this  subject  here  offered  may  extend 
and  do  something  to  dissipate  the  prevailing  doubt,  ob- 
scurity, and  confusion. 

The  primordial  pigmentary  anomalies  due  to  syphilis  * 
consist  essentially  in  a  superpigmentation,  which  may  in 
whole  or  in  part  be  replaced  by  a  corresponding  loss  of 
color  or  leucodermatous  condition.  This  primordial  hyper- 
pigmentation  is  the  essential  pigmentary  syphilide  ;  all  other 
discolorations  are  secondary  processes  and  in  no  manner 
entitled  to  be  classed  as  pigmentary  syphilide. 

The  pigmentary  syphilide  is  seen  in  three  well-marked 
and  quite  distinct  conditions  : 

1.  In  the  form  of  spots  or  patches  of  various  sizes. 

2.  As  a  diffuse  pigmentation  of  greater  or  less  intensity, 
which  sooner  or  later  becomes  the  seat  of  leucodermatous 
changes  in  the  shape  of  small  spots  which  gradually  in- 
crease in  size.  This  is  the  retiform  pigmentary  syphilide — 
the  syphilide  pigmentaire  a  dentelles  of  Fournier. 

3.  In  an  abnormal  distribution  of  the  pigment  of  the 
skin,  in  which,  owing  to  the  lack  of  or  crowding  out  of  the 
pigment  in  places,  they  become  whiter,  while  the  parts  in- 
volved in  the  abnormal  distribution  become  darker  ;  in  this 
way  a  dappled  appearance  is  presented.  In  this  form  there 
is  probably  no  excess  of  pigment ;  it  is  seemingly  unequally 
disiiibuted  throughout  the  tissue  expanse.  This  form  has 
been  termed  the  marmoraceous,  from  its  resemblance  to 
some  forms  of  marble  in  which  there  is  an  intimate  inter- 
blending  of  light  and  darker  colors.  This  marmoraceous 
pigmentary  syphilide  is  not  common,  and  it  is  peculiarly 
liable,  by  reason  of  its  delicacy  of  tone  and  tint,  to  pass 
unobserved. 

The  pigmentary  syphilide  in  the  form  of  spots  or  patches 
consists  of  round,  oval,  or  irregular  plaques,  which  may 
have  sharply  defined  borders  or  their  margins  may  be  den- 
tated  or  jagged.  Their  color  varies  from  a  light-brown  cafe 
au  lait  to  even  a  quiet  deep-brown  tint.  They  are  unaffected 
by  pressure  and  the  condition  of  the  circulation.  In  persons 
of  light  and  delicate  skin  they  may  be  very  faint  in  tint  and 
perhaps  only  perceptible  in  oblique  light.  In  Fig.  3  an  ad- 
mirable picture  of  the  spot-form  pigmentary  syphilide  is 
shown.  In  this  case  the  pigmentation  was  very  deep.  It 
was  under  my  observation  for  a  long  time,  during  which  I 


178 


TAYLOR:   THE  PIGMENTARY  SYPHILIDE. 


[N.  y.  Mkd.  Joob., 


observed  its  evolution  as  pin-head-size  spots,  which  in- 
creased in  area  until  they  reached  the  size  shown  in  the 
figure.  In  this  woman  this  eruption  appeared  toward  the 
end  of  the  first  year  of  syphilis.  Prior  to  its  onset  the 
neck  had  not  been  invaded  by  syphilitic  lesions  of  any 
form  ;  consequently  this  eruption  was  not  a  posthumous  ex- 
pression of  an  antecedent  eruption. 

In  this  form  of  pigmentary  syphilide  it  is  common  to 
see  the  uneven  distribution  of  the  pigmentation  ;  sometimes 
the  color  is  deeper  at  the  margin.  Commonly  there  is  no 
involvement  of  the  intervening  skin,  though  sometimes  the 
hyperchromatous  condition  produces  the  illusion  that  the 
unaffected  skin  is  whiter  than  normal.  These  pigmented 
spots  may  remain  unchanged  and  indolent  for  months, 
particularly  in  cold  weather.  In  the  course  of  time  they 
show  evidence  of  fading  and  they  slowly  disappear.  The 
process  of  involution  may  begin  at  the  margin  and  extend 
centripetally,  or  it  may  take  place  in  the  whole  morbid 
area.  In  some  cases  colorless  patches  are  left  after  the 
disappearance  of  the  pigmentation  ;  there  is  then  produced 
a  secondary  or  pseudo-leucoderma.  Now,  if  a  case  is  seen 
only  in  this  stage,  I  can  well  understand  an  observer  reach- 
ing the  conclusion  that  the  process  was  an  atrophic  one ; 
consequently  it  is  easy  to  see  why  so  much  is  written  upon 
syphilitic  leucoderma  and  syphilitic  vitiligo.  These  ex- 
pressions clearly  show  the  want  of  a  full  knowledge  of  the 
disease,  and  that  the  observer  has  only  acquainted  himself 
with  its  stage  of  decline.  In  most  cases  the  skin  retains 
its  normal  appearance  after  the  full  involution  of  this  syph- 
ilide. In  Figs.  4  and  5  is  well  shown  a  disseminated  erup- 
tion of  pigmented  spots  which  followed  a  papular  syphilide. 
This  is  an  excellent  illustration  of  secondary  pigmentation. 

The  second  form  of  pigmentary  syphilide — the  lace  or 
retiform  variety — is  far  more  common  than  the  previous 
form.  More  or  less  slowly  and  even  rapidly  the  sides  of  the 
neck  become  discolored,  the  tint  being  that  of  cafe  au  lait, 
or  even  of  decided  yellowish  brown.  The  most  common 
site  of  this  eruption  is  on  the  sides  of  the  neck  and  perhaps 
on  the  back  of  the  neck.  The  patients  usually  say  that 
they  noticed,  or  were  told,  that  their  necks  were  getting 
or  had  got  dirty.  Intelligent  and  observant  patients  will 
very  often  distinctly  state  that  their  trouble  began  with  a 
browning  of  the  skin,  and  they  will  state  positively  that 
there  was  no  intermingling  of  white  spots.  From  the  neck 
this  eruption  may  extend  more  or  less  extensively  over  the 
trunk,  mostly  anteriorly  or  down,  the  arms.  I  have  never 
seen  it  go  up  on  the  face.  In  many  cases  this  eruption 
passes  unnoticed  and  may  be  attributed  to  the  action  of 
the  sun,  to  irritation,  or  even  to  uncleanliness.  When  the 
pigmented  patch  has  involved  more  or  less  of  the  sides  of 
the  neck  a  peculiar  change  will  be  observed  in  it — namely, 
the  development  of  whitish  spots  which  may  be  taken  for 
leucoderma.  Scattered  irregularly  over  the  pigmented  sur- 
face close  observation  will  show  a  few  or  many  minute 
white  specks,  which  in  a  short  time,  particularly  in  hot 
weather,  will  be  large  enough  to  present  definite  shapes, 
which  may  be  round,  oval,  linear,  or  irregular.  These 
white  spots  gradually  grow,  and  in  many  instances  the  neck 
l.^  largely  covered  with  them  before  the  patient  knows  of 


any  change  having  taken  place.  They  then  say  or  are  told 
that  their  necks  are  growing  white.  Undoubtedly  many  a 
doctor,  upon  this  information  being  given  him,  has  con- 
cluded that  he  has  a  case  of  leucoderma  before  him. 
Sometimes  the  white  patches  are  distinctly  lighter  than  the 
normal  skin ;  in  other  instances  the  contrast  between  dark 
and  light  is  illusory,  and  there  is  really  no  difference  in  color 
between  the  so-called  leucodermatous  patches  and  the  unaf- 
fected skin.  The  white  spots  may  or  may  not  be  sharply 
marginated,  in  some  cases  the  line  of  margination  being 
clear  and  sharp  and  in  others  indistinct.  I  have  never 
seen  the  thin,  filmy,  superpigmented  area  around  white 
patches  x>i  true  pigmentary  syphilide  which  we  see  so 
clearly  and  so  commonly  at  the  circumference  of  patches  of 
leucoderma  or  vitiligo,  as  it  is  called.  This  point,  in  my 
judgment,  is  of  diagnostic  import,  and  is  explained  by  the 
pathology  of  the  disease  to  be  considered  further  on.  The 
tendency  of  the  white  spots  to  extend  necessarily  means 
the  diminution  of  the  brown  background.  In  this  way  we 
have  various  pictures  presented,  as  shown  in  Figs.  1  and  2. 
In  this  way  is  produced  a  dappled  appearance,  which  war- 
rants the  name  for  this  eruption  at  this  time  of  the  dappled 
syphilide.  Toward  the  final  stage  of  the  disease  the  pre- 
ponderance of  the  white  spots  leaves  only  round,  oval,  or 
wavy  lines  or  strands  of  brown  pigment,  which  gives  the 
appearance  of  lace  with  large  meshes,  the  interstices  being 
formed  by  the  white  spots,  which  are  round,  oval,  gyrate, 
linear,  or  irregular.  In  this  way  the  skin  in  the  course  of 
months,  and  in  some  cases  of  a  year  or  more,  gradually 
seemingly  returns  to  its  normal  condition.  In  the  study  of 
these  cases  I  have  sometimes  seen  during  the  activity  of 
the  process  a  mild  and  ephemeral  hyperaemia,  which  might 
easily  have  escaped  observation,  and  the  question  suggests 
itself  to  my  mind  whether  or  not  a  mild  form  of  conges- 
tion may  precede  the  hyperpigmentation. 

In  Fig.  1  this  form  of  the  pigmentary  syphilide  is  well 
shown  covering  the  neck,  the  anterior  and  lateral  parts  of 
the  trunk,  and  the  anterior  surface  of  the  arms  as  far  as  the 
insertion  of  the  deltoids.  This  case  is  remarkable  and  ex- 
ceptional and  well  merits  record.  It  was  that  of  a  girl, 
nineteen  years  old,  who  had  two  large  vulvar  chancres.  At 
the  date  of  evolution  of  the  secondary  manifestation  she 
had  a  mild  roseola  upon  the  forehead,  lower  part  of  th» 
neck,  and  of  the  whole  chest.  The  back  was  quite  well  cov- 
ered, as  were  also  the  thighs.  She  also  had  pharyngitis. 
With  the  evolution  of  the  roseolar  eruption  the  pigmentary 
syphilide  began  upon  the  neck,  and  within  three  weeks  the 
whole  anterior  portion  of  the  trunk  was  invaded  from  above 
downward.  In  the  course  of  a  month  involution  began 
around  the  roseolar  spots  and  also  upon  the  abdomen,  where 
there  were  no  spots.  The  appearances  as  shown  in  the 
lithographic  plate  are  so  clear  and  striking  that  further 
description  is  not  necessary.  Here,  then,  we  have  a  well- 
marked  instance  of  the  coeval  appearance  of  the  roseolar 
and  pigmentary  syphilide  at  the  very  onset  of  the  secondary 
stage.  In  six  months  no  evidence  of  pigmentation  could 
be  found  on  this  girl's  body.  She  also  suffered  from  anal- 
gesia of  the  backs  of  the  hands  and  fingers.  This  case 
stands  out  strongly  in  refutation  of  the  assertion — based,  I 


Fig.  3. — Retiform  pigmentary  syphilide. 


Fig.  4.  Fio. 
Pigmentations  secondary  to  the  jjapular  sypbilide. 


5. 


Feb.  18,  1893.] 


TAYLOR:   THE  PIGMENTARY  SYPHILIDE. 


17a 


think,  on  faulty  and  limited  observation — that  the  pigment- 
ary syphilide  always  and  invariably  follows  in  the  wake  of 
some  other  syphilitic  process,  exanthematous  or  papular. 
From  all  these  facts  and  considerations  I  am  at  a  loss  to 
understand  why  two  opinions  can  be  held  regarding  this  af- 
fection which  is  so  decidedly  uniform  in  its  development, 
course,  and  decline. 

The  third  or  marmoraceous  form  of  pigmentary  syphi- 
lide is  by  far  the  least  common.  Its  mode  of  invasion  is 
slow  and  aphlegmasic,  and  there  is  little  or  no  hyperpig- 
mcntation.  The  natural  color  of  the  skin,  in  spots  of  irregu- 
lar size  and  shape,  becomes  white,  while  the  margins,  which 
are  hazy  and  indefinite,  become  browner  than  normal.  It 
seems  to  be  a  displacement  of  pigment  resembling  strikingly 
some  delicate  varieties  of  marble  in  which  there  are  imper- 
ceptibly blended  shades  of  white  and  very  light  black.  In 
my  experience,  this  form  is  always  seen  on  the  sides  of  the 
neck,  and  it  does  not  show  a  tendency  to  extend.  It  can 
only  be  found  upon  persons  of  delicate  skin,  and  very  often 
only  by  close  observation.  It  slowly  disappears  and  the 
skin  is  left  in  its  normal  color. 

As  I  have  already  stated,  I  attach  little  if  any  impor- 
tance to  the  mass  of  literature  relating  to  the  pathological 
anatomy  of  the  pigmentary  syphilides,  since  the  investiga- 
tions were  made  in  general  at  haphazard  upon  any  pig- 
mented or  achromatous  skin  without  any  consideration  for 
the  stage  of  the  process  or  for  the  clearness  of  the  diag- 
nosis. 

Maieff's  *  observations,  made  under  the  direction  of  Pro- 
fessor Tarnowsky,  are  worthy  of  unqualified  acceptance,  for 
the  sections  of  skin  were  taken  only  from  patients  sulfering 
with  the  primary  pigmentary  syphilide,  and  the  morbid 
process  was  studied  upon  very  many  sections  made  in  tis- 
sues in  all  the  progressive  stages  from  its  evolution  to  invo- 
lution. Further,  these  microscopic  studies  were  supple- 
mented by  prolonged  and  accurate  clinical  observation. 
Maieli  thinks  the  pigmentary  syphilide  is  due  to  a  chronic 
specific  inflammation  of  the  minute  blood-vessels  of  the  skin 
which  may  be  due  to  nutritional  changes  incident  to  the  early 
and  active  period  of  syphilis.  At  its  inception  the  morbid 
process  consists  in  endothelial  inflammation  with  cellular  in- 
filtration into  the  adventitia  of  the  vessels,  which  are  there- 
by diminished  in  caliber  and  even  occluded.  As  a  result  of 
the  circulatory  disturbance  the  red  blood-cells  lose  their  pig- 
ment, which  escapes  and  infiltrates  the  adventitia  of  the  ves- 
sels, the  connective-tissue  cells,  those  of  the  derma  and  of 
the  Malpighian  layer,  and  even  works  its  way  into  the  lym- 
phatics. During  the  evolution  of  the  process  most  of  the 
altered  vessels  become  completely  obliterated,  the  papiliic 
become  stunted  and  undergo  atrophy.  Then  the  pigmenta- 
tion begins  to  be  gradually  absorbed,  the  color  of  the  skin 
grows  less  intense,  and  gradually  and  slowly  ihe  discolora- 
tion disappears,  leaving  in  its  wake  a  whitish  surface. 

These  microscopic  demonstrations,  it  will  be  seen,  agree 
perfectly  with  the  clinical  history  of  the  pigmentary  syphi- 


*  Contribution  il  I'dtude  de  la  Kypliilide  jiif!;nieiitaire.  Comptcs  rcn- 
dm  du  conyrh  irUernaiional  de  derinatologie  et  de  syphiligrapkie,  Parin, 
1890. 


lide  and  show  beyond  a  doubt  that  this  eruption  has  a  defi- 
nite and  orderly  mode  of  evolution  and  of  involution. 

In  the  light  of  its  clinical  history  and  of  its  pathological 
anatomy,  it  is,  I  think,  now  clearly  proved  that  this  syphi- 
lide begins  as  a  true  specific  superpigmentation  which  is 
the  essential  feature  of  the  morbid  process,  and  that  the 
subsequent  leucodermatous  changes  are  those  of  a  degenera- 
tive nature,  consequently  dependent  upon  and  secondary  to 
the  initial  dischromia.  It  can  therefore  be  seen  how  illogi- 
cal and  incorrect  it  is  to  call  this  aifection  syphilitic  leuco- 
derma,  or  syphilitic  vitiligo. 

It  is  refreshing,  when  one  has  goue  through  a  mass  of 
immature  and  unsatisfactory  literature  upon  this  subject  by 
men  who  have  generalized  cind  dogmatized  upon  feeble  and 
insufficient  bases,  to  read  a  communication  which  bears  evi- 
dence of  patient,  prolonged  study  by  a  man  who  starts  in 
without  bias,  theory,  or  prejudice.  Such  a  communication 
is  that  on  the  pigmentary  syphilide  made  by  Dr.  Fiveisky  * 
at  the  suggestion  of  Professor  Pospeloff.  (It  thus  happens 
that  the  most  reliable  and  noteworthy  of  recent  contri- 
butions to  this  subject  have  been  made  at  the  suggestion 
of  two  eminent  Russian  professors — namely,  Tarnowsky 
and  PospelofE.)  After  an  exhaustive  study  and  research  on 
this  subject,  Fiveisky  has  convinced  himself  that  the  disease 
commences  with  an  increased  pigmentation  of  the  skin, 
usually  of  the  neck,  and  that,  after  a  while,  there  appear 
upon  the  brown  surface  minute  circular  or  oval  white 
patches  or  islets,  which  gradually  increase  in  size  and  take 
the  place  of  the  diffuse  brown  pigmentation.  This  is  in 
direct  confirmation  of  what  I  have  maintained  for  many 
years,  and  which  has  been  denied  by  several  (xerman 
authors. 

There  are  men  who,  by  their  utterances,  show  that  they 
have  observed  little  and  know  less  concerning  this  syphilide, 
who  in  a  flippant  way  pass  it  over,  or  speak  of  it  as  a  curi- 
osity unworthy  of  a  place  among  the  numerous  manifesta- 
tions of  syphilis.  Such  a  position  is  both  faulty  and  un- 
scientific. I  have  many  times  been  aided  in  the  diagnosis 
of  syphilis  by  the  observation  of  the  pigmentary  syphilide 
when  all  the  other  early  manifestations  had  disappeared 
(even  the  ganglia  in  some  cases  were  not  sufficiently  en- 
larged to  offer  aid  in  diagnosis).  So  that  to  me  a  knowl- 
edge of  the  clinical  history  of  the  syphilide  has  been  im- 
portant and  helpful.  I  am  therefore  glad  to  see  that  Fi- 
veisky says  (and  his  opinion  is  indorsed  by  Professor  Pos- 
peloff and  Dr.  Jebuneff)  that  this  syphilide  constitutes  one 
of  the  most  characteristic  and  most  reliable  diagnostic 
signs  of  condylomatous  syphilis  (that  is,  of  syphilis  in  the 
secondary  stage). 

Before  a  man  makes  dogmatic  statements  and  takes  a 
stand  hereafter  in  this  question  of  the  pigmentary  syphi- 
lide he  must  show,  first,  that  he  is  well  versed  in  der- 
matology and  syphilography  in  order  that  we  may  feel 
confident  of  his  diagnosis  ;  second,  he  must  show  a  full 
knowledge  of  the  secondary  pigmentary  and  leucodermatous 
conditions  observed  in  syphilis ;  third,  he  must  give  evi- 
dence that  he  has  seen  at  least  ten  typical  cases  of  this 


*  Meditzimkote  Obozrenie,  No.  2,  1891,  p.  167. 


180 


HAMILTON:   THE  ABUSE'OF  OOPHORECTOMY. 


[N.  Y.  Med.  Joub., 


sypliilide,  and  that  he  has  observed  and  recorded  its  vary- 
ing appearances  and  features  from  the  time  of  its  first  in- 
vasion until  its  final  disappearance;  fourth,  he  sliould,  if 
possible,  study  (or  have  some  competent  person  in  histology 
study  for  him)  the  varying  pathological  changes  beginning 
in  the  brown  stage  and  running  through  the  course  of  the 
disease  until  its  final  extinguishment.  I  hope  my  readers 
will  insist  upon  the  fulfillment  of  at  least  the  first  three  of 
these  requirements.  If  they  will  do  this,  they  will  see  in 
future  fewer  of  the  jejune  and  misleading  essays  upon  the 
pigmentary  syphilide.  For  my  own  part,  I  like,  for  the 
sake  of  completeness,  to  append  to  an  essay  of  the  size  of 
this  one  a  complete  bibliography,  but,  though  I  have  it 
under  my  hand,  in  charity  I  refrain  from  inflicting  it  upon 
my  readers.  There  have  been  published,  however,  within 
the  past  ten  years  a  few  essays  of  some  merit,  besides  those 
above  quoted,  on  this  subject,  but  they  have  not  been  of 
such  striking  character  that  I  deem  them  worthy  of  special 
mention. 


THE  ABUSE  OF  OOPHORECTOMY 
IN  DISEASES  OF  THE  NERVOUS  SYSTEM. 
By  ALLAN  MoLANE  HAMILTON,  M.  D. 

The  empirical  treatment  of  nervous  and  mental  diseases 
has  lately  received  a  new  impetus  at  the  hands  of  certain 
injudicious  persons,  and  while  some  excuse  is  afforded  by 
the  general  disturbance  which  is  often  associated  with  per- 
verted function  or  disease  of  the  pelvic  organs,  it  can  not 
be  denied  that  in  a  great  number  of  cases  there  is  little 
warrant  for  a  certain  class  of  operations  when  the  hoped- 
for  results  are  simply  a  matter  of  guesswork.  Since  the 
practice  of  excision  of  the  ovaries  became  more  or  less  the 
fashion,  I  have  watched  its  use  and  abuse  so  far  as  its  bear- 
ings upon  my  own  special  line  of  study  were  concerned,  and 
in  speaking  as  I  am  about  to,  it  is  with  a  full  appreciation 
of  its  value,  which  I  believe  is  exceedingly  limited,  except 
when  well-marked  and  previously  recognized  structural  dis- 
ease of  the  organs  is  determined.  Of  the  necessity  for  sur- 
gical measures  for  the  relief  of  these  local  conditions  I 
wiil  not  speak.  So  far  as  I  know,  oophorectomy  has 
never  cured  a  case  of  well-established  or  even  incipient  or- 
ganic nervous  disease,  or  has  proved  to  be  of  the  least  use 
except  in  functional  disturbances  that  could  have  been 
cured,  or  at  least  helped,  by  agencies  of  a  far  less  danger- 
ous nature.  Perhaps  in  making  this  statement  I  shall  an- 
tagonize a  great  many  persons  who  have  been  quick  to 
ascribe  all  manner  of  erratic  manifestations  to  derange- 
ments of  the  organs  contained  in  the  female  pelvis,  but  an 
experience  of  many  years  has  impressed  me  with  the  fact 
that  a  great  many  fanciful  causes  are  often  supposed  to 
account  for  equally  unstable  neurotic  expressions.  Often- 
times theories  are  built  upon  the  imperfectly  understood 
and  elastic  conditions  known  as  "  reflex  excitability  "  and 
"  reflex  irritation,"  and  while  the  retroactive  and  local  dis- 
turbances that  may  be  explained  in  this  way  have  to  some 
extent  an  underlying  basis  of  physiological  experiment,  I 
am  convinced  that  the  gyna!Cologist  is  frequently  at  fault 


in  not  considering  the  part  the  entire  nervous  system  plays 
in  the  development  or  existence  of  local  depraved  states. 
To  what  particular  degree  the  ovaries  enter  into  the  pro- 
duction of  nervous  disorders  is  a  matter  of  great  doubt 
and  speculation,  and  it  is  always  well  to  assume  that  the 
disturbances  in  which  they  are  supposed  to  figure  are  of 
a  general  character,  and  follow  a  more  or  less  profound 
upheaval  of  the  functions  of  the  cerebro-spinal  and  sympa- 
thetic systems,  and  as  well  to  inquire  whether  the  pelvio 
derangements  are  not  more  a  result  than  a  cause.  The 
researches  of  neuro-physiologists  and  clinicians  go  far  to 
show  that  neuroses  of  development  are  those  in  which  dis- 
eased ovarian  functions  are  quite,  if  not  more,  common 
than  where  intrinsic  disease  of  the  organ  itself  is  regarded. 
Bevan  Lewis  emphasizes  this  statement,  and  my  own  expe- 
rience confirms  his  views.  In  the  majority  of  cases  it  is 
certainly  well  to  inquire  whether  the  difficulty  is  not  due 
rather  to  causes  that  have  to  do  with  the  general  physical 
defects,  and  particularly  those  of  the  nervous  system,  than 
a  variety  of  neuroses  in  which  irregularity  of  the  functions 
of  the  pelvic  organs  plays  a  more  prominent  part  than  any- 
thing else ;  and  I  think  there  can  be  no  difficulty  in  proving 
that  most  conditions,  whether  they  arise  from  the  influence 
of  defective  heredity  or  incidental  setiological  causes,  are 
the  determining  factors.  It  is  well  known  that  a  variety  of 
disorders  which  are  supposed  to  be  essentially  seated  in 
the  genital  organs  may  exist  without  lesions  or  abnormi- 
ties of  these  parts,  and  whether,  as  Rosenthal  says,  "  hys- 
teria is  nothing  but  a  congenital  feebleness  of  resistance  or 
one  acquired  by  the  vaso-motor  centers."  Fox,  in  speaking 
of  the  cases  which  are  nowadays  so  often  operated  upon, 
adds  the  weight  of  his  testimony  by  the  assertion  that 
"  neurotic  symptoms  may  be  developed  without  any  con- 
nection with  the  generative  organs ;  many  lesions  of  the 
uterus  and  ovaries  occur  without  any  trace  of  such  phe- 
nomena." He,  however,  while  admitting  the  important 
local  disturbances  of  function,  adds :  "  The  condition  of 
these  organs  explains  nothing  as  to  the  real  nature  of  the 
disease." 

When  we  study  the  origin  of  nervous  disease  in  con- 
nection with  the  development  of  the  organs  of  the  nervous 
system,  and  when  our  subjects  are  sufficiently  varied,  there 
can  be  little  doubt  that  the  underlying  condition  should  be 
the  first  consideration  as  the  genesis  of  delayed  or  aborted 
function. 

In  speaking  of  mental  diseases,  Lewis  tersely  expresses 
himself :  "  Often  is  the  question  asked  in  cases  of  insanity 
accompanied  by  amenorrhoeal  states  at  this  period  of  life, '  Is 
the  menstrual  disturbance  the  origin  of  the  cerebral  disturb- 
ance, a  simply  coincidental  state  or  the  result  of  the  nerv- 
ous disturbance  ? '  If,  however,  we  regard  this  period  as  a 
great  psychical  developmental  stage  in  which  the  unfolding 
of  the  generative  system  goes  on  pari  passu  with  its  repre- 
sentation throughout  the  innermost  penetralia  of  the  cen- 
tral nervous  system,  then  we  must  regard  the  physical  and 
mental  expression  of  this  development  (the  sexual  charac- 
teristics, bodily  and  mental,  and  the  menstrual  flux)  as 
associated  features  as  to  the  obvious  signs  of  what  is  going 
on  within  the  pelvis  and  within  the  cranium." 


Feb.  18,  1893.] 


HAMILTON:   THE  ABUSE  OF  OOPHORECTOMY. 


181 


It  is  hardly  necessary  to  refer  to  the  thousand  and  one 
influences  that  interfere  with  the  "  development  of  the  or- 
ganism," or  the  development  of  all  manner  of  nervous  de- 
rangements that  react  upon  the  pelvic  organs  and  give  rise 
to  evidences  of  malnutrition ;  there  is  perverted  function, 
which  expresses  itself  in  morbid  emotional  states,  vicious 
habits,  and  sexual  disturbance,  and  these  are  not  infre- 
quently associated  with  well-defined  expressions  of  general 
nervous  disease. 

The  mistake  is  made,  I  think,  too  often  in  regarding 
the  amenorrhoea  which  frequently  evidences  the  condition 
leading  to  cerebro-spinal  malnutrition,  and  which,  after  all, 
has  a  central  causation  rather  than  a  pelvic  one ;  and  in  this 
connection  it  quite  possible,  in  the  opposite  condition, 
with  perfectly  healthy  ovaries,  to  have  disorders  consisting 
in  losses  of  blood  which  do  not  directly  depend  upon  any 
excitement  per  se  of  the  organs  of  generation  themselves. 

My  first  personal  knowledge  of  oophorectomy  dates 
back  nearly  ten  years,  when  a  medical  man,* whose  faith  in 
the  use  of  the  knife  was  a  matter  of  comment,  removed 
both  ovaries  of  a  cataleptoid  woman,  who  died  a  few  days 
afterward  without  any  other  change  resulting  from  the  op- 
eration. This  was  in  a  public  institution,  and  the  operation 
was  performed  without  due  consultation  and  without,  I  am 
convinced,  proper  knowledge  of  the  disease  upon  the  part 
of  the  surgeon.  Why  removal  of  the  ovaries  should  have 
been  done  was  and  is  a  question  of  grave  doubt,  for  there 
was  nothing  to  excuse  it  except  the  antiquated  theory  that 
all  diseases  of  this  class  in  women  are  due  to  some  derange- 
ment of  the  pelvic  organs.  The  fact  was  lost  sight  of,  al- 
though the  woman  had  remained  in  the  state  for  a  consid- 
erable period.  The  facts  that  the  cataleptoid  rigidity  and 
trance  sometimes  disappear  almost  spontaneously,  that  in 
this  case  the  patient  was  well  nourished  and  showed  no  low- 
ering of  the  vital  powers,  and  that  there  are  several  agreed- 
upon  causes  which  might  have  been  attacked  were  disre- 
garded. 

Since  that  time,  while  I  have  not  had  the  opportunities 
possessed  by  many  of  my  professional  friends  who  have  de- 
voted themselves  to  the  treatment  of  the  diseases  of  women, 
T  have  nevertheless  had  a  limited  experience,  and  if  the  in- 
vestigations of  others  who  are  more  fortunate  are  proportion- 
ately anything  like  my  own,  the  extent  of  the  evil  and  use- 
lessness  of  oophorectomy  can  not  be  too  strongly  condemned. 

Besides  the  cases  that  have  fallen  under  my  observa- 
tion, I  have  learned  from  reliable  sources  the  histories  of 
others. 

A  familiar  disease  for  the  supposed  relief  of  which  the 
operation  is  performed  is  epilepsy,  and  the  clinical  features 
of  this  affection  have  been  perhaps  more  often  disregarded 
than  any  other.  A  few  years  ago  I  examined  a  lady  with 
reference  to  a  long-existing  epilepsy  which  had  defied  the 
most  approved  treatment.  Her  attacks  were  severe,  were 
attended  by  a  variable  loss  of  consciousness,  she  had  bitten 
her  tongue,  and  there  was  some  slight  mental  degeneration 
as  well  as  diplopia,  and  the  convulsions  were,  as  a  rule, 
dominantly  unilateral.  In  fact,  all  the  features  of  the  dis- 
ease and  the  seizures  showed  it  to  be  conclusively  a  case  of 
cortical  epilepsy  with  two  probable  lesions.    The  medical 


gentleman  who  brought  her  to  me  said  that  the  patient  and 
her  family  were  anxious  to  have  her  ovaries  removed,  but  I 
frankly  expressed  my  disapproval  of  such  an  operation.  It 
was  argued  that  the  attacks  were  more  numerous  at  the 
menstrual  period,  and  this  was  alleged  to  be  an  indication 
that  there  was  some  local  cause.  Despite  my  objections, 
oophorectomy  was  determined  upon  and  the  patient  ether- 
ized. During  the  administration  of  the  ether  she  had  a 
convulsion,  and,  though  the  operation  was  most  skillfully 
performed,  there  seemed  afterward  to  be  no  amelioration  of 
her  condition,  let  alone  a  cure,  and  she  died  a  year  or  two 
later.  Unfortunately,  a  post-mortem  examination  was  not 
obtained,  but  there  can  be  little  doubt  but  that  it  would 
have  shown  some  coarse  cerebral  lesions. 

In  cases  which  I  have  known,  considerable  emphasis  has 
been  laid  upon  the  fact  which  is  an  accepted  one  in  nearly 
all  cases  of  this  disease  in  women — viz.,  that  the  fits  are  ag- 
gravated periodically.  But  I  do  not  think  that  this  can 
have  any  weight,  nor  should  the  circumstance  that  disor- 
dered menstruation,  which  most  often  occurs  under  the  form 
of  amenorrhoea,  points  of  necessity  to  ovarian  disease.  Be- 
fore oophorectomy  is  thought  of,  most  of  these  patients 
have  been  saturated  with  the  bromides,  and  are  nearly  al- 
ways exceedingly  anaemic.  Then,  again,  I  think  it  is  the 
experience  of  all  neurologists  that  the  menstrual  function  is 
influenced  in  the  most  eccentric  way  by  the  disease.  In 
other  cases  the  mental  feebleness  and  weakness  of  will  re- 
sults in  the  loss  of  sexual  restraint,  which  is  so  common 
with  idiots  and  the  epileptic  insane  that  the  one-sided  ob- 
server is  quite  apt  to  ascribe  these  manifestations  to  exalta- 
tion of  local  sensibility.  The  instances  where  the  operation 
has  been  performed  in  which  epilepsy  existed  in  a  quasi- 
hysterical  form  appear  to  have  been  those  which  have  not 
had  the  benefit  of  systematic  moral  treatment,  and  in  one 
case  there  was  a  temporary  impairment  I  believe  due  to  the 
mental  impression,  but  the  patient  in  other  ways  has  re- 
mained as  perverse  and  troublesome  as  before  the  surgical 
measures  were  employed. 

To  those  of  us  who  are  familiar  with  the  genesis  of  in- 
sane delusions  and  the  conduct  of  the  insane  themselves, 
there  can  be  little  doubt  of  the  exaggeration  and  false  in- 
terpretation of  local  hypertesthetic  disorders.  Evolution  of 
erotic  delusions  is  a  complex  process,  and  occurs  in  women 
whose  primary  derangement  is  of  a  perfectly  pure  and  some- 
times religious  nature.  So  far  as  my  own  experience  has 
gone,  especially  in  melancholia,  there  has  been  a  period  in 
which  introspection,  self-depreciation,  and  morbid  religious 
fancies  have  for  some  time  preceded  the  erotic  concepts,  the 
resulting  impulses,  and  the  indulgence  in  actions  which  to 
the  casual  or  superficial  observer  would  indicate  peripheral 
genital  excitability  as  the  solution  of  the  problem,  and  would 
impel  the  unthinking  physician  to  primarily  operate. 

The  importance  of  detecting  and  properly  estimating  the 
value  of  a  primary  mental  disturbance  which  results  in  sex- 
ual perversion  can  not  be  too  strongly  insisted  upon,  for  this 
is  universal,  and  these  states,  familiar  to  the  alienist,  are 
found  in  both  men  and  women,  sometimes  without  any  local 
excitability  whatever. 

I  do  not  think  the  operation  is  permissible  in  any  case 


182 


HAMILTON:    THE  ABUSE  OF  OOPHORECTOMY. 


[N.  Y.  Mkd.  JotiB., 


of  insanity.  It  is  certainly  not  warranted  where  the  insane 
manifestations  have  become  chronic  or  typical,  and  where 
physical  evidences  of  cerebral  degeneration  have  made  their 
appearance,  and  with  this  in  mind  I  was  exceedingly  sur- 
prised a  few  months  ago  to  hear  that  the  ovaries  had  been 
removed  from  a  patient  I  had  seen,  the  history  being  the 
following : 

She  was  a  younfj  woman  between  twenty  and  tliirty  years 
of  age,  whose  mental  disorder  had  lasted  at  least  ten  years  and 
had  defied  the  most  skillful  treatment  which  had  been  directed 
in  asylums  abroad  and  in  this  country.  She  was  of  a  well- 
established  insane  stock,  her  mother  and  several  members  of 
her  family  upon  the  maternal  side  having  presented  more  or 
less  marked  evidences  of  insanity.  The  patient  herself  exhibited 
the  symptoms  of  dementia  secondary  to  chronic  mania,  and  it 
was  one  of  the  clearest  cases  I  ever  saw.  She  was  exceedingly 
violent,  destructive,  homicidal,  and  suicidal,  and  her  erotic  aber- 
ration was  in  comparison  an  insignificant  feature  of  her  disease. 
I  saw  her  upon  several  occasions,  and  at  the  last  visit  she  cer- 
tamly  had  entered  upon  secondary  dementia,  and,  besides  othasm- 
atoma  and  the  well-marked  facial  and  cutaneous  characteris- 
tics, there'was  mental  involution  which  would  have  impressed 
any  one  with  the  least  experience  in  mental  disease  that  the 
last  and  degenerative  stage  of  her  disease  bad  been  reached. 
Notwithstanding  this  condition  of  affairs,  it  was  thought  advis- 
able to  perform  oophorectomy,  which  was  done  with  fatal  con- 
sequences; but  had  the  patient  lived  there  is  not  the  least  doubt 
but  that  her  confirmed  insanity  would  have  advanced  to  the 
only  possible  termination  in  spite  of  this  entirely  unnecessary 
and  ill-judged  operation. 

I  am  cognizant  of  other  cases  where  the  operation  has 
been  done,  the  subjects  being  the  victims  of  degenerative 
insanity,  and  where  not  the  slightest  benefit  resulted  from 
the  ablation  of  the  organs  which  are  supposed  to  play  so 
prominent  a  part  in  the  mental  disturbance. 

In  a  certain  number  of  these  cases  there  is  resulting  in- 
sanity in  about  nine  per  cent.,  which,  however,  is  not  more 
than  follows  other  great  operations  of  tliis  kind ;  and,  so 
far  as  I  can  learn,  those  that  are  essentially  traumatic  cases 
recover  quickly.  Sometimes  the  operation,  when  performed 
upon  neurasthenic  women  with  an  underlying  insane  dia- 
thesis, through  shock  is  apt  to  develop  a  mental  disorder 
which  may  be  more  or  less  permanent. 

I  think  the  great  principle  is  lost  sight  of  that  hysteria 
is  essentially  a  psychosis,  and  is  as  much  due  to  primary 
neurotic  inheritance,  environment,  and  education  as  to  any- 
thing else.  Physicians  of  strong  personality  and  tact,  as  is 
well  known,  do  more  through  mental  therapeutics  than  by 
any  other  more  material  remedy,  and  in  making  this  asser- 
tion I  simply  reiterate  something  which  has  been  said  over 
and  over  again,  but  has  been  neglected  by  those  who  have 
an  all-abounding  faith  in  drugs  and  the  knife. 

The  rapid  advances  that  have  been  made  in  the  past 
few  years  by  Janet,  Ricliet,  Bernheim,  Myers,  James,  and 
others,  both  therapeutically  and  experimentally,  show  that 
we  possess  in  suggestion  a  means  that  is  to  revolutionize 
the  treatment  of  many  j)sychoses. 

Where  oophorectomy  has  done  good  in  functional  cases 
I  am  strongly  convinced  that  it  has  been  through  the  pro- 
found impression  upon  the  mind  of  the  subject  rather  than 


upon  the  removal  of  the  ovaries,  and  in  two  or  three  cases 
I  have  been  made  fully  aware  of  this,  not  only  in  the  cure 
of  imaginary  troubles,  but  in  the  relief  of  the  psychical 
disturbance,  in  one  case  leaving  all  the  other  neurotic 
symptoms  as  they  were  before  the  operation.  Much  of  the 
credit  that  has  been  claimed  by  operating  gynajcologists 
results  largely  from  this  mental  reformation,  leading  the 
patients  to  exaggerate  their  improvement  and  to  magnify 
the  weight  of  the  burden  they  had  previously  borne,  just  as 
befoi'e  the  laparotomy  they  had  gone  to  the  other  extreme 
in  indulging  in  the  luxury  of  despair. 

The  curious  psychical  results  that  I  have  witnessed  in 
patients  who  have  undergone  the  operation  have  been  of  in- 
tense interest,  although  I  have  not  encountered  any  of  those 
extreme  departures  from  the  feminine  type,  either  mental 
or  physical,  that  have  been  described  or  are  the  subject  of 
speculation.  In  one  case,  that  of  a  married  woman,  all  the 
longings  for  maternity,  which  had  not  been  known  before, 
were  brought 'to  the  surface,  and  there  was  a  condition  of 
dejection  approaching  melancholia  and  a  disinclination  to 
go  into  society.  This,  I  understand  from  some  medical 
fiiends,  is  by  no  means  uncommon.  The  absence  of  altera- 
tion in  disposition  of  a  material  character  rather  suggests 
the  feeble  influence  of  these  organs  upon  the  mental  and 
moral,  processes  as  a  direct  connection,  though  my  friend 
Dr.  Polk  tells  me  that  he  has  witnessed  a  dullness  and  tor- 
por, as  well  as  a  certain  physical  coarseness,  but  this  I  have 
not  known.  In  many  cases  after  the  operation  there  is  apt 
to  be  prolonged  mental  distress,  which  comes  with  the  real- 
ization that  in  one  way  the  woman  is  unsexed  forever. 

Most  writers  upon  medical  jurisprudence  have  given 
much  space  to  the  discussion  of  the  results  which  follow  a 
corresponding  operation  in  the  male,  and  Ogstou,  whose 
opinion  is  as  high  as  any,  maintains  the  position  that  while 
the  operation  before  puberty  effects  a.  material  change  in 
the  mental  and  physical  condition  of  the  young  male,  no 
such  result  follows  the  deprivation  at  a  later  period.  He, 
however,  agrees  with  Devergie  that  there  may  be  rare  ex- 
ceptions. These  organs  in  the  female,  which  are  supposed 
to  play  so  important  a  part  in  development,  can  not,  I 
think,  be  for  a  moment  compared  with  the  thyreoid  glands, 
which,  when  removed  or  diseased,  very  often  effect  a  gen- 
eral and  very  striking  alteration  in  the  appearance  and  be- 
havior of  the  subject,  suggestive  of  a  general  involution. 

Dr.  T.  Addis  Emmet,  who  has  been  so  kind  as  to  give 
me  the  benefit  of  his  experience,  does  not  believe  that  the 
removal  of  these  organs  has  any  other  permanent  effect 
than  that  which  generally  takes  place  after  the  menopause, 
and  the  change  in  appearance  is  not  always  a  rapid  one. 

It  can  not  be  denied  that  the  temptation  to  use  the 
knife  in  these  cases  is  very  strong,  and,  even  though  the 
gynecological  surgeon  may  have  doubts  of  the  appropriate- 
ness of  the  treatment,  he  is  urged  by  the  despondent  and 
desperate  friends  of  the  patient,  who  have  received  little 
hope  either  from  previous  neurological  treatment  or  the 
prognosis  given  by  well-informed  physicians. 

What  the  medico-legal  complications  are  that  may  arise 
in  the  future  from  the  wholesale  unsexing  of  women  that 
has  gone  on  in  recent  years  it  is  difficult  to  predict,  and 


Feb.  18,  1893.] 


MURRAY:   THE  TREATMENT  OF  POST-PARTUM  HEMORRHAGE. 


183 


how  much  it  will  enter  into  the  dissolution  or  formation  of 
marriage  contracts  and  other  legal  agreements  no  one  can 
say.  I  have  already  heard  of  one  case  of  separation  that 
has  taken  place,  and  doubtless  there  are  others  that  are  un- 
known. The  operator  should,  therefore,  not  only  be  care- 
ful in  the  selection  of  his  subjects,  but  should  make  a  per- 
fectly clear  statement  of  the  possible  results  of  his  surgical 
treatment. 

In  conclusion,  I  may  recapitulate  by  expressing  my  ob- 
jections to  the  operation  in  any  case  of  typical  or  systemic 
nervous  disease  where  there  are  objective  evidences  of  de- 
generation or  coarse  disease,  and  it  is  only  to  be  thought 
of  where  all  other  means  of  mental  therapeutics  have  failed, 
and  only  then  as  a  form  of  suggestive  treatment,  and  in  a 
small  number  of  cases  where  menorrhagia  results  in  the 
malnutrition  of  the  nervous  system,  such  menorrhagia  be- 
ing intractable  and  not  due  to  any  accessible  disease.  There 
is  no  doubt  but  what  the  most  conservative  gynaecologists 
have  discarded  the  operation  almost  entirely.  In  response 
to  a  question  I  propounded  to  one  of  the  most  learned  and 
consistent  specialists  in  women's  diseases  in  America — viz., 
"  In  what  proportion  of  cases  does  this  operation  cure  nerv- 
ous diseases,  so  far  as  you  know  ?  " — he  replied  :  "  I  never 
remove  the  ovaries  for  nervous  disorders,  as  I  believe  the 
fault  to  lie  in  such  cases  in  the  nerve  centers."  This  terse 
answer  virtually  voices  the  sentiments  of  the  advanced  and 
most  careful  surgeons. 


THE  TREATMENT  OF 
POST-PARTUM  HEMORRHAGE.* 
By  ROBERT  A.  MDRRAY,  M.  D. 

I  KNOW  of  no  accident  in  obstetrics  so  fraught  with 
anxiety  to  the  accoucheur,  so  appalling  in  its  effects  on  a 
household,  casting  it  into  sudden  darkness,  where  before 
■was  joyous  expectancy,  as  fatal  post-partum  hismorrhage. 

The  suddenness  of  the  emergency ;  the  necessity  of 
meeting  it  single-handed,  ofttimes  at  night,  with  few  capa- 
ble assistants ;  the  many  causes  that  may  be  operative,  and 
therefore  to  be  combated;  and  the  quickly  fatal  result  if 
remedial  measures  are  not  effective — all  these  require  that 
the  subject  should  be  studied  frequently,  so  that  a  knowl- 
edge of  the  resources  of  his  art  may  make  the  accoucheur 
cool,  prompt,  and  decisive  in  his  efforts.  Success,  however, 
■is  not  attained  solely  by  familiarity  with  the  procedures 
ordinarily  advocated,  but  by  a  thorough  appreciation  of  the 
mechanism  by  which  the  haaraorrhage  is  to  be  arrested. 

Post-partum  hjcraorrhage  is  usually  due  to  mismanage- 
ment of  the  third  stage  of  labor — that  is,  the  lack  of  con- 
traction and  retraction  of  the  uterus.  To  this  may  be  add- 
ed all  causes  predisposing  to  this  condition.  Contractions 
of  the  uterus,  or  pains,  cause  the  uterus  to  become  smaller 
and  force  the  foetus  from  the  uterus  into  the  vaginal  canal 
and  into  the  world  ;  but  these  contractions  are  intermittent, 
paroxysmal,  and  followed  by  relaxation.    If  it  were  not  for 


*  Read  before  the  Northwestern  Medical  and  Surgical  Society,  No- 
vember 16,  1892. 


the  retraction  of  the  uterus,  its  contents  would  not  be  com- 
pressed during  labor,  its  volume  gradually  reduced  as  the 
foetus  and  placenta  were  expelled,  and  the  organ  left  in  a 
tonic  state,  which  prevents  relaxation. 

In  this  tonic  state  of  retraction  the  flow  of  blood  from 
the  uterine  sinuses  is  controlled  not  only  by  the  contraction 
of  the  muscular  fibers  of  the  uterus,  but  also  by  the  forma- 
tion of  thrombi  in  the  open  mouths  of  the  veins.  So  that 
the  contracted  uterus  is  hard  like  a  billiard  ball  and  is  tem- 
porary, while  retraction  should  be  permanent,  and  the  organ 
is  relatively  relaxed.  Retraction  is  important  during  labor, 
for  if  the  uterus  does  not  follow  its  contents  down,  the 
interval  between  the  contractions,  through  relaxation  of  the 
uterus,  may  cause  partial  detachment  of  the  placenta ;  this, 
combined  with  fatty  and  other  degenerative  changes  of  the 
placenta,  has  seemed  to  me  the  explanation  of  the  sudden 
effusions  of  blood  into  the  uterus  with  large  distention  and 
loss  of  contractility  of  the  organs,  collapse,  shock,  and 
fatal  result,  as  described  in  some  cases  of  ante  partum 
hiemorrhage.  Contractility  of  the  uterus  may  be  hindered 
by  the  thinning  of  the  walls  by  overdistention,  as  in  twin 
cases,  hydramnion,  by  general  debility,  prolonged  exhaust- 
ive labors,  forceps  or  other  operative  deliveries,  multiparas, 
too  rapid  emptying  of  the  uterus,  full  bladder,  and  in  some 
cases  by  prolonged  pressure  on  the  oedematous  lower  seg- 
ment of  the  cervix. 

Retractility,  besides  the  causes  enumerated  above — for  a 
deficiency  in  contractility  is  the  most  frequent  cause — has 
also  for  cause  the  retention  of  coagula,  portions  of  placenta, 
and  shock  from  labor. 

Other  causes  of  post-partum  hajmorrhage  are  injuries  to 
the  soft  parts,  lacerations  of  the  cervix,  vagina,  vulva,  and 
perinaeum  ;  to  these  and  their  treatment  I  wish  to  draw  par- 
ticular attention.  Syphilis,  albuminuria,  and  a  short  funis 
have  in  some  instances,  in  my  experience,  been  causes— the 
first  two,  no  doubt,  by  premature  separation  of  the  placenta. 

With  this  short  review  of  the  causes  we  pass  to  the 
treatment  of  post-partum  hsemorrhage. 

It  is  wise,  on  being  called  to  a  parturient  case,  to  pro- 
vide yourself  immediately  with  means  to  prevent  any  oc- 
currence of  hajmorrhage.  Ice,  ergot,  hot  and  cold  water, 
some  antiseptic,  a  Davidson  or  fountain  syringe,  Monsell's 
solution  of  iron,  and  a  bed- pan  should  be  near  at  hand. 
Follow  the  uterus  down  with  the  hand  as  the  foetus  is  ex- 
pelled, and  while  attending  to  the  child  have  the  womb  held 
either  by  the  nurse  or  the  patient.  Wait  till  the  patient  has 
recovered  from  the  shock  of  labor  before  expressing  the 
placenta.  The  too  early  application  of  Credo's  method,  I  be- 
lieve, often  causes  ha3morrhage  by  not  allowing  for  recovery 
of  nerve  force  to  retain  the  uterus  retracted.  Be  very 
sure  that  placenta  and  membranes  are  thoroughly  expelled. 
If  htemorrhage  does  come  on,  the  uterus  should  be  grasped 
by  the  hand  spread  over  the  fundus  and  a  downward  pres- 
sure in  the  axis  of  the  pelvis  maintained  while  the  body  of 
the  organ  is  kneaded.  Contractions  not  supervening,  the 
fingers  of  the  other  band  are  introduced  into  the  cervix, 
clots  expelled,  and  the  womb  is  anteverted  and  pressed  for- 
ward on  the  pubis  by  the  external  hand,  and  at  the  same 
time  the  aorta  may  be  compressed.    Pieces  of  ice  may  at>« 


184 


MURRAY:  TEE  TREATMENT  OF  POST-PARTUM  HEMORRHAGE.     [N.  Y.  Med.  Joob., 


be  passed  along  the  hand  into  the  cavity  of  the  womb  and 
ice  applied  externally. 

A  measure  introduced  by  the  late  Professor  I.  E.  Tay- 
lor of  flagellation  of  the  abdomen  by  a  towel  wrung  out  of 
cold  water  is  often  effectual.  The  hand  introduced  into 
the  uterus  and  the  organ  compressed  between  it  and  the 
external  hand  is  a  powerful  stimulant  to  contraction,  and, 
if  not  altogether  effectual,  allows  of  cleaning  tlie  uterus  of 
placenta,  clots,  etc.,  and  affords  time  to  obtain  hot  douche, 
tampon,  or  other  measures. 

The  hot  douche  of  one  per  cent,  creolin,  temperature 
115°  F.,  is  next  to  be  tried,  and  is  very  powerfully  effect- 
ive. To  it  may  be  added  tincture  of  iodine  for  its  stimu- 
lant and  astringent  effects  on  the  endometrium.  The  per- 
chloride  or  persulphate  of  iron,  as  recommended  by  Barnes, 
or  its  application  on  swabs,  I  think  unfavorably  of,  for  the 
clots  formed  stop  up  the  cervix,  and  the  thrombi  formed 
in  the  veins  are  prone  to  decomposition  and  may  extend  to 
the  iliacs  or  pulmonary  veins  with  fatal  effects. 

A  sliced  lemon  has  proved  useful  as  an  astringent,  as 
suggested  by  Dr.  Wallace. 

The  use  of  the  tampon  made  of  iodoform  gauze,  as 
recommended  by  Stahele  in  Germany,  and  by  Grandin, 
Polk,  and  others  in  this  country,  is  certainly  the  greatest 
advance  lately  made  in  the  treatment  of  post  partum  hasm- 
orrhage.  Especially  is  it  useful  in  atony  of  the  uterus,  and 
where  the  uterus  is  prevented  contracting  by  the  presence 
of  fibroids  or  other  tumors  ;  in  lacerations  of  the  cervix  and 
vagina  it  has  been  recommended,  though,  as  I  shall  state 
hereafter,  I  believe  it  far  better  practice  to  treat  these 
lacerations  surgically. 

At  the  same  time  while  these  measures  are  employed, 
the  patient's  head  should  be  lowered,  the  feet  and  pelvis 
elevated,  the  blood  supply  to  the  heart  maintained  by  manual 
compression  of  the  arteries  to  the  arms  and  lower  limbs, 
and  by  pressure  on  the  aorta  by  the  hand  of  the  obstetri- 
cian. Hypodermics  of  ergot,  brandy,  and  ammonia  may 
be  used  to  rouse  the  patient  and  to  increase  the  amount  of 
circulating  fluid.  Saline  solutions  should  be  injected  in  the 
rectum  and  in  the  subcutaneous  tissue  by  the  use  of  the 
hypodermic  needle  attached  to  the  tube  of  the  fountain 
syringe. 

Cerebral  anaemia,  with  its  restlessness,  jactitations,  yawn- 
ing, and  even  convulsions,  should  be  treated  by  the  use  of 
opium,  morphine  hypodermically,  and  tincture  of  digitalis. 
As  large  an  amount  of  liquid  nourishment  as  possible  should 
also  be  given  by  mouth  to  fill  the  blood-vessels. 

I  am  convinced,  however,  that  many  cases  of  post-par- 
tum  haemorrhage  are  not  due  to  non-contractility  of  the 
uterus,  but  are  frequently  due  to  lacerations  of  the  cervix, 
vagina,  or  external  genitals,  and  proceed  to  grave  results, 
while  these  measures  before  stated  are  unsuccessfully  tried. 
I  would  therefore  insist  that  as  soon  as  the  hand  is  placed 
on  the  uterus  externally,  the  other,  rendered  aseptic,  should 
always  be  introduced  into  the  vagina  after  careful  inspec- 
tion of  the  external  genitals,  and  the  cervix  and  fornix  vagi- 
uic  be  examined  carefully  for  lacerations. 

This  is  not  so  easy  as  it  would  seem,  since  the  cervix  is 
soft  and  flabby  ;  but,  by  grasping  the  anterior  and  posterior 


lips,  the  lacerations  at  the  sides,  front,  or  back  will  be  easily 
appreciated.  At  the  same  time  tliis  constitutes  the  proper 
immediate  treatment,  since  the  pressure  of  the  fingers  closes 
the  bleeding  points,  and  the  lips  can  readily  be  pulled  down 
to  the  vulva,  when  the  tear  will  be  clearly  seen,  as  the  fun- 
dus, being  contracted,  traction  on  the  cervix  arrests  bleeding 
in  the  puerperal  as  in  the  non-puerperal  uterus — an  expedi- 
ent in  every-day  use  in  gyna;cological  practice.  If  the 
bleeding  be  arrested  by  this  means,  grasping  the  cervix 
with  a  clamp  forceps  enables  one  of  very  moderate  surgical 
skill  to  pass  a  silver  wire  suture,  twist  it,  control  the  bleed- 
ing, and  at  the  same  time  repair  the  lesion.  This  procedure 
I  advocated  some  years  ago  in  a  paper  before  the  obstetric 
section  of  the  Academy  of  Medicine,  and  it  was  also  advo- 
cated before  the  same  section  in  a  paper  by  Dr.  Dickinson, 
of  Brooklyn,  last  year. 

That  the  statement  I  make  is  not  theoretical  is  shown 
by  the  frequent  lacerations  of  the  cervix  that  come  to  the 
specialist ;  and  in  ascertaining  the  histories  of  many  cases, 
they  have  remembered  that  they  lost  a  great  deal  of  blood 
in  labor  and  had  a  protracted  convalescence.  I  shall  pre- 
sent succinctly  three  cases  which  occurred  in  the  New  York 
Maternity,  during  the  past  two  months,  of  severe  flooding 
post  partum,  one  of  them  terminating  fatally,  where  the 
cause  was  laceration  of  the  cervix  : 

Case  I. — Annie  B.,  aged  nineteen,  single,  Austria;  admitted 
August  12, 1892.  Primipara,  pelvis  normal.  Labor  in  first  stage 
complete,  October  lOtli,  1.30  a.m.,  in  seven  hours  and  thirty 
minutes;  second  stage,  2.15  a.m.,  forty-five  minutes;  third 
stage,  2.30  a.  m.,  fifteen  minutes;  whole  duration,  eight  hours 
and  thirty  minutes. 

The  child  weighed  seven  pounds  and  nine  ounces ;  head 
presentation,  left  occipito- anterior.  After  delivery  of  placenta, 
haemorrhage,  lacerations  of  vulva  and  vagina  were  observed,  but 
the  bleeding  did  not  proceed  from  these.  Hot  vaginal  and  uter- 
ine douches  of  creolin  (one  per  cent.)  had  no  effect;  the  uterus 
was  tlien  tamponed  with  iodoform  gauze,  ergot  was  given  sub- 
cutaneously,  and  ice  was  used.  These  controlled  the  uterus  but 
slightly.  After  packing  the  uterus,  the  oozing  continued  for 
three  hours,  then  ceased ;  bed  was  raised,  stimulants  and  heat 
applied,  and  patient  revived. 

Eight  hours  afterward  I  removed  the  gauze;  oozing  came  on, 
but  from  the  uterus  ;  the  gauze  was  replaced  after  examination 
had  shown  that  the  primary  bleeding  had  been  from  the  lacer- 
ated cervix;  gauze  removed  in  twenty-four  hours;  no  sepsis; 
patient  recovered. 

Cask  II. — Alice  H.,  aged  twenty-five.  United  States ;  ad- 
mitted October  13, 1892.  Pelvis  normal.  Labor  began  October 
13,  1892,  at  6.30  p.  m.    Membranes  ruptured  the  day  before. 

rThe  first  stage  was  complete,  October  14th,  at  2.45  a.  m.,  in 
eight  hours  and  fifteen  minutes ;  the  second  stage  at  3  a.  m., 
after  fifteen  minutes ;  the  third  stage  at  3.15  a.  m.,  after  fifteen 
minutes;  total  duration,  eight  hours  and  forty-five  minutes. 

The  pains  were  good,  the  labor  was  normal;  ergot  was  given 
on  delivery  of  the  head.  The  placenta  was  expelled  by  Cred6'8 
method  in  fifteen  minutes,  and  was  at  once  followed  by  spurt- 
ing haemorrhage.  A  large  swelling,  afterward  recognized  as 
the  oedematous  anterior  lip,  was  felt  at  the  vulvar  orifice.  This 
had  not  been  observed  during  examination  in  the  course  of  the 
labor,  though  a  large  tab  on  the  anterior  lip  from  previous  lacer- 
ations had  been  noticed  on  entry  into  hospital.  A  vaginal  creo- 
lin douche  was  given,  followed  by  temporary  cessation  of  bleed- 


Feb.  18,  1893.] 


MURRAY:  THE  TREATMENT  OF  POST-PARTUM  HEMORRHAOE. 


185 


ing ;  on  its  recurrence,  specular  examination  was  naade,  but  no 
bleeding  point  found. 

A  liot  uterine  creolin  douche  was  then  given,  about  two 
hours  after  labor,  as  ice  was  ineffectual,  and  iodoform  gauze  was 
used  to  pack  the  uterus  and  vagina,  which  arrested  the  bleeding. 
The  patient  revived  under  stimulants,  and  when  the  packing  was 
removed  in  twenty-four  hours  there  was  no  recurrence  of  the 
flow.  A  marked  recent  laceration  on  the  right  side  was  ob- 
served and  an  old  one  on  the  left,  leaving  the  anterior  lip  pro- 
jecting as  a  bluish  cedeinatous  tumor. 

No  sepsis  occurred  and  the  patient  had  a  normal  convales- 
cence. 

Case  III. — Norah  McQ.,  aged  twenty-one,  Ireland,  single. 
Primipara,  pelvis  normal.  Labor  began  October  17,  1892,  at 
6  A.  M.,  left  occipito-anterior.  Duration  of  first  stage,  four  hours 
and  five  minutes ;  second  stage,  two  hours  ;  third  stage,  twenty 
minutes ;  total,  sis  hours  and  twenty-five  minutes. 

Labor  normal  till  head  rested  on  perinajum,  when  all  ad- 
vancement ceased ;  low  forceps  used  after  two  hours'  waiting 
and  child  delivered.  Ten  minutes  before  delivery  of  placenta 
a  slight  bleeding.  Credo's  method  tried,  but  unavailing;  as  the 
hremorrhage  was  more  sharp,  the  hand  was  introduced  and 
hour-glass  contraction  and  adherent  placenta  found.  Pla- 
centa was  detached  and  hot  intra-uterine  douche  (1  to  8,000) 
given  immediately  without  effect  on  bleeding. 

Speculum  showed  no  bleeding  points ;  iodoform  tampon  was 
applied  at  once,  as  patient  became  quickly  collapsed,  eighteen 
yards  of  four-inch-wide  gauze  being  used  ;  pressure  on  fundus 
and  also  on  gauze  packing  below  being  maintuined. 

The  patient  was  now  in  collapse;  pulse,  130  to  140,  pale  and 
feeble ;  was  stimulated  with  brandy  and  ether  ;  arteries  to  the 
limbs  compressed  by  bandages;  head  lowered  and  feet  elevated; 
normal  salt  solution  to  extent  of  twenty  ounces  given  subcuta- 
neously,  and  also  injected  into  cephalic  veins,  and  the  faradaic 
battery  used  to  stimulate  the  heart  and  respiration,  but  the 
patient  sank  rapidly  and  died  at  4.40  p.  m.,  four  hours  after 
delivery. 

I  was  called  to  the  case,  but  when  seen  the  patient's  condi- 
tion was  hopeless. 

After  death  the  gauze  was  removed  and  the  cause  was  im- 
mediately apparent  in  a  large  laceration  of  the  cervix  to  the 
right  from  the  os  up  to  vaginal  junction.  The  specimen  was  re- 
moved and  showed  the  tear  higher  internally  than  on  the  ex- 
terior of  the  OS.  The  placenta  was  markedly  calcareous  in 
nodules,  and  had  been  thorouglily  removed.  A  few  slight 
lacerations  were  seen  in  the  vagina. 

It  was  the  opinion  of  the  curator,  as  well  as  of  each  one  who 
flaw  the  case,  that  the  sudden  flow  rather  than  the  amount  lost 
was  the  cause  of  the  fatal  collapse. 

I  shall  not  add  any  more  cases,  as  they  may  be  con- 
sulted in  my  former  paper,  but  shall  discuss  briefly  those 
presented. 

In  each  of  these  cases  there  must  have  been  undue 
pressure  exerted  on  the  anterior  lip,  though  it  was  unrecog- 
nized by  even  an  experienced  attendant,  which  emphasizes 
^  the  necessity  of  examinations  made  at  the  time  of  the  pains, 
and  also  the  treatment  to  push  up  the  anterior  lip  gently 
between  the  pains,  that  the  head  may  descend  without 
opposition. 

I  executed  this  little  manoeuvre  in  a  case  which  had 
been  almost  a  day  in  labor,  the  cause  not  being  determined, 
1 1    with  the  gratifying  result  of  terminating  the  confinement 
in  half  an  liour,  at  the  same  time  showing  tlie  house  sur- 
geon how  cervical  lacerations  are  oftpn  caused. 


Two  of  these  patients  were  multiparae,  and  they  more 
frequently  have  haemorrhage.  May  it  not  be  due  to  the  ex- 
tension of  former  lacerations  by  the  fixation  of  tabs  of  the 
cervix  against  the  symphysis  ? 

In  all  the  cases  the  douche,  vaginal  and  uterine,  was 
used  ;  heat,  cold,  ergot,  and,  finally,  the  tampon,  after  specu- 
lar examination  showed  no  bleeding  point.  The  speculum 
as  a  means  of  diagnosis  or  treatment  is  useless  and  unneces- 
sary, for  the  constant  flow  of  blood  from  the  flabby  cervi- 
cal tissue  precludes  vision,  and  the  cervix  can  be  grasped 
with  the  thumb  and  fingers  of  the  hand  and  readily  pulled 
down  to  the  vulva,  the  traction  and  pressure  arresting 
haemorrhage  and  enabling  the  part  to  be  properly  and 
quickly  sutured. 

The  speculum  also  makes  a  very  hurtful  pressure  on  the 
bruised  perinaeum,  which  extends  slight  lacerations  and 
may  cause  hasmorrhage  from  small  thrombi  and  tears.  I 
am  in  favor  of  the  use  of  the  hot  douche,  but  it  is  not  al- 
ways available,  with  glass  tube  and  bed-pan,  as  in  hospital 
practice,  and  it  necessitates  lifting  and  changing  the  posi- 
tion of  the  patient,  and  though  effectual  in  producing  con- 
traction of  the  uterus,  it  will  not  stop  bleeding  from  the 
circular  artery. 

The  tampon  has  lately  come  into  vogue,  and  it  is  a 
remedy  of  the  greatest  value.  When,  however,  the  bleed- 
ing is  from  the  cervix,  it  is  not  as  quickly  applied,  nor  is  it 
as  sure  as  the  suture ;  the  hand  has  to  be  introduced  into 
the  vagina,  and  very  great  care  must  be  employed  to  pre- 
vent extension  of  the  lacerations  in  pushing  the  tampon 
into  the  womb ;  again,  it  is  not  always  thoroughly  aseptic 
when  hastily  used  in  a  bed  deluged  with  blood,  meconium, 
liquor  amnii,  etc.  If,  however,  it  is  used,  it  must  be  thorough, 
for  the  loss  of  very  little  blood  in  oozing  may  be  sufficient 
to  cause  a  fatal  result. 

A  very  great  advantage  of  the  surgical  treatment  of  the 
cervical  lacerations  at  the  time  of  labor  is  that  the  involu- 
tion of  the  uterus  proceeds  normally,  and  the  frequent 
subsequent  haemorrhages  from  subinvolutions  are  prevented, 
as  also  the  long  train  of  chronic  troubles  so  well  described 
by  Dr.  Emmet.  I  am  not  at  all  convinced  that  the  state- 
ment that  most  lacerations  of  the  cervix  heal  up  if  kept 
scrupulously  clean  is  true,  for  if  it  were  there  wouH  not  be 
the  large  number  presenting  from  the  well-to-do  classes  to 
have  the  secondary  operation  done. 

The  lacerations  in  the  vagina,  vulva,  and  perinaeum 
should  always,  when  possible,  be  sutured,  that  the  involu- 
tion of  these  parts  may  go  on  pari  passu  with  that  of  the 
uterus,  and  also  to  avoid  the  great  danger  of  sepsis. 

The  patient  should,  after  labor,  be  left  in  a  perfect 
physiological  condition,  to  take  care  of  her  offspring  and 
bear  the  burdens  of  life — the  sole  end  of  a  physician's  at- 
tendance not  being  the  birth  of  a  live  child  without  losing 
the  parent. 

235  West  Twenty-third  Street. 


The  Buffalo  Academy  of  Medicine. — At  the  recent  annual  meeting 
of  the  Section  in  Surgery  Dr.  (Jeorge  F.  Colt  read  a  paper  entitled  Some 
Remarks  on  Intubation,  and  officers  for  the  ensuing  year  were  elected 
as  follows  :  President,  Dr.  Herman  E.  Hayd;  vice  ])resident,  Dr.  Mar- 
cell  llartwig;  secretary  and  treasurer,  Dr.  William  G.  Ring. 


186 


MANGES:   CYLINDROIDS  IN  TEE  URINE. 


[N.  Y.  Med.  Joto., 


CYLINDROIDS  OR  SO-CALLED  MUCOUS  CASTS 
IN  THE  URINE* 
By  morris  manges,  A.M.,  M.  D., 

PHTBICIAN  TO  OUTDOOU  DEPARTMENT,  MOUNT  8INAI  HOSPITAL,  NEW  YORK. 

Although  earlier  writers  bad  not  infrequently  called 
attention  to  bodies  in  the  urine  whose  form  resembled  that 
of  renal  casts,  yet  it  was  not  till  1870  that  Thomas  (1), 
while  observing  the  urine  in  scarlet  fever,  carefully  studied 
the  forms  to  which  he  gave  the  name  cylindroids.  This 
name  he  applied  not  alone  on  account  of  their  resemblance 
to  true  casts,  but  because  they  so  frequently  occurred  with 
the  latter,  and  also  reacted  in  a  similar  manner  toward 
acetic  acid.  Rovida  (2)  carefully  analyzed  them  chemically 
and  showed  the  identity  of  their  composition  with  that  of 
renal  casts.  They  were  mentioned  by  Bartels  (3)  and 
Wagner  (4).  Bizzozero  (5),  Eichhorst  (6),  Neubauer  and 
Vogel  (V),  von  Jaksch  (8),  Fiirbringer  (9),  Leube  (10),  and 
Rosenstein  (11)  also  described  tliem.  The  most  exhaust- 
ive study  on  this  subject  was  made  by  von  Torok  and  Pol- 
lak  (12)  in  a  prize  essay  entitled  Ueber  die  Entstehung  der 
homogenen  Harncylinder  und  Cylindroide. 

Most  of  these  writers  agree,  in  some  measure  at  least, 
in  recognizing  cylindroids  as  renal  products  bearing  a 
more  or  less  close  resemblance  to  hyaline  casts.  Other 
authors  regard  them  only  as  forms  of  mucin.  Thus 
Baginsky  (13)  spoke  of  them  as  hyaline  mucous  shreds, 
which  may  be  found  in  the  urine  of  scarlet-fever  patients. 
Tyson  (14)  states  that  occasionally  casts  may  be  found 
which  are  apparently  "  pure  mucus-molds  of  the  urinifer- 
ous  tubules."  These  forms,  in  his  opinion,  undoubtedly 
come  from  the  kidney  and  must  be  distinguished  from  the 
bands  of  mucin  which  are  found  in  hyperacid  urines. 

Millard  (15),  in  his  treatise  on  Bright's  disease,  in 
which  he  has  so  carefully  and  thoroughly  distinguished 
the  relations  of  mucin  to  albuminuria,  speaks  of  mucous 
casts,  but  denies  that  they  have  any  significance  except 
that  they  are  often  mistaken  for  hyaline  casts.  The  mucous 
cast,  as  distinguished  from  true  casts,  he  maintains,  is  not 
an  inflammatory  product.  Vierordt  (16),  while  describing 
mucin,  says :  "  Several  forms  are  characteristic ;  among 
these  are  cylindroids,  or  microscopic  shreds  of  mucus 
which  careless  observers  may  mistake  for  casts.  Their 
origin  and  diagnostic  significance  are  uncertain ;  they  may 
be  found  (accompanying  casts)  in  nephritis,  in  cystitis,  and 
even  in  liealthy  individuals." 

Peyer  (17)  also  considers  them  products  of  mucus.  He 
gives  excellent  plates  (see  Plates  6,  32,  and  64)  showing 
various  varieties,  including  prostatic  and  spermatic  cylin- 
ders. Saundby  (18)  coincides  with  the  above  views  and 
simply  speaks  of  them  as  mucous  cylinders. 

Von  Ilosslin  (19),  in  1889,  described  an  unusual  form 
of  casts  which  he  found  in  the  urine  of  an  epileptic  after  a 
very  severe  renal  colic  which  lasted  eighteen  hours.  The 
urine  passed  after  the  attack  had  a  specific  gravity  of 
1*03.5  and  was  laden  with  urates.    With  the  naked  eye 


*  Read  before  the  Section  in  Genito-urinary  Surgery  of  the  New 
York  Academy  of  Medicine,  December  8,  1 892. 


numerous  flakes  could  be  seen  floating  in  the  urine.  Under 
the  microscope  these  were  found  to  consist  of  sharply  con- 
toured hyaline  casts,  branching  dichotomously,  and  be- 
tween which  were  finely  granular  uratic  deposits.  As  the 
urine  was  free  from  albumin,  von  Ilosslin  believed  that 
these  casts  could  not  consist  of  any  albuminoid  substance. 
Inasmuch  as  mucin  is  increased  in  quantity  in  renal  colic, 
he  therefore  asserted  that  in  this  case  the  secretion  of  mu- 
cin was  so  great  that  mucin  casts  were  formed  in  the  kid- 
ney. The  fact  that  he  could  never  find  casts  after  any  of 
the  epileptic  attacks  which  the  patient  subsequently  had, 
excludes  the  possibility  of  including  them  under  this  lat- 
ter group. 

In  a  paper  on  Tube  Casts  and  their  Diagnostic  Value, 
read  before  this  year's  meeting  of  the  Association  of 
American  Physicians,  Danforth  (20)  divides  these  bodies 
(«'.  e.,  casts)  into  two  groups,  of  which  one  includes  the 
ordinary  forms,  the  other  being  the  mucin  casts.  These, 
he  states,  are  "  the  characteristic  morphologic  products  of 
catarrhal  nephritis  and  establish  its  differential  diagnosis." 

Cylindroids  have  also  been  variously  mentioned  as  pro- 
static cylinders  or  tubules,  spermatic  casts,  etc.  On  the 
other  hand,  very  many  recognized  standard  text-books  do 
not  even  mention  them.* 

Description. — Cylindroids  are  ribbon-like  forms,  usually 
of  great  length  and  of  about  the  same  diameter  as  renal  casts. 
They  may  assume  various  shapes,  due  to  bends  and  twists 
which  are  usually  in  their  lorrgitudinal  axis,  giving  them  a 
corkscrew  appearance.  These  axial  twists  are  most  fre- 
quently observed  near  the  extremities.  Folds  and  lateral 
indentations  are  very  common.  The  diameter  may  be  uni- 
form or  varying ;  the  latter  is  by  far  more  common.  Hence, 
as  a  rule,  the  extremities  are  narrow  and  elongated,  and 
often  bifurcated.  Subdivision  into  three  or  even  four 
branches  is  by  no  means  rare.  They  are  frequently  thicker 
at  one  end  than  at  the  other.  Their  outlines  are  delicate, 
although  more  highly  refracting  than  hyaline  casts.  A 
very  characteristic  feature  is  the  longi- 


tudinal situation  of  various  grades  of 
delicacy ;  these  markings  not  alone  as- 
sist us  in  finding  them,  but  are  also  a 
very  important  diagnostic  feature  which 
distinguishes  them  from  true  cylinders. 

They  may  occur  isolated  or  in 
groups  of  two  or  three,  or  even  in  large 
snarls :  the  latter  may  often  be  detected 


.                                   .  Fig.  1. -Snarl  of  In- 

by  following  up  one  extremity  of  the  teriacing cylindroids. 

cylindroid  (Fig.  1).    Not  infrequently  a  (Low power.)  From 

,       ,.1     .1  Bizzozero. 

specimen  is  at  once  cast  and  cylindroid, 
as  where  one  end  of  a  cast  terminates  in  a  spiral,  striated 
form  (Fig.  2).    I  have  observed  both  extremities  assume 
this  form.    One  example  which  I  saw  of  this  variety  had  a 
body  like  a  granular  cast  (probably  due  to  some  extra- 

*  Da  Costa's  paper  in  the  American  Journal  of  the  Medical  Sciences 
for  January,  1893,  is  an  excellent  proof  of  this  assertion.  Although 
very  careful  chemical  and  microscopical  examinations  of  the  urine  were 
made  in  all  his  cases,  yet  cylindroids  are  never  referred  to.  This  is  all 
the  more  striking  since  nowhere  else  do  these  bodies  occur  more  fre- 
quently. I 


Feb.  18,  1893.] 


MANGES:   GYLINDROIDS  IN  TEE  URINE. 


18T 


neous  precipitation) ;  in  still  another  example  this  granu- 
lar appearance  was  present  in  two  portions  of  the  specimen, 


Fio.  2.— Combined  casts  and  cylindroids.  (x400.)  The  specimen  to  the  left 
was  found  in  an  acid  urine  (drawn  by  catheter)  containing  much  free  uric 
acid.  The  specific  gravity  was  1  030.  Albumin  and  mucin  were  present  in 
traces,  with  sugar  0  4  per  cent.  It  contained  three  renal  epithelial  cells  and 
numerous  small  fat  globules.  Hyaline  and  fatty  casts  also  were  present. 
The  other  specimen  also  is  from  a  gouty  urine,  very  acid,  of  the  specific 
gravity  of  1'082,  containing  many  crystals  of  uric  acid  and  oxalate  of  cal- 
cium, together  with  hyaline  and  granular  casts. 

the  intervening  space  being  quite  hyaline,  while  the  ex- 
tremities were  typically  cylindroidal  (Fig.  3).  Finally, 

cylindroids  may  occur  in- 
closed in  hyaline  casts,  as 
is  well  shown  in  Fig.  4. 

Like  true  casts,  cylin- 
droids may  bear  various 
forms  of  epithelium,  red 
and  white  blood-cells, 
crystals,  detritus,  fat- 
droplets,  and  bacteria. 
These  may  be  inclosed 
within  or  may  simply  be 
adherent.  When  covered 
with  amorphous  deposits 
they  may  strongly  resem- 
ble granular  casts. 

Their  length  is  char- 
acteristic. According  to 
Bizzozero  (5)  {loc.  cit.,  p. 
281),  they  may  even  be 
one  millimetre  long.  It 
is  common  to  see  them 
extend  over  two,  three,  or  even  five  fields  of  the  microscope. 
The  diameter  of  the  thin  forms  (Bizzozero)  is  1  to  2  /x ;  the 
broader  varieties  measure  between  5  and  10  /u..  False  cylin- 
droids may  be  much  broader  than  this. 

Classification. — The  classification  of  these  bodies  into 
two  great  groups — the  true  and  false  cylindroids — is  of  im- 
portance, not  alone  in  estimating  their  diagnostic  signifi- 
cance, but  also  in  explaining  the  differences  of  opinions 
held  by  various  writers  on  this  subject.  That  some  cylin- 
droids are  renal  in  origin  is  positively  shown  by  the  fact 
that  von  Torok  and  Pollak  (12)  have  actually  seen  them 
in  the  uriniferous  tubules  in  sections  of  a  large  white  kid- 
ney, of  a  waxy  kidney,  and  numerous  cases  of  chronic 
parenchymatous  nephritis.     Furthermore,  they  were  also 


Fio.  3. — False  cylindroid  with  deposit  of 
amorphous  urates.  BYom  a  case  of 
oxaluria ;  urine  was  very  acid,  speci- 
fic gravity  r098;  contained  urethral 
shreds,  hyaline  casts,  and  a  small  num- 
ber of  red  and  white  blood-cells.  A 
large  trace  of  albumin  and  mucin  also 
present.  (x400.) 


found  in  the  kidneys  of  rabbits  poisoned  with  cantharides 
and  bichromate  of  potasssium ;  in  experimental  stenosis  of 
the  renal  veins ;  in  ligation  of  the  renal  arteries ;  and  also 
where  the  ureters  were  tied  off  (Fig.  5).  Another  very 
strong  proof  that  cylindroids  are  formed  in  the  kidneys  is 
shown  in  the  curious  casts  inclosing  cylindroids  (Fig.  4). 
As  von  Torok  and  Pollak  observe,  unless  we  accept  the  view 
that  the  cylindroid  already  existed  in  the  tubule  where  it 
was  subsequently  inclosed  in  a  mantle  of  albuminoid  mate- 
rial, we  must  assume  that  the  cylindroid  forced  its  way  into 
the  already  formed  cast.  For  this,  however,  it  is  not  rigid 
enough,  as  any  pressure  from  behind  would  simply  press 
the  spirals  of  the  cylindroid  closer  together.  The  alterna- 
tion of  casts  and  cylindroids,  their  occurrence  in  the  same 


Fig.  4.— a  hyaline  cast  Pi».  .5.— Sections  of  uriniferous  tubules  containing 

containing  a  cylin-  cylindroids.   The  specimen  at  the  left  was  from 

droid.  From  a  case  the  kidney  of  a  rabbit  in  which  the  renal  veins 

of  Bright's  disease.  had  been  narrowed.    The  one  at  the  right  is 

(Von   TOrOk   and  from  the  kidney  of  a  rabbit  poisoned  with  can- 

Pollak.)  tharldes.   (Vtn  TOrOk  and  Pollak.) 

specimen  in  which  they  both  contain  exactly  the  same  va- 
rieties of  epithelial  cells,  blood-cells,  detritus,  etc.,  the 
similarity  of  their  reactions  to  various  chemical  reagents — 
all  these  attest  the  correctness  of  this  view.  Finally,  I 
have  also  seen  them  in  urine  drawn  with  the  catheter  in 
cases  where  there  was  absolutely  no  indication  of  pyelitis 
and  cystitis  (Fig.  6). 

On  the  other  hand,  it  is  just  as  certain  that  others  are 
formed  outside  of  the  kidneys.  They  may  be  readily  ob- 
served in  the  secretions  of  the  prostate,  Cowper's  and  Lit- 
tre's  glands,  the  bladder,  vagina,  uterus,  and  urethra.  They 
may  also  be  seen  in  the  urine  voided  post  coitum,  or  after  a 
hard  passage,  or  after  what  Keyes  has  termed  "  milking 
the  prostate."  If  any  of  the  above  secretions  be  mingled 
with  perfectly  normal  urine,  cylindroids  may  then  be  ob- 
served in  tlie  specimen  (Figs.  7,  8,  and  9). 

Renal  cylindroids  have  been  subdivided  into  three 
groups  :  (a)  small,  narrow  threads  ;  (6)  ribbon-like  bodies ; 
(c)  collapsed  tubules.  Von  T5rok  and  Pollak  also  mention 
another  variety  where  tlie  contours  are  very  vague.  This 
classification  referring  only  to  the  shape  has  no  practical 
significance. 


188 


MANGES:  CYLINDR0ID8  IN  THE  URINE. 


[N.  Y.  Mkd.  Joue., 


Composition. — The  exact  composition  of  casts  being  un- 
known, a  corresponding  degree  of  uncertainty  must  neces- 
sarily exist  concerning  the  nature  of  the  basement  substance 


Fio.  6.— Renal  cylindroids  from  a  case  of  typhus  fever.  XJrine  contained  small  trace  of 
albumin,  red  blood-cells,  hyaline  and  epithelial  casts.  Cylindroids  were  soluble  in 
acetic  acid.  A  few  adlierent  red  blood-cells  in  one  of  the  specimens.  Urine  was  high- 
colored,  acid  ;  specific  gravity,  1'028.  (x400.) 


of  cylindroids.  Of  casts,  Knoll  (21)  says  that  their  sub- 
stance is  identical  with  none  of  the  known  forms  of  albu- 
min— as  acid  albumin,  albumin,  albumose,  globulin,  fibrin, 
mucin,  or  peptone.  Rovida  (2),  who  has  paid  more  atten- 
tion to  this  subject  than  any  one  else,  claimed  that  casts  and 


above,  true  and  false  cylindroids  react  differently  to  acetic 
acid,  the  former  being  rapidly  dissolved,  while  of  the  latter 
some  are  unaffected,  but  others  are  swollen  up  and  appar- 
ently disappear ;  however,  they  again  become  visi- 
ble after  staining. 

This  effectually  disposes  of  the  belief  of  many 
who  have  regarded  all  cylindroids  as  being  sim- 
ply shreds  of  mucus.  Even  admitting  that  renal 
cylindroids  could  consist  of  mucin,  from  what  part 
of  the  kidney  could  the  necessary  mucin  be  ob- 
tained ?  The  only  rational  source  would  be  the 
pelvis ;  but  in  that  case  they  would  have  a  much 
less  marked  resemblance  to  true  casts  than  they 
actually  possess.  Whatever  cylindroids  are  formed 
there  undoubtedly  belong  to  the  false  variety. 
Mucus  can  not  be  secreted  within  the  kidney,  for 
it  contains  no  muciparous  glands.  Millard  and 
Danforth  still  adhere  to  the  possibility  of  a  ca- 
tarrhal nephritis.  The  latter  writer  assumes  that 
the  necessary  mucin  is  furnished  by  the  tubal  epi- 
thelium, most  likely  by  that  of  the  convoluted 
tubules.  He  maintains  that,  "  under  certain  cir- 
cumstances, the  epithelial  cells  seem  to  undergo 
a  change  which  is  equivalent  to  the  '  mucoid  de- 
generation '  of  Ziegler,  the  protoplasm  of  the 
cell  being  transformed  into  a  mucoid  substance, 
which  is  afterward  cast  into  the  lumen  of  the  tubule, 
there  to  aggregate  itself  with  the  similar  product  of 
neighboring  cells."  Such  views  of  pathology  may  be 
dismissed  as  antiquated,  for  very  few  writers  any  longer 


Fig.  7. — False  cylindroids  from  a  case  of  gout  and  cystitis.  Urine  acid  ;  spe- 
cific gravity,  1019  ;  faint  trace  of  albumin,  large  trace  of  mucin  ;  free  uric 
acid  crystals  very  abundant.  Epithelial  cells  of  bladder  and  pus  cells  quite 
abundant.   ( x  400.) 

cylindroids  were  identical  in  composition.  This  is  true  if 
pseudo-cylindroids  are  not  included ;  for,  as  already  shown 


Flo.  8.— Very  long  false  cylindroid  containing  blood-cells.  Both  extremitiei 
bifurcated.  From  concentrated  acid  urine  with  traces  of  albumin  and 
mucin.  (x400.) 

speak  of  a  catarrhal  nephritis.  The  only  other  possible 
explanation  would  be  that  mucin,  being  now  recognized 
as  a  nucleo-albumin,  might  arise  from  changes  in  the 
renal  cells.  However,  if  so  marked  a  lesion  were  pres- 
ent, we  would  have  other  manifestations  of  a  well-marked 
nephritis. 


Feb.  18,  1893.J 


MANGES:  G7LINDR0IDS  IN  THE  URINE. 


189 


Thus  we  may  assume  that  renal  cylindroids  consist  of 
eome  as  yet  unknown  albuminoid  substance.  On  the  other 
hand,  pseudo- cylindroids  are  probably  formed  from  some 
variety  of  mucin. 


Fin.  9. — False  (spermatic)  cylindroids  found  in  urine  after  passage  of  hard 
fajces.   (  X  300.) 

Mode  of  Formation. — Of  the  three  theories  put  forth  to 
explain  how  casts  are  formed — viz.,  (a)  by  the  liquefaction 
and  metamorphosis  of  desquamated  renal  epithelium ;  (6) 
from  secretory  products  of  renal  epithelial  cells,  the  so- 
called  vacuoles ;  (c)  the  coagulation  of  an  albuminous  tran- 
sudate into  the  tubules — only  the  latter  comes  into  play 
when  considering  the  origin  of  renal  cylindroids.  Their 
very  form  speaks  for  the  correctness  of  this  assumption, 
for  according  to  the  amount  of  the  transudate  will  the  cyl- 
indroid  assume  the  shape  either  of  a  thin  flat  ribbon,  or  a 
hollow  tube,  or  a  solid  cylinder.  Originally  the  albuminous 
material  is  coagulated  in  straight  lines ;  but  the  urine  com- 
ing down  from  the  glomerulus  while  they  are  still  semi- 
solid, causes  the  various  corkscrew  twists,  bends,  and 
transverse  folds.  Their  great  length  and  the  frequent  oc- 
currence of  dichotomous  division  would  seem  to  indicate 
that  they  are  usually  formed  in  the  straight  tubules,  al- 
though it  is  true  that  the  branching  of  their  extremities 
might  also  be  explained  by  a  subsequent  splitting. 

This  view  will  also  readily  explain  the  bodies  which  are 
cast  and  cylindroid  combined,  by  assuming  either  that 
through  some  obstruction  the  transudate  was  forced  to  fill 
out  the  entire  tubule  at  some  point,  or  that,  although  its 
amount  was  enough  to  form  a  cast  in  some  portions,  it  did 
not  sufBce  at  other  parts.  The  occurrence  of  snarls  of  in- 
terlacing cylindroids  does  not  weaken  this  assumption,  for 
Thomas  (23)  asserts  that  they  may  be  formed  by  the  meet- 
ing in  the  calyces  of  the  streams  from  the  various  collect- 
ing tubules. 

The  occurrence  of  cylindroids  in  tubules  with  unaltered 
epithelium  indicates  either  the  coagulation  of  transuded 
albuminous  fluids,  or  that  the  specimen  was  carried  down 
from  some  point  higher  up.  But  to  discuss  this  subject  at 
greater  lengths  would  only  bring  us  back  to  the  considera- 
tion of  all  the  various  theories  on  the  formation  of  hyaline 
casts. 

Pseudo-cylindroids  are  simply  bands  of  mucin  precipi- 
tated in  the  excretory  ducts  of  the  various  glands  of  the 
urinary  tract  by  the  acid  reaction  of  the  urine. 

Occurrence. — It  is  surprising  how  frequently  these  forms 
may  be  observed  in  the  urine  after  we  have  once  learned  to 


recognize  them.  Where  the  urine  has  been  mixed  with  va- 
rious discharges — as  in  cystitis,  leucorrhcea,  or  gonorrhoea, 
after  coitus,  after  a  hard  passage,  etc. — they  may  be  readily 
discovered,  as  they  are  then  quite  abundant.  They  are 
also  present  in  pyelitis,  the  various  forms  of  nephritis, 
and  congestion  of  the  kidneys  ;  consequently  they  are  pres- 
ent in  diphtheria,  scarlet  fever,  and  other  exanthemata.  1 
have  even  recently  observed  them  in  a  case  of  typhus  fever 
(see  Fig.  6).  They  may  occur  alone  or  with  casts,  fre- 
quently alternating  with  the  latter  as  the  renal  lesion  abates 
in  severity.  These  are  least  abundant  in  the  chronic  forms 
of  nephritis.  In  normal  urines  they  are  by  no  means  rare. 
Jaksch  (8)  [loc.  cit.,  p.  236)  found  cylindroids  very  fre- 
quently in  the  urine  of  children,  with  and  without  albu- 
min, where  renal  disease  could  otherwise  not  be  demon- 
strated. Among  the  non- albuminous  urines  they  are  espe- 
cially liable  to  occur  in  jaundice,  in  concentrated  and 
hyperacid  specimens,  and,  finally,  in  subjects  sutfering 
from  gouty  manifestations  and  imperfect  metabolism.  It 
is  just  these  cases  which  give  us  so  much  trouble  in  de- 
termining whether  or  no  a  trace  of  albumin  might  be  pres- 
ent. These  specimens  are  usually  of  a  very  high  specific 
gravity  (over  1"030),  hyperacid,  and  contain  a  large  quantity 
of  urates  ;  free  crj'stals  of  uric  acid  and  oxalate  of  lime  are 
present  when  the  urine  is  voided,  or  appear  soon  on  stand- 
ing. In  these  cases  mucin  is  always  present,  often  in  con- 
siderable amounts.  Hyaline  casts,  a  moderate  number  of 
pus-cells,  and  at  times  even  red  blood-cells  (where  the  pel- 
vis of  the  kidney  or  other  parts  of  the  urinary  tract  have 
been  irritated  by  sharp  pointed  crystals),  are  by  no  means 
rare  in  such  specimens.  Many  of  these  cases  are  put  back 
and  often  rejected  by  life-insurance  companies. 

False  cylindroids  have  absolutely  no  relation  to  albu- 
minaria,  but  appear  to  accompany  mucinuria.  The  renal 
varieties  may  be  present  with  or  without  albumin.  The 
trace  of  albumin  which  is  so  frequently  present  in  these  cases 
is  often  probably  due  to  the  excess  of  mucin  which  is  so  com- 
mon in  these  patients.  However,  Le  Nobel  (22)  has  always 
found  globulin  in  urines  containing  cylindroids. 

The  youngest  age  at  which  I  have  observed  them  was 
five  years — in  a  little  girl  with  psoriasis  ;  her  family  history 
was  decidedly  gouty. 

Diagnosis. — For  the  purpose  of  studying  the  general 
characteristics  of  cylindroids,  the  urine  of  any  patients  suf- 
fering from  gonorrhoea  offers  a  good  field,  since  the  forms 
here  present  are  very  easily  recognized  on  account  of  the 
distinctness  of  the  longitudinal  striation,  their  greater  re- 
fracting power,  and  their  length.  Moderate  powers  (300  to 
400  diameters)  are  ample.  The  delicacy  of  the  contours 
of  these  bodies  requires  that  the  illumination  be  not  too 
strong ;  they  may  be  very  easily  overlooked  when  gaslight 
is  used.  Staining  with  Lugol's  iodine  solution,  picric  acid, 
etc.,  is  always  of  assistance. 

Cylindroids  are  most  readily  found  in  freshly  voided 
urine,  especially  if  the  minute  flakes  which  are  often  in- 
closed in  the  mucus  be  examined.  These  flakes  are  very 
hard  to  find  if  the  urine  has  been  shaken  up.  Another 
means  of  detecting  them  is  to  look  for  the  snarls  already 
referred  to. 


190 


MANGES:   GYLINDROIDS  IN  THE  URINE. 


[N.  Y,  Med.  Joitb., 


The  differential  diagnosis  is  important.  The  greatest 
diificulty  will  be  encountered  in  distinguishing  the  true 
from  the  false  forms.  The  only  absolute  test  is  the  solu- 
bility of  the  former  in  acetic  acid  and  the  insolubility  of 
the  latter  in  the  same  reagent.  However,  the  accuracy  of 
this  test  is  vitiated  by  the  fact  that  some  pseudo-cylindroids 
will  swell  np  on  the  addition  of  this  reagent  and  apparently 
disappear.  Staining  with  Lugol's  solution  will,  however, 
show  that  the  specimen  can  still  be  rendered  visible.  How- 
ever, to  carry  out  this  test  successfully  requires  not  a  little 
skill  in  microscopic  technique  to  constantly  keep  the  par- 
ticular specimen  in  the  field  of  the  microscope. 

The  presence  of  albumin,  casts,  and  renal  epithelial 
cells  would  lead  us  to  expect  the  renal  forms,  while  an  ex- 
cess of  mucin,  the  admixture  with  products  from  the  blad- 
der, prostate,  urethra,  vagina,  and  uterus,  would  indicate 
pseudo-cylindroids.  In  the  latter,  also,  the  striations  are 
coarser,  the  refractive  power  is  greater,  the  diameter  varies 
more,  the  extremities  are  more  frequently  divided  into 
more  than  two  branches — in  a  word,  the  less  the  resem- 
blance to  true  casts,  the  greater  the  probability  that  we  are 
dealing  with  pseudo-cylindroids.  Naturally,  the  differen- 
tiation is  materially  aided  by  the  presence  of  adventitious 
products — viz.,  spermatozoa,  epithelium  of  the  lower  uri- 
nary tract,  etc. 

In  spite  of  all  these  distinctions,  the  differentiation  be- 
tween these  two  groups  will  not  infrequently  be  attended 
with  the  greatest  difficulties ;  and  in  some  cases  it  is  even 
impossible,  especially  where  both  forms  are  present. 

From  casts  cylindroids  may  readily  be  distinguished  by 
their  length,  irregular  contours,  twists,  and,  above  all,  the 
longitudinal  striations  already  referred  to.  Casts  resemble 
a  cylinder,  while  cylindroids  are  more  band-like.  Granular 
casts  may  be  closely  simulated  where  many  of  these  charac- 
teristics have  been  obliterated  by  the  presence  of  amorphous 
deposits.  I  have  even  seen  true  blood  casts  simulated  by 
cylindroids  bearing  a  large  number  of  closely  packed  red 
blood-cells.  In  this  connection  it  might  be  well  for  super- 
ficial observers  to  bear  in  mind  how  much  renal  casts  differ 
from  the  usual  typical  drawings  in  most  text-books,  show- 
ing a  cylinder  with  parallel  sides  and  rounded  extremities. 
Hyaline  casts  are  quite  frequently  irregular  in  their  con- 
tours, their  sides  often  taper  toward  one  extremity,  bends 
are  common,  and  Neubauer  and  Vogel  even  state  (loc.  cit.,  ii. 
Theil,  S.  155)  that  some  may  have  bifurcated  extremities.* 
I  have  already  spoken  of  the  forms  which  are  at  once 
cast  and  cylindroid — i.  e.,  either  the  casts  with  spiral  and 
tapering  extremities,  which  are  quite  common,  or  the  very 
rare  forms  in  which  cylindroids  are  inclosed  in  casts. 

Significance. — Having  thus  shown  the  necessity  of  re- 
garding these  bodies  as  something  more  than  mucous  casts, 
and  having  also  proved  the  existence  of  both  true  and  false 
cylindroids,  the  question  naturally  arises.  What  is  their  sig- 
nificance and  what  prognostic  conclusions  may  be  drawn 
from  them  ? 

*  Examples  of  the  very  irregular  outlines  of  casta  may  be  seen  in 
Basliam,  On  Dropsy  connected  v>ith  Diseases  of  the  Kidney,  London, 
1858,  Plate  IX;  Salkowski  and  Leubo,  loc.  cit.,  p.  444,  Fig.  36;  von 
.laksch,  loc.  cit.,  KigH.  78  and  81. 


The  pseudo-cylindroids,  as  such,  may  be  dismissed  with- 
out another  word,  as  their  significance  is  limited  to  simply 
recognizing  them  as  such.  Whatever  bearings  these  forms 
have  in  diagnosis  is  merely  due  to  the  difficulty  which  may 
be  encountered  in  absolutely  distinguishing  them  from  the 
true  renal  varieties. 

Leube  (10)  [loc.  cit.,  p.  447)  asserts  that  in  his  opinion 
there  is  no  reason  for  specially  distinguishing  cylindroids 
from  ordinary  casts,  especially  as  the  latter  so  frequently 
have  lateral  indentations  and  axial  twists.  Rosenstein  (11) 
{loc.  cit.,  p.  45)  denies  the  right  of  attributing  to  cylindroids 
a  special  importance  which  renders  their  distinction  from 
casts  necessary.  Fiirbringer  (9)  {loc.  cit.,  p.  36)  coincides 
with  the  latter. 

Thomas  (23)  believes  that  where  cylindroids  are  replaced 
by  casts  an  exacerbation  of  the  nephritis  may  be  inferred  ; 
and,  vice  versa,  cylindroids  take  the  place  of  casts  when  the 
renal  process  abates.  He  also  assumes  that  cylindroids  are 
present  where  the  quantity  of  albumin  is  very  minute,  and 
that  they  may  even  be  the  only  signs  of  a  mild  nephritis. 
The  latter  may  frequently  be  due  to  the  excretion  of  infec- 
tious elements ;  in  some  cases  the  process  resolves ;  in 
others  it  goes  on  to  a  nephritis.  He  suggests  that  bacte- 
rial influences  may  be  discovered  in  many  other  cases  where 
cylindroids  occur. 

The  views  of  von  Torok  and  Pollak,  Tyson,  and  others 
have  already  been  stated. 

Danforth,  in  addition  to  what  has  already  been  quoted 
of  his  contention  that  "  mucin  casts  "  establish  the  diagnosis 
of  catarrhal  nephritis,  also  maintains  that  these  bodies  are 
of  great  importance  in  the  early  recognition  of  interstitial 
nephritis. 

My  own  belief  is  that  if  we  can  be  absolutely  sure  that 
we  are  dealing  with  true  renal  cylindroids,  their  significance 
would  be  about  the  same  as  that  of  hyaline  casts.  But  the 
value  of  such  inferences  is  materially  lessened  by  the  great 
difficulties  which  often  attend  this  differentiation.  Not  in- 
frequently I  have  found  it  impossible.  So  experienced  an 
observer  as  Peyer  admits  the  same.  Therefore,  to  attribute 
any  absolutely  diagnostic  significance  to  cylindroids  is  not 
justified,  as  these  doubtful  cases  usually  occur  where  our 
other  means  of  diagnosticating  nephritis  also  leave  us  in  the 
lurch.  Such  a  conclusion  once  more  reminds  us  that  a  di- 
agnosis of  nephritis  ought  not  to  be  made  from  an  exami- 
nation of  the  urine  alone  ;  but  that  all  the  other  organs 
should  be  interrogated  before  making  absolute  statements 
as  to  the  existence  of  renal  disease. 

Literature. 

1.  Thomas.    Archiv  fur  Heillcunde,  1870,  Bd.  xi,  8.  130. 

2.  Rovida.   J.  Moleschott's  Untersuchungen,  Bd.  xi,  8.1-29. 

3.  Bartels.    Von  Ziemssen's  Cycloimdia,  1875,  Bd.  ix. 

4.  Wagner.    Der  Morbus  Brightii,  1882. 

5.  Bizzozero.  Klinische  Mikroslcopie.  German  Translation, 
1887,  S.  211. 

6.  Eicliborst.  Physikalische  Untersuchungsmethoden  in- 
neren  Kranhheiten. 

7.  Neubauer  und  Vogel.  Analyse  des  Earns,  9te  Auflage, 
2te  Theil,  S.  151. 

8.  Von  Jaksoh.    Klinische  Diagnostik,  2te  Auflage,  8.  236. 


Feb.  18,  1893.] 


KELSEY:  DISEASES  OF  THE  RECTUM. 


191 


9.  Fiirbringer.  Krankheiten  der  Ham-  und  Geachlechta- 
organe,  1890,  S.  36. 

10.  Siilkowski  und  Leube.  Die  Lehre  mm  Ham,  1882,  S. 
447. 

11.  Rosenstein.  Pathologie  und  Therapie  der  Nierenkrank- 
heiten,  3te  Auflage,  1886,  S.  45. 

12.  Von  TorOk  und  Pollak.  Archiv  far  experiment.  Pa- 
thologie und  Pharmakologie,  1888,  Bd.  xxv,  S.  87. 

13.  Baginsky.    Lehrhuch  der  Kinde-rkrankheiten,  1883. 

14.  Tyson.    Examination  of  Urine,  1886,  p.  214. 

15.  Millard.    BrighVs  Disease.    Third  Edition,  chap.  x. 

16.  Vierordt.  Diagnostik  der  inneren  Krankheiten,  1888, 
S.  355. 

17.  Peyer.  Atlas  of  Clinical  Microscopy,  1885,  Plates  6, 
82,  64. 

18.  Saundby.    Brighfs  Disease,  1889,  p.  40. 

19.  Von  Ilosslin.  Ueber  eine  ungewohnliche  Form  von 
Harncylindern  in  eiweissfreiem  Urin.  Munchener  med.  Woch- 
mschrift,  1889,  Bd.  xxxvi,  S.  771. 

20.  Danforth.    Medical  News,  vol.  Ixi,  No.  4,  p.  85. 

21.  Knoll.  Zeitschrift  fur  Heilkunde,  1882,  Bd.  iii,  S.  148  ; 
quoted  by  von  Jaksch,  loc.  cit.,  S.  238. 

22.  Le  Nobel.  CentralMatt  far  med.  Wissenschaft,  1887, 
Bd.  xxxiv,  S.  625.  . 

23.  Thomas  in  Gerhardt's  Handbuch  der  Kinderheilkunde, 
1878,  iv,  8te  Abtheilung,  S.  294. 

941  Madisok  Avenue. 


THE  THIRD  YEAR'S  WORK  AT 
THE  CLINIC  FOR  DISEASES  OF  THE  RECTUM 
IN  THE  NEW  YORK  POST-GRADUATE  HOSPITAL. 
By  CHARLES  B.  KELSEY,  M.  D. 

At  the  end  of  this,  the  third  year's  work  of  the  clinic, 
it  will  perhaps  be  profitable  to  spend  a  short  time  review- 
ing some  of  the  cases  you  have  seen  and  the  results  of 
treatment. 

I  show  you  here,  under  ether,  the  young  physician 
whose  rectum  I  amputated  several  weeks  ago.  You  will 
remember  the  case  was  one  of  non-malignant  but  extensive 
and  incurable  ulceration — incurable,  I  mean,  by  any  topical 
applications  or  minor  surgical  operation. 

The  cause  of  the  ulceration,  which  had  completely  de- 
stroyed the  lower  two  inches  of  the  gut,  it  was  impossible 
to  determine  positively.  He  thought  it  might  be  syphi- 
litic, but  he  had  never  had  any  other  sign  of  syphilis,  and 
the  argument  was  evidently  in  his  own  mind  from  the  effect 
back  to  a  supposed  necessary  cause,  and  not  vice  versa.  He 
had  been  operated  upon  years  ago  for  fissure,  but  had  not 
been  cured ;  he  had  been  curetted  and  cauterized  without 
effect ;  he  had  taken  mercurials  without  benefit,  and  all  the 
time  the  ulceration  of  the  rectum  had  been  progressing. 
This  sort  of  history,  as  you  know,  is  common  enough. 
Some  slight  lesion  causes  an  abrasion  of  the  rectum  or 
anus ;  this,  under  one  treatment  or  another,  progresses  and 
does  not  heal ;  operations  are  done  and  antisyphilitic 
treatment  is  prescribed  without  result ;  and  finally  the  pa- 
tient, after  about  five  years  of  suffering,  comes  before  us 
with  more  or  less  destruction  of  the  rectal  tissues  and  an 
unfounded  diagnosis  of  syphilis. 


This  patient  had  absolutely  no  sign  or  history  of  syphi- 
lis. He  had  ulceration  of  the  rectum  as  he  might  have 
been  bald.  It  would  be  as  sensible  to  accuse  every  bald 
man  of  syphilitic  alopecia  as  to  accuse  this  man  of  syphilis 
because  he  had  ulceration  of  the  rectum.  However,  the 
disease  was  incurable  by  local  treatment,  and  you  saw  the 
operation  of  extirpation  and  amputation  of  the  diseased 
portion  of  the  gut. 

I  told  you  at  the  time  that  a  colotomy  would  be  at- 
tended by  much  less  risk  and  would  give  as  good  an  ulti- 
mate result,  but  that  the  patient  preferred  an  anus  without 
sphincteric  power  in  the  perinseum  to  one  of  the  same  sort 
in  the  left  groin,  and  at  a  considerable  risk  of  life  we  would 
give  it  to  him.  I  therefore  amputated  about  two  inches 
and  a  half  of  the  rectum,  drew  down  the  stump  and  stitched 
it  to  the  anus,  where  the  external  sphincter  had  been  care- 
fully preserved. 

The  case  has  done  badly  from  the  time  of  the  opera- 
^tion. 

Had  I  done  a  colotomy  the  man  would  have  been  home 
at  his  work,  as  many  of  our  other  patients  with  the  same 
trouble  now  are.  But  here  he  is.  Two  days  after  the 
operation  his  temperature  was  105°  F.  We  had  no  sooner 
brought  this  down  than  he  had  a  severe  haemorrhage  from 
the  wound,  which  left  him  in  collapse.  To  stop  this,  all 
stitches  were  broken  loose  and  the  wound  plugged.  After 
lying  between  life  and  death  for  weeks  he  is  now  steadily 
improving,  and  I  have  brought  him  to  the  operating-room 
to  try  and  overcome  the  faulty  condition  of  the  parts. 

At  the  time  of  the  operation  great  care  was  taken  to 
preserve  as  much  of  the  sphincters  as  possible,  and  the  end 
of  the  bowel  was  carefully  stitched  to  them.  When  the 
secondary  haemorrhage  occurred  there  was  already  some 
union  of  the  surfaces,  enough  to  have  prevented  what  has 
happened,  but  this  was  necessarily  broken  down  in  packing 
the  wound.  The  gut  has  retracted  and  now  ends  two 
inches  from  the  perinseum.  In  the  cavity  thus  formed 
solid  faeces  are  prone  to  become  lodged,  and  as  the  skin  in- 
cision heals  their  removal  becomes  more  and  more  painful 
and  difficult.  This  can  be  avoided  by  laxatives  ;  but  to 
avoid  future  stenosis  I  propose  now  to  try  and  loosen  the 
gut  once  more  and  bring  it  down  to  the  skin. 

The  attempt  is  a  failure.  I  can  not  loosen  the  bowel 
without  practically  doing  another  resection,  so  firmly  has  it 
become  united  to  the  tissues,  and  this  would  not  be  justifi- 
able in  his  present  exhausted  condition.  It  will  be  much 
better  for  him  to  allow  the  parts  to  heal  as  they  will,  and 
to  trust  to  healing  over  a  bougie. 

This  is  not  an  unusual  result  after  resection.  All  cases 
are  followed  by  more  or  less  stenosis  or  incontinence,  and 
there  is  never  a  very  useful  anus.  So  that  the  choice  be- 
tween colotomy  and  extirpation  in  these  cases  is  more  a 
choice  of  the  place  where  an  anus  over  which  the  patient 
will  have  no  control  shall  be  located  than  a  choice  between 
a  useful  anus  and  incontinence  or  stenosis.  Colotomy, 
properly  performed,  is  never  followed  by  stenosis,  but  al- 
ways by  loss  of  control. 

You  see,  then,  the  price  this  man  has  paid  rather  than 
have  a  colotomy.    He  has  been  very  near  death  from  an 


192 


KELSEY:  DISEASES  OF  THE  RECTUM. 


[N.  Y.  Med.  Jot^., 


operation  which,  in  the  best  of  cases,  has  a  mortality  of 
twenty  per  cent,  rather  than  have  a  colotomy  which  would 
have  been  almost  without  risk,  and  how  much  he  has  gained 
in  utility  of  the  parts  is  very  problematical. 

One  case  of  extirpation  during  the  year  was  fatal — a 
case  of  cancer  not  very  great  in  extent,  but  involving  the 
neck  of  the  bladder  and  part  of  the  prostate.  All  the  dis- 
ease was  removed,  of  course,  and  the  bladder  widely  opened, 
and  yet  it  seemed  for  several  days  as  though  he  might  re- 
cover, but  he  died  on  the  tenth  day  from  hiccough.  It  is 
probably  the  last  case  of  cancer  you  will  ever  see  removed 
at  the  clinic  by  me  where  the  disease  is  not  strictly  limited 
to  the  gut  itself. 

In  one  other  Case  you  saw  me  abandon  an  attem[)t  at 
extirpation  of  a  non-malignant  stricture  because  of  a  pe- 
culiar condition  of  the  parts.  The  constriction  was  two 
inches  from  the  anus,  was  very  hard  and  tight,  and  could 
not  be  passed  by  the  finger  without  incision.  The  gut 
being  perfectly  normal  up  to  the  stricture,  I  made  the  diag- 
nosis of  congenital  malformation,  and  expected  to  resect 
the  part  and  suture  the  ends.  But  after  we  came  down 
upon  the  disease  by  Kraske's  incision,  I  found  two  unex- 
pected complications.  One  was  that  the  gut  above  the 
constriction  was  enormously  dilated.  It  was  large  enough 
easily  to  contain  a  foetal  head.  The  other  was  that  the 
stricture,  instead  of  being  limited  to  a  small  section  of  the 
gut,  as  I  had  supposed,  extended  farther  up  than  I  could 
reach. 

It  being  impossible,  therefore,  to  do  what  had  been 
planned,  the  wound  was  closed  and  the  patient  left  for  a 
future  colotomy.  We  might  have  excised,  but  the  opera- 
tion would  have  been  very  extensive,  and  it  would  have 
been  impossible  to  have  sutured  the  ends  of  the  gut  as  I 
had  hoped. 

Of  the  seven  colotomies,  some  have  been  of  remarkable 
interest.  Among  others  you  have  seen  me  lose  my  first 
patient  whose  death  could  be  attributed  directly  to  the 
operation,  and  that  too  from  an  accident  which  could  easily 
have  been  avoided.  I  recall  it  to  your  minds  both  because 
of  its  interest  and  because  no  other  such  accident  has  ever 
been  recorded. 

It  was  a  perfectly  simple  case  of  colotomy  for  cancer 
of  the  rectum  in  a  man  in  good  condition.  I  remember  at 
the  time  of  the  operation  the  physician,  who  had  brought 
us  the  case  from  a  distance,  leaned  over  the  rail  and  asked 
me  what  the  risk  of  the  operation  was,  and  I  answered  be- 
fore you  all  that  there  was  no  risk ;  that  in  colotomies 
such  as  this  the  mortality  was  below  one  per  cent.  ;  and 
that  the  patient  would  be  able  to  return  home  in  about 
three  weeks.  In  three  days  he  was  dead.  He  did  well  for 
forty-eight  hours,  when  it  was  discovered  that  the  dress- 
ing was  wet  through  with  serous  discharge.  This  alone 
to  an  experienced  dresser  would  have  excited  suspicion ; 
but,  as  the  attendant  said,  he  had  seen  so  many  colotomies 
in  this  clinic,  and  all  the  patients  get  well  without  an  acci- 
dent, that  he  did  not  imagine  anything  could  be  wrong. 
This  was  in  the  evening.  Next  morning  it  was  evident 
something  had  gone  wrong.  The  patient  was  vomiting  and 
partially  collapsed,  and  all  of  the  bowel  that  could  get  out 


through  a  two-inch  incision  in  the  left  inguinal  region  was 
out  of  the  body  and  mixed  up  with  the  dressings.  It  took 
me  an  hour  and  a  half  to  separate  the  bowel  from  the  bi- 
chloride gauze  by  careful  dissection,  so  firmly  were  they 
united  by  plastic  exudation.  Then  the  original  incision 
was  enlarged  and  the  bowel  returned,  but  the  man  died  of 
shock. 

And  now  I  want  to  tell  you  that  I  have  had  in  my  own 
practice  the  same  accident  once  before,  but  without  fatal 
result,  and  with  a  surgeon's  usual  luck  the  two  cases  came 
within  two  weeks  of  each  other ;  and  that  these  two  cases 
are  the  only  ones  on  record.  Other  operators  may  have 
met  with  the  same  thing,  but,  if  so,  they  have  not  cared  to 
report  it.  If  they  were  merely  accidents  without  special 
bearing  upon  the  operation,  I  also  might  not  care  to  report 
them ;  but  the  accident,  though  always  liable  to  happen 
after  colotomy,  can  also  always  be  guarded  against  when 
once  its  liability  has  been  noted. 

In  my  other  case  the  evisceration  was  also  marked  by  a 
sudden,  unusual,  and  unaccountable  gush  of  serum,  which 
soaked  the  dressings  twenty-four  hours  after  the  opera- 
tion. In  this  case  I  accounted  for  the  'evisceration  by  the 
fact  that  there  was  considerable  distention  and  obstruc- 
tion at  the  time  of  the  operation,  but  in  the  other  case 
these  conditions  were  absent.  Fortunately,  my  assistant 
called  soon  after  the  bandages  had  become  soaked,  and, 
noticing  that  something  unusual  had  happened,  insisted 
upon  removing  them.  Three  or  four  feet  of  gut  had  es- 
caped and  were  strangulated  and  cold ;  stitches  were  cut, 
the  wire  suture  removed,  circulation  returned,  and  the 
bowel  reduced.  On  my  arrival  the  sigmoid  was  still  in 
place,  holding  by  the  sutures  on  one  side.  It  was  at  once 
incised  to  allow  of  the  escape  of  gas  and  faeces  and  to  pre- 
vent further  accident,  and  after  this  the  gut  was  stitched 
to  the  edges  of  the  wound  by  sutures  passing  through 
its  entire  thickness.  The  patient  recovered  without  a 
bad  symptom.  The  other  one  would  probably  also  have 
recovered  had  the  evisceration  been  discovered  when  it 
occurred. 

What  is  the  lesson  from  these  two  cases  ?  Shall  we  al- 
ways open  the  gut  at  the  time  of  the  operation  instead  of 
waiting  forty-eight  hours,  as  has  been  our  custom  ?  Or  shall 
we  suture  the  gut  to  the  skin  wound  more  firmly  ?  Rather,  I 
think,  the  latter.  These  two  accidents  have  been  due  directly 
to  the  reports  which  I  have  heard  and  read  of  certain  opera- 
tions abroad  where  no  sutures  at  all  were  used,  a  glass  rod 
being  passed  through  the  mesentery  of  the  gut,  and  kept 
in  position  by  straps  of  plaster  till  the  incision  had  been 
closed  by  plastic  exudation.  No  accidents  having  been  re- 
ported, I  have  gradually  reduced  the  number  of  sutures  in 
my  own  cases  from  twelve  or  fourteen  to  five  or  six — with 
the  result  of  my  first  fatal  case. 

It  may  be  noted  that  an  accident  exactly  the  opposite 
of  this  has  been  reported  by  Cripps.  After  one  or  two  of 
his  operations  (in  one  I  think  even  after  (he  gut  had  been 
incised)  the  bowel  tore  loose  from  the  wound,  dropping 
into  the  abdomen,  and  had  to  be  recovered.  This,  of  course, 
could  not  happen  with  the  silver  suture  which  is  passed 
through  the  mesentery  in  the  cases  operated  upon  here, 


Feb.  18,  1893.] 


TOWNSEND:   THE  TEE  A 


TMENT  OF  HIP  DISEASE. 


193 


and  I  had  supposed  also  that  hernia  was  impossible — but 
experientia  docet. 

You  saw  an  operation  not  long  since  in  a  phenomenal 
case  of  haemorrhoids.  The  tumors  were  the  largest  I  had 
ever  seen.  There  was  an  enormous  mass  on  each  side  of 
the  anus,  which  had  to  be  first  cut  into  smaller  sections  be- 
fore the  clamp  could  be  applied. 

I  told  you  of  the  gentleman  who  had  asked  if  we  used 
the  clamp  in  the  mild  cases  what  we  did  in  the  severe  ones, 
and  that  this  case  would  answer  his  question.  I  also  of- 
fered it  as  a  test  case,  explaining  that  if  the  clamp  and 
cautery  did  not  act  satisfactorily  in  controlling  the  bleeding, 
we  would  abandon  its  use  and  go  back  to  the  ligature.  I 
am  glad  to  report  that  the  results,  both  at  the  time  of  op- 
eration and  subsequently,  were  perfectly  satisfactory. 


THE  TREATMENT  OF  HIP  DISEASE.* 

Bt  W.  R.  TOWNSEND,  A.M.,  M.D. 

In  this  short  paper  it  is  not  my  intention  to  describe 
any  particular  forms  of  braces,  or  to  advocate  the  use  of 
any  special  apparatus,  but  rather  to  speak  of  general  prin- 
ciples of  treatment  that  can  be  carried  out  by  any  general 
practitioner.  I  will  consider  the  subject  under  the  follow- 
ing heads : 

1.  General  or  constitutional  treatment. 

2.  Local  protection  to  the  diseased  joint. 

3.  Treatment  of  abscesses. 

4.  Correction  of  deformity. 

5.  Excision. 

In  the  first  place,  we  will  assume  that  a  correct  diagno- 
sis has  been  made,  and,  while  in  the  majority  of  cases  I  do 
not  believe  a  differential  diagnosis  can  be  made  between 
the  femoral  and  acetabular  varieties,  yet  the  principles  of 
treatment  are  the  same. 

In  the  large  majority  of  cases  the  disease  is  of  tubercu- 
lar origin ;  and,  while  tuberculosis  of  bone  may  not  be  as 
fatal  to  life  as  tuberculosis  of  the  pulmonary  tissues,  yet 
in  most  cases  too  little  attention  is  paid  to  hygienic  sur- 
roundings and  to  constitutional  treatment.  In  many  in- 
stances a  brace  is  applied  and  nothing  further  done.  An 
out-of-door  life  is  of  great  advantage,  and  if  climatic  influ- 
ences are  of  any  value  in  pulmonary  phthisis,  they  should 
also  be  of  use  in  tubercular  osteitis.  The  improvement  in 
some  children  by  even  a  short  trip  to  the  seaside  or  the 
mountains  is  often  very  marked,  and  may  in  some  cases  be 
followed  by  a  favorable  change  in  all  the  symptoms  of  the 
disease.  At  the  Hospital  for  the  Ruptured  and  Crippled 
during  the  summer  months  the  children  are  sent  to  Sum- 
mit, N.  J.,  Bath  Beach,  Long  Island,  and  Saratoga ;  and 
children  that  have  left  the  hospital  in  very  poor  physical 
condition  have,  in  nearly  all  instances,  been  greatly  im- 
proved. They  are  weighed  before  going  and  on  return, 
and  we  have  found  the  gain  in  body  weight  to  average 
about  five  pounds  for  the  two  months'  stay,  and  that  even 
after  the  return  the  improvement  continues.    They  sleep 

*  Read  before  the  Hospital  Graduates'  Club,  December  1,  1892. 


and  eat  better ;  in  some,  sinuses  that  had  discharged  pro- 
fusely for  many  months  have  closed,  and  the  change  of  air 
seems  of  the  greatest  benefit. 

In  addition  to  good  hygiene,  cod-liver  oil  is  a  most  use- 
ful remedy  and  should  be  used  in  nearly  all  cases.  Tonics 
should  be  employed  where  appetite  is  poor  or  the  child 
anaemic.  Tablets  of  albuminate  of  iron,  or  iron  and  strych- 
nine, seem  to  be  as  useful  as  any  of  the  various  tonics. 
Other  preparations  may  be  made  up  to  suit  individual  pa- 
tients, or  to  suit  the  views  of  various  practitioners ;  but  I 
would  strongly  urge  that  in  all  cases  constitutional  treatment 
be  not  neglected. 

Local  Protection  to  the  Diseased  Joint. — Two  methods 
of  treatment  are  possible  to  protect  the  inflamed  joint — one 
by  complete  rest  in  the  recumbent  position,  either  with  or 
without  the  use  of  any  apparatus,  and  the  other  by  allowing 
the  patient  to  go  about,  and  keeping  the  limb  more  or  less 
completely  immobilized  by  means  of  a  brace.  The  combi- 
nation of  both  methods  promises  the  best  results.  If  the  dis- 
ease is  very  acute,  rest  in  bed  is  of  the  utmost  importance, 
and  the  patient  should  be  kept  flat  on  the  back.  In  very 
young  children  this  can  be  done  by  placing  them  on  a  frame 
or  cuirass.  Extension  can  be  made  either  by  Buck's  method 
or  by  means  of  a  brace.  By  this  method  absolute  protection 
is  afforded  the  joint,  and  the  only  question  to  be  considered 
is  whether  the  general  health  is  being  impaired  by  the  con- 
finement to  bed.  In  most  cases  the  children  do  remarkably 
well,  and  in  Europe  many  children  are  kept  thus  on  the 
back  for  the  entire  course  of  the  disease,  and  retain  their 
general  health  in  a  very  marked  degree.  After  the  acute 
symptoms  have  subsided,  patients  may,  however,  with  ad- 
vantage be  allowed  to  go  about;  and,  with  a  properly  ap- 
plied splint,  either  with  or  without  the  use  of  crutches,  in 
the  majority  of  cases  do  well.  Crutches  are  of  great  assist- 
ance and  render  more  perfect  the  protection  to  the  joint, 
and  the  extension  is  much  more  satisfactorily  kept  up,  no 
matter  what  form  of  splint  is  used.  If  during  treatment 
an  exacerbation  occurs,  by  putting  the  child  to  bed  for  a 
few  weeks  until  it  has  subsided  the  subsequent  course  of 
the  disease  will  usually  be  much  more  favorable.  The  joint 
should  be  protected  until  all  signs  of  disease  have  disap- 
peared. Never  remove  the  apparatus  while  reflex  spasm  is 
present.  Never  do  away  with  the  brace  while  abscesses  or 
sinuses  exist,  and  remember  that,  in  the  average  case  with- 
out complications,  the  joint  should  be  protected  for  at  least 
eighteen  months.  The  mistake  of  leaving  a  brace  on  too 
long  is  much  less  often  made  than  of  taking  it  off  too  soon. 

The  Treatment  of  Abscesses. — In  considering  this  part 
of  the  subject  I  believe  we  must  recognize  a  difference  be- 
tween the  abscesses  of  hip  disease  and  those  of  Pott's  dis- 
ease, for  in  the  latter,  so  long  as  the  abscess  causes  no 
symptoms,  it  can  be  safely  left  alone ;  and  if  treated  by  as- 
piration, either  with  or  without  the  use  of  injections  of  iodo- 
form and  oil,  in  about  fifty  per  cent,  of  the  cases  the  fluid 
contents  will  be  absorbed  and  only  a  cheesy  mass  remain. 
Abscesses  within  the  pelvis  are  hard  to  drain ;  sepsis  usu- 
ally follows  sooner  or  later  after  they  are  opened,  the  origi- 
nal source  of  the  disease  can  not  be  reached,  and  the  more 
abscesses  of  Pott's  disease  one  sees,  the  less  anxious  In-  is  to 


TOWNSEKD:   THE  TREATMENT  OF  HIP  DISEASE. 


[N.  Y.  Mbd.  Joor., 


resort  to  radical  operations.  About  the  hip,  however,  ab- 
scesses are  usually  near  the  surface ;  they  generally  inter- 
fere with  the  proper  application  of  a  brace ;  they  have  a 
tendency  to  dissect  between  the  muscles,  to  destroy  tissue 
which,  when  healing  occurs,  may  cause  interference  with 
free  muscular  movements,  and,  by  proximity  to  important 
blood-vessels,  may  cause  danger  from  hjemorrhage.  In  small 
abscesses,  removal  by  aspiration  and  the  injection  into  the 
sac  of  iodoform  and  oil  may  give  good  results ;  but  if  this 
fail,  and  in  all  large  abscesses,  the  best  plan  of  treatment, 
I  believe,  is  to  freely  open,  thoroughly  scrape  with  a  Volk- 
mann  spoon,  dust  well  with  iodoform,  and  endeavor  to  get 
healing  by  first  intention.  If  when  the  abscess  is  opened 
the  sinus  leading  to  bone  can  be  found,  it  should  be  scraped 
and  any  diseased  bone  also  removed.  If  the  bone  is  found 
markedly  diseased — the  head  separated,  for  instance,  from 
the  shaft — a  more  or  less  complete  excision  should  be  done 
and  thorough  drainage  established.  The  incision  should  be 
in  most  instances  the  full  length  of  the  abscess,  and  I  have 
seen  incisions  of  twelve  and  fourteen  inches  on  the  thigh  in 
children  with  hip  abscesses  heal  by  primary  union  and  the 
patient  progress  from  that  time  on  much  more  favorably. 
Where  sinuses  exist  after  abscesses,  they  should  be  thor- 
oughly scraped  and  packed  with  gauze  impregnated  with 
iodoform,  guiacol,  balsam  of  Peru,  or  some  such  substance. 

Correction  of  Deformity. — It  must  be  clearly  understood 
that  our  aim  in  treatment  is  to  prevent  deformity  ;  but  as 
deformity  is  one  of  the  early  symptoms  and  we  rarely  see 
the  patients  prior  to  its  occurrence,  the  problem  of  how 
best  to  correct  it  is  all-important.  We  have  the  choice  of 
four  methods : 

1.  Rest  in  bed  with  extension  by  weight  and  pulley  or 
brace. 

2.  Complete  immobilization  of  the  joint  by  brace  or 
plaster  of  Paris. 

3.  Forcible  correction  without  an  anaesthetic,  as  by  use 
of  the  Thomas  splint. 

4.  Correction  under  an  anaesthetic. 

The  first  method  is  the  best  where  symptoms  are  acute, 
and  whether  we  use  a  weight  and  pulley  or  brace,  the  ex- 
tension must  be  made  in  the  line  of  the  deformity.  A  con- 
venient way  of  accomplishing  this  is  to  place  the  affected 
lower  extremity  upon  an  inclined  plane  and  allow  the  weight 
to  hang  over  the  foot  of  the  bed,  the  pulley  being  fastened 
to  an  upright.  If  the  weight  of  the  body  does  not  produce 
sufficient  counter-extension,  a  band  may  be  made  to  pass 
under  the  pelvis  to  the  head  of  the  bed  or  under  the  arm- 
pits to  the  head  of  the  bed.  If  a  splint  is  used,  the  inclined 
plane  will  also  be  of  service,  although,  of  course,  traction  is 
made  by  splint.  As  reflex  spasm  subsides  and  deformity 
decreases,  the  inclined  plane  may  be  lowered  until  finally 
the  limbs  can  be  brought  down  flat  and  parallel  without  any 
tilting  of  the  pelvis. 

The  second  method  is  applicable  in  patients  who  can  not 
for  various  reasons  have  bed  treatment,  and  consists  in 
completely  immobilizing  the  joint  at  the  angle  of  deformity 
and  allowing  the  plaster  of  Paris  or  the  splint  to  remain  on 
for  several  weeks,  then  taking  it  off  and  reapplying  in  the 
most  favorable  position.    By  this  method  1  have  seen  ten 


and  fifteen  degrees  of  deformity  corrected  at  each  applica- 
tion of  the  plaster  or  brace  until,  finally,  the  limb  was 
straightened  completely. 

The  third  method  consists  in  the  application  of  a  pos- 
terior brace  fastened  to  the  body  above  and  to  the  leg  be- 
low, and,  by  forcibly  bending  the  brace  which  firmly  presses 
against  the  hip,  to  forcibly  overcome  the  deformity.  No 
traction  is  used,  and,  unless  great  care  is  exercised,  much 
damage  may  be  done  to  the  joint.  This  method  is  not 
much  in  use  at  the  present  day. 

The  fourth  method  also  must  be  used  with  great  cau- 
tion ;  but  if  during  the  administration  of  the  anaisthetic  the 
limb  be  carefully  held  to  prevent  any  traumatism  occurring, 
and,  after  the  reflex  spasm  has  disappeared,  if  the  limb  can 
be  brought  down  straight  without  the  employment  of  much 
force,  no  damage  will  be  done  to  the  joint ;  but  it  is  a 
method  that  should  not  be  used  indiscriminately.  When 
the  limb  is  brought  down  straight  it  is  held  there  by  means 
of  plaster  of  Paris  or  a  brace. 

In  cases  where  all  acute  symptoms  have  subsided  and 
the  disease  is  cured,  but  with  deformity,  if  this  is  excessive 
it  should  be  corrected  by  operation.  Under  an  anaesthetic, 
effort  is  first  made  to  overcome  the  flexion  or  adduction  by 
means  of  tenotomies  of  resistant  muscles  or  by  division  of 
shortened  fascia  and  skin.  If  this  fails,  an  osteotomy  below 
the  trochanter  minor  is  indicated.  This  operation  is  useful 
whether  we  have  ankylosis  or  motion  at  the  joint.  The 
limb  is  put  up  in  plaster  of  Paris  or  a  brace  and  held 
firmly  until  union  of  the  fracture  occurs,  when  the  patient 
is  allowed  to  go  about,  the  limb  being  supported  by  a  suita- 
ble brace.  This  is  an  extremely  satisfactory  operation,  espe- 
cially where  the  deformity  is  excessive,  for,  by  overcoming 
the  flexion,  patients  are  cured  of  the  troublesome  lordosis 
and  several  inches  in  length  added  to  the  limb,  and  the 
lameness  thereby  much  diminished. 

Excision  of  the  Hip. — In  my  opinion,  except  in  rare  in- 
stances, excision  should  be  resorted  to  only  in  cases  where 
abscesses  are  extensive,  destruction  of  bone  is  great,  or  the 
life  of  the  patient  endangered  by  excessive  suppuration  or 
amyloid  changes.  Konig,  in  a  recent  article,  states  that 
four  fifths  of  all  patients  with  tubercular  joint  disease  have 
also  other  forms  of  tubercular  disease.  This  is  probably 
too  high;  but  one  of  the  principal  arguments  in  favor  of 
excision  has  been  much  weakened  since  it  is  now  known 
that  but  rarely  is  the  bone  lesion  the  only  focus,  and  that 
but  a  very  small  percentage  of  cases  of  bone  tuberculosis 
develop  general  tuberculosis.  The  results  of  proper  and 
efiicient  conservative  treatment  are  so  good  that  excisions 
are  rarely  done  to-day  in  early  cases. 

Much  more  could  be  said  on  the  subject  of  the  treat- 
ment of  hip  disease,  but  I  have  endeavored  to  speak  only 
of  a  few  general  principles  that  we  should  have  in  mind 
in  treating  any  case.  There  is  one  point,  however,  I  would 
like  to  emphasize — namely  :  be  sure,  if  possible,  to  overcome 
all  deformity  before  applying  a  walking  brace,  for,  if  not,  a 
deformity  will  increase  and  become  permanent ;  and  if  the 
case  is  seen  after  deformity  has  occurred,  let  the  first  ob- 
ject be  to  properly  protect  the  inflamed  joint,  and,  secondly, 
overcome  the  deformity. 


Feb.  18,  1893.] 


OOLDSBOROUGH:  HTSTERECTOMT. 


195 


HYSTERECTOMY 
PERFORMED  FIVE  DAYS  AFTER  LABOR  FOR 
PDERPERAL  METRITIS. 

BY   THE    ATTENDING  PHTSICIiN, 

BRICE  W.  GOLDSBOROCGII,  M.  D., 

CAMBMDQK,  MD. 

I  OFFER  the  following  contribution  under  the  conviction 
that  a  certain  percentage  of  cases  of  "  puerperal  fever " 
tending  to  run  a  fatal  course  could  be  rescued  by  a  timely 
radical  operation,  cleansing  the  peritonaiuin,  removing  ova- 
ries and  tubes  or  uterus ;  in  other  words,  wherever  a  local 
septic  focus  exists  which  can  not  be  reached  per  vaginam, 
attacking  it  per  abdomen. 

My  patient,  Mrs.  S.,  came  to  term,  giving  birth  to  a  normal 
healthy  living  boy,  December  8,  1891.  She  was  a  primipara, 
aged  thirty-four,  in  excellent  health.  The  labor  was  natural 
and  but  few  examinations  were  made,  and  each  time  after 
scrubbing  hands  and  nails,  both  before  and  after  the  examina- 
tion. There  was  no  hajmorrhage,  the  placenta  came  away 
under  gentle  expression  in  about  fifteen  minutes,  and  I  could 
detect  no  tear  on  careful  inspection  of  the  genitals  within  as 
well  as  outside.  Her  condition  remained  normal  until  seventy- 
two  liours  after  labor,  when  she  was  seized  with  a  severe  chill 
lasting  over  an  hour.  1  saw  her  between  three  and  four  hours 
later,  when  the  temperature  was  104-5°  F.  and  the  pulse  120 ;  she 
had  an  anxious,  collapsed  expression.  There  was  no  abdominal 
pain  or  nausea,  but  much  headache ;  the  abdomen  was  flat. 
Tlie  lociiia  was  suppressed  to  a  slight  foul,  odorous  discharge. 
Tenderness  on  pressure  was  marked  ;  she  screamed  upon  press- 
ure on  the  uterus.  My  first  efforts  at  treatment  were  directed 
toward  washing  out  the  uterus  with  the  long  point  of  an  alpha 
syringe,  using  warm  carbolized  water.  I  also  ordered  at  once 
large  doses  of  sulphate  of  quinine,  forty  grains  in  the  day,  and 
phenacetine  in  ten-grain  doses  every  few  hours,  as  soon  as  the 
temperature  arose  above  103°  F.  I  hastened,  in  addition,  to 
evacuate  the  intestinal  tract  by  giving  her  five  grains  of  calomel 
and  soda.  Hot  mush  poultices  were  kept  constantly  on  the  ab- 
domen. In  this  way  I  secured  some  temporary  relief,  but,  as  I 
now  fear,  at  the  expense  of  masking  some  of  the  important 
symptoms  necessary  to  a  correct  estimate  of  her  condition. 

On  the  following  day  (Sunday,  the  fourth  day),  Dr.  T.  B. 
Steele  was  called  in  consultation.  The  general  condition  was 
manifestly  worse,  the  uterus  furnisliing  a  scant,  foetid,  black 
discharge,  and  the  tenderness  increased.  Specular  examination 
showed  a  large,  congested,  blacliish-bhio  cervix  covered  witli 
grayish,  diphtlieritic  exudate,  closely  adherent;  this  could  not 
he  detached  en  masse,  but  broke  off,  leaving  a  bleeding  surface; 
this  deposit  extended  down  into  the  vagina  and  involved  the 
labia.  The  temperature  was  105°,  pulse  130,  prostration  ex- 
treme, facies  anxious  and  drawn,  tongue  coated  and  dry,  thirst 
intense,  abdomen  tympanitic,  no  vomiting,  frequent  urination. 
She  had  had  several  cojjious  evacuations  fi'om  the  calomel. 
The  diplitlieritic  masses  were  removed  with  peroxide  of  hydro- 
gen applied  witliin  the  uterus  as  well  us  in  the  vagina,  and  the 
uterus  was  again  waslied  out  with  warm  carbolized  water,  and 
phenacetine  was  continued.  A  fatal  issue  seemed  certain  under 
the  present  condition,  and  we  therefore  decided,  on  account  of 
her  rapidly  failing  condition,  to  telegraph  for  Dr.  H.  A.  Kelly, 
of  the  Johns  Hopkins  Hospital,  to  come  prepared  to  perform  a 
hysterectomy. 

Dr.  Kelly  responded  at  once,  arriving  the  following  day 
(Monday)  at  one  o'clock,  and,  finding  her  condition  as  described, 


in  addition  to  a  septic  pleurisy  under  way,  while  the  patient 
appeared  to  be  approaching  collapse,  performed  abdominal 
hysterectomy. 

Operation. — An  incision  was  made  in  the  linea  alba  fifteen 
centimetres  (six  inches)  in  length,  and  the  distended  intestines^ 
which  were  embarrassing  throughout  the  operation,  were  held 
to  one  side  by  pieces  of  sterilized  gauze,  while  the  large,  softish^ 
putty-like,  deeply  injected  uterus  was  lifted  out  of  the  abdomen 
and  a  temporary  rubber  ligature  thrown  around  its  cervical  end, 
and  the  uterus  and  ovaries  and  tubes  were  at  once  cut  away 
above  the  ligature,  thus  removing  the  whole  septic  body  with 
the  enlarged  ovaries  and  tubes.  Extreme  care  was  taken  to  pre- 
vent any  fluid  from  the  uterus  escai)ing  on  to  the  peritonaeum 
while  cutting  tlie  organ  away.  The  stump  of  the  cervix  was 
thoroughly  burned  out  with  a  Paquelin  cautery  managed  by  Dr, 
Steele,  and  then  sewed  together  in  two  layers— a  lower  of  buried 
sutures  and  an  upper  of  symperitoneal  silk  sutures ;  this  stump, 
was  then  suspended  in  the  lovs'er  angle  between  the  lips  of  the 
incision  where  the  parietal  peritona5um  on  all  sides  was  attached 
to  the  peritonaeum  of  the  stump,  thus  secluding  it  from  the  ab- 
dominal cavity,  closed  down  to  the  stump  without  drainage,  and 
avoiding  the  more  dangerous  method  of  leaving  the  constricting 
ligature  on  the  stump  to  slough  off  later. 

The  symperitoneal  ligatures  w^ere  left  long  for  the  purpose 
of  suspending  the  stump,  and  avoiding  a  tendency  to  drag  back 
into  the  abdomen. 

A  small  opening  was  left  in  the  lower  angle  of  the  skin 
wound  leading  down  to  the  stump,  and  was  packed  with  iodo- 
form gauze.  There  was  no  peritonitis  and  there  were  no  adhe- 
sions; the  right  ligament  was  distended  by  bright-red  cords^ 
looking  like  lymph  vessels,  as  large  as  the  little  finger.  Both 
ovaries  were  swollen.  The  uterus  was  large  and  everywhere 
infiltrated,  containing  necrotic  areas  in  its  substance  where  the- 
muscular  tissue  was  disintegrated. 

After  the  Operation. — Following  the  removal  of  this  great- 
septic  focus  there  was  an  immediate  marked  improvement;  the 
temperature  became  normal  within  an  hour,  and  the  pulse 
dropped  to  120.  The  pulse  varied  from  120  to  130  for  three 
days  and  the  temperature  100°  to  102-5°. 

Subsequently  there  was  no  vomiting,  no  tympany,  and  no 
pain  ;  there  were  no  chills  until  five  days  after  operation,  when 
a  stitch-hole  abscess  formed  with  severe  local  pain  and  eleva- 
tion of  temperature  and  pulse  (140);  this  discharged  on  the 
eighth  day  with  relief  of  the  symptoms.  At  this  time  all  ab- 
dominal stitches  were  removed.  Her  subsequent  recovery  was 
interrupted  in  the  fourth  week  by  phlebitis  beginning  in  the  left 
ankle,  extending  up  to  the  body,  involving  the  right  leg  on  the 
following  day.  In  three  to  four  weeks  the  suspensory  ligature 
came  away,  and  without  any  further  drawbacks  she  recovered 
complete  health  and  resumed  all  household  duties  in  four 
months.  To-day,  just  a  year  after  the  operation,  she  is  in  the 
best  of  health,  with  no  sequels  save  a  small  abscess  which 
formed  in  the  abdominal  cavity  and  healed. 


An  Ohio  Association  of  Railway  Surgeons.— A  circular  has  been 
issued  ciiUing  upon  all  the  railwiiy  surgeons  of  Ohio  to  meet  in  the 
aiti[)hitlieatie  of  tlie  Ohio  Medical  University,  in  rohimhus,  on  March 
17th,  at  0  A.  M.,  standard  time,  for  the  pin-pose  of  organizing  a  State 
association  of  railway  surgeons.  Those  who  expect  to  l)e  present  arc 
asked  to  comnuuiicate  with  Dr.  Charles  II.  Merz,  of  Sandusky. 

The  West  End  Medical  Society. — Officers  for  the  year  1893  have 
been  elected  as  follows :  President,  Dr.  George  W.  Leonard ;  vice- 
president,  Dr.  J.  M.  Kennedy ;  recording  secretary.  Dr.  V.  Spencer  Hal- 
sey ;  corresponding  secretary.  Dr.  F.  J.  Hlodgett;  treasurer,  Dr.  S. 
Ten  Eyck  ;  pathologist.  Dr.  Charles  N.  Dowd. 


196 


LEADING  ARTICLES. 


[N.  Y.  Med.  Joub., 


THB 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

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


NEW  YORK,  SATURDAY,  FEBRUARY  18,  1893. 


THE  NEW  NATIONAL  QUARANTINE  ACT. 

We  publish  elsewhere  the  entire  text  of  the  national  quar- 
antine act  recently  passed  by  both  Houses  of  Congress  and  now 
awaiting  the  signature  of  the  President.  We  believe  that 
an  inspection  of  its  provisions  will  justify  our  assertion 
that  it  is  a  poor  law  that  has  been  formulated  as  a  matter 
of  expediency  and  offered  as  a  "  sop  to  Cerberus,"  the  public 
being  led  to  believe  that  it  will  accomplish  something,  while 
its  provisions  are  such  that  there  is  but  little  change  in  existing 
conditions. 

It  is  entitled  "  An  act  granting  additional  powers  and  im- 
posing additional  duties  upon  the  Marine-Hospital  Service," 
and  yet  the  second  section  of  the  act  states  that  the  Secretary 
of  the  Treasury  shall  prescribe  the  form  for  the  bill  of  health, 
and  authorizes  the  President  to  detail  any  medical  officer  of  the 
Government  to  serve  as  an  inspector  attached  to  a  consular 
oflBce.  The  first  part  of  section  third  has  been  a  law  of  the 
United  States  since  1799,  but  that  portion  of  this  section  that 
authorizes  the  Secretary  of  the  Treasury  to  make  such  addi- 
tional rules  and  regulations  as  are  necessary  to  prevent  the  in- 
troduction of  contagious  or  infectious  diseases  into  the  United 
States,  where  the  quarantine  regulations  of  the  State  or  muni- 
cipality are  insufficient,  is  a  new  feature  that  is  fraught  with 
endless  possibilities  of  conflict  between  State  and  national  au- 
thorities. While  the  Supreme  Court  of  the  United  States  has 
held  that,  at  any  time  that  Congress  may  see  fit,  national  laws 
assuming  control  of  quarantine  may  be  enacted,  it  has  not  held 
that,  granting  the  right  or  prerogative  to  any  State  or  munici- 
pality to  administer  a  local  quarantine,  any  department  of  the 
national  Government  can  sit  in  judgment  on  the  way  and  man- 
ner in  which  that  quarantine  is  administered.  There  is  a  great 
difference  between  the  two  positions,  and  we  believe  that  any 
health  officer  would  be  justified  in  disregarding  such  regulations 
as  would  be  tantamount  to  a  pronounced  judgment  of  incapaci- 
ty on  his  administration;  and  we  further  believe  that  the 
United  States  courts  would  sustain  him  should  he  ignore  such 
additional  rules  and  regulations  as  the  Secretary  of  the  Treasury 
might  prescribe. 

All  the  provisions  of  section  four  are  in  operation  under  the 
law  of  1878. 

Section  six  partakes  of  the  nature  of  a  Delphic  oracle,  as  it 
may  be  interpreted  in  several  ways;  the  Secretary  of  the 
Treasury  is  to  judge  of  the  efficiency  of  a  local  or  State  quar- 
antine, and,  if  its  provisions  are  inadequate,  he  may  order  a 
vessel  to  a  national  quarantine  station.  Are  such  stations  to 
be  established  along  the  Atlantic  coast  to  bo  in  readiness  for 


this  emergency  ?  As  not  a  dollar  is  appropriated  to  carry  out 
the  provisions  of  this  act,  even  those  of  section  eight,  authoriz- 
ing the  purchase  of  State  quarantine  establishments  by  the 
United  States,  it  is  not  apparent  where,  north  of  Delaware 
Breakwater,  a  vessel  bound  to  Portland  (Maine),  Boston, 
or  New  York  may  be  ordered  for  quarantine  at  a  national 
station. 

No  uniform  system  of  quarantine  administration  or  estab- 
lishment is  provided  by  this  act,  and  it  is  to  be  hoped  that  the 
public  will  expect  no  more  from  it  than  the  medical  profession 
expects. 


ISOLATED  TUBERCULAR  PERICARDITIS. 

At  a  recent  meeting  of  the  Medical  Society  of  Berlin  a  case 
of  this  affection  was  reported  by  Professor  Virchow.  In  his 
experience,  according  to  the  Medical  Press  and  Circular  for 
December  21,  1892,  isolated  pericarditis  of  the  tubercular  va- 
riety has  been  a  rare  occurrence.  He  met  with  his  first  case  as 
long  ago  as  when  he  resided  at  Wiirzburg,  and  he  now  remem- 
bers that  it  surprised  liim  not  a  little  that  the  patient,  a  man  of 
eighty,  manifested  no  other  signs  of  tubercular  degeneration. 
Subsequent  cases  of  this  disease  have  been  of  a  like  nature  in 
this  respect.  Many  of  these  cases,  perhaps  the  majority  ot 
them,  showed  the  remarkable  complication  of  extensive  peri- 
cardial haamorrhages,  as  if  a  rupture  of  the  heart  had  taken 
place. 

The  present  case  was  that  of  a  robust  man  from  Salzwedel. 
He  had  enjoyed  good  health  until  about  eight  weeks  before 
coming  under  Virchow's  observation.  His  attack  began  with 
a  severe  chill.  About  five  weeks  later  he  was  taken  to  the 
hospital,  where  the  diagnosis  of  hydropericarditis  was  made. 
There  was  dyspnoea,  but  no  fever,  with  oedema  of  the  legs  and 
ascites.  This  otherwise  powerful  man  had  given  no  evidences 
of  renal  disease,  of  cancer,  or  of  tuberculosis.  At  the  autopsy 
the  pericardium,  pleuree,  and  peritonaeum  were  found  to  contain 
fluid  ;  that  of  the  pericardium  was  hsmorrhagic.  The  surface 
of  the  heart,  which  was  considerably  hypertrophied,  had  the 
appearance  of  having  been  the  seat  of  a  frequently  recurrent 
pericarditis.  On  a  more  thorough  examination  of  the  cut  sur- 
face of  the  heart  an  enormous  eruption  of  tubercles  was  seen 
in  the  deeper  tissue  of  the  pericardium  and  in  the  heart's  mus- 
cular structure  itself.  The  tubercles  were  full  of  giant  cells, 
unusually  large,  but  there  were  comparatively  few  tubercle  ba- 
cilli. The  origin  of  the  disease — which  was  one  of  the  first  to 
lead  Virchow  to  dispute  the  old  prevalent  doctrine  of  dyscrasia 
in  the  causation  of  tubercular  disease — he  held  to  be  local  to 
the  pericardium ;  his  opinion  is  that  the  disease  may  begin  in  a 
non-specialized  inflammation  of  the  serous  membrane.  After 
a  time  adhesions  and  sclerotic  conditions  occur,  and  the  morbid 
tissues  become  highly  vascularized.  The  nest  step  is  a  haemor- 
rhage, and  then  a  tubercular  degeneration  follows.  The  affec- 
tion must  therefore  be  set  down  as  a  typical  local,  and  non- 
dyscrasic,  tuberculosis.  Virchow  had,  from  his  first  case  of  the 
kind,  formed  such  an  opinion,  but  the  full  explanation  of  it  did 
not  come  to  him  until  later. 


Feb.  18,  1893.] 


MINOR  PARAGRAPHS.— ITEMS. 


197 


MINOR    PA  RA  OR  A  PUS. 

ST.  LUKE'S  HOSPITAL. 

TnK  board  of  managers  of  the  hospital  announces  that  a 
completely  equipped  country  seat  on  the  banks  of  the  Hudson, 
with  a  furnished  house  sufficient  for  fifty  patients,  has  been 
generously  offered  to  the  hospital  for  a  convalescent  home,  and, 
as  it  is  admirably  adapted  for  such  a  purpose  by  its  location  and 
surroundings,  distance  from  the  city,  and  convenience  of  access, 
and  as  such  a  homo  is  of  great  importance  to  the  charity  work 
of  the  hospital  as  a  place  for  poor  patients,  not  well  enough 
to  be  sent  to  their  homes  without  risk  to  their  recovery,  but 
not  eick  enough  to  justify  keeping  them  in  the  wards  to  the  ex- 
clusion of  others  needing  immediate  medical  or  jsurgical  care, 
they  add  that  it  is  most  desirable  that  St.  Luke's  should 
accept  this  gift.  The  offer  of  the  property  is  accompanied, 
however,  with  the  condition  that  $200,000  be  set  apart  for  its 
endowment,  so  that  its  perpetuity  may  be  assured,  and  the 
board  of  managers  of  the  hospital  recognizes  the  propriety  and 
wisdom  of  this  condition ;  but,  as  the  income  of  the  present  en- 
dowment fund  is  fully  required  for  the  ordinary  work  of  the 
hospital,  it  is  unwilling  to  appropriate  any  portion  of  the  fund 
for  the  use  of  a  convalescent  home,  unless  the  $200,000  required 
is  specially  provided  for  it.  The  board  therefoVe  very  properly 
appeals  to  the  community  to  subscribe  the  required  amount. 


CONTRACT  PRACTICE  IN  CONNECTICUT. 

The  Hartford  Courant  states  that  the  Medical  Society  of  the 
Central  District  of  Connecticut  has  declared  itself  opposed  (very 
properly,  we  should  say)  to  the  principle  of  the  contract  system 
as  applied  to  medical  ])ractice.  The  growth  of  this  system  ap- 
pears to  have  been  great  during  the  last  few  years.  In  Hart- 
ford alone  there  are  said  to  be  twenty  co-operative  organiza- 
tions that  provide  their  members  with  medical  attendance  for 
fees  ranging  from  fifty  cents  to  three  dollars  per  annum.  In 
regard  to  one  of  these  societies,  whose  secretary  conceived  the 
idea  of  getting  the  contesting  physicians  to  bid  against  each 
other,  it  is  stated  that  he  finally  obtained  the  services  of  "  a 
doctor  in  good  standing  "  who  would  accept  a  fee  of  thirty- 
eight  cents  a  head  per  annum.  The  remuneration  is  held  to  be 
only  a  small  part  of  the  advantages  reaped  by  the  contracting 
physician,  for  the  reason  that  his  connection  with  a  large  so- 
ciety brings  him  into  relation  with  a  large  "outside  practice"; 
and  if  at  any  time  the  contract  becomes  irksome,  the  incum- 
bent is  likely  to  find  no  difficulty  in  securing  a  successor. 


NEW  MEDICAL  WORKS  PUBLISHED  IN  1892. 

Notwithstanding  the  impression  that  might  naturally  exist 
that  a  great  many  medical  works  were  published  in  this  country 
during  1892,  the  Publisher's  Weekly  states  that  there  were  128 
new  works  published  on  medicine  and  hygiene  in  1892,  or  20 
more  than  were  published  in  1891.  In  a  graded  list  of  nineteen 
classes  of  new  books,  medicine  stands  number  thirteen ;  so  it 
can  not  be  said  that  physicians  are  exceedingly  prolific  book- 
makers. 


THE  HINDOOSTANEE  IDEA  OF  THE  ORIGIN  OF  MALARIAL 
FEVERS. 

As  a  curious  illustration  of  a  fundamentally  correct  idea  ex- 
isting in  the  traditions  of  a  nation,  the  following  passage  fiom 
Orton's  work  on  Cholera.,  published  in  1831,  is  of  interest: 
"  The  natives  of  India  are  an  unenlightened  race.    Some  idea 


ofthe  value  of  their  opinion  on  any  doubtful  subject  may  be 
formed  from  the  fact  of  their  universally  believing  that  malarial 
fevers  are  owing  to  drinking  bad  water."  Time  has  justified 
the  Hindoo  rather  than  Orton's  belief. 


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  14,  1893 : 


DISEASES. 

Week  ending  Feb.  7. 

Week  ending  Feb.  14. 

Cases. 

Deaths. 

Cases. 

Deaths. 

28 

21 

26 

16 

8 

3 

6 

3 

198 

17 

168 

16 

Cerebro-spinal  meningitis.  .  .  . 

5 

1 

0 

0 

86 

6 

67 

2 

121 

43 

106 

35 

3 

1 

0 

0 

The  Marine-Hospital  Service. — A  board  of  officers  will  be  con- 
vened at  Washington,  on  March  20,  1893,  for  the  purpose  of  examin- 
ing applicants  for  admission  to  the  grade  of  assistant  surgeon.  Candi- 
dates must  be  between  twenty-one  and  thirty  years  of  age  and  graduates 
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  examination,  candidates  are  required  to 
certify  that  they  believe  themselves  free  from  any  ailment  which  would 
disqualify  tliem  for  service  in  any  climate.  The  examinations  are 
chiefly  in  writing,  and  begin  with  a  short  autobiography  by  the  candi- 
date. The  remainder  of  the  written  exercise  consists  in  examination 
on  the  various  branches  of  medicine,  surgery,  and  hygiene.  The  oral 
examination  includes  subjects  of  preliminary  education,  history,  litera- 
ture, and  the  natural  sciences.  The  clinical  examination  is  conducted 
at  a  hospital,  and  when  practicable  candidates  are  required  to  perform 
surgical  operations  on  the  cadaver.  Successful  candidates  will  be  num- 
bered according  to  their  attainments  on  examination,  and  will  be  com- 
missioned 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  Boston,  New  York,  New  Orleans,  Chicago, 
or  San  Francisco.  After  four  years'  service,  assistant  surgeons  are  en- 
titled to  examination  for  promotion  to  the  grade  of  passed  assistant 
surgeon.  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  hundred  dollars,  passed  assistant 
surgeons  eighteen  hundred  dollars,  and  surgeons  twenty-five  hundred 
dollars  a  year.  When  quarters  are  not  provided,  commutation  at  the 
rate  of  thirty,  forty,  or  fifty  dollars  a  month,  according  to  grade,  is  al- 
lowed. All  grades  above  that  of  assistant  surgeon  receive  longevity 
pay,  ten  per  centum  in  addition  to  the  regular  salary  for  every  five 
years'  service  up  to  forty  per  centum  after  twenty  years'  service.  The 
tenure  of  office  is  permanent.  Officers  traveling  under  orders  are  al- 
lowed actual  expenses.  For  further  information,  or  for  invitation  to 
appear  before  the  board  of  examiners,  address  Dr.  Walter  Wyman, 
Supervising  Surgeon-General,  U.  S.  Marine-Hospital  Service,  Washing- 
ton, D.  C. 

The  New  York  Polyclinic. — The  faculty  gave  a  dinner  at  the  VVMnd- 
sor  Hotel  on  Thursday  evening,  the  16th  inst. 

Change  of  Address. — Dr.  George  E.  Walton,  from  Cincinnati  to  St. 
Augustine,  Florida. 

Army  Intelligence. — Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army,  from  January  29  to  February  11,  1893 : 

La  Gaudk,  Louis  A.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  Fort  McUenry,  Maryland,  and  will  proceed  to  Chicago,  111., 


/ 


198 


ITEMS.— LETTERS 


TO  THE  EDITOR.. 


[N.  Y.  Med.  Joue., 


and  assume  his  duties  in  connection  with  the  World's  Columbian 
Exposition. 

Macauley,  C.  N.  Berkeley,  Captain  and  Assistant  Surgeon,  now  await- 
ing orders  at  Baltimore,  Md.,  will  report  in  person  to  the  superin- 
tendent of  the  U.  S.  Military  Academy,  West  Point,  N.  Y.,  for  duty 
at  that  post. 

EwiNG,  Charles  B.,  Cajitain  and  Assistant  Surgeon,  will,  in  addition  to 
bis  present  duties  as  attending  surgeon  and  examiner  of  recruits  in 
Baltimore,  Md.,  report  in  person  to  the  commanding  officer.  Fort 
McHenry,  Maryland,  for  duty  as  post  surgeon,  taking  station  there. 

Ek»iE,  Guy  L.,  Captain  and  Assistant  Surgeon,  will  proceed  from  New 
York  city  to  Fort  Wadsworth,  New  York  Harbor,  and  report  to  the 
post  commander  for  temporary  duty. 

A  board  of  medical  officers — to  consist  of  Alden,  Charles  H.,  Colonel 
and  Assistant  Surgeon-General ;  Sternberg,  George  M.,  Lieutenant- 
Colonel  and  Deputy  Surgeon-General;  Hoff,  John  Va.v  R.,  Major 
and  Surgeon;  Edie,  Guy  L.,  Captain  and  Assistant  Surgeon — is 
constituted  to  meet  in  New  York  city  on  the  twenty-seventh  day  of 
March,  1893,  or  as  soon  thereafter  as  practicable,  for  the  examina- 
tion of  candidates  for  admission  to  the  medical  corps  of  the  army, 
and  for  such  other  business  as  may  be  brought  before  it. 

WiLLCOX,  Charles,  First  Lieutenant  and  Assistant  Surgeon,  is  granted 
leave  of  absence  for  one  month,  with  permission  to  apply  for  an  ex- 
tension of  one  month. 

Shillock,  Paul,  Captain  and  Assistant  Surgeon,  promoted  as  such,  to 
date  from  January  81,  1893,  in  accordance  with  the  act  of  June 
23,  1874. 

By  direction  of  the  Secretary  of  War,  the  order  assigning  Ewi.ng, 
Charles  B.,  Captain  and  Assistant  Surgeon,  to  duty  as  post  surgeon. 
Fort  McHenry,  Maryland,  is  suspended  until  June  1,  1893,  when  he 
will  comply  with  the  order. 

Powell,  Junius  L.,  Captain  and  Assistant  Surgeon.  The  leave  of  ab- 
sence granted  is  hereby  extended  one  month. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  two  weeks  ending  February  11,  1S93 : 
Btone,  L.  H.,  Assistant  Surgeon.   Ordered  to  the  Naval  Hospital,  Brook, 

lyn,  N.  Y. 

Barber,  G.  H.,  Passed  Assistant  Surgeon.  Detached  from  the  Naval 
Hospital,  Brooklyn,  N.  Y.,  and  ordered  to  the  U.  S.  Steamer  Mian- 
tonomoh. 

Blackwood,  N.  J.,  Assistant  Surgeon.  Detached  from  the  U.  S.  Steamer 
Miantonomoh  and  ordered  to  the  Navy  Yard,  Brooklyn,  N.  Y. 

Ward,  B.  R.,  Assistant  Surgeon.  Ordered  to  the  Training-ship  Rich- 
mond. 

WiNSLOW,  George  F.,  Surgeon.  Ordered  to  the  U.  S.  Steamer  Mon- 
terey. 

Arnold,  W.  F.,  Passed  Assistant  Surgeon.  Ordered  to  the  U.  S.  Steamer 
Monterey. 

Von  Wedekind,  L.  L.,  Assistant  Surgeon.  Ordered  to  examination  pre- 
liminary to  promotion. 

Lung,  George  A.,  Assistant  Surgeon.  Ordered  to  examination  pre- 
liminary to  promotion. 

Marine-Sospital  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  February  4,  1893 : 

Mead,  F.  W.,  Surgeon.  To  proceed  to  New  London  and  New  Haven- 
Conn.,  as  inspector.    February  4,  1893. 

Carter,  H.  R.,  Surgeon.  Granted  leave  of  absence  for  thirty  days. 
February  3,  1893. 

Stoner,  J.  B.,  Passed  Assistant  Surgeon.  To  assume  command  of 
service  at  Portland,  Ore.    January  17,  1893. 

Young,  G.  B.,  Assistant  Surgeon.  When  relieved,  to  proceed  to  Pitts- 
burgh, Pa.,  for  duty.    January  17,  1893. 

CoFKR,  L.  E.,  Assistant  Surgeon.  Placed  on  "  waiting  orders."  Janu- 
ary 23,  1893. 

Eager,  J.  M.,  Assistant  Surgeon.  To  proceed  to  Cape  Charles  Quaran- 
tine for  temporary  duty.    February  3,  1893. 


Stewart,  W.  J.  S.,  Assistant  Surgeon.  To  proceed  to  Norfolk,  Va.,  for 
temporary  duty.    February  1,  1893. 

Death. 

Passed  Assistant  Surgeon  Spencer  C.  Devan  died  February  3,  1893,  at 
Philadelphia,  Pa. 

Society  Meetings  for  the  Coming  Week : 

Monday,  February  SOth :  New  York  Academy  of  Medicine  (Section  in 
Ophthalmology  and  Otology) ;  New  York  County  Medical  Associa- 
tion ;  Hartford,  Conn.,  Medical  Society ;  Chicago  Medical  Society. 

Tuesday,  February  21st :  New  York  Academy  of  Medicine  (Section  in 
General  Medicine) ;  New  York  Obstetrical  Society  (private) ;  Medical 
Societies  of  the  Counties  of  Kings  and  Westchester  (White  Plains), 
N.  Y.  ;  Ogdensburgh,  N.  Y.,  Medical  Association ;  Baltimore  Acad- 
emy of  Medicine. 

Wednesday,  February  22d:  New  York  Academy  of  Medicine  (Section 
in  Laryngology  and  Rhinology) ;  New  York  Surgical  Society ;  New 
York  Pathological  Society ;  American  Microscopical  Society  of  the 
City  of  New  York  ;  Metropolitan  Medical  Society  (private) ;  Medical 
Society  of  the  County  of  Albany  ;  Auburn,  N.  Y.,  City  Medical  As- 
sociation ;  Berkshire,  Mass.,  District  Medical  Society  (Pittsfield); 
Philadelphia  County  Medical  Society. 

^■B^-BSOKY,  February  23d:  New  York  Academy  of  Medicine  (Section 
in  Obstetrics  and  Gynajcology) ;  New  York  Orthopeedic  Society; 
BrookljTi  Pathological  Society ;  Roxbury,  Mass.,  Society  for  Medi- 
cal Improvement  (private). 

Friday,  February  2Jilh  :  Yorkville  Medical  Association  (private) ;  New 
York  Society  of  German  Physicians ;  New  York  Clinical  Society 
(private);  Philadelphia  Clinical  Society;  Philadelphia  Laryngologi- 
cal  Society. 

Saturday,  February  26th:  New  York  Medical  and  Surgical  Society 
(private). 


f  ctffrs  to  tijt  (gbitor. 

SUMMER  DIARRH(EA. 

Cincinnati,  Ohio,  Jamuxry  11,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  In  yoar  issue  of  November  5,  1892,  there  appeared 
under  the  captinn  "Summer  Diarrlicea"  a  letter  from  Dr.  A. 
Seibert  reflecting  upon  me.  This  letter  is,  to  speak  mildly,  but 
a  tissue  of  misstatements. 

I  did  not  quote  Dr.  Seibert  at  second  hand  and  "give  the 
reader  to  understand  through  a  lengthy  quotation  from  Dr. 
Clark  Miller,  »tc.,"  as  he  there  .says.  At  the  time  when  I  wrote 
the  article  in  question  I  had  Seibert's  original  paper,  as  pub- 
lished in  the  Medical  Record  of  March  24.  1888,  before  me,  and 
I  quoted  him  therefrom  verbatim,  literatim  et  punctatim. 

In  that  article  he  plainly  says:  "Now,  then,  we  have  found 
so  far  that,  though  the  temperature  has  some  decided  relation 
to  the  frequency  of  cholera  infantum,  yet  we  have  no  right  to 
accept  our  first  impression  that  the  higher  tiie  more,  the  lower 
the  temperature  the  less,  frequent  do  we  find  this  complaint; 
on  the  contrary,  we  must  admit  that  comparison  of  monthly 
means  [Italics  mine — I.]  of  temperature  during  the  summer 
months  shows  that  the  frequency  of  summer  complaint  (like  its 
mortality)  is  independent  of  the  rise  and  fall  of  atmospheric 
temperature." 

I  believe  that  he  who  runs  can  read  in  this  paragraph  that 
we  must  not  pay  too  much  attention  to  daily  temperatures  in 
our  study  of  the  aetiology  of  summer  complaint,  as  they  are  mis- 
leading, but  must  draw  our  conclusioni  from  the  monthly 
mean. 


Feb.  18,  1893.]  LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES.  199 


It  was  tliis  inetliod  of  study,  tlii.s  drawing  of  conclusions 
from  the  monthly  mean,  that  I  criticised  as  erroneous,  and  cor- 
roborated myself  by  quoting  from  Dr.  Chirk  Miller,  who  had 
expressed  a  similar  opinion  in  an  article  published  in  the  Medi- 
cal Record  in  July,  1888,  and  given  good  and  valid  reason  for 
such  criticism. 

I  further  demonstrated  the  fallaciousness  of  this  mode  of 
study  regarding  the  (etiology  of  summer  complaint  by  compar- 
ing Seibert  with  Turner. 

Turner  (long  before  Seibert  ever  thouglit  of  itj  collected, 
during  a  period  of  ten  years — 1867  to  1876— the  data  concerning 
epidemic  infantile  cholera  in  sixteen  towns  in  England.  In  tlie 
same  way  as  Seibert,  by  a  comparison  of  monthly  means  of 
temperature  for  the  summer  months,  he  arrives  at  the  conclu- 
sion that  a  continued  minimal  temperature  of  50°  F.  is  neces- 
sary for  the  production  of  summer  complaint. 

Seibert,  in  his  article  above  quoted  [in  my  paper  he  is  again 
quoted],  concludes,  from  a  comparison  of  monthly  means,  that  a 
continued  minimal  temperature  of  not  less  than  60°  F.  is  neces- 
sary for  the  occurrence  of  summer  diarrhtua,  and  that  when  the 
daily  minimal  temperature  is  below  60°  F.  it  loses  its  epidemic 
character. 

There  is  no  need  of  saying  anything  further  upon  this  point. 
I  leave  the  impartial  reader  to  iudge  between  us  with  whom  is 
the  right. 

In  the  concluding  paragraph  he  says :  "  As  to  one  of  them, 
the  belief  of  Dr.  Illoway  that  Baginski  in  his  VerdauungsTcrank- 
heiten  der  Kinder,  1884,  etc."  The  paragraph  quoted  in  my 
paper,  in  a  foot-note  to  which  this  belief  is  expressed,  is  not 
taken  at  all  from  the  Verdnuungslcranhheiten  der  Kinder  ;  it  is 
from  an  address  delivered  by  Baginski  in  1889  and  published  in 
the  Berliner  Minische  Wochenschrift,  No.  46,  1889.  This  is 
shown  by  the  reference  foot-note  in  my  paper,  as  anybody  who 
can  read  plain  English  can  readily  see.  Tne  statement  by  Sei- 
bert in  his  letter,  that  Baginski's  reference  to  American  charts 
was  published  in  1884,  is  as  erroneous  as  are  his  conclusions. 
If,  however,  Dr.  Seibert  feels  hurt  at  my  having  expressed  sucli 
belief,  I  will  recant  it  here  publicly,  acknowledge  that  I  had  no 
good  ground  therefor,  and  admit  that  at  the  time  when  Bagin- 
ski wrote  the  aforementioned  paragraph  he  never  even  dreamed 
of  Seibert,  but  referred  to  the  charts  of  some  other  American 
worker  in  this  field  whose  name  has  unfortunately  escaped 
me. 

As  to  his  insinuation  concerning  the  other  references  found 
in  my  paper  I  shall  say  nothing,  for  I  am  confident  that  on  re- 
flection Dr.  Seibert  will  himself  frankly  admit  that  it  should 
not  have  been  made.  H.  Illoway,  M.  D. 


NASAL  CAUTERIZATION. 
Main  Street,  Memphis,  Tenn.,  February  3,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  I  have  just  read  with  much  interest  the  paper  of  De 
Blois  on  The  After-effects  of  Nasal  Cauterization  and  the  dis- 
cussion of  the  same  by  members  of  the  American  Laryngological 
Association.  I  feel  much  interest  in  this  work,  as  I  have  done 
a  large  amount  of  it  within  the  past  six  years.  I  agree  fully 
with  Dr.  Delavan  in  his  classification  of  these  cases.  I  think 
the  lack  of  success  in  the  hands  of  some  of  these  gentlemen 
has  been  duo  to  their  burning  when  it  was  contraindieated. 
In  the  acute  stage  of  hypertrophy  I  have  found  constitutional 
treatment,  combined  with  the  local  use  of  alterative  astringents, 
all  that  is  necessary  to  effect  a  cure.  Where  the  stomach,  liver, 
or  kidneys  are  at  fault  they  should  be  restored  to  a  normal 
condition,  and  if  rheumatism  or  gout  is  present  it  should  bo 
eliminated.    For  local  use  I  have  found  iodo-tannin,  made  after  | 


Sajous's  formula,  give  the  best  results.  It  bleaches  the  tissue 
and  restores  it  to  a  normal  state.  When  the  hypertrophy  is 
chronic,  the  cautery  applied  with  care  gives  the  most  rapid  and 
permanent  cure.  I  have  seen  no  returns  in  any  case  within 
the  past  six  years.  I  prepare  the  nose  by  cleansing  with  an 
antiseptic  wash  of  boric  acid  or  mercury  bichloride,  dry  with 
cotton,  cocainize,  and  then  apply  the  cautery  at  nearly  a  white 
heat,  being  sure  to  burn  the  entire  hypertrophied  surface  and 
none  other.  I  never  burn  to  the  bone,  but  try  rather  to  stop 
about  midway  of  the  submucous  tissue.  I  follow  the  operation 
with  an  ointment  of  cocaine  hydrochloride  and  white  vaseline. 
I  direct  the  patients  to  apply  it  over  the  burn  whenever  they  ex- 
perience any  discomfort.  This  has  seemed  to  prevent  reac- 
tionary trouble,  and  the  burn  heals  more  kindly  under  its  use. 
After  the  healing  is  complete,  I  see  the  patient  every  two  or 
three  days  for  a  month  or  six  weeks,  and  make  such  applica- 
tions as  are  indicated  until  the  surrounding  membrane  has  re- 
gained its  normal  color  and  thickness.  I  think,  if  these  pre- 
cautions are  carried  out.  Dr.  De  Blois  will  find  no  return  of  the 
hypertrophies.  John  I.  Tayloe,  M.  D. 


IProccctrings  of  Sofietics. 


NORTHWESTERN  MEDICAL  AND  SURGICAL  SOCIETY 
OF  NEW  YORK. 

Meet  ing  of  November  16,  1892. 

The  President,  Dr.  E.  S.  Peck,  in  the  Chair. 

The  Treatment  of  Post-partum  Haemorrhage.  —  Dr, 

Robert  A.  Murray  read  a  paper  on  this  subject,  (See  page 
183.) 

Dr.  A.  M.  Jacobus  said  that  he  had  seen  very  few  severe 
post-partum  hfemorrhages,  but  where  such  occurred  he  con- 
sidered the  use  of  ice,  external  frictions,  and  anteflexing  the 
uterus  the  best  measures  to  control  it.  Severe  haemorrhages 
would  not  often  occur  if  the  obstetrician  made  it  a  practice  to 
follow  down  the  uterus  with  the  hand  as  the  child  was  ex- 
pelled, and  then  kept  his  hand  there  for  some  time  afterward 
to  make  sure  that  the  uterus  remained  firmly  contracted.  The 
use  of  Monsel's  solution  of  iron  for  the  purpose  of  checking 
haemorrhage  in  any  part  of  the  body  was  to  be  condemned.  It 
had  been  recommended  to  administer  to  patients  subject  to 
uterine  haemorrhages  such  remedies  as  strychnine  and  quinine 
for  several  weeks  prior  to  confinement,  and  he  had  adopted  this 
plan  with  apparent  advantage. 

Dr.  Fruitnigiit  thought  that  the  author  had  rendered  a 
good  service  by  calling  attention  to  lacerations  as  a  frequent 
cause  of  severe  haemorrhage,  and  in  emphasizing  the  point  about 
the  retraction  of  the  uterus.  The  use  of  iron  as  a  styptic  should 
be  unequivocally  condemned.  He  thouglit  it  would  be  very 
difficult  to  estimate  the  value  of  such  prophylactic  medication 
as  that  described  by  the  preceding  speaker,  for  it  was  not  easy 
to  decide  in  what  cases  such  treatment  was  indicated.  Severe 
post-partum  haemorrhages  would  bo  considerably  less  frequent 
if  care  was  taken  to  make  adequate  preparation  for  such  an 
accident,  particularly  when  an  anajsthetic  had  been  given.  The 
effect  of  multiple  pregnancies  in  predisposing  to  hicmorrhage 
had  been  impressed  upon  him  many  years  ago  when  he  had  at- 
tended a  woman  in  her  seventeenth  confinement.  In  this,  aa  in 
a  number  of  other  cases,  ho  had  found  the  hiDmorrhago  very 
promptly  controlled  by  an  intra-uterino  douche  of  hot  water 
containing  a  little  vinegar. 


■200 

Dr.  M.  Bltimentiial  said  that  in  a  practice  extending  over 
forty  years  lie  had  never  lost  a  patient  from  post-parturn  haem- 
orrhage, and,  while  this  had  been  largely  a  matter  of  good  for- 
tune, the  infrequency  of  severe  haamorrhages  could  he  in  ])art 
ascribed  to  the  fact  that  he  was  in  the  habit  of  making  prepa- 
ration for  the  possible  occurrence  of  such  a  complication.  The 
use  of  ice,  and  especially  the  early  administration  of  ergot,  had 
■often  prevented  more  serious  trouble.  In  his  experience,  severe 
haemorrhage  arising  from  lacerations  of  the  soft  parts  had  been 
very  infrequent;  such  a  hsemorrhage  was  almost  always  due  to 
atony  of  the  uterus,  and  for  this  condition  there  was  no  remedy 
better  than  ergot. 

Dr.  MoLatjet  said  that  in  a  somewhat  extensive  midwifery 
practice  he  had  met  with  only  two  fatal  cases  of  post-partum 
haemorrhage.  In  one  apparently  desperate  case — a  twin  labor 
— although  there  had  been  no  very  excessive  loss  of  blood,  the 
woman's  abdomen  had  become  enormously  distended  ;  it  had 
l)een  compressed  by  means  of  a  sheet  passed  around  the  abdo- 
men, the  haemorrhage  had  ceased,  and  the  patient  had  recov- 
ered. He  knew  of  nothing  better  than  ergot  and  compression 
to  bring  about  proper  uterine  contraction. 

Dr.  S.  D.  Powell  said  that  he  had  never  seen  a  serious 
haemorrhage  which  be  could  attribute  to  lacerations,  and,  al- 
though he  had  met  with  several  severe  cases  of  haBmorrhage, 
none  of  them  had  proved  fatal.  He  could  not  understand  how 
a  laceration  of  the  circular  artery  could  produce  such  a  gush  of 
blood  as  was  seen  in  severe  post-partum  haemorrhage.  Just  as 
the  child's  head  protruded  from  the  vulva,  it  was  his  custom  to 
administer  ergot  in  doses  of  one  or  two  ounces,  and  he  had  seen 
nothing  but  good  follow  these  large  doses.  By  turning  out  the 
clots  from  the  uterus,  and  at  the  same  time  giving  a  hot  intra- 
uterine douche,  powerful  contractions  would  be  excited. 

Dr.  Stevens  agreed  for  the  most  part  with  what  had  been 
said  by  Dr.  Blumenthal  and  Dr.  McLaury,  and  he  was  glad  to 
know  that  such  large  doses  of  ergot  could  be  given  with  safety. 

Dr.  Dessau  said  that  in  a  rather  limited  obstetrical  experi- 
ence he  had  seen  only  one  severe  case,  and  that  one  he  had  seen 
with  Dr.  Powell.  He  was  accustomed  to  administer  ergot 
hypodermically  to  prevent  hajmorrhage.  Several  years  ago, 
when  practicing  early  expression  of  the  placenta,  he  had  no- 
ticed that  the  uterus  did  not  remain  firmly  contracted  notwith- 
standing the  administration  of  ergot;  but  since  he  had  adopted 
the  plan  of  waiting  for  evidence  of  uterine  contraction  before 
resorting  to  expression  he  had  not  had  this  trouble.  He  had 
only  seen  one  case  of  considerable  haemorrhage  from  a  lacera- 
tion, and  he  could  hardly  understand  how  a  haemorrhage  sufB- 
ciently  profuse  to  endanger  life  could  occur  from  such  a  cause. 

Dr.  Robert  Newman  said  that  the  mode  of  treatment  out- 
lined by  Dr.  Blumenthal  seemed  to  him  the  most  practical,  but 
he  was  nevertheless  of  the  opinion  that  in  those  rare  cases  of 
post-partum  haemorrhage  which  ended  fatally  it  made  very  little 
difference  what  plan  of  treatment  was  adopted,  as  from  the  first 
they  were  beyond  all  medical  aid.  He  cited  a  case  in  which, 
although  he  had  reached  the  bedside  within  seven  minutes  after 
delivery,  tlie  jjatient  was  already  dead. 

Dr.  S.  Baruch  agreed  in  the  main  with  the  views  which  had 
been  expressed,  but  he  wished  to  call  attention  to  a  statement 
which  had  been  made  concerning  the  "  too  early  use  of  Grede's 
method."  Credo's  method  could  not  be  used  "  too  early,"  for 
Cred6  distinctly  said  that  the  expression  of  the  placenta  was  to 
be  begun  at  a  definite  time — viz.,  as  soon  as  the  first  uterine 
contraction  was  felt  after  the  birth  of  the  child.  Statistics 
showed  that  Crede,  and  those  who  carefully  followed  his  direc- 
tions, observed  no  post-partum  haemorrhages.  With  the  exception 
perhaps,  of  the  uterine  tampon,  hot  water  was  the  best  means 
of  checking  the  haemorrhage,  and  it  had  been  shown  that  even 


[N.  Y.  Mkd.  Joub.. 

a  solution  of  corrosive  sublimate  was  not  such  a  powerful  anti- 
septic as  hot  water.  All  irritants  when  applied  to  the  peripheral 
nerves  acted  filike,  and  consequently  both  beat  and  cold  produced 
contractions  ;  but  it  nmst  be  remembered  that  if  either  ice  or  hot 
water  was  applied  for  more  than  a  brief  period,  the  opposite  effect 
would  be  produced.  The  only  fatal  case  which  he  had  seen  had 
occurred  about  twentj-five  years  ago,  when,  in  accordance  with 
the  teaching  of  Barnes,  he  had  advised  the  use  of  sulphate  of 
iron ;  the  haemorrhage  had  been  stopped,  but  the  woman  had 
died  of  sepsis. 

The  President  suggested  that  it  would  be  interesting  to  hear 
from  Dr.  Murray  concerning  the  comparative  frequency  of  post- 
])artum  haemorrhage  now  and  in  former  days  when  the  forceps 
was  less  freely  used,  and  also  as  to  the  relation  of  albuminuria 
and  syphilis  to  post-partum  haemorrhage. 

Dr.  Murray  said  that  most  of  the  measures  usually  em- 
ployed depended  upon  the  nervous  system,  and,  as  the  nervous 
system  was  not  capable  of  responding  to  such  influences  when 
there  was  a  profuse  haemorrhage,  recourse  must  be  had  to 
the  uterine  tampon.  Since  uterine  contractions  started  from 
the  cervix,  a  laceration  of  the  cervix  caused  inefficient  con- 
traction of  the  uterus,  just  as  it  afterward  caused  subinvolution. 
Sepsis,  albuminuria,  and  syphilis  were  all  very  potent  causes  of 
uterine  atony.  One  of  the  first  evidences  of  the  development 
of  sepsis  in  a  lying-in  ward  was  the  tendency  of  the  uterus  to 
relax  again  and  again  after  delivery.  If  the  ward  was  immedi- 
ately emptied  and  cleaned,  this  at  once  disappeard.  It  did  not 
follow,  because  the  lower  part  of  the  cervix  was  flabby,  that  the 
contraction  did  not  start  at  the  cervix.  It  was  only  the  mis- 
application  of  the  forceps  which  predisposed  to  hsemorrhage. 
Syphilis  was  such  a  powerful  predisposing  cause  that  anti- 
syphilitic  treatment  should  be  instituted  previous  to  confinement 
'n  sypliilitic  subjects.  He  had  seen  haemorrhage  occur  after  a 
uraemic  convulsion,  but  never  during  the  convulsion. 


MEDICAL  SOCIETY  OF  THE  STATE  OF  NEW  YORK. 

Eighty -seventh  Annual  Meeting,  held  in  Albany  on  Tuesday, 
Wednesday,  and  Thursday,  February  7,  8,  and  9,  1893. 

The  President,  Dr.  Lewis  S.  Piloher,  of  Brooklyn,  in  the  Chair. 

{Continued  from  page  170.) 

A  Discussion  on  Epilepsy  (continued).— Reflex  Disturb- 
ances in  the  Causation  of  Epilepsy  was  the  title  of  a  paper  by 
Dr.  William  C.  Krauss,  of  Buffalo.  The  author  objected  to 
the  term  idiopathic  in  this  connection.  Its  use  implied  that  we 
were  ignorant  as  to  causation.  Reflex  epilepsy  meant  a  dis- 
turbance of  nerve  centers  in  the  brain  from  peripheral  irrita- 
tion. It  should  be  sharply  distinguished  from  traumatic  epi- 
lepsy. The  peripheral  irritation  could  be  of  many  varieties,  and 
not  every  peripheral  irritation  would  cause  disturbance  of  the 
nerve  centers.  A  neuropathic  disposition  was  fundamental  in 
every  case  of  epilepsy  ;  aside  from  that,  epilepsy  might  be  in- 
herited or  spontaneous.  Every  patient  should  be  carefully  ex- 
amined from  head  to  foot  to  discover  any  possible  source  of 
irritation.  The  external  causes  were  usually  much  more  readily 
discovered  than  the  internal.  Of  the  latter,  the  location  was 
most  frequently  in  the  stomach  or  in  the  urethra.  Of  those 
which  were  referable  to  the  stomach,  the  symptoms  should  be 
considered  as  epileptopathic  rather  than  epileptogenic.  Of  those 
which  were  referable  to  the  urethra,  there  were  many  that 
were  congenital.  The  treatment  for  cases  of  urethral  origin 
consisted  in  the  internal  use  of  bromides  and  the  passage  of  a 
very  mild  galvanic  current  through  the  urethra. 

Mental  Epilepsy  was  the  title  of  a  paper  by  Dr.  J.  Mont- 


PROCEEDINOS  OF  SOCIETIES. 


Feb.  18,  1893.] 


BOOK  NOTICES. 


201 


GOMERY  MosHER,  of  Ogdensburgh.  The  author  reviewed  the 
many  tlieoriea  that  had  been  advanced  concerning  the  nature 
of  mental  ei)ilei)sy.  They  had  all  yielded  to  tiiat  of  Hughlings 
Jackson,  which  was  that  the  condition  was  due  to  sudden,  oc- 
casional discharges  or  explosions  in  the  gray  matter  of  the  brain. 
The  condition  might  be  motor,  sensory,  or  psychic,  with  con- 
vulsions in  one  class  of  cases  and  without  thera  in  another. 
The  latter  form  was  rare,  and  was  attended  with  pallor  of  tlie 
surface  in  some  cases,  with  flushing  in  others.  Such  cases  were 
often  regarded  as  cases  of  pcf  mal.  In  ])lace  of  the  spasm 
there  were  frequently  involuntary  co-ordinated  })henoinena,  at- 
tended with  loss  of  memory,  often  with  uncontrollable  impulse 
to  acts  of  violence  without  appreciable  cause.  They  might  be 
associated  with  hallucinations,  with  a  gradual  weakening  of 
mental  force,  stupor  and  coma  following  each  attack,  and  final- 
ly terminating  in  dementia  and  death. 

Dr.  A.  Jaoobi,  of  New  York,  in  opening  the  discussion,  re- 
marked that  too  much  stress  was  laid  upon  the  hereditary  na- 
ture of  epilepsy.  The  cause  was  very  often  traceable  to  dele- 
terious conditions  experienced  by  the  subject  during  birth  and 
infancy.  Asphyxia  at  birth,  associated  with  hasinorrhage  or 
thrombosis  of  the  brain  or  meninges,  frequently  resulted  in  epi- 
lepsy or  idiocy.  The  earlier  in  life  cerebral  injury  was  received, 
the  greater  the  tendency  to  the  subsequent  development  of  cere- 
bral disease.  Early  closure  of  the  cranial  sutures  was  also  a 
frequent  cause  of  epilepsy.  Confirmed  idiocy  was  often  asso- 
ciated with  defective  development  or  injury  of  the  genital  or- 
gans. Paraplegia  dependent  upon  irritation  of  the  genital  organs 
had  never  yet  been  satisfactorily  demonstrated. 

Dr.  Angell,  of  Rochester,  called  attention  to  the  intended 
establishment  by  the  State  of  an  epileptic  colony  at  Sonyea, 
Livingston  County,  and  believed  that  much  was  to  be  expected 
from  the  observation  of  the  disease  under  the  favorable  influ- 
ences which  would  then  exist. 

The  Relation  in  the  Male  and  Female  of  Genital  Dis- 
ease to  Mental  and  Nervous  Affections  was  the  title  of  a  pa- 
per read  by  Dr.  Landon  C.  Gray,  of  New  York.  Stanley,  in 
1833,  he  said,  had  been  the  first  among  modern  authors  to  teach 
the  doctrine  of  reflex  paralysis.  In  1861  Gull  had  shown  that 
Stanley's  propositions  were  not  well  founded.  In  1886  Weir 
Mitchell  had  shown  that  cerebral  or  spinal  lesions  were  present 
in  cases  of  reflex  paralysis  supposed  to  be  due  to  lesions  of  the 
genital  organs. 

Fashions  in  medicine  were  easily  established,  and  novelty 
was  often  mistaken  for  progress.  Irritation  of  the  genital  or- 
gans had  never  yet  been  demonstrated  as  the  permanent  cause 
of  serious  nervous  disease,  but  it  was  often  an  exciting  cause  in 
individuals  who  were  already  predisposed.  Night  terrors  or 
other  disorders  of  the  nervous  system  had  frequently  been 
cured  by  circumcision  in  the  male,  or  the  cure  of  an  existing 
vaginal  inflammation  in  the  female  ;  but  there  was  no  authentic 
record  of  the  cure  of  severe  lesions  of  the  nervous  system  by 
an  operation  upon  the  genital  organs.  In  the  psycho-neuroses 
it  was  readily  admitted  that  the  result  of  operations  upon  the 
genital  organs  was  often  remarkable.  Many  factors  must  be 
considered  in  studying  the  effect  of  such  operations,  in  addition 
to  the  mere  question  of  the  removal  of  organs.  The  proof  had 
not  appeared  that  irritation  of  the  male  or  female  genital  organs 
could  cause  well-defined  mental  or  nervous  disease. 

Lithsemia,  its  Treatment,  was  the  subject  of  a  pai)er  by 
Dr.  R.  W.  WiLoox,  of  New  York.  The  question  of  litha3niia 
and  the  uric-acid  diathesis  had  been  devotedly  studied  by  Eng- 
lish physicians,  but  they  had  not  yet  reduced  the  question  to 
its  simplest  condition.  The  condition  signified  imperfect  tissue 
metabolism.  If  the  condition  was  exaggerated,  the  phenomena 
of  oxaluria  were  presented,  and  all  the  tissues  and  organs  miglit 


be  afi'ected.  The  treatment  involved  the  consideration  of  two 
classes  of  cases,  in  the  first  of  which  the  subjects  were  obese 
and  sluggish,  in  the  second  of  a  nervous  temperament. 

For  the  former  an  animal  diet  was  appropriate,  the  omis- 
sion of  proteid  foods  being  a  mistake.  A  vegetable  diet  for 
such  individuals  overtaxed  the  oxygenating  power  of  the  blood; 
but  green  vegetables  were  not  unsuitable.  Skimmed  milk  and 
ripe  fruits  might  also  be  given,  but  spices  and  smoked  and  salt- 
ed food  should  bo  avoided.  Alcohol  might  also  be  used  in  small 
quantities,  without  sugar,  also  the  alkaline  mineral  waters  with 
the  addition  of  lithia.  Hygienic  conditions  should  be  carefully 
considered,  including  exercise  in  the  open  air,  sun  baths,  and 
plenty  of  sleep.  Sufficient  Carlsbad  Sprudel  salts,  aloin,  and 
podophyllin  should  be  administered  to  secure  two  or  three  stools 
daily.  If  the  potash  salts  were  used,  they  should  not  be  taken 
in  large  doses  for  long  periods.  Salicylates  might  occasionally 
be  taken  with  advantage,  and  lavage  of  the  stomach  occasion- 
ally practiced.  Phosphate  of  sodium  would  also  be  useful  in 
moderate  doses. 

The  Registration  of  Midwives  was  the  subject  of  a  paper 
by  Dr.  J.  L.  Kortrigut,  of  Brooklyn.  There  was  at  present 
no  statute  in  this  State  authorizing  the  occupation  of  mid- 
wives,  though  they  combined  the  functions  of  both  physician 
and  nurse.  It  was  generally  supposed  that  they  treated  only 
simple  cases  of  obstetrics,  but  this  was  not  in  accordance  with 
the  facts.  Many  cases  of  still-birth,  as  well  as  many  fatal  cases 
of  septica3mia,  were  attended  by  them.  A  bill  was  proposed 
which  would  require  that  all  midwives  be  licensed  by  the  State, 
and  only  after  careful  and  sufficient  examination  in  anatomy 
and  physiology  ;  also  that  their  licenses  be  renewed  each  year  or 
revoked  for  good  cause.  It  was  also  believed  that  they  should 
have  no  power  to  make  returns  of  deaths  during  labor  or  of 
still-births,  such  cases  being  deemed  proper  for  investigation  at 
the  hands  of  physicians. 

Dr.  C.  A.  VON  Ramdohr,  of  New  York,  presented  a  con- 
venient receptacle  for  gauze  used  in  the  tamponade  of  the  puer- 
peral uterus. 

{To  be  continued.) 


Alcoholism  and  its  Treatment.  By  J.  E.  Usher,  M.  D.,  Fellow 
of  the  Royal  Geographical  Society  of  London,  formerly  Sur- 
geon Superintendent  and  Medical  oflficer  of  Health  to  the 
Queensland  Government.  New  York  :  G.P.  Putnam's  Sons, 
1892.    [Price,  $1.2.5.] 

Alcoholism  seems  to  have  at  last  attained  the  dignity  of 
being  styled  a  disease.  That  certain  conditions  resulting  from 
the  continued  use  of  alcohol  are  actually  those  of  disease  is  an 
undoubted  fact.  There  is  a  wide  difference,  however,  between 
alcoholism  and  drunkenness,  and  much  discrimination  is  re- 
quired in  treating  the  subject  properly.  The  laity,  and  particu- 
larly the  drunken  part  of  the  laity,  have  been  quick  to  catch 
the  idea  that  alcoholism  is  a  disease,  and  it  is  very  ])opular 
among  them.  If  it  is  a  disease,  it  should  be  so  taught;  but  it 
does  not  necessarily  follow  that  the  subject  of  the  disease  is 
irresponsible  and  beyond  control.  Depravity  may  be  an  in- 
herited disease;  it  is  very  fre()uently  acquired  "  cussednoss." 
People  suffering  from  this  latter  disorder  should  be  carefully 
distinguished  from  those  suflVring  from  true  alcoholism.  The 
author  of  this  little  book  has  succeeded  extremely  well  in  do- 
ing this.    He  has  also  succeeded  in  treating  a  difficult  subject 


202 


BOOK  NOTICES.- 


.—MISCELLANY. 


[N.  Y.  Med.  Jorn., 


in  a  fairly  judicious  and  unbiased  manner.  It  would  be  impos- 
sible to  write  a  book  to  suit  the  various  extremists  upon  this 
subject,  no  matter  in  how  scientific  a  spirit  it  were  done.  One 
of  the  best  chapters  is  that  upon  the  legal  relations  of  alcohol- 
ism, though  the  chapters  on  treatment  are  extremely  good. 

BOOKS,  ETC.,  RECEIVED. 

A  System  of  Geni to -urinary  Diseases,  Syphilology,  and  Der- 
matology. By  Various  Authors.  Edited  by  Prince  A.  Morrow, 
A.  M.,  M.  D.,  Clinical  Professor  of  Genito-urinary  Diseases, 
formerly  Lecturer  on  Dermatology  in  the  University  of  the  City 
of  New  York,  etc.  With  Illustrations.  In  Three  Volumes. 
Vol.1.  Genito-urinary  Diseases.  New  York  :  D.  Appleton  and 
Company,  1893.    Pp.  xxvii-1074. 

Handbook  of  Insanity  for  Practitioners  and  Students.  By 
Dr.  Theodor  Kirchhoff,  Physician  to  the  Schleswig  Insane  Asy- 
lum, and  Privatdocent  at  the  University  of  Kiel.  Illustrated 
with  Eleven  Plates.  New  York:  William  Wood  &  Company, 
1893.    Pp.  vi-362.    [Medical  Practitioner's  Library.] 

The  Use  of  the  Curette  in  Uterine  Surgery.  By  A.  Vander 
Veer,  M.  D.,  of  Albany. 

A  Case  of  Homatropine  Suscei)tibility.  By  George  M.  Gould, 
M.  D.,  of  Philadelphia.    [Reprinted  from  the  Medical  News.] 

Hystero-epilepsy,  with  Report  of  Cases.  By  A.  Vander 
Veer,  M.  D.,  of  Albany.  [Reprinted  from  the  Transactions  of 
the  Medical  Society  of  the  State  of  New  York.] 

The  Reconstruction  of  the  Pelvic  Structures  in  Woman — The 
Advantages  of  the  Buried  Tendon  Suture.  By  Henry  O.  Marcy, 
A.  M.,  M.  D.,  of  Boston.  [Reprinted  from  the  American  Jour- 
nal of  Obstetrics.] 

Umbilical  Hernia ;  Operation  ;  Cure.  Ligation  ot  Femoral 
Artery  for  Popliteal  Aneurysm ;  Cure.  Ftecal  Fistula  caused 
by  Appendicitis;  Operation  ;  Cure.  By  W.  W.  Keen,  M.D.,  of 
Philadelphia.    [Reprinted  from  the  Medical  News.] 

Amblyopiatrics.  By  George  M.  Gould,  M.  D.,  of  Philadel- 
phia.   [Reprinted  from  the  Medical  News.] 

Hot  Water  Flushing  applied  to  General  Surgery.  By  Robert 
O'Callaghan,  F.  R.  C.  S.  I.,  etc.  [Reprinted  from  the  Dublin 
Journal  of  Medical  Science.] 

The  Nervous  Affections  that  may  arise  from  Malaria.  By 
William  Browning,  M.  D.  [Reprinted  from  the  Brooldyn  Medi- 
cal Journal.] 

Syringomyelia.  Clinical  Lecture  delivered  at  the  Arapahoe 
County  Hof'pital,  Denver,  Col.  By  James  T.  Eskridge,  M.  D. 
[Reprinted  from  the  International  Clinics.] 

Arterial  Saline  Infusion.  A  Report  of  Three  Additional 
Oases  by  the  New  Technique ;  also,  of  a  Case  of  Infant  Diar- 
rhoea treated  by  Saline  Infusion.  By  Robert  H.  M.  Dawbarn, 
M.  D.,  of  New  York.    [Reprinted  from  the  Medical  Record.] 

A  New  Method  of  checking  Bleeding  after  Tonsillotomy. 
By  Robert  H.  M,  Dawbavn,  of  New  York.  [Reprinted  from  the 
Medical  Record.] 

Zur  Ehrenrettung  des  Perinealschnitts.  Von  Dr.  Carl  Beck, 
New  York. 

Transactions  of  the  Colorado  State  Medical  Society.  Twen- 
ty-second Annual  Convention.  By-laws  and  List  of  Members. 
Denver,  June,  1892. 

Twenty-second  Annual  Report  of  St.  Catherine's  Hospital, 
Brooklyn.    For  the  Year  1892. 

The  One  Hundred  and  Third  Annual  Report  of  the  Board  of 
Trustees  of  the  New  York  Dispensary,  for  the  Year  1892. 

Report  of  the  German  Poliklinik  of  the  City  of  New  York, 
for  the  Year  1892. 

Ueber  eine  neue  Behandlungsmetbode  der  Nephrolithiasis 
mit  Glycerin.  Von  Dr.  August  Hermann.  [Sonderabdruck  a. 
d.  Prager  med.  Wochenschrift.] 


The  National  Quarantine  Act  of  1893.— The  Ahatract  of  Sanitary 
Reports  for  Fel)niary  10th  piibhshes  the  following  as  the  text  of  the 
National  Quaiantine  Act  wliich  has  passed  both  Houses  of  Congress 
and  awaits  the  signature  of  tlie  President : 

"  An  act  granting  additional  quarantine  powers  and  imposing  addi- 
tional duties  upon  the  Marine-Hoppital  Service. 

"  Be  it  euacted  by  the  Senate  and  House  of  Representatives  of 
the  United  States  of  America  in  Congress  assembled,  That  it  shall 
be  unlawful  for  any  merchant  sliip  or  other  vessel  from  any  foreign 
port  or  place  to  enter  any  poit  of  the  United  States  except  in  ac- 
cordance with  the  provisions  of  tliis  act  and  witli  such  rules  and  regu- 
lations of  State  and  municipal  health  authorities  as  may  be  made  in 
pursuance  of,  or  consistent  with,  this  act;  and  any  such  vessel  which 
shall  enter,  or  attempt  to  enter,  a  port  of  the  United  States  in  violation 
thereof  shall  forfeit  to  the  United  States  a  sum,  to  be  awarded  in  the 
discretion  of  the  court,  not  exceeding  five  thousand  dollars,  which  shall 
be  a  lien  upon  said  vessel,  to  be  recovered  by  proceedings  in  the  proper 
district  co\irt  of  the  United  States.  In  all  such  proceedings  the  United 
States  District  Attorney  for  such  district  shall  appear  on  behalf  of  the 
United  States ;  and  all  such  proceedings  shall  be  conducted  in  accord- 
ance with  the  rules  and  laws  governing  eases  of  seizure  of  vessels  for 
violation  of  the  revenue  laws  of  the  United  States. 

"  Sec.  2.  That  any  vessel  at  any  foreign  port  clearing  for  any  port 
or  place  in  the  United  States  shall  be  required  to  obtain  from  the  consul, 
vice-consul,  or  other  consular  officer  of  the  United  States  at  the  port  of 
departure,  or  from  the  medical  officer  where  such  officer  has  been  de- 
tailed by  the  President  for  that  purpose,  a  bill  of  health,  in  duplicate, 
in  the  form  prescribed  by  the  Secretary  of  the  Treasury,  setting  fortli 
the  sanitary  history  and  condition  of  said  vessel,  and  that  it  has  in  all 
respects  complied  with  the  rules  and  regulations  in  such  cases  pre- 
scribed for  securing  the  best  sanitary  condition  of  the  said  vessel,  its 
cargo,  passengers,  and  crew  ;  and  said  consular  or  medical  officer  is  re- 
quired, before  granting  such  duplicate  bill  of  health,  to  be  satisfied  that 
the  matters  and  things  therein  stated  are  true ;  and  for  his  services  in 
that  behalf  he  shall  be  entitled  to  demand  and  receive  such  fees  as 
shall  by  lawful  regulation  be  allowed,  to  l)e  accounted  for  as  is  required 
in  other  cases. 

"  The  President,  in  his  discretion,  is  authorized  to  detail  any  medical 
officer  of  the  Government  to  serve  in  the  office  of  the  consul  at  any, 
foreign  port  for  the  purpose  of  furnishing  information  and  making  the 
inspection  and  giving  the  bills  of  health  hereinbefore  mentioned.  Any 
vessel  clearing  and  sailing  from  any  such  port  without  such  bill  of 
health,  and  entering  any  port  of  the  United  States,  shall  forfeit  to  the 
United  States  not  more  than  five  thousand  dollars,  the  amount  to  be 
determined  by  tlie  court,  which  shall  be  a  lien  on  the  same,  to  be  re- 
covered by  proceedings  in  the  proper  distiict  court  of  the  United  States. 
In  all  such  pi-oceedings  the  United  States  District  Attorney  for  such 
district  shall  appear  on  behalf  of  the  United  States  ;  and  all  such  pro- 
ceedings shall  be  conducted  in  accordance  with  the  rules  and  laws  gov- 
erning cases  of  seizure  of  vessels  for  violation  of  the  revenue  laws  of 
the  United  States. 

"  Sec.  3.  That  the  Supervising  Surgeon-General  of  the  Marine-Hos- 
pital Service  shall,  immediately  after  this  act  takes  effect,  examine 
the  quarantine  regulations  of  all  State  and  municipal  boards  of  health, 
and  shall,  under  the  direction  of  the  Secretary  of  the  Treasury,  co- 
operate with  and  aid  State  and  municipal  boards  of  health  in  the  exe- 
cution and  enforcement  of  the  rules  and  regulations  of  such  boards  and 
in  the  execution  and  enforcement  of  the  rules  and  regulations  made  by 
the  Secretary  of  the  Treasury  to  prevent  the  introduction  of  contagious- 
or  infectious  diseases  into  the  United  States  from  foreign  countries, 
and  into  one  State  or  Territory  or  the  District  of  Columbia  from  an- 
other State  or  Territory  or  the  District  of  Columbia ;  and  all  rules  and 
regulations  made  by  the  Secretary  of  the  Treasury  shall  operate  uni- 
formly and  in  no  manner  discriminate  against  any  port  or  place  ;  and 
at  such  ports  and  places  within  the  United  States  as  have  no  quaran- 
tine regulations  under  State  or  umuicipal  authority,  where  such  regula- 


Fob.  18,  lHa3.J 

tions  are,  in  the  opinion  of  the  Secretary  of  the  Treasury,  necessary  to 
prevent  the  introduction  of  contagious  or  infectious  diseases  into  the 
United  States  from  foreign  countries,  or  into  one  State  or  Territory  oi' 
the  District  of  Cohnubia  from  another  State  or  Territory  or  the  District 
of  Cohinihia,  and  at  such  ports  and  places  witliin  the  United  States 
where  quarantine  reguhitions  exist  under  the  authority  of  the  State  or 
municipality  which,  in  the  opinion  of  the  Secretary  of  the  Treasury, 
are  not  sufficient  to  prevent  the  introduction  of  such  diseases  into  the 
United  States,  or  into  one  State  or  Territory  or  the  District  of  Columbia 
from  another  State  or  Territory  or  the  District  of  Columbia,  the  Secre- 
tary of  the  Treasury  shall,  if  in  his  judgment  it  is  necessary  and  proper, 
make  such  additional  rules  and  regulations  as  are  necessary  to  prevent 
the  introduction  of  such  diseases  into  the  United  States  from  for- 
eign countries,  or  into  one  State  oi'  Territory  or  the  District  of  Colum- 
bia from  another  State  or  Territory  or  the  District  of  Columbia,  and 
when  said  rules  and  regulations  have  been  made  they  shall  be  pro- 
mulgated by  the  Secretary  of  the  Treasury  and  enforced  by  the  sani- 
tary authorities  of  the  States  and  municipalities,  where  the  State  or 
municipal  health  authorities  will  undertake  to  execute  and  enforce 
them ;  but  if  the  State  or  municipal  authorities  shall  fail  or  refuse  to 
enforce  said  rules  and  regulations  the  President  shall  execute  and  en- 
force the  same  and  adopt  such  measures  as  in  his  judgment  shall  be 
necessary  to  prevent  the  introduction  or  spread  of  such  diseases,  and 
may  detail  or  appoint  officers  for  that  purpose. 

"  The  Secretary  of  the  Treasury  shall  make  such  rules  and  regula- 
tions as  are  necessary  to  be  observed  by  vessels  at  the  port  of  depart- 
ure and  on  the  voyage,  where  such  vessels  sail  from  any  foreign  port  or 
place  to  any  port  or  place  in  the  United  States,  to  secure  the  best  sani- 
tary condition  of  such  vessel,  her  cargo,  passengers,  and  crew ;  which 
shall  be  published  and  communicated  to  and  enforced  by  the  consular 
officers  of  the  United  States.  None  of  the  penalties  herein  imposed 
shall  attach  to  any  vessel  or  owner  or  officer  thereof  until  a  copy  of 
this  act,  with  the  rules  and  regulations  made  in  pursuance  thereof,  has 
been  posted  up  in  the  office  of  the  consul  or  other  consular  officer  of 
the  United  States  for  ten  days,  in  the  port  from  which  said  vessel 
sailed ;  and  the  certificate  of  such  consul  or  consular  officer  over  his 
official  signature  shall  be  competent  evidence  of  such  posting  in  any 
court  of  the  United  States. 

"  Sec.  4.  That  it  shall  be  the  duty  of  the  Supervising  Surgeon-Gen- 
eral of  the  Marine-Hospital  Service,  under  the  direction  of  the  Secretary 
of  the  Treasury,  to  perform  all  the  duties  in  respect  to  quarantine  and 
quarantine  regulations  which  are  provided  for  by  this  act,  and  to  ob- 
tain information  of  the  sanitary  condition  of  foreign  ports  and  places 
from  which  contagious  and  infectious  diseases  are  or  may  be  imported 
into  the  United  States,  and  to  this  end  the  consular  officer  of  the  United 
States  at  such  ports  and  places  as  shall  be  designated  by  the  Secretary 
of  the  Treasury  shall  make  to  the  Secretary  of  the  Treasury  weekly  re- 
ports of  the  sanitary  condition  of  the  ports  and  places  at  which  they 
are  respectively  stationed,  according  to  such  forms  as  the  Secretary  of 
the  Treasury  shall  prescribe ;  and  the  Secretary  of  the  Treasury  shall 
also  obtain,  through  all  sources  accessible,  including  State  and  muni- 
cipal sanitary  authorities  throughout  the  United  States,  weekly  reports 
of  the  sanitary  condition  of  ports  and  places  within  the  United  States, 
and  shall  prepare,  publish,  and  transmit  to  collectors  of  customs  and  to 
State  and  municipal  health  officers  and  other  sanitarians  weekly  ab- 
stracts of  the  consular  sanitary  reports  and  other  pertinent  information 
received  by  him,  and  shall  also,  as  far  as  he  may  be  able,  by  means  of 
the  voluntary  co-operation  of  State  and  municipal  authorities,  of  pub- 
lic associations,  and  private  persons,  procure  information  relating  to 
the  climatic  and  other  conditions  affecting  the  public  health,  and 
^  shall  make  an  annual  report  of  his  operations  to  Congress,  with  such 
recommendations  as  he  may  deem  important  to  the  public  interests. 

"  Sec.  5.  That  the  Secretary  of  the  Treasury  shall  from  time  to 
time  issue  to  the  consular  officers  of  the  United  States  and  to  the  medi- 
cal officers  serving  at  any  foreign  port,  and  otherwise  make  publicly 
known,  the  rules  and  regulations  made  by  him,  to  be  used  and  com- 
plied wiih  by  vessels  in  foreign  ports,  for  securing  the  best  sanitary 
condition  of  such  vessels,  their  cargoes,  passengers,  and  crew,  before 
their  departure  for  any  port  in  the  United  States,  and  in  the  course  of 
the  voyage ;  and  all  such  other  rules  and  regulations  as  shall  be  ob- 


203 

served  in  the  inspection  of  the  same  on  the  arrival  thereof  at  any  quar- 
antine station  at  the  port  of  destination,  and  for  the  disinfection  and 
isolation  of  the  same,  and  the  treatment  of  cargo  and  persons  on  board, 
so  as  to  prevent  the  introduction  of  cholera,  yellow  fever,  or  other  con- 
tagious or  infectious  diseases ;  and  it  shall  not  be  lawful  for  any  vessel 
to  enter  said  port  to  discharge  its  cargo,  or  land  its  passengers,  except 
upon  a  certificate  of  the  health  officer  at  such  quarantine  station  certi- 
fying that  said  rules  and  regulations  have  in  all  respects  been  observed 
and  complied  with,  as  well  on  his  part  as  on  the  part  of  the  said  ves- 
sel and  its  master,  in  respect  to  the  same  and  to  its  cargo,  passengers, 
and  crew ;  and  the  masfer  of  every  such  vessel  shall  produce  and  de- 
liver to  the  collector  of  customs  at  said  port  of  entry,  together  with  the 
other  papers  of  the  vessel,  the  said  bills  of  health  required  to  be  ob- 
tained at  the  port  of  departure  and  the  certificate  herein  required  to  be 
obtained  from  the  health  officer  at  the  port  of  entry ;  and  that  the  bills 
of  health  herein  prescribed  shall  be  considered  as  part  of  the  ship's 
papers,  and  when  duly  certified  to  by  the  proper  consular  or  other  officer 
of  the  United  States,  over  his  official  signature  and  seal,  shall  be  ac- 
cepted as  evidence  of  the  statements  therein  contained  in  any  court  of 
the  United  States. 

"  Sec.  6.  That  on  the  arrival  of  an  infected  vessel  at  any  port  not 
provided  with  proper  facilities  for  treatment  of  the  same,  the  Secre- 
tary of  the  Treasury  may  remand  said  vessel,  at  its  own  expense,  to  the 
ne^arest  national  or  other  quarantine  station,  where  accommodations 
and  appliances  are  provided  for  the  necessary  disinfection  and  treat- 
ment of  the  vessel,  passengers,  and  cargo  ;  and  after  treatment  of  any 
infected  vessel  at  a  national  quarantine  station,  and  after  certificate 
shall  have  been  given  by  the  United  States  quarantine  officer  at  said 
station  that  the  vessel,  cargo,  and  passengers  are  each  and  all  free  from 
infectious  disease,  or  danger  of  conveying  the  same,  said  vessel  shall  be 
admitted  to  entry  to  any  port  of. the  United  States  named  within  the 
certificate.  But  at  any  ports  where  sufficient  quarantine  provision  has 
been  made  by  State  or  local  authorities  the  Secretary  of  the  Treasury 
may  direct  vessels  bound  for  said  ports  to  undergo  ([uarantine  at  said 
State  or  local  station. 

"  Sec.  7.  That  whenever  it  shall  be  shown  to  the  satisfaction  of  the 
President  that  by  reason  of  the  existence  of  cholera  or  other  infectious 
or  contagious  diseases  in  a  foreign  country  there  is  serious  danger  of 
the  introduction  of  the  same  into  the  United  States,  and  that  notwith- 
standing the  quarantine  defense  this  danger  is  so  increased  by  the  in- 
troduction of  persons  or  property  from  such  country  tha^  a  suspension 
of  the  right  to  introduce  the  same  is  demanded  in  the  interest  of  the 
public  health,  the  President  shall  have  power  to  prohibit,  in  whole  or 
in  part,  the  introduction  of  persons  and  property  from  such  countries 
or  places  as  he  shall  designate  and  for  such  period  of  time  as  he  may 
deem  necessary. 

"  Sec.  8.  That  whenever  the  proper  authorities  of  a  State  shall  sur- 
render to  the  United  States  the  use  of  the  buildings  and  disinfecting 
apparatus  at  a  State  quarantine  station,  the  Secretary  of  the  Treasury 
shall  be  authorized  to  receive  them  and  to  pay  a  reasonable  compensa- 
tion to  the  State  for  their  use,  if,  in  his  opinion,  they  are  necessary  to 
the  United  States. 

"  Sec.  9.  That  the  act  entitled  '  An  act  to  prevent  the  introduction 
of  infectious  or  contagious  diseases  into  the  United  States,  and  to  estab- 
lish a  national  board  of  health,'  approved  March  third,  eighteen  hun- 
dred and  seventy-nine,  be  and  the  same  is  hereby  repealed.  And  the 
Secretary  of  the  Treasury  is  directed  to  obtain  possession  of  any  prop- 
erty, furniture,  books,  paper,  or  records  belonging  to  the  United  States 
which  are  not  in  the  possession  of  an  officer  of  the  United  States  under 
the  Treasury  Department  which  were  formerly  in  the  use  of  the  na. 
tional  board  of  health  or  any  officer  or  employee  thereof." 

Recent  Investigations  regarding  Ringworm. — Dr.  (Jeorge  D.  Hol- 
sten,  of  Brooklyn,  contributes  the  following: 

Dr.  Louis  Wickham,  of  Paris,  in  a  letter  published  in  the  Afonais- 
licfte  fur  praktische  Derrnatoloffie  for  December  15,  1892,  rejiorts  a 
communication  made  by  Sabouraud,  a  pupil  of  Besnier  and  the  Pasteur 
Institute,  to  the  French  Society  of  Dermatology  and  Syphilography  on 
November  10,  1892,  on  the  existence  of  various  forms  of  trichojjhy- 
tina. 


MISCELLANY. 


204 


MISCELLANY. 


(N.  Y.  Med.  JonK. 


Sabouraud's  investigations  embraced  more  than  one  hundred  cases 
in  which  the  liiiirs  and  scales  were  examined  niicrosco]iically ;  over 
six  hundred  cultures  made  from  this  diseased  matei  ial ;  more  than 
eixty  cultures  in  hanging  drops,  a  method  especially  suited  to  the  study 
of  the  botanical  structure  of  the  parasite ;  and,  lastly,  more  than  thirty 
inoculations. 

In  examining  the  hairs  he  found  that  all  the  trichophyton  spores 
from  a  certain  diseased  scalp  were  of  equal  size,  but  on  comparing  the 
spores  from  different  scalps  there  was  a  marked  difference  in  that  in 
certain  cases  small  spores  (3  /i),  in  others  large  (V  to  8  ft),  were  present. 
Further,  the  small  spores  were  not  combined  with  an  appreciable 
amount  of  mycelium,  but  were  irregularly  arranged  in  large  heaps  in 
the  hairs  and  were  also  covered  externally  with  a  sort  of  veil.  The 
large  spores,  on  the  contrary,  would  be  combined  with  quite  an  appre- 
ciable amount  of  mycelium,  the  spores  being  regularly  arranged  in  rows 
between  the  mycelial  threads,  which  were  also  inclosed  in  the  hair,  but 
not  surrounded  by  a  membrane.  All  this  could  be  observed  under 
a  microscope  after  boihng  the  hairs  in  a  forty-per-cent.  potash  solu- 
tion. In  cases  of  direct  contagion — in  the  household  or  school — the 
spores  were  and  remained  the  same  as  in  the  case  from  which  the  dis- 
ease had  been  contracted.  In  twenty  especially  severe  cases  of  falling 
of  tlie  hair  the  disease  was  due  in  nineteen  of  them  to  the  small  spores 
without  any  appreciable  mycelium.  Altogether  sixty  per  cent,  of  the 
cases  of  alopecia  were  due  to  the  small  as  against  forty  per  cent,  due  to 
the  large  spores. 

The  bacteriological  examination  sustained  the  differences  found 
microscopically.  The  trichophyton  with  large  spores  cultivated  on  gela- 
tin was  at  first  feathery  and  white,  but  after  from  fourteen  to  eighteen 
days  became  mealy  and  yellow.  On  potato  a  yellowish-brown  culture 
was  obtained,  but,  on  whatever  media  cultivated,  the  cultures  retained 
their  mealy  appearance  and  light  yellowish-brown  color. 

The  small  trichophyton  spores  assumed  the  feathery  appearance 
much  later,  were  always  of  a  clear  white,  and  remained  so  on  all  media. 
On  potatoes,  during  the  first  ten  days  before  the  feathery  appearance 
obtained,  they  appeared  as  a  reddish-brown  spot  very  much  resembling 
dried  blood. 

Not  one  of  his  cultures — more  than  a  hundred  in  number — showed 
any  intermediate  forms,  and  never  did  one  form  pass  into  the  other. 

All  his  cases  of  ringworm  of  the  beard,  six  in  number,  as  well  as  all 
of  non-hairy  portions  of  tlie  body  (twenty-three),  showed  the  large 
spores.  From  these  facts  he  draws  the  conclusion  that  the  most  diffi- 
cult cases  to  treat  are  those  due  to  the  small  spores,  which  seem  to 
have  a  preference  for  the  scalp  in  children,  giving  rise  to  a  tinea  ton- 
surans and  producing  alopecia,  which,  however,  is  to  a  great  extent  not 
contagious  for  adults ;  while  cases  of  tinea  circinata  and  ringworm  of 
the  beard  in  adults  are  due  to  the  large  spores. 

In  about  one  third  of  the  cases  of  tinea  circinata — namely,  those 
having  a  sycosis-like  appearance — in  tinea  agminata,  and  in  kerion  Celsi 
of  children,  he  also  found  a  large  spore  whose  cultures  appeared  iden- 
tical with  the  above-described  macrosporon,  but  differed  somewhat 
through  certain  secondary  or  non-essential  divergences,  which  were, 
however,  always  more  or  less  conspicuous  and  nearly  always  appeared, 
60  that  up  to  the  present  it  is  impossible  to  say  if  these  were  due  to  an 
unalterable  variety  or  only  dependent  upon  some  peculiarity  in  the 
method  of  cultivation,  and  would  again  return  to  the  normal  type. 

The  same  reservation  is  made  with  regard  to  a  fourth  spore  (Tricho- 
phyton macrosporon  anommon),  wliich  he  once  found  in  a  case  of  herpes 
tonsurans.  The  spores  were  large,  of  irregular  form,  and  of  variable 
size,  without  appreciable  mycelium.  The  disease  showed  many  pecul- 
iarities of  variation,  as  did  also  the  cultures,  which  were  not  entirely 
identical  with  the  trichophytina  macrosporon. 

Finally,  besides  these  four  forms,  he  found  in  two  cases  an  entirely 
peculiar  culture  which  had  no  resemblance  whatever  to  the  parasites  of 
trichophytina  humana.  One  was  a  trichophyton  giving  black  cultures, 
found  in  a  case  of  tinea  circinata  of  a  peculiar  form  ;  the  other,  a  rose- 
colored  culture  found  in  a  tinea  barboe.  All  the  circumstances  pointed 
to  these  two  cases  being  directly  due  to  contagion  from  animals. 

Inoculations  with  the  small-spored  trichophyton  on  non-hairy  por- 
tions of  skin  produced  only  a  moderate  degree  of  erythema  with  subse- 
quent detachment  of  epidermis  in  large  scales  and  subsidence  of  all 


symptoms.  With  tlw^  different  forms  of  large  spore,  however  (besides 
many  failures),  the  trichophytosis  circinata  communis  was  obtained,  the 
appearance  of  which,  no  matter  from  which  variety  inoculated,  always 
remained  the  same. 

The  New  York  Academy  of  Medicine. — The  programme  for  the 
meeting  of  Tliurs<iay  evening,  the  10th  inst.,  included  a  paper  entitled 
A  Consideration  of  some  Points  in  the  Applied  Physics  of  Physical  Diag- 
nosis,  by  Dr.  Charles  E.  Quimby. 

At  the  next  meeting  of  the  Section  in  Ophthalmology  and  Otology, 
on  Monday  evening,  the  20th  inst..  Dr.  H.  Knapp  will  read  a  paper  on 
The  Early  Diagnosis  of  Sarcoma  of  the  Chorioid. 

At  the  next  meeting  of  the  Section  in  General  Medicine,  on  Tuesday 
evening,  the  21st  inst..  Dr.  George  B.  Fowler  is  to  read  a  paper  on  Diet 
in  Disease. 

At  the  next  meeting  of  the  Section  in  Laryngology  and  Rhinology, 
on  Wednesday  evening,  the  22d  inst..  Dr.  George  A.  Richards  will  read 
a  paper  on  Gangrenous  Gingivitis. 

At  the  next  meeting  of  the  Section  in  Obstetrics  and  Gyna;cologj',  on 
Thursday  evening,  the  23d  inst.,  Dr.  Horace  T.  Hanks  will  read  a  paper 
on  Pelvic  Inflammation  following  the  Puerperal  State. 


fo  Contributors  and  Correspondents. — The  attention  of  all  whopurpoi* 

favoring  us  with  communications  is  respectfully  called  to  the  follow- 
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Authors  of  articles  intended  for  publication  binder  the  liead  of  "  original 
contributions  "  are  respectfully  inforyned  that,  in  accepting  such  arti- 
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tions are  to  be  observed :  (1)  when  a  maiLuscript  is  sent  to  this  jour- 
nal, a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
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into  the  type-setters^  hands.  We  are  often  constrained  to  declim 
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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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at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
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dressed Co  the  publiihert,  > 


THE  JSTEW  YORK  MEDICAL  JOURNAL,  February  25,  1893. 


(fricjmal  Communications. 


THE  MECHANISM  AND  DIAGNOSIS  OF 
VERTEX  PRESENTATION* 
Bt  J.  CLIFTON  EDGAR,  M.  D., 

ADJTNOT  PROFESSOR  OP  OBSTETRICS  IN  THE  MEDICAL  DEPARTMENT  OF 
THE  UNIVERSITY  Or  THE  CITY  OF  NEW  YORK  ; 
ASSISTANT  OBSTETRIC  SURGEON  TO  THE  NEW  YORK  MATERNITY  HOSPITAL  ; 
OBSTETRICIAN  TO  THE  EMERGENCY  LYING-IN  HOSPITAL  ; 
ATTENDING  PHYSICIAN  TO  THE  NEW  YORK  LYING-IN  HOSPITAL. 

If  we  are  familiar  with  the  three  factors  of  labor — 
namely,  the  passages,  the  passenger,  and  the  forces — we  are 
in  a  position  to  appreciate  that  most  interesting  part  of  the 
subject  of  parturition  :  the  manner  or,  better,  the  combina- 
tion of  movements  by  which  Nature  guides  the  foetus  from 
the  uterine  cavity  through  the  pelvis  into  the  external 
world.  In  the  whole  range  of  obstetric  science  and  art 
there  is  perhaps  no  one  subject  more  worthy  of  a  careful, 
conscientious,  and  diligent  study.  There  is  no  one  subject 
upon  which  so  much  depends  as  regards  the  prognosis  for 
both  mother  and  child.  If  perchance  one  link  in  the  chain 
of  these  movements  going  to  make  up  the  mechanism  of 
labor  fails,  and  we  are  unable,  by  reason  of  our  ignorance 
of  Nature's  methods,  to  step  in  at  the  right  moment  and 
supply  the  deficiency,  either  mother  or  child  is  bound  to 
suffer. 

It  is  quite  true  that  in  our  first  ten  or  twelve  cases  of 
labor  absolutely  no  interference  may  be  called  for  in  their 
management,  but  it  is  equally  true  that  in  our  next  series 
of  ten  or  a  dozen  cases  Nature  may  fail  us  in  some  par- 
ticular ;  we  are  unable  to  appreciate  the  difficulty  and  to 
correct  it,  and  untold  disaster  is  the  result.  With  equal 
success  might  we  hope  to  appreciate  and  treat  certain 
cardiac  diseases  without  an  understanding  of  the  anatomy 
and  physiology  of  the  heart  as  to  attempt  the  management 
of  labor  cases  without  a  clear  knowledge  of  the  mechanism 
of  parturition. 

Before  turning  our  attention  to  the  mechanism  of  labor 
in  vertex  presentations,  let  us  recall  the  statement  of  Pajot 
that  "all  labors,  from  a  mechanical  standpoint,  are  subject 
to  the  same  law,  and  that  there  is  really  only  one  mechan- 
ism of  labor,  no  matter  what  the  presentation  or  position, 
.  .  .  provided  only  that  expulsion  occurs  spontaneously  and 
at  term,  as  abortions  do  not  result  in  regular  expulsion." 
We  may  state,  then,  to-day  that  there  is  but  one  mechan- 
ism of  labor,  no  matter  if  the  presentation  is  the  vertex, 
the  brow,  the  face,  or  the  breech.  A  recent  writer  upon 
midwifery  would  compare  the  mechanism  of  labor  in  ver- 
tex presentation  to  a  tune,  the  mechanism  of  labor  in  all 
other  presentations  being  the  same  with  variations.  Fur- 
ther, we  may  state  that,  in  the  mechanism  of  labor  in  all 
presentations  and  positions,  six  stages  may  be  described  : 
1.  In  the  first  stage  the  fcEtus,  pressed  upon  and  influenced 
by  the  general  intra-uterine  pressure,  and  perhaps  also  to  a 
slight  extent  by  the  voluntary  efforts  of  the  mother,  tends 


*  A  lecture  delivered  at  the  University  Medical  College,  December 
6  and  8,  1892. 


to  accommodate,  to  mold  the  shape  of  its  presenting  part 
to  suit  the  canal  through  which  it  has  to  pass.  2.  In  the 
second  stage  this  molded  presentation  engages  and  descends 
into  the  pelvis.  This  stage,  then,  is  the  stage  of  engaging 
and  descent.  3.  Having  molded,  having  engaged,  having 
descended  a  certain  distance — namely,  to  the  pelvic  floor — 
the  presenting  part  executes  a  movement,  so  as  to  bring  its 
long  axis  in  correspondence  with  the  longest  diameter  of  the 
outlet  of  the  pelvic  canal.  This  is  the  third  stage,  or  stage  of 
internal  rotation.  4.  Again  the  presenting  part  executes  a 
further  movement  by  which  it  sets  itself  free  from  the  geni- 
tal canal.  This  is  the  fourth  stage,  or,  as  we  may  say,  the 
stage  of  expulsion  of  the  first  part  of  the  foetus.  5.  Again, 
as  the  result  of  the  internal  rotation  of  that  portion  of  the 
child  which  is  still  within  the  birth  canal,  we  have  a  rota- 
tion of  that  part  which  has  already  been  delivered,  and  this 
is  termed  the  stage  of  external  rotation.'  6.  Then  the  sixth 
and  last  stage  is  a  second  period  of  expulsion,  or  the  escape 
of  that  part  of  the  foetus  heretofore  unexpelled. 

While  these  six  stages  in  the  mechanism  of  labor  are 
not  always  absolutely  the  same  for  all  presentations  and  for 
all  positions  of  the  foetus  ;  while  we  may  have  flexion  in  one 
instance,  extension  in  another ;  while  it  may  be  the  right 
shoulder  that  rotates  to  the  front  in  one  and  the  left  in 
another ;  while  the  presentation  may  be  face,  brow,  ver- 
tex, or  breech,  yet  we  shall  be  certain  to  encounter  these 
stages  in  all  labors,  no  matter  what  the  presentation,  no 
matter  what  the  position. 

Having  thoroughly  grasped  these  facts,  then,  let  us  turn 
immediately  to  the  consideration  of  vertex  presentation. 
The  number  of  positions  of  the  vertex  described  vary  in 
different  countries  and  according  to  different  authorities. 
The  English  usually  describe  four  positions  ;  those  American 
writers  who  follow  the  teachings  of  Hodge,  on  the  other 
hand,  would  have  us  describe  six  positions ;  while  the  Ger- 
mans, thinking  both  these  classifications  too  complicated, 
describe  usually  but  two  positions.  The  simplest  classifi- 
cation is  to  speak  of  four  positions,  and  we  shall  therefore 
adopt  that ;  and  this  is  more  readily  understood  if  we  im- 
agine that  the  pelvic  inlet  is  divided  into  four  quadrants  by 
the  antero  posterior  and  transverse  diameters,  and  that  the 
positions  vary  according  as  the  vertex  occupies  one  or  other 
of  these  four  quadrants.  And  just  here  let  us  remember 
that  by  the  right  oblique  diameter  we  mean  the  one  passing 
through  the  right  sacro-iliac  synchondrosis,  and  by  the  left 
the  one  passing  through  the  left  sacro-iliac  joint. 

The  four  positions  of  the  vertex,  then,  are :  1.  The  first 
or  left  occipito-anterior  position.  2.  The  second  or  right 
occipito-anterior  position.  3.  The  third  or  right  occipito- 
posterior  position.  4.  The  fourth  or  left  occipito-posterior 
position.  And,  as  regards  the  relative  frequency  of  these 
several  positions,  it  is  to- day  pretty  well  agreed  by  authori- 
ties upon  the  subject  that  the  first  position  obtains  in  from 
sixty- five  to  eighty  per  cent,  of  cases,  and  that  the  third, 
second,  and  fourth  positions  are  the  next  most  frequent  in 
the  order  named. 

We  shall  first  describe  the  mechanism  of  labor  in  the 
first  or  left  occipito-anterior  position,  and  then  in  the  third. 


206 


EDGAR:   VERTEX  PRESENTATION. 


[N.  Y.  Med.  Jottb., 


the  next  most  frequent,  or  the  right  occipito-posterior  posi- 
tion of  the  vertex. 

In  the  first  stage,  the  mechanism  that  we  have  to  describe 
is  one  of  flexion  and  molding,  and  we  can  readily  compre- 
hend how  flexion  is  brought  about  when  we  hold  up  a  foetal 
cadaver,  and  we  immediately  perceive  that  the  forehead,  or 
the  long  end  of  the  lever  made  by  the  head  upon  the  spinal 
column,  falls,  by  reason  of  its  own  weight,  upon  the  chest  of 
the  foetus  ;  consequently,  when  the  force  of  uterine  contrac- 
tion acts  upon  the  head  through  the  spinal  column,  the  short 
end,  or  the  occipital  extremity  of  the  head,  is  more  directly 
in  the  line  of  action  of  this  force,  and  consequently  tends 
to  be  driven  farther  downward  in  the  birth  canal,  and  hence 
flexion  of  the  child's  chin  upon  its  sternum  is  produced. 
We  have  every  reason  to  believe,  however,  that  flexion  is 
in  many  cases  complete  before  labor  actually  sets  in,  for  we 
know  that  the  normal  attitude  or  posture  of  the  chil  1  with- 
in the  uterus  is  one  of  flexion,  and  we  can  recall,  from  our 
observations  of  labor  cases  in  the  New  York  Lying-in  Hos- 
pital, how  the  child's  posture,  immediately  after  its  expul- 
sion from  the  birth  canal,  was  often  one  of  flexion  between 
the  thighs  of  its  mother.  Even  in  the  absence  of  uterine 
contraction,  flexion  may  be  brought  about  by  this  tendency 
on  the  part  of  the  child  to  take  up  this  particular  attitude, 
and  also  by  a  principle  of  mechanics  that  is  termed  a  coup- 
let, which  latter  we  will  pass  over  for  the  present.  Mold- 
ing, then,  and  flexion  constitute  the  first  stage  in  the  mech- 
anism. 

Recalling  our  general  principles,  the  next  stage  will  be 
one  of  engagement  and  gradual  descent ;  and,  as  in  all 
mechanisms  of  labor,  one  great  principle — namely,  accom- 
modation or  adaptation — plays  a  prominent  part,  conse- 
quently the  long  diameter  of  the  head  would  tend  to  enter 
the  pelvic  inlet  in  its  longest  diameter,  which  is,  as  we 
know,  the  transverse ;  and  Spiegelberg  has  shown  that 
the  head  does  in  vertex  presentation  enter  the  transverse 
diameter  of  the  pelvic  inlet  in  81 '4  per  cent,  of  all  cases. 
So  far  it  has  been  all  very  simple ;  there  is  nothing  that 
any  one  of  us  can  not  readily  understand  and  comprehend ; 
but  we  come  now  to  the  third  stage  in  the  mechanism — 
namely,  the  internal  rotation  of  the  first  part,  or,  in  this 
case,  the  head. 

Perhaps  there  is  no  part  of  the  mechanism  of  labor  that 
has  caused  the  student  such  difficulty  and  concerning  which 
there  has  been  such  difference  of  opinion  as  the  cause  of 
this  internal  rotation,  whether  it  be  the  internal  rotation  of 
the  head,  or  of  a  shoulder,  or  of  a  buttock.  There  have 
been  various  explanations  advanced,  most  of  them  more  or 
less  unsatisfactory.  For  instance,  Baudelocque  and  his  fol- 
lowers taught  that  the  anterior  and  the  posterior  inclined 
planes  of  the  ischia  determined  the  anterior  or  the  poste- 
rior rotation  of  the  lowest  portion  of  the  presenting  part. 
Naegele,  however,  pointed  out  the  fallacy  of  this  explana- 
tion ;  for,  contrary  to  Baudelocque,  he  demonstrated  that 
the  occiput  rotates  anteriorly  even  when  it  is  originally  situ- 
ated on  a  posterior  inclined  plane.  Cazeaux  would  have  us 
explain  the  rotation  upon  mathematical  and  mechanical 
principles ;  but,  without  going  into  the  matter,  suffice  it  to 
8ay  that  while  they  beautifully  explain  the  cause  of  anterior 


rotation  in  anterior  positions,  yet  they  are  absolutely  insuf- 
ficient to  account  for  the  anterior  rotation  in  originally  pos- 
terior positions.  Tyler  Smith,  Leishman,  and  Playfair,  as 
we  are  aware,  teach  that  the  anterior  rotation  is  determined 
by  the  ischial  spines,  and  while  here  again  the  explanation 
fully  accounts  for  the  anterior  rotation  in  anterior  positions, 
we  are  unable  to  understand  how  they  produce  anterior 
rotation  in  the  third  and  fourth  positions  of  the  vertex.  It 
was  not  until  Paul  Dubois  performed  his  experiments  upon 
the  cadaver  that  we  find  anything  like  a  satisfactory  ex- 
planation for  anterior  rotation  of  the  lowest  portion  of  the 
presenting  part  under  all  circumstances.  Dubois's  experi- 
ments consisted  in  pushing  f(jetal  cadavers  of  various  sizes 
through  the  birth  canal  of  puerpcrse  recently  dead,  and  he 
found  that,  no  matter  in  what  position  he  placed  the  vertex, 
whether  to  the  front  or  to  the  rear,  anterior  rotation  of  the 
vertex  occurred  as  soon  as  it  reached  the  pelvic  floor;  but 
there  came  a  time  in  his  experiments  when  anterior  rotation 
completely  failed  and  the  long  diameter  of  the  presenting 
part  would  remain  in  the  same  diameter  of  the  pelvis  in 
which  it  entered. 

Recently,  through  the  courtesy  of  the  coroner,  I  was  en- 
abled to  perform  similar  experiments  here  at  the  University 
Medical  College.  A  German  girl,  twenty  years  of  age,  was 
found  one  morning  upon  the  floor  of  her  employer's  store 
dead  from  post-partum  haemorrhage.  One  twin  had  been 
born,  and  when  the  cadaver  was  turned  over  to  me  the 
second  twin  and  the  double  placenta  I  found  within  the 
uterine  cavity.  The  twin  born  spontaneously  was  of  such 
a  size  as  to  dilate  the  passages  to  a  very  small  extent  and 
to  cause  no  appreciable  laceration  whatsoever.  Into  the 
head  of  a  foetal  cadaver  at  a  point  half  an  inch  posterior 
to  the  small  fontanelle  I  fastened  this  swivel,  and,  having 
well  lubricated  it,  I  attached  to  the  ring  of  the  swivel 
this  whipcord.  Then  opening  the  abdomen  and  uterus  of 
the  unfortunate  woman,  by  means  of  a  uterine  dressing- 
forceps  I  passed  the  cord  attached  to  the  swivel  down 
through  the  cervix,  vagina,  and  out  at  the  vulva.  Then  I 
commenced  my  experiments.  I  placed  this  foetus  in  its 
normal  attitude  within  the  uterus,  first  in  the  L.  O.  A.,  then 
in  the  R.  O.  A.  position,  and  each  time  upon  making  trac- 
tion upon  the  cord  through  the  vagina,  and  always  in  the 
axis  of  that  part  of  the  parturient  canal  in  which  the  pre- 
senting part  rested,  I  found  that  as  the  head  approached 
the  pelvic  floor  internal  rotation  of  the  head  took  place 
completely,  so  that  the  sagittal  suture  would  appear  exactly 
in  the  antero-posterior  diameter  of  the  outlet.  In  watching 
for  the  internal  rotation  of  the  shoulders,  I  found  that  while 
in  the  first  two  experiments  internal  rotation  was  complete, 
yet  in  the  subsequent  ones  the  rotation  became  less  and  less 
marked,  until  finally  there  was  no  attempt  at  rotation  what- 
soever on  the  part  of  the  shoulders.  I  placed  the  foetus  in 
the  third  and  in  the  fourth  positions  in  its  normal  attitude 
at  the  pelvic  brim ;  and  here  again,  upon  making  traction 
from  below,  anterior  rotation  occurred  in  the  former  in- 
stance about  the  right  side  of  the  pelvis,  and  in  the  latter 
about  the  left  side,  until  the  sagittal  suture  once  more  was 
brought  into  the  antero-posterior  diameter  of  the  pelvic 
outlet  and  the  small  fontanelle  just  under  the  pubic  arch. 


Feb.  25,  IH'JS.] 


207 


Still  another  test  I  made  :  The  vertex  was  placed  directly 
posterior  and  just  under  the  promontory  of  the  sacrum,  and, 
upon  making  traction  and  drawing  the  occiput  to  the  pelvic 
floor,  we  found  that,  instead  of  remaining  permanently  at 
the  rear,  after  a  few  seconds  anterior  rotation  on  the  part 
of  the  occiput  commenced,  and  once  more  we  found  the 
vertex  at  the  puhes. 

A  second  time  anterior  rotation  was  secured  in  the 
R.  0.  P.  and  in  the  L.  O.  P.  position,  and  then  the  occiput 
was  placed  once  more  in  the  hollow  of  the  sacrum  to  test 
this  position  further,  and  it  was  found  that,  in  spite  of  the 
strongest  traction  we  were  able  to  make  on  the  cord  through 
the  vulva,  the  vertex  remained  firmly  and  permanently  in 
the  hollow  of  the  sacrum. 

The  same  result  followed  experiments  in  other  oblique 
;  and  transverse  positions — namely,  anterior  rotation  of  the 
1  occiput  failed  and  the  sagittal  suture  appeared  at  the  out- 
let in  almost  the  same  diameter  in  which  it  was  originally 
placed  at  the  inlet,  thus  proving  that  some  factor  in  the 
causation  of  anterior  rotation  of  our  first  experiments  failed 
us,  or  performed  its  duty  imperfectly,  in  the  subsequent 
ones. 

We  may  draw  our  own  conclusions  as  regards  these  ex- 
periments. If  anterior  rotation  in  any  position  is  caused 
by  the  ischial  planes  or  spines,  then  why  was  it,  in  the  ex- 
periments that  I  have  just  cited,  rotation  of  the  presenting 
part  failed  after  the  foetus  had  been  drawn  a  certain  num- 
ber of  times  through  the  pelvis  ?  If  the  rotation  is  due  to 
the  inclination  of  the  pelvis,  as  was  maintained  by  Tarnier, 

I  or  to  the  shape  of  the  fatal  head,  as  was  taught  by  Pajot,  or 
to  the  ischial  planes  or  spines,  why  should  the  rotation  fail 
when  no  evident  change  took  place  in  the  shape  of  the 

■■  child's  head  in  the  inclination  of  the  mother's  pelvis,  or  in 
the  ischial  planes  or  spines  ?   We  are  pretty  safe  in  stating, 

I  then,  that  the  main  and  determining  cause  of  the  rotation 
of  the  lowest  portion  of  the  presenting  part  is  the  resist- 

I  ance  of  the  posterior  portion  of  the  pelvic  floor,  and  more 
particularly  of  the  two  levator  ani  muscles  which  have  been 
so  beautifully  dissected  out  and  illustrated  by  Dr.  Dickin- 
son, of  Brooklyn.  When  they  lost  their  resistance  and  be- 
came relaxed  in  the  cadaver,  as  the  result  of  repeated  trials 
with  the  fcEtus  and  swiveled  string,  anterior  rotation  failed 
to  occur.  It  is  undoubtedly  the  fact  that  it  is  not  one 
factor  alone,  but  several  that  determine  this  internal  rota- 
tion. Accommodation  ;  adaptation  ;  the  great  principle  that 
runs  through  all  the  mechanism  of  labor,  whereby  the  long 
diameter  of  the  presenting  part  adapts  itself  to  the  long  di- 
ameter of  that  part  of  the  pelvis  in  which  it  may  find  itself ; 
this  corkscrew-like  arrangement  of  the  pelvis ;  the  lessened 
resistance  caused  by  the  urethral  and  vaginal  orifices  in  front ; 
the  greater  resistance  of  the  thicker  and  heavier  tissues  in  the 
posterior  half  of  the  pelvis  ;  the  inclination  of  the  pelvis  ;  the 
shape  of  the  child's  head  ;  the  inclination  of  the  uterus 
causing  the  anterior  portion  of  the  presenting  part  to  reach 
the  pelvic  floor  first — all  play  their  part  in  the  causation  of 
anterior  rotation. 

Having  understood  this,  then,  the  remaining  stages  are 
readily  comprehended.  Rotation  being  complete,  there 
comes  a  time  when  the  occiput,  having  passed  under  the 


subpubic  ligament  and  being  partially  born,  the  shoulders 
attempt  to  enter  the  pelvis  with  the  head ;  and  as  under 
ordinary  circumstances  there  is  not  sufficient  room  for  both, 
the  head  escapes  from  the  vulva  by  a  movement  of  exten- 
sion, thereby  leaving  the  pelvis  free  for  the  shoulders  to 
enter.  We  say  the  head  escapes  by  a  movement  of  exten- 
sion. This  is  not  strictly  true,  for  repeated  observations 
have  convinced  me  tliat  the  bulk  of  the  head,  including  the 
occiput,  is  born  before  the  chin  leaves  the  sternum — a  fact 
we  must  always  remember  in  our  attempts  at  perineal  pro- 
tection and  forceps  delivery.  This  escape  of  the  head  is 
caused  by  the  force  of  uterine  contraction  acting  through 
the  spinal  column  and  by  the  contraction  of  the  muscles 
that  go  to  make  up  the  pelvic  floor,  and  we  see  the  beauti- 
ful provision  of  Nature  that  has  caused  only  the  smallest 
diameter — namely,  the  suboccipito-bregmatic,  three  and  a 
half  inches  in  length — to  be  passed  through  the  birth  canal. 
And  even  at  the  vulva,  as  we  can  readily  appreciate  from 
the  manikin,  the  occiput  having  been  born  first,  all  the 
diameters  of  the  foetal  head  that  pass  in  succession  through 
the  vulvar  opening  are  measured,  not  from  the  occipital 
protuberance,  but  from  a  point  midway  between  it  and  the 
foramen  magnum,  and  are  consequently  the  smallest  or  the 
suboccipital  diameters. 

The  first  part  now  is  born  and  it  only  remains  to  follow 
the  mechanism  of  the  second  part,  and  we  have  completed 
the  mechanism  of  labor  in  the  first  position.  The  shoulders, 
we  have  every  reason  to  believe,  enter  the  pelvic  inlet  in 
the  opposite  oblique  to  the  one  in  which  the  head  entered ; 
or,  if  the  head  entered  in  a  transverse  diameter,  it  is  possible 
in  a  roomy  pelvis,  and  with  a  child  that  is  not  too  large,  for 
the  shoulders  to  enter  in  the  opposite  diameter  or  in  the 
antero- posterior  diameter  of  the  inlet.  At  all  events,  we 
usually  find  the  shoulders  first  in  an  oblique  diameter, 
and,  as  we  have  learned,  the  anterior  portion  of  the  pre- 
senting part,  because  of  the  direction  of  the  axis  of  the 
superior  strait,  is  lower  than  is  the  posterior ;  consequently 
it  is  this  part  that  first  reaches  and  is  first  influenced  by 
the  resistance  at  the  floor  of  the  pelvis  and  is  deflected  an- 
teriorly to  the  pubic  arch.  If  both  shoulders  came  to  the 
pelvic  floor  at  one  and  the  same  time,  we  have  every  rea- 
son to  believe  that  they  would  both  be  equally  influenced  by 
the  factors  causing  anterior  rotation,  and  consequently  the 
bisacromion  diameter  would  remain  in  the  same  diameter  in 
which  it  entered  the  pelvic  inlet.  Investigation  has  taught 
m3  that  while  complete  anterior  rotation  of  the  head  is  the 
rule,  yet  complete  rotation  of  the  shoulders  is  not  by  any 
means  so  constant  as  is  that  of  the  head.  Even  before  the 
shoulders  begin  to  rotate  internally  we  see  an  unwinding,  as 
it  were,  of  the  muscles  of  the  neck  that  have  been  twisted  in 
the  internal  rotation  of  tlie  fcetal  head,  and,  as  a  consequence, 
the  head  makes  a  partial  movement  of  external  rotation, 
and  this  first  partial  movement  of  rotation  is  termed  resti- 
tution. Now,  a  glance  only  at  the  manikin  will  show  us 
that  when  the  shoulders  rotate  within  the  pelvis  there  must 
in  consecpicnce  bo  a  decided  rotation  on  the  j)art  of  the 
head  which  is  already  delivered,  and  this  further  and  more 
marked  rotation  of  the  head  is  termed  the  external  rotation 
of  the  head  that  you  are  familiar  with,  whereby  the  face  of 


208 


ED  OAR:   VERTEX  PRESENTATION: 


[N.  Y.  Mkd.  Joub., 


the  child  looks  almost  directly  to  the  inner  surface  of  the 
right  thigh  of  its  mother. 

We  have  now  followed  the  bisacromion  diameter  into 
the  antero-posterior  diameter  of  the  pelvic  outlet,  and  if 
we  have  observed  our  cases  of  labor  in  the  tenement 
houses  carefully,  we  shall  remember  that  in  most  instances 
the  anterior  shoulder  was  the  one  that  first  ap[)eared  at  the 
vulva ;  and  if  we  are  close  observers,  we  shall  further  re- 
member that  sometimes  it  was  this  anterior  or  right  shoul- 
der that  first  was  fully  born,  and  in  other  instances  it  was 
the  posterior  or  left  shoulder  and  arm  that  were  born  first, 
and  circumstances  seem  to  determine  whether  it  shall  be  the 
anterior  or  the  posterior  arm  that  is  first  expelled.  In  a  mul- 
tipara, particularly  if  her  parts  are  roomy,  if  her  pcriniEum 
has  been  partially  destroyed  at  a  previous  confinement,  the 
posterior  shoulder  and  arm  are  very  apt  to  be  the  first  born  ; 
whereas,  on  the  other  hand — and  we  are  speaking,  you  un- 
derstand, of  spontaneous  delivery  where  we  do  not  inter- 
fere with  the  birth  of  the  shoulders — if  the  case  is  one  of 
a  primipara  with  perinseum  intact  and  with  somewhat  rigid 
soft  parts,  it  may  be  the  anterior  shoulder  and  arm  that  are 
first  brought  into  the  world.  So  the  shoulders  are  born  ; 
the  body  usually  follows  immediately  afterward.  Some 
obstetricians  would  speak  of  a  stage  of  rotation  of  the  but- 
tocks, but  we  have  every  reason  to  believe  that  when  the 
shoulders  rotate  the  buttocks  rotate  with  them,  and  conse- 
quently there  is  little  or  no  torsion  of  the  body,  but  the 
buttocks  come  down  and  are  expelled  in  the  antero-pos- 
terior diameter  of  the  outlet  in  practically  the  same  way  as 
are  the  shoulders. 

Let  us  now  describe  the  mechanism  of  the  third  or 
R.  O.  P.  position,  and  this  will  be  sufficient  to  illustrate  the 
mechanism  in  all  posterior  positions  of  the  vertex.  The 
suboccipito-bregmatic  diameter  in  this  instance,  as  you  see 
in  this  pelvis,  enters  the  inlet  in  the  right  oblique  or  per- 
haps in  the  transverse  diameter ;  of  course  we  presuppose 
that  tiexion  and  molding  have  taken  place.  Following 
engagement  we  have  descent — descent  in  some  cases  until 
the  pelvic  floor  is  reached — before  any  rotation  in  either 
direction  takes  place  ;  and  yet  we  will  observe  cases  where 
anterior  rotation  of  this  vertex  occurs  before  the  pelvic 
floor  is  reached,  and  in  these  instances  we  have  every  rea- 
son to  believe  that  it  is  the  resistance  of  the  posterior  wall 
of  the  uterus  or  of  the  rectovaginal  sseptum  that  determines 
this  rotation.  When  once  the  vertex  has  reached  the  pelvic 
floor  the  case  may  terminate  in  one  of  four  ways,  and,  stat- 
ing them  in  the  order  of  their  frequency,  they  are  as  fol- 
lows :  First,  complete  anterior  rotation  of  the  occiput  about 
the  right  half  of  the  pelvis  until  the  pubes  is  reached  ; 
second,  posterior  rotation  of  the  vertex  into  the  hollow  of 
the  sacrum  and  birth  of  the  head  with  the  occiput  to  the 
rear  by  extension  over  the  perinaium  ;  third,  posterior  rota- 
tion and  impaction  ;  and  fourth,  the  conversion  of  the  ver- 
tex presentation  into  one  of  face  presentation  ;  and  al- 
though this  latter  termination  is  extremely  rare,  yet,  as 
there  are  some  half  a  dozen  cases  on  record,  we  are  com- 
pelled to  recognize  its  possibility. 

1.  It  is  needless  for  us  to  spend  any  time  in  a  descrip- 
tion of  llie  first  method  of  termination  ;  the  same  princi- 


ples apply  here  as  apply  in  the  first  and  second  positions. 
The  increased  resistance  of  the  posterior  inclined  plane  of 
the  pelvis  causes  the  occiput  to  be  deflected  in  the  direc- 
tion of  least  resistance — namely,  to  the  vulvar  orifice. 

2.  We  see  instances,  however,  where  from  some  cause — 
it  may  be  the  roominess  of  the  pelvis  ;  the  smallness  of  the 
child ;  want  of  rigidity  of  the  pelvic  floor  from  numerous 
labors  or  from  other  causes ;  rupture  of  the  floor ;  distention 
of  the  floor  by  the  passage  of  the  first  twin ;  incomplete 
flexion  of  the  head,  permitting  the  sinciput  to  be  as  low  or 
lower  than  the  occiput — this  anterior  rotation  fails.  Ac- 
cording to  authorities  it  is  a  rare  condition,  yet  according 
to  Naegele's  statistics  it  occurred  once  in  seventy-three 
cases  of  labor.  Should,  then,  anterior  rotation  fail  and  the 
occiput  remain  in  the  posterior  half  of  the  pelvis,  it  is  pos- 
sible, under  certain  conditions,  for  the  occiput  to  follow 
the  posterior  wall  of  the  parturient  canal  and  be  born  by 
extension  over  the  edge  of  the  perinaeum.  Labor  then  is  al- 
most always  prolonged  and  in  some  instances  impossible  as 
the  result  of  impaction.  The  cause  of  the  prolongation  of 
the  labor  under  such  circumstances  was  first  pointed  out  by 
P.  Dubois,  and  by  reference  to  this  diagram  that  hangs  be- 
fore us  and  to  this  foetal  cadaver  which  I  hold  up  in  my  hand, 
we  can  readily  see  how  it  is  that  the  labor  is  either  exceed- 
ingly tedious  and  prolonged  or  absolutely  impossible. 
Glance  at  the  back  of  a  child's  neck,  and  we  see  that  it  is 
not  much  over  two  inches  in  length  ;  observe  the  posterior 
wall  of  the  parturient  canal  from  the  promontory  of  the 
sacrum  to  the  edge  of  the  perineum,  and  we  readily  see 
that  the  distance  is  in  the  neighborhood  of  ten  inches,  count- 
ing five  inches  from  the  promontory  to  the  tip  of  the  coccyx 
and  five  more  from  the  tip  of  the  coccyx  to  the  edge  of  the 
distended  pelvic  floor.  If  an  anterior  position  of  the  vertex 
obtains,  birth  of  the  head  is  readily  and  easily  accomplished, 
for  the  two  inches  of  the  back  of  the  neck  without  any 
difficulty  pass  over  the  inch  and  a  half  of  the  anterior 
pelvic  wall  measured  at  the  symphysis,  and  the  head  is  born 
before  the  shoulders  necessarily  enter  the  pelvic  inlet. 
How  different  when  the  reverse  obtains  !  For  the  head  to 
be  born  in  an  occipito-posterior  position  we  may  hope  for 
no  break  in  the  straight  or  rigid  branch  that  the  foetus 
represents  until  the  head,  together  with  the  neck,  has  trav- 
ersed the  ten  inches  of  the  posterior  pelvic  and  perineal 
wall,  and  the  head  is  finally  permitted  to  be  born  by  exten- 
sion over  the  perineum. 

Delivery  under  such  circumstances  is  certainly  possible 
by  the  natural  forces,  and  some  of  you,  to  my  certain  knowl- 
edge, have  seen  such  instances  in  your  service  in  the  New 
York  Lying-in  Hospital,  and  you  will  recall  how,  after  an 
exceedingly  tedious  labor  and  extreme  flexion  of  the  head 
on  the  sternum  and  with  the  occiput  distending  the  pelvic 
floor  for  perhaps  several  hours,  finally,  with  tremendous  bear- 
ing-down efforts  on  the  part  of  the  parturient,  the  occiput 
was  enabled  to  climb  up,  as  it  were,  over  the  perinaeum,  the 
forehead  and  face  apjjeared  under  the  pubes,  the  perinasum 
slipped  by  the  occiput  and  along  the  neck  of  the  child,  and 
extension  completed  the  birth  of  the  head. 

3.  But,  unfortunately,  we  occasionally  meet  with  in- 
stances in  our  practice  where  either  anterior  rotation  of  the 


Feb.  25,  1893.] 


EDGAR:  VERTEX  PRESENTATION. 


209 


occiput  or  spontaneous  delivery  with  the  occiput  to  the  rear 
absolutely  fails  to  occur.  And  then,  if  we  have  added  to 
this  an  impaction  and  swelling  of  the  shoulders  that  have 
partially  entered  the  pelvic  cavity,  we  have  one  of  those 
tragedies  of  midwifery  practice  which  I  trust  you  may  never 
be  called  upon  to  face.  Given  a  normal-sized  foetus,  a  pelvis 
of  ordinary  dimensions  in  perhaps  a  priraipara  with  rigid 
soft  parts,  and  the  cause  of  the  impaction  of  those  cases  of 
occipito-posterior  position  that  have  been  improperly  treated 
early  in  the  second  stage  of  labor  is  easily  understood. 
Once  more  I  must  ask  your  attention  to  this  diagram  and 
to  the  foetal  cadaver  which  I  hold  up  before  you.  The  oc- 
ciput passes  into  the  hollow  of  the  sacrum,  reaches  the  coc- 
cyx perchance,  but  still  is  several  inches  from  the  edge  of 
the  perinasum — what  must,  what  only  can  happen  under  the 
given  circumstances  ?  Why,  the  body  of  the  child  must 
enter  the  pelvic  cavity  together  with  the  head  in  order  to 
allow  of  the  occiput's  reaching  its  ultimate  goal.  Then  wliy 
do  we  have  impaction  ?  We  have  impaction  because  the 
dorso-sternal  diameter  (four  inches)  is  added,  as  you  see,  to 
the  fronto-mental  diameter  (three  inches  and  a  half),  giving 
us  an  antero-posterior  diameter  of  the  foetal  mass  of  seven 
inches  and  a  half  that  the  uterine  forces  are  attempting  to 
drive  through  a  pelvis  the  average  diameter  of  which  is 
usually  considered  to  be  not  more  than  four  inches  and  three 
quarters.  And  this  is  not  all ;  as  has  been  pointed  out,  the 
length  of  the  foetal  ellipse  when  the  child  is  in  its  normal 
attitude  is  half  the  length  of  the  entire  fcetus — namely,  about 
eleven  inches ;  consequently,  when  the  occiput  has  come  up 
to  the  edge  of  the  perina3um  the  breech  of  the  child  has 
practically  entered  the  inlet  of  the  pelvis,  and  the  uterus 
under  such  circumstances  can  not  but  act  at  a  disadvantage. 
We  can  readily  see,  then,  what  either  spontaneous  or  arti- 
ficial birth  of  the  foetus  means  to  the  mother — almost  in- 
variably a  partial  or  complete  loss  of  her  perineal  structures. 
I  have  only  recently  been  requested  to  see  a  puerperal  woman 
suffering  from  sepsis,  where  the  forceps  had  been  applied 
under  the  conditions  that  we  have  just  named,  and  the  for- 
ceps delivery  had  resulted  in  an  entire  loss  of  the  wom- 
an's perinfeum  and  an  inch  and  a  half  of  the  recto-vaginal 
sajptum. 

4.  The  fourth  manner  in  which  this  posterior  position 
may  terminate  is  for  the  occiput  in  some  way  to  become  ar- 
rested in  its  course,  and  then,  the  chin  leaving  the  sternum,  ■ 
rotation  on  a  biparietal  diameter  takes  place,  the  head,  as 
it  were,  turns  a  somersault,  becomes  extended  within  the 
pelvic  cavity,  and  we  have  resulting  a  face  presentation  of 
the  mento- anterior  variety.  This  is  all  that  we  shall  say 
concerning  the  mechanism  of  vertex  presentation  until  we 
speak  of  the  management  of  the  same. 

Diagnosis  of  Vertex  Presentation. — We  are  now  in  a  po- 
sition to  consider  the  diagnosis  of  vertex  presentation,  and 
we  are  here  called  upon  to  make  the  diagnosis,  first,  during 
pregnancy;  secondly,  during  labor;  and  thirdly,  after  labor 
has  been  completed.  The  diagnosis  of  vertex  presentation 
during  pregnancy  or  before  the  os  is  sufficiently  dilated  to 
permit  of  our  distinguishing  sutures  or  fontanelles  or  the 
character  of  the  presenting  part  is  made  almost  entirely  by 
what  is  known  as  external  or  abdominal  palpation.    Let  me 


say  here  that  the  subject  of  abdominal  palpation  is  one  that 
we  can  not  become  too  familiar  with  and  one  that  we  can 
not  practice  too  often.  There  are  those  who  maintain  that 
if  we  could  do  away  with  all  personal  contact  (by  that  we 
mean  all  internal  examination  or  the  use  of  instruments  or 
catheters)  we  could  absolutely  do  away  with  that  scourge 
of  former  years — namely,  puerperal  septicaemia.  In  fact, 
Leopold,  of  Dresden,  professes  to  have  demonstrated  by  sta- 
tistics— and  statistics  do  occasionally  prove  something — 
that  in  proportion  as  the  number  of  vaginal  examinations 
diminishes,  the  percentage  of  fever-free  convalescences  in- 
creases. Such  an  assertion  of  necessity  implies  that  there 
is  no  such  thing  as  self-infection  in  the  puerperal  woman, 
that  the  cause  of  the  infection  resides  not  in  the  patient 
herself  but  in  her  attendants.  And  while  we  are  not  ready 
as  yet  to  do  away  entirely  with  vaginal  examinations  dur- 
ing labor,  still  our  aim  should  be  to  make  these  examina- 
tions as  infrequently  as  an  intelligent  management  of  the 
case  will  permit. 

1.  [In  the  lecture  as  delivered  the  author  proceeded  as 
follows]  :  "  In  order  to  illustrate  more  clearly  how  abdomi- 
nal palpation  should  be  conducted,  I  have  had  one  of  my 
patients  brought  over  from  the  p]mergency  Lying-in  Hos- 
pital who  is  a  primipara  and  within  two  weeks  of  full  term. 
The  patient,  as  you  see,  is  placed  ujjon  a  hard  examining  table, 
with  her  clothes  so  loosened  and  arranged  that  we  may 
readily  examine  the  abdomen  from  the  hips  to  the  free  bor- 
der of  the  ribs  ;  and  then,  to  render  the  anterior  abdominal 
walls  as  lax  as  possible,  we  have  the  woman  flex  her  thighs 
somewhat.  As  you  see,  I  take  my  stand  at  the  woman's 
right  and  facing  her.  I  place  the  palms  of  my  hands  over 
the  lower  part  of  the  uterus  so  that  the  finger-tips  meet  in 
the  median  line,  and  then,  by  passing  them  gently  upward, 
all  the  time  carefully  manipulating  the  uterine  contents,  we 
determine  whether  the  long  axis  of  the  child  lies  vertically 
or  obliquely  in  the  uterus,  whether  the  head  or  breech  occu- 
pies the  fundus,  and  something  regarding  the  size  of  the 
foetus.  Having  determined  that  the  child  lies  vertically, 
that  the  breech  and  not  the  head  occupies  the  fundus,  and 
that  the  fundus  reaches  nearly  to  the  ensiform  cartilage,  we 
next  seek  by  another  manipulation  the  position  of  the  small 
parts  and  the  dorsal  plane  of  the  fa'tus.  To  do  this  the 
hands  are  separated  and  are  placed  flat,  one  on  each  side  of 
the  fundus  of  the  uterus.  Then,  by  passing  the  contained 
foetus  gently  from  hand  to  hand,  we  determine  to  which 
side  lies  the  smooth  hard  plane  of  the  back,  and  in  which 
side  lie  the  irregular,  movable  small  parts.  We  may  great- 
ly aid  our  endeavors  by  pushing  the  foetus  with  one  hand 
firmly  up  against  the  palm  of  the  other,  thus  dislodging 
the  liquor  amnii,  which  may  interfere  with  our  palpat- 
ing. So  far  we  have  learned  that  the  head  presents,  that 
the  back  of  the  child  looks  to  the  left  of  its  mother,  and 
that  the  small  parts — namely,  the  feet — lie  to  the  right  in 
the  fundus  uteri.  The  next  question  to  be  decided  is.  Is  the 
head,  which  we  can  now  feel  in  the  lower  part  of  the  uterus, 
engaged  ?  To  determine  this  we  separate  the  thumb  and 
fingers  of  either  hand  as  widely  as  possible,  and  with  the 
tips  of  the  thumb  and  middle  finger  wc  atten:pt  to  seize 
the  presenting  part  just  above  the  pubes  in  this  manner* 


210 


WOOLSET:  IODOFORM  INJECTIONS  IN  LOCAL  TUBERCULOSIS.     fN.  Y.  Med.  Johb., 


Were  this  woman  a  multipara,  in  all  probability  we  could 
move  the  head  readily  from  side  to  side  by  this  means  ; 
but  we  find  when  we  grasp  what  appears  to  be  the  head 
just  at  the  pelvic  inlet  that  we  are  unable  to  move  it  from 
side  to  side,  or,  in  other  words,  the  head,  as  is  usually  the 
case  in  a  primipara,  is  engaged  in  the  entrance  of  the  pel- 
vis. Now,  to  determine  the  amount  of  this  engagement, 
we  take  another  position — namely,  with  our  back  to  the 
face  of  the  patient.  Then,  with  the  tips  of  the  fingers  of 
both  hands,  we  slowly  and  gradually  follow  the  lower  part 
of  the  foetus  as  deeply  along  the  sides  of  the  pelvis  as  we 
are  able ;  and  you  see,  by  exerting  no  sudden  or  jerking 
movements,  after  we  have  partially  overcome  the  resistance 
of  the  muscles,  that  we  may  pass  our  fingers  to  a  consid- 
erable extent  into  the  pelvis  of  this  gravid  woman,  and  we 
determine  that  the  head,  which  we  can  now  distinctly  feel, 
has  descended  somewhat  in  the  pelvic  cavity.  Now,  what 
have  we  determined  so  far  ?  We  have  a  cephalic  presenta- 
tion, with  the  back  of  the  child  pointing  to  the  left  of  the 
mother ;  and  if,  moreover,  we  make  use  of  the  stethoscope 
and  find  that  the  foetal  heart  sounds  are  most  distinct  at  a 
point  midway  between  the  left  anterior  superior  spine  of  the 
ilium  and  the  umbilicus,  and  if  by  this  last  manipulation  of 
forcing  the  finger-tips  alongside  of  the  head  into  the  pelvic 
cavity  we  feel  certain  there  is  no  extension  of  the  head,  we 
have  every  reason  to  believe,  without  any  internal  examina- 
tion whatsoever,  that  we  have  a  vertex  presentation  to  deal 
with,  and  that  the  position  is  or  will  be  the  left  occipito- 
anterior." 

2.  Such  abdominal  palpation  may  be  carried  out,  as  you 
have  seen  me  perform  it  upon  this  gravid  woman,  just  as 
well  during  labor,  in  the  intervals  between  the  pains,  as  in 
pregnancy,  and  while  I  would  not  advise  you  to  do  away 
entirely  with  internal  examination  during  parturition,  yet  in 
most  instances  one  examination  at  the  beginning  of  the  first 
stage,  to  corroborate  our  external  examination  and  to  deter- 
mine the  condition  of  the  cervix,  membranes,  and  pelvis, 
and  one  when  the  membranes  rupture,  to  satisfy  ourselves 
that  there  is  no  prolapse  of  the  cord  or  an  arm,  and  that 
the  presentation  and  position  are  normal,  will  be,  in  most 
instances,  quite  suflficient.  When  labor  has  far  enough  ad- 
vanced for  us  to  palpate  the  vault  of  the  skull,  the  diagnosis 
of  vertex  positions  is  made  from  the  position  and  character 
of  the  fontanelles  and  sutures  which  we  are  enabled  to  pal- 
pate, and  which  we  become  sufficiently  familiar  with  in  our 
biweekly  practice  with  the  manikins  and  in  the  tenement- 
house  service. 

3.  After  labor  is  completed  we  are  sometimes  called 
upon,  for  medico- legal  purposes,  to  express  an  opinion  re- 
garding the  presentation  in  which  the  child  was  born.  To 
illustrate  this  point  I  have  had  sent  over  to-day  from  the 
morgue  the  cadavers  of  three  still-born  children,  and  we 
notice  several  points  of  interest  about  the  conformation  of 
their  heads.  We  usually  rely  upon  two  points  in  making 
the  diagnosis  of  the  presentation  after  delivery.  The  first 
of  these  is  the  shape  of  the  child's  head,  and  the  second  is 
the  position  of  the  caput  succedaneum.  Where  labor  has 
been  rapid,  where  there  has  been  no  caput  formed,  and 
where  there  has  been  little  or  no  molding  of  the  child's 


head,  as  was  undoubtedly  the  case  in  this  cadaver  which  I 
hold  up,  there  is  absolutely  nothing  by  which  we  may  be 
enabled  to  express  a  positive  opinion ;  and  we  may  say  just 
here  that  there  is  nothing  in  any  case  in  the  genital  canal  of 
the  woman  to  aid  us  in  making  our  diagnosis.  But  when 
we  select  this  second  cadaver  we  find  that  the  shape  of  the 
child's  head  is  distinctly  different  from  the  first.  On  ex- 
amining it  closely,  we  find  that  the  diameters  of  the  fcjetal 
head  have  been  extensively  changed  from  the  normal  as  the 
result  of  the  resistance  and  pressure  within  the  parturient 
canal.  You  see  as  we  measure  them  that  there  is  a  distinct 
diminution  of  the  suboccipito-brcgmatic,  of  the  occipito- 
frontal, and  the  bitemporal  diameters,  and  that  there  is  a 
compensatory  increase  in  the  diameter  running  from  the 
chin  to  a  point  in  the  vertex  situated  between  the  apex  of 
the  occipital  bone  and  the  large  fontanelle.  This  molding 
of  the  head,  of  course,  is  rendered  possible  by  the  approxi- 
mating and  overlapping  of  the  bones  at  the  sutures  and 
fontanelles,  and  this  particular  shape  of  the  head  that  we 
have  in  this  foetus  is  always  characteristic  of  a  vertex  presen- 
tation and  an  anterior  position,  and  we  still  further  strength- 
en our  opinion  by  finding  that  the  caput  succedaneum  is 
situated  along  the  inner  posterior  border  of  tlie  right  parie- 
tal bone.  And,  moreover,  in  this  instance  we  may  distinctly 
see  the  eccliymotic  spots  left  by  the  blades  of  the  forceps 
that  were  evidently  applied  over  the  occipito-mental  cir- 
cumference of  the  head.  We  take  up  another  foetal  cada- 
ver, and  while  there  is  in  this  instance  a  somewhat  charac- 
teristic molding  of  the  head,  still  it  is  much  less  marked 
than  in  the  second  case,  and  upon  a  superficial  examination 
we  are  unable  to  find  anything  that  resembles  a  caput  suc- 
cedaneum. But,  by  incising  the  scalp  from  the  root  of  the 
nose  to  the  posterior  extremity  of  the  sagittal  suture  and 
pulling  back  the  scalp  from  the  cranium,  we  find  that  the 
tissues  that  cover  the  inner  and  posterior  portion  of  the 
right  parietal  bone  appear  somewhat  more  tumefied  and 
certainly  contain  more  serum  than  the  corresponding  re- 
gion on  the  left  parietal  bone,  and  hence  the  diagnosis  of 
vertex  presentation  is,  to  say  the  least,  probable. 


IODOFORM  INJECTIONS 
IN  LOCAL  TUBERCULOSIS.* 
By  GEORGE  WOOLSEY,  M.  D. 

I  HAVE  chosen  the  subject  of  this  paper  because  of  the 
interest  I  have  taken  in  this  method  of  treatment  after  em- 
ploying it  in  a  limited  number  of  cases. 

Furthermore,  on  account  of  the  comparatively  extensive 
literature  in  German  and  French  and  the  very  meager  no- 
tices of  it  in  English  and  American  periodicals,  I  wanted  to 
find  the  personal  experience  or  opinion  of  the  members  of 
the  Surgical  Society  as  to  the  value  of  this  method  of  treat- 
ing local  tuberculosis. 

Dr.  Senn  has  deemed  it  of  sufficient  interest  to  read  a 
paper  on  it  before  the  congress  held  September,  1892,  in 
Washington,  and  liis  final  resume,  as  published  in  several 

*  Read  before  the  New  York  Surgical  Society,  April  27,  1892. 


Feb.  25,  1893.] 


WOOLSEY:  IODOFORM  INJECTIONS  IN  LOCAL  TUBERCULOSIS. 


211 


medical  journals  at  that  time,  was  very  favorable  to  this 
method  of  treatment ;  but,  apart  from  this,  American  medi- 
cal literature  is  singularly  barren  on  this  subject.  This  is 
the  more  remarkable  on  account  of  the  uniformly  good  re- 
sults obtained  and  reported  by  German  and  French  sur- 
geons. 

Iodoform  as  an  injection  in  local  tuberculosis  was  first 
employed  in  Billroth's  clinic  by  Mikulicz,  who  reported,  in 
1881,  on  two  cases  of  fungous  joint  disease  treated  by  in- 
;   jections  of  a  twenty- per- cent,  solution  of  iodoform  in  ether. 
,   Since  then  this  treatment  has  been  employed  in  Billroth's 
■   clinic,  with  some  modifications,  for  over  ten  years. 

Billroth's  recommendation  alone,  when  he  says  "the  re- 
sults have  surpassed  my  keenest  expectations,"  is  enough  to 
i   encourage  one  to  give  it  a  trial. 

The  use  of  iodoform  injections  in  surgical  tuberculosis 
has  spread  widely  over  Germany  and  France.  Throughout 
the  German  clinics  this  treatment  has  been  tried  and  praised, 
in  some  cases  enthusiastically.  As  the  result  of  experience 
the  method  has  become  modified,  and  an  emulsion  in  steril- 
ized glycerin,  glycerin  and  water,  mucilage  or  olive  oil  has 
been  substituted  for  the  solution  in  ether  or  alcohol  and 
ether.  The  French  surgeons,  however,  have  mostly  kept  to 
the  original  ether  solutions. 

I  first  saw  it  used  in  this  country  as  an  ether  solution  in 
1885  in  the  Roosevelt  Hospital  by  Dr.  Sands,  after  reading 
the  report  of  Vemeuil's  cases  so  treated. 

The  effect  of  iodoform  on  the  pathology  of  the  tuber- 
cular process  is  variously  explained.  We  are  all,  doubt- 
less, familiar  with  the  good  results  of  iodoform  when  used 
on  tubercular  cases.  Thus  Tilanus,  of  Amsterdam,  and  Wen- 
delstadt,  reporting  from  Trendelenburg's  clinic  in  Bonn,  con- 
clude that  the  antitubercular  action  of  iodoform  is  beyond 
doubt  and  of  great  value. 

Thus,  too.  Dr.  Pilcher  has  reported  the  case  of  two  simi- 
lar tubercular  ulcers  on  the  same  patient,  of  which  the  one 
treated  with  iodoform  healed  in  one  third  of  the  time  taken 
for  the  other  treated  antiseptically. 

It  has  also  been  found  by  Stockum  that  the  contents  of 
an  abscess  treated  by  iodoform  injections  are  not  infective 
li   when  inoculated  in  the  eye  of  a  rabbit. 

We  can  not,  therefore,  deny  the  ellect  of  iodoform  in 
tubercular  cases  even  if  we  may  doubt  its  theoretical  value 
as  a  general  antiseptic.  Bacteriology  is  of  little  assistance 
here,  for  the  conditions  are  so  hard  to  reproduce  that,  where 
clinical  results  are  at  variance  with  experimental  results,  we 
must  accept  the  former  as  the  more  trustworthy. 

In  general  there  are  two  views  as  to  the  mode  of  action 
of  iodoform  on  the  tubercular  process — the  one,  that  it  acts 
directly  or  specifically;  the  other  view  supposes  an  indirect 
I  action.  This  latter  view  has  been  maintained  by  Konig, 
who  explains  the  action  as  a  general  antiseptic  one,  and  es- 
pecially as  a  drying  or  desiccating  action  of  the  iodoform 
powder.  This  drying  action  favors  the  primary  union  of  a 
wound,  and  opposes  a  large  secretion  from  the  wound  sur- 
faces, which  secretion  would  favor  the  spreading  of  rein- 
fection over  the  wound  surface  from  spots  where  the  process 
had  not  been  entirely  removed.  This  explanation  may  suf- 
j    fice  for  cases  which  we  treat  as  open  wounds,  but  fails  to 


explain  cases  of  joint  disease  or  abscess  which  we  merely 
inject,  with  or  without  drainage. 

Here  we  must  suppose  a  direct  action  of  the  drug  on 
the  tubercular  process,  and  in  support  of  this  view  we 
have  the  positive  evidence  of  microscopical  examinations. 
Marchand  has  observed  that  the  production  of  giant  cells 
and  other  elements  characteristic  of  the  tubercular  pro- 
cess ceased  under  the  influence  of  iodoform.  This  al- 
lowed healthy  granulation  to  take  the  place  of  tubercular 
granulation. 

The  observations  of  Bruns  and  Nauwerck  are  the  most 
convincing.  They  reported  on  the  examination  of  the  wall 
of  tubercular  abscesses  without  treatment  by  iodoform  and 
after  varying  periods  of  such  treatment.  Eight  cases  were 
thus  accurately  examined.  Four  layers  were  distinguished 
in  the  abscess  wall,  of  which  the  inner  two  only  were  tuber- 
cular, and  alone  or  mostly  contained  the  bacilli.  (These 
layers  are  an  inner  fatty  and  necrotic  and  an  outer  tubercu- 
lar granulation  layer.)  As  the  effect  of  the  injections  of 
iodoform  it  was  found  that,  first,  the  tubercle  bacilli  con- 
stantly disappear.  Further,  the  growth  of  cells  of  the  tu- 
bercles becomes  more  sparing  and  then  stops  altogether,  and 
an  exudation,  rich  in  cells,  penetrates  and  loosens  the  tuber- 
cular tissue,  and  results  in  its  disappearance.  Healthy 
granulation  tissue  forms  in  its  place  or  beneath  it,  and  dis- 
places it.  After  the  disappearance  of  tubercular  tissue  the 
granulation  tissue  becomes  less  vascular,  exudation  ceases, 
the  contents  are  resorbed,  and  the  wall  becomes  cicatricial 
tissue  and  contracts. 

The  cause  of  the  above-named  changes  is  the  killing  of 
the  tubercle  bacilli,  and  this  is  due  not  to  a  caustic  or  in- 
flammatory destruction,  but  rather  to  a  specific  antitubercle 
bacillary  action  of  iodoform.* 

This  seems  to  be  almost  if  not  quite  proof  positive  of 
the  specific  or  antibacillary  action  of  iodoform  in  tubercu- 
lar cases. 

But  this  is  not  all.  Senger  found  that  impure  glycerin 
gave  better  results  than  purified  glycerin,  the  chemical  dif- 
ference being  that  there  was  more  formic  acid  in  the  im- 
pure variety.  Olive  oil,  however,  has  been  found  almost  if 
nof  quite  as  effective  a  menstruum  as  glycerin. 

(This  fact  has  been  adduced  by  Bruns  to  prove  that  it 
is  the  iodoform  which  is  the  active  element  and  not  the 
ether,  alcohol,  or  glycerin,  though  Billroth  holds  the 
glyerin  to  be  an  important  active  part  of  the  mixture.) 

But  it  has  been  shown  that  iodoform  is  only  active 
when  split  up  chemically,  and  this  oxidation  or  hydration 
which  occurs  develops  nascent  iodine  and  formic  acid. 
Senger  therefore  added  formic  acid  or  a  formate  to  the 
emulsions,  with  a  resulting  greater  inflammatory  action  and 
more  rapid  breaking  down  in  the  case  of  tubercular  glands. 
Finally,  he  used  a  solution  of  a  formate,  but  the  results 
were  no  better — in  fact,  scarcely  as  good. 

So  it  appears  likely,  it  seems  to  me,  that  the  formic  acid 

*  Billroth's  tlieoi-y  of  the  action  of  iodoform  on  the  tubercular  pro- 
cess is  that  it  acts  by  a  formative  irritation  on  the  smaller  blood-vessels, 
removing  the  nourishment  from  the  bacilli  to  the  g  owing  cells  of  the 
blood-vessel  wall.  But  he  adds  that  the  mode  of  action  of  iodoform  iu 
tubercular  cases  is  still  not  clear. 


212 


WOOLSET:  IODOFORM  INJECTIONS  IN  LOCAL  TUBERCULOSIS.      |N.  Y.  Mbi>.  Joub., 


is  only  a  part  of  the  active  principle,  the  free  nascent  iodine 
also  playing  an  important  part. 

Riedel  raised  the  question  in  the  German  Surgical  Con- 
gress in  1890  as  to  what  became  of  the  sequestrum,  and 
Krause  affirmed  in  reply  that  spondylitis  often  healed  per- 
manently under  this  treatment,  in  spite  of  an  existing 
sequestrum. 

Methods. — There  are  several  methods  employed  in  the 
use  of  iodoform  as  an  injection. 

Ether  was  the  first  substance  used  as  a  solvent,  with  or 
without  alcohol,  and  the  solution  varied  from  five  to  twenty 
per  cent,  in  strength,  five  to  ten  per  cent,  being  the  strength 
generally  used.  Of  the  five-per-cent.  strength  up  to  200 
c.  c,  of  the  ten-per  cent,  up  to  50  c.  c,  were  used. 

The  advantage  alleged  for  the  ether  solution  is  the  un- 
folding of  the  abscess  wall  by  the  ether  vapor  and  conse- 
quent contact  of  the  solution  with  all  parts.  This  is  more 
than  offset  to  my  mind  by  its  disadvantages,  which  have 
been  pointed  out  by  many  writers.  Some  of  these  are 
ether  intoxication,  burning  pain,  gangrene  of  the  abscess 
wall,  vomiting,  strangury,  retention.  The  gangrene  of  the 
abscess  wall  might  be  especially  dangerous  in  closed  psoas 
abscesses.  I  saw  many  of  these  disadvantages  of  ether  so- 
lutions in  Dr.  Sands's  case  already  mentioned — i.  e.,  ether 
intoxication,  intense  pain,  gangrene  of  abscess  wail.  Ether 
solutions  are, still  used  by  many  if  not  most  French  sur- 
geons, and  some  of  the  bad  effects  of  the  ether  are  avoided 
by  Reclus  by  relieving  the  pressure  of  the  ether  vapor  by 
repeated  use  of  the  hypodermic  needle,  or  the  ether  is 
allowed  to  flow  out  of  the  trocar  after  a  few  minutes. 

With  the  exception  of  French  surgeons,  ether  solutions 
of  iodoform  have  been  abandoned  by  most  all  others  in 
favor  of  sterilized,  freshly  prepared  emulsions  in  glycerin, 
glycerin  with  water  or  alcohol  (p.  e.),  olive  oil  or  mucilage, 
in  strengths  varying  from  five  to  twenty  per  cent,  and  in 
amounts  of  5  c.  c.  to  100  c.  c.  of  a  ten  per  cent,  strength. 
Of  these  menstrua,  glycerin  seems  to  be  the  one  most  gener- 
ally useful  and  advisable,  especially  as  many  surgeons,  and 
among  them  Billroth,  attribute  some  of  the  good  effect  to 
tTie  glycerin.  Next  to  glyceiin  I  should  place  olive  oil, 
which  may  be  used  in  some  cases  where  glycerin  can  not 
be,  and  vice  versa. 

Substitutes. — There  are  two  substitutes  for  iodoform 
which  might  be  mentioned  here.  One  is  balsam  of  Peru, 
introduced  by  Landerer,  and  used  pure  or  in  ten  per  cent, 
to  twenty  per  cent,  emulsion  in  mucilage,  oil,  or  ether.  It 
has  also  been  used  by  intravenous  injection  on  the  princi- 
ple that,  like  cinnabar,  it  would  be  deposited  where  inflam- 
mation was  present.  Balsam  of  Peru  was  used  on  a  con- 
siderable number  and  variety  of  patients  with  good  results, 
the  general  condition  being  especially  improved. 

Secondly,  Lannelongue  has  reported  on  the  use  of  a  ten- 
per-cent.  solution  of  chloride  of  zinc,  with  fairly  good  re- 
sults, in  a  limited  number  of  cases.  lie  explains  its  action 
as  a  sclerosing  one — i.  e.,  by  an  inflammatory  accumulation 
of  cellular  elements  and  the  formation  of  cicatricial  tis- 
sue. He  is  uncertain  as  to  the  disappearance  of  the  bacilli, 
and  the  results  are  better  in  the  closed  non-suppurating 
cases. 


As  to  internal  treatment,  cod-liver  oil,  iron,  and  ton- 
ics are  indicated  in  most  cases  where  iodoform  injections 
are. 

Schiiller  strongly  recommends  at  the  same  time  the  in- 
ternal use  of  guaiacol,  alleging  as  its  advantage  that  the 
cures  are  more  lasting  with  its  use. 

Technique. — As  to  the  technique  of  the  injections,  it  is 
of  the  utmost  importance  to  observe  thorough  antiseptic  pre- 
caution, and  the  emulsions  should  be  freshly  prepared  so  as 
to  contain  no  iodine,  and  sterilized.  The  choice  lies  be- 
tween a  large  hypodermic  with  a  large  needle  and  a  me- 
dium-sized trocar,  and  many  prefer  the  trocar. 

In  the  case  of  abscess  the  contents  are  generally  first 
evacuated,  and  then  most  surgeons  wash  out  the  cavity 
with  Thiersch's  solution  or  something  similar,  and  finally 
the  cavity  is  moderately  filled  with  the  iodoform  emulsion, 
up  to  100  c.  c.  being  used.  This  is  repeated  every  one, 
two,  or  four  weeks. 

In  the  case  of  a  joint,  if  abscess  is  present  the  above- 
described  procedure  is  adopted ;  if  there  is  no  pus,  an  in- 
jection is  made  into  the  cavity  of  the  fungous  joint  and 
tlie  fluid  is  distributed  by  passive  motion  and  massage. 
In  both  cases  it  is  well  to  introduce;  the  trocar  obliquely 
to  obviate  leakage  after  removal. 

In  the  case  of  a  fistula,  parenchymatous  injections  into 
the  walls  of  the  fistulous  tract  by  means  of  a  hypodermic 
needle  are  far  more  effective  than  mere  injection  into  its 
lumen. 

In  the  case  of  other  tubercular  processes,  or  in  organs 
not  hollow,  parenchymatous  injections  are  made  unless  ab- 
scess is  present,  when  they  are  treated  as  above  described. 
Fistula3  are  injected  every  week  with  small  amounts — 2  to 
10c.  c.  in  the  wall,  joints,  and  abscesses;  every  two  to  four 
weeks  with  larger  amounts — 10  to  50,  or  even  to  100  c.  c. 

In  the  case  of  joints,  fixation  is  only  necessary  when 
there  is  pain — i.  e.,  in  the  early  part  of  the  treatment. 

The  later  injections  require  more  force  on  account  of 
the  cicatricial  contraction  which  has  been  and  is  going  on. 
Krause  gives  very  minute  directions  as  to  the  place  of 
puncture  for  the  various  joints  of  the  body  [Archiv  fur 
Iclinische  Chirurgie,  vol.  xli,  p.  113). 

Billroth's  present  method  is  different  from  the  above 
and  combines  operation  and  injection  as  follows  : 

In  the  case  of  "cold  abscesses"  Billroth  opens  them  up 
freely,  scrapes  off  the  abscess  membrane  with  a  tampon  of 
iodoform  gauze  or  a  large,  sharp  spoon,  slops  hicraor- 
rhage  by  tamponing  for  a  time,  sutures  the  wound  tightly 
with  sterilized  silk  (he  lays  great  stress  on  its  sterilization), 
and  injects  enough  ten-per  cent,  glycerin  and  iodoform 
CTnulsion  to  moderately  fill  the  cavity.  He  recommends 
this  method  especially  for  caries  of  the  ribs  and  in  the  ex- 
tremities, and  in  children  or  adults  under  thirty.  The  di- 
vision of  the  operation  into  two  days  (tamponing  the  first 
day)  he  thinks  is  objectionable.  He  adds  that  juncture 
and  injection  is  still  the  best  method  for  large  congestion 
abscesses  with  caries  of  the  vertebra). 

Ca^es  Applicable. — The  following  classes  of  cases  are 
applicable  to  this  treatment,  and  in  them  it  has  been  tried 
with  more  or  less  success: 


Feb.  26,  1893.] 


WOOLSET:  IODOFORM  INJECTIONS  IN  LOCAL  TUBERCULOSIS. 


213 


1.  Tubercular  abscesses  from  a  focus  in  bone  or  soft 
parts. 

2.  Tubercular  joint  disease,  with  or  without  abscess. 

3.  Tubercular  fistulae. 

4.  Tubercular  epididymitis  and  tubercuIo.sis  of  the 
bladder. 

5.  Tubercular  lymphadenitis. 

6.  Tubercular  empyema,  and  even  tuberculosis  of  the 
lung. 

As  to  abscesses,  this  method  is  especially  applicable  to 
large,  deep  abscesses  not  otherwise  easily  accessible,  niso 
when  the  patients  are  too  feeble  for  a  more  severe  proced- 
ure. It  is  also  indicated  to  avoid  scars.  There  is  less 
unanimity  of  opinion  as  to  abscesses  near  the  surface  and 
threatening  to  rupture.  In  the  early  days  of  this  use  of 
iodoform  it  was  thought  to  be  contraindicated  in  such 
cases,  but  not  so  now,  except  possibly  where  ether  is  used, 
and  even  then  it  is  given  as  Verneuil's  experience  that 
healing  is  often  quicker  under  these  conditions  when  a 
sinus  forms.  I  have  found  the  formation  of  a  small  sinus 
no  hindrance  to  the  complete  and  speedy  healing.  It  is  the 
experience  of  Trendelenburg's  clinic,  in  Bonn,  that  freshly 
diseased  parts,  especially  if  acutely  diseased,  heal  quickest 
and  surest ;  that  children  give  a  better  prognosis  than 
adults,  and  that  unaltered  skin  gives  the  best  chances  of 
success. 

On  the  other  hand,  Billroth  says  that  the  worst  and 
largest  abscesses  give  the  best  results  and  fewest  recur- 
rences ;  therefore  he  is  now  in  favor  of  active  treatment  of 
cold  abscesses  by  this  method,  because  of  the  danger  of 
amyloid  degeneration  if  they  are  not  treated.  His  "  open 
method "  he  also  especially  recommends  in  cases  with 
fistulse. 

Krause  treats  the  severest  cases  of  joint  disease  as  well 
as  the  less  severe,  and  both  classes  of  cases  show  cures ; 
though,  as  Brums  says  as  to  joint  cases,  fresh  cases  without 
fistulas,  especially  in  children,  are  most  favorable. 

This  method  of  treatment  of  empyema  has  been  recom- 
mended by  Kydygier  and  Bruns,  especially  if  it  be  tuber- 
cular. Though  but  few  cases  of  this  kind  have  been  so 
far  reported,  it  seems  likely  to  prove  of  great  service  in 
this  worst  class  of  cases  of  empyema. 

Contraindications  and  Accidents. — Most  all  surgeons 
who  have  used  this  method  report  that  they  have  seen  no 
cases  of  iodoform  poisoning,  and  class  this  treatment  as 
simple,  successful,  and  without  danger.  Bruns  reports 
iodoform  poisoning  only  once,  and  not  at  all  in  joint  cases, 
where  a  less  amount  is  always  injected.  Billroth  saw  iodo- 
form intoxication  very  seldom,  but  advises  not  to  increase 
the  dose  above  that  given  above.  In  general,  the  dose  is 
small  and  the  surface  is  not  favorable  for  absorption,  so 
that  we  would  hardly  expect  iodoform  poisoning  to  occur 
often ;  and,  in  fact,  I  find  no  other  reports  of  it,  but  all 
others  are  careful  to  state  that  they  have  seen  none. 
Krause  reports  one  patient  who  died  of  acute  general 
miliary  tuberculosis  three  or  four  weeks  after  an  abscess 
was  opened  and  injected,  also  one  patient  who  died  of 
phthisis,  though  the  knee  was  improved.  Such  occasional 
results  are  met  with  in  any  form  of  operative  treatment. 


The  only  reaction  after  the  injections  is  a  rise  in  tem- 
perature of  one  to  two  degrees  centigrade.  "Where  it  is 
more  than  this  it  has  been  attributed  to  imperfect  steriliza- 
tion of  the  emulsion.  A  part  of  the  febrile  rise  has  been 
attributed  to  the  glycerin,  but  otherwise  it  has  not  been 
satisfactorily  accounted  for. 

The  time  required  by  this  method  of  treatment  is  rather 
long  in  actual  days  or  weeks,  though,  as  Fraenkel  says,  com- 
paratively short.  The  procedure  must  generally  be  more  or 
less  often  repeated.  Some,  however,  report  cures  after  a 
single  injection,  and  others  in  four  or  five  weeks  by  two  to 
three  injections.  I  have  cured  one  large  abscess  in  four  to- 
five  weeks  by  two  injections.  The  general  rule,  however, 
is  that  though  the  symptom  of  pain  is  quickly  relieved,  the 
healing  process  does  not  begin  to  show  itself  even  before 
five  to  six  or  even  seven  to  eight  weeks,  after  two  to  four 
injections,  and  then  healing  goes  on  rather  rapidly,  the 
complete  cure  requiring  sometimes  four  to  five  months. 

The  deduction  from  this  is  not  to  stop  treatment  too 
soon,  either  from  discouragement  at  first  or  belief  that  the 
case  is  healed  later  on. 

Results. — The  first  effect  is  a  moderate  amount  of  pain, 
not  lasting  over  twenty-four  hours  generally.  Then  there 
is  usually  a  refilling  of  the  abscess  or  joint  cavity,  with 
more  or  less  tension. 

The  first  sign  of  improvement  is  the  relief  of  the  pain, 
especially  in  joint  cases.  Then  there  is  almost  always  a  de- 
cided improvement  in  the  general  condition.  Thus  I  have 
seen  stoppage  of  night  sweats,  disappearance  of  hectic 
fever,  improvement  of  appetite,  and  gain  of  flesh  and 
strength. 

The  abscess  or  joint  cavity  refills  with  a  thinner, 
browner  pus,  which  generally  requires  a  second  or  third 
tapping  and  injection ;  but  after  a  varying  interval  of  two 
to  eight  weeks  there  is  a  gradual  or  rapid  shrinkage  until 
only  a  certain  amount  of  induration  remains.  Motion  may 
return  completely  in  a  joint,  though  in  the  hip  there  is 
finally  generally  an  ankylosis.  In  other  joints  many  cases 
of  complete  restoration  of  motion  have  been  reported. 

The  results  are  remarkable,  especially  as  they  occur  in 
adults  as  well  as  in  children,  and  in  cases  where  otherwise 
an  amputation  would  have  been  the  only  operative  treat- 
ment. 

The  results  vary  considerably  among  the  various  classes 
of  cases  to  which  the  treatment  is  applicable. 

Abscesses  give  by  far  the  best  results.  Thus  Fraenkel 
reports  twenty  cases  with  eighteen  cures.  Billroth  gives 
sixty-three  per  cent,  cured,  and  Trendelenburg  finds  a  marked 
result  in  sixty-eight  per  cent,  of  cases.  Bruns  reports  ten 
cures  out  of  twelve  abscesses  from  spinal  caries,  and  twenty- 
four  cures  in  thirty  five  cases,  whereas  by  former  methods 
the  statistics  were  thirty-five  cures  in  a  hundred  and  one 
cases.  Finally,  Bruns's  most  complete  statistics  show  eighty 
per  cent,  of  cures  in  cold  abscesses. 

Cases  of  fistuluj  are  more  obstinate  and  generallv  take 
longer.  Cases  of  tubercular  joint  disease  show  a  smaller  per- 
centage of  cures  than  do  the  abscesses,  yet  the  results  hero 
are  most  remarkable,  considering  the  kind  of  cases  sus- 
ceptible of  cure  and  the  results  of  other  forms  of  treatment. 


214 


WOOLSEY:  IODOFORM  INJECTIONS  IN  LOCAL  TUBERCULOSIS.      [N.  Y.  Mkd.  Jom, 


Bruns  reports  fifty  per  eent.  of  cures  in  all  joint  cases, 
and,  by  a  re-exainiuation  of  these  cases,  the  cures  are  found 
to  be  permanent.  The  prognosis  varies  with  the  different 
joints.  Thus  Krause  reports  cures  as  follows :  Wrists, 
sixty  per  cent. ;  knees,  forty- one  per  cent. ;  hip,  thirty  per 
cent. ;  ankle,  sixteen  per  cent. ;  improvement  in  all  cases. 
Trendelenburg's  figures  are  sixty  per  cent,  of  wrists,  thirty- 
seven  per  cent,  of  elbows,  thiity-three  per  cent,  of  knees 
and  ankles. 

It  is  thus  seen  that  the  best  results  are  obtained  in  the 
wrist  joint,  many  cases  being  reported  cured  which  would 
otherwise  have  been  subjected  to  amputation.  Next  to 
the  wrist,  the  knee  and  elbow  show  the  best  results  and  the 
ankle  the  worst. 

My  personal  experience  with  this  method  of  treatment 
is  briefly  as  follows.  The  cases,  with  two  or  three  excep- 
tions, were  treated  under  my  care  in  the  wards  of  Bellevue 
Hospital : 

Class  I.  Abscesses. — 1.  G.  W.  M.,  aged  thirteen.  Large  ab- 
scess at  upper  end  of  the  thigh,  anterior  and  inner  aspect.  Co- 
caine, tapping,  cavity  washed  out  with  Thiersch's  solution,  ten 
drachms  of  a  ten-per-cent.  emulsion  of  iodoform  in  glycerin  in- 
jected. Two  weeks  later,  same  repeated,  with  olive-oil  emul- 
siou.    Result,  euro  in  five  to  six  weeks. 

2.  Psoas  abscess  on  both  sides.  F.  J.  L.,  aged  twenty-six. 
Abscesses  opened  and  drained ;  injections  frequently  repeated. 
In  hospital  two  months.  Result,  cure.  The  patient  was  seen 
fifteen  months  after  discharge  from  hospital ;  abscesses  have 
remained  healed. 

3.  Don  hie  psoas  abscess.  J.  M.,  aged  twenty-five.  Abscesses 
opened  and  drained  for  five  months  before  injections  were  used. 
After  use  of  injections  there  was  marked  improvement,  but  be- 
fore being  com|iletely  cured  he  left  the  hospital  against  advice. 
Result,  improvement. 

Class  II.  Joint  Cases. — 1.  0.  S.,  aged  two.  Hip  joint,  with 
abscess  of  large  size.  The  patient  was  very  feeble  and  anasmic. 
Abscess  aspirated  and  injected ;  injections  repeated  every  one 
to  two  weeks.  A  fistula  formed.  Patient  under  treatment  nine 
to  ten  weeks.  Result,  cure.  Patient  not  seen  since,  so  can  not 
settle  the  question  of  ankylosis. 

2.  Boy,  aged  about  nine.  Hii)-joint  disease  of  one  year's 
duration  ;  no  abscess ;  more  or  less  pain  ;  uses  a  cane.  Two  to 
three  injections  at  intervals  of  two  to  three  weeks.  Result, 
improvement;  pain  relieved;  can  walk  somewhat  without  a 
cane. 

3.  Girl,  aged  about  fifteen.  Hip  joint;  old  case;  wearing 
an  apparatus.  Sinus  some  distance  down  on  outer  and  poste- 
rior aspect  of  tlie  thigh.  Two  injections  at  intervals  of  two 
weeks.  Result,  improvement;  sinus  temporarily  healed.  The 
patient  withdrew  from  treatment. 

4.  A.  McN.,  aged  about  twenty.  Elbow  shows  spindle- 
shaped  white  swelling  of  tubercular  joint  disease.  Fixation  at 
first;  injections  every  week  or  ten  days.  In  hos])ital  about 
six  weeks.  Result,  improvement;  no  pain;  little  or  no  swell- 
ing; good  motion.    Treatment  not  completed. 

5.  U.,  aged  about  eighteen.  Ankle.  History  dates  back  six 
months  or  more.  Tubercular  periostitis  in  lower  third  of  tibia. 
Pus  in  joint.  Joint  aspirated  and  injected  every  two  weeks  for 
eight  to  ten  weeks.  Improvement  first  shown  at/ six  to  seven 
weeks.  The  patient  finally  lott  before  treatment  was  complete. 
Result,  improvement;  almost  cure  of  ankle;  no  pain;  little 
swelling;  no  fiuotuation.  Periostitis  only  just  began  to  be 
treated. 


6.  J.  M.,  aged  eight.  Knee.  No  abscess;  little  effusion. 
Injections  into  joint  cavity.  Result,  process  stationary;  some 
flexion  of  the  knee  existed  and  stdl  remains;  no  pain. 

Class  III.  Fistulm. — 1.  Ischio-rectal  abscess  and  fistula. 
W.  A.  S.,  aged  thiity-six.  Bad  case.  Cavities  extend  up  on 
both  sides  of  the  rectum  five  and  six  inches.  Treatment:  Free 
opening;  fistula  cut;  abscess  membrane  scraped  with  sharp 
spoon ;  iodoform  and  glycerin  injected  every  one  to  two  days 
through  catheter  introduced  into  wound.  Result:  Discharged 
cured  in  three  weeks,  which  seems  a  remarkable  result  consider- 
ing the  extent  of  the  process. 

2.  Wrist  joint,  joint  previously  excised,  one  sinus  leading  to 
soft  bone.  Two  injections;  sinus  healed  in  from  three  to  four 
weeks. 

3.  Upper  part  of  calf,  fistula)  in  soft  parts.  Injected  every 
week  for  five  or  six  weeks.    Result,  cure. 

4.  Posterior  lumbar  region ;  sinus  resulting  from  operation 
for  abscess  for  which  no  cause  was  found.  Injections  parenchy- 
matously.  Result,  improvement,  especially  in  general  condition  ; 
appetite  improved;  night  sweats  and  hectic  stopped ;  flesh  and 
strength  gained. 

5.  Miss  X.,  aged  twenty-five.  Tuberculosis  of  breast ;  si- 
nuses in  axilla.  Operation.  Breast  and  axillary  contents  re- 
moved. Hinus  found  leading  from  axilla  to  supraclavicular 
glands.  Sinus  scraped  and  injected.  Injections  repeated  through 
the  tube  brought  out  of  the  wound.  Result,  complete  cure  in 
about  three  weeks. 

6.  E.  F.,  aged  twenty-six.  Ankle.  Operation;  sinus  re- 
mains.   Cured  by  injections  in  sinus  and  parenchymatously. 

7.  T.  M.,  aged  twenty-eiglit.  Shoulder.  Excision;  two  fis- 
tula) remain.  Cured  by  scraping,  combined  with  injections  of 
iodoform  in  sinus  and  parenchymatously. 

Class  IV.  Epididymitis  and  Bladder. — 1.  J.  McC,  aged  twen- 
ty-seven. Double  tubercular  epididymitis  of  some  time  stand- 
ing. Scraping  operation  had  previously  been  done.  Two  fistu- 
la) remain;  both  testicles  enlarged.  Injection  into  sinuses  and 
parenchymatously  quite  frequently,  i.  e.,  twice  a  week,  for  some 
weeks.  Result,  one  cured  and  one  improved,  and  was  later  on 
removed.    The  patient  since  then  has  remained  entirely  well. 

2.  Unilateral  tubercular  epididymitis.  T.  M.,  aged  twenty- 
eight.  Tlie  same  patient  whose  shoulder  was  excised  and  sinuses 
cured,  developed  a  tubercular  epididvmitis.  Injection  of  iodo- 
form in  olive  oil.  This  was  quickly  followed  by  pain  in  the 
chest  and  slight  haemoptysis.  It  seemed  possible  if  not  proba- 
ble that  this  was  due  to  the  injection  entering  a  vein  and  a  small 
fatty  embolism  occurring  in  the  lung.  Consequently,  I  think 
olive-oil  emulsions  are  contraindicated  for  parenchymatous  in- 
jections. One  or  two  further  injections  with  glycerin  emulsion 
were  used.    Result,  process  stopped  ;  cure. 

3.  Cystitis,  probably  tubercular.  Tubercular  history,  and 
patient  had  had  tubercular  epididymitis.  Very  frequent  mic- 
turition; pain.  No  treatment  or  injections  or  irrigations  relieved 
him.  Bladder  washed  out  with  Tiiierscb's  solution,  after  which 
emulsion  of  iodoform  in  olive  oil  was  injected  and  held  as  long 
as  possible.  This  repeated  every  day.  In  two  weeks  patient 
could  hold  his  urine  two  to  three  hours  and  has  no  pain,  sleeps 
well,  and  is  gaining  flesh  and  strength.  Treatment  continued 
some  little  time  longer.    Result,  cure. 

I  have  made  no  attempt  to  arrange  the  above-given  cases 
statistically,  as  they  are  too  few  in  number,  and  in  many  the 
treatment  was  never  completed. 

In  general,  I  can  say  that  I  have  been  quite  well  satisfied 
with  the  results  of  this  method  of  treatment. 

Failures  or  partial  failures  have  been  generally  due  to 


Feb.  25,  1893.] 


WYMAN:  APPENDICITIS. 


215 


the  fact  that  either  the  treatment  was  not  carried  out  thor 
oughly  or  that  the  patient  insisted  on  leaving  before  the 
cure  was  complete,  in  many  cases  being  satisfied  with  the 
improvement.  This  would  partly  account  for  the  differ- 
ence between  our  statistics  and  those  from  German  clinics, 
where  the  patients  are  under  more  control. 

Finally,  as  the  result  of  my  limited  experience,  I  can 
heartily  recommend  that  injections  of  iodoform  emulsions 
be  given  a  trial  in  all  cases  of  local  tuberculosis  in  which  this 
method  of  treatment  is  applicable.  Failure  only  adds  to  the 
advisability  of  an  operation. 

IIT  East  Thirty-sixth  Street. 


APPENDICITIS  * 
By  HAL  C.  WYMAN,  M.  So.,  M.  D., 

pr.OFESSOR  OP  SURGERY  IN 
^  THE  MICHIGAN  COLLEGE  OF  MEDICINE  AND  SDROEBT,  DETROIT. 

In  the  course  of  one  of  those  delightful  little  tete-a-tetes 
that  sometimes  take  place  after  an  adjourned  meeting  of  a 
medical  association,  a  gentleman  who  had  spent  many  years 
in  the  practice  of  medicine  said  to  me,  "  Doctor,  how  is  it 
that  you  surgeons  find  so  many  cases  of  what  you  call  '  ap- 
pendicitis '  to  operate  upon  ?  "  I  answered  that  I  did  not 
know  that  we  found  any  more  cases  nowadays  than  for- 
merly existed.  "But,"  he  said,  "I  have  practiced  medicine 
for  forty  years,  have  been  constantly  busy  during  those 
years,  and  have  seen  a  great  deal  of  sickness.  I  have  never 
encountered  a  case  of  appendicitis  requiring  any  surgical 
operation."  I  answered,  "  That  is  probably  because  you 
fail  to  recognize  the  lesion,  and  attribute  the  malady  to  some 
other  cause."  I  asked  if  he  had  not  seen  a  great  many 
cases  of  death  resulting  from  inflammation  of  the  bowels, 
and  he  replied  that  he  had  seen  a  great  many  cases  of  fatal 
inflammation  of  the  bowels  in  which  no  little  difficulty  was 
had  in  determining  the  cause.  He  had  seen  cases  which 
he  believed  were  due  to  rheumatism  ;  cases  which  were  due 
to  no  apparent  cause — quite  a  number  of  them.  I  asked  if 
he  had  not  occasionally  encountered  cases  in  which  ab- 
scesses made  their  appearance  in  the  region  of  the  caecum, 
requiring  opening.  Yes,  he  said,  he  had  operated  upon 
three  or  four  cases  of  such  abscesses — cases  wliich  he  looked 
upon  as  perityphlitis.  And  he  said  further  that  writers  of 
his  time,  like  Rokitansky  on  pathological  anatomy,  like 
Gross  and  Eberle  and  Flint  and  Cullen  and  Brown,  had 
very  little  to  say  about  diseases  of  the  appendix  verrai- 
formis.  Rokitansky,  in  his  description  of  the  pathology  of 
the  alimentary  canal,  distinctly  states  that  the  appendix 
vermiformis  is  not  infrequently  the  seat  of  inflammatory 
processes,  the  result  of  the  presence  of  foreign  bodies  in  it. 
"  But,"  the  gentleman  continued,  "  I  have  never  encoun- 
tered them  and  I  do  not  see  why  there  should  be  such  an 
apparent  epidemic  of  appendicitis  during  the  las*  few 
years."  Other  gentlemen  who  were  present  and  who  had 
been  many  years  in  practice  spoke  in  pretty  much  the  same 
terms,  and  evidently  seemed  to  think  that  appendicitis  was 

*  Read  before  the  Northern  Tri-State  Medical  Association  at  its 
Hudson  meeting,  December  5,  1892. 


a  sort  of  fad  that  had  taken  possession  of  the  surgical  side 
of  the  profession,  and  was  leading  men  to  perform  opera- 
tions that  were  unnecessary.  One  gentleman  spoke  about 
the  "  medical  "  treatment  of  appendicitis,  and  stated  that 
no  doubt  if  medical  treatment  was  begun  early  and  properly 
carried  out,  a  great  many  of  the  patients  could  be  saved ; 
that  he  had  seen  a  good  many  cases  of  tenderness  and  inflam- 
mation in  the  region  of  the  appendix  vermiformis  which  had 
disappeared  after  a  rest  in  bed  and  an  exhibition  of  suffi- 
cient quantities  of  opium  or  morphine  to  control  the  pain, 
with  due  attention  to  the  bowels.  Certainly  the  cases  that 
had  come  under  his  observation  were  not  cases  requiring 
operation.  A  younger  member  of  the  party  said  :  "  The 
question  of  appendicitis  with  the  older  members  of  the  pro- 
fession is  simply  this  :  cases  that  might  be  relieved  by  op- 
eration die,  and  the  mortality  is  attributed  to  some  other 
disease  when  medical  treatment  fails." 

No  doubt  many  of  those  who  listen  to  me  have  heard 
conversations  similar  to  that  I  have  just  recited,  and  the 
reason  for  it  is  that  a  pathological  condition  has  been  con- 
founded with  an  operative  procedure.  There  is  nothing 
new  in  the  history  of  appendicitis.  Early  surgical  writers 
upon  faecal  abscesses  define  clearly  cases  of  appendicitis,  and 
speak  of  opening  abscesses  in  the  region  of  the  appendix, 
from  which  foreign  bodies,  such  as  cherry  pits,  seeds  of 
fruit,  etc.,  have  been  removed.  But  they  say  nothing  about 
the  removal  of  the  appendix  ;  and  this  operation — which  is 
of  recent  origin — of  the  removal  of  this  apparently  useless 
member  of  the  human  anatomy  has  made  the  confusion  in 
professional  minds. 

The  development  of  antiseptic  surgery  has  given  a  great 
impetus  to  operative  procedures  within  the  abdominal  cav- 
ity, and  this  has  no  doubt  had  much  to  do  with  determin- 
ing the  present  surgical  aspect  of  appendicitis.  Previous 
to  this  advance,  while  the  different  causes  of  peritonitis 
were  carefully  described  by  surgical  writers,  still  the  almost 
uniformly  fatal  results  of  operations  for  the  relief  of  any  of 
them  led  practitioners  to  pursue  the  "  medical  "  or  "  do- 
nothing  "  course  generally.  Little  care  was  taken  by  the 
average  physician  to  make  a  differential  diagnosis  in  a  case 
of  peritonitis  and  determine  the  source  of  the  lesion.  The 
tendency  was  to  look  upon  it  as  an  idiopathic  malady  to  be 
treated  with  opium  as  a  splint  for  the  bowels.  Beyond  this 
practice  treatment  rarely  went.  But  with  the  knowledge 
that  the  peritonaeum  could  be  explored  without  increased 
danger  of  a  fatal  termination  of  an  attack  of  peritonitis,  the 
profession  was  not  slow  to  differentiate  in  all  cases,  ignor- 
ing the  idea  of  an  idiopathic  origin  for  the  disease,  and 
seeking  to  find  the  actual  lesion. 

Naturally,  lesions  of  the  appendix  were  found  not  infre- 
quently to  be  a  cause  of  general  peritonitis  ;  and  then,  the 
cause  being  known,  its  removal  was  suggested. 

As  matters  stand  to-day  in  relation  to  cases  of  "inflam- 
mation of  the  bowels" — using  the  term  in  the  popular  sense 
— the  first  thing  the  medical  attendant  does  is  to  ascertain 
the  cause  of  the  inflammation;  and,  when  the  lesion  is  lim- 
ited to  the  right  side,  as  indicated  by  tenderness  and  recog- 
nition of  an  unusual  tumefaction  in  the  region  of  the  ap- 
pendix, surgical  procedures  are  entertained.     The  older 


216 


WYMAN:  APPENDICITIS. 


[N.  Y.  Mkd.  Jo0b., 


members  of  the  profession,  as  these  facts  are  being  made 
clear  to  tliem,  are  by  no  means  dilatory  in  recognizing  le- 
sions as  they  occur,  and  treating  them  in  the  best  possible 
manner. 

It  is  impossible  to  make  a  set  of  rules  which  will  govern 
all  cases  of  appendicitis.  No  doubt  the  endeavors  to  do 
this  are  another  source  of  the  confusion  which  exists  in 
some  professional  minds,  as  indicated  in  the  dialogue  at 
the  commencement  of  this  paper.  Every  case  must  stand 
by  itself,  and  he  alone  is  competent  to  make  a  diagnosis 
who  is  thoroughly  familiar  with  the  anatomy  of  the  organs 
included  within  the  peritoneal  cavity,  with  their  relations 
to  the  abdominal  parietes,  and  with  the  changes  which 
these  organs  undergo  in  consequence  of  disease.  A  few 
cases  which  have  come  under  my  observation  may  illustrate 
this  point. 

I  was  called  one  night  Inst  winter  to  see  a  lioy,  fifteen  years 
old,  who  liad  been  siok  for  a  week.  His  physician  told  me  tliat 
the  trouble  began  alter  a  strain  received  in  jmnping  from  a 
wagon  in  motion,  and  that  he  fir.-tf comi)]aiiied  of  pain  in  the 
iieighborliood  of  the  navel.  That  the  pain  increased  steadily 
for  four  days.  That  the  abdomen  became  tympanitic  and  the 
bowels  confined.  He  was  obliged  to  use  morphine  to  relieve 
the  suffering,  which  wns  constant  and  required  large  doses  to 
afford  any  relief.  On  the  fourth  day  the  pain  suddenly  abated, 
and  the  doctor  endeavored  to  promote  the  action  of  the  bowels 
by  the  use  of  enemas  and  cathartics.  The  distention  of  the  ab- 
domen, however,  continued  and  increased.  The  pulse  became 
exceedingly  small  and  rapid,  and  vomiting  was  added  to  the 
other  symptoms.  Gradually  it  became  apparent  that  the  pa- 
tient was  verging  on  collapse,  and  when  I  saw  him  he  was 
clearly  in  a  condition  which  offered  very  little  hope  of  success 
by  any  treatuient.  A  careful  physical  examination  showed  the 
region  of  the  abdomen,  internal  to  and  above  the  anterior  su- 
perior si)ine  of  the  ilium,  markedly  hnrder  than  usual,  but  in 
every  |)art  there  was  distinct  tymjjanitic  resonance  on  percus- 
sion. A  cold,  clammy  sweat  stood  u|)on  the  patient,  and  he 
was  vomiting  peculiar,  foetid  ejecta,  which  were  stercoraceous  in 
character.  The  pulse  was  not  so  rapid  or  so  feeble  as  it  had 
been  three  days  before.  Ilis  mind  was  clear,  and  he  told  me 
distinctly  how  his  injury  occurred,  and  where  he  first  felt 
pain;  and  furthermore  stated  that  he  had  had  two  similar  at- 
tacks within  the  past  three  .years,  which  had  disaj)peared  after 
his  mother  had  applied  a  large  poultice  and  had  given  him  a 
dose  of  paregoric.  No  movement  had  taken  place  in  this  pa- 
tient's bowels  since  his  first  attack  of  pain,  but  the  first  few 
days  of  constipation  were  supposed  to  be  due  to  the  adminis- 
tration of  anodynes.  It  was  apparent  lhat  unless  some  relief 
could  be  given  to  the  continuity  of  the  alimentary  canal,  the 
patient  must  soon  perish  in  consequence  of  the  obstruction.  I 
Lad  him  anaasthetized,  prepared  his  abdomen  with  antiseptics, 
scad  made  an  incision  reaching  from  the  navel  to  the  symphysis 
pubis,  fir^t  having  thoroughly  emptied  the  bladder  with  a  cathe- 
ter. Through  this  opening  the  peritonaeum  was  reached  and  the 
■cavity  opened.  A  quantity  of  purulent,  serous  fluid,  juixed  with 
fsecal  matter,  ran  from  the  wound.  Gently  insinuating  my  in- 
dex finger  into  the  peritoneul  cavity,  adhesions  were  encoun- 
tered in  the  region  of  the  apj)endix.  The  nozzle  of  a  syringe 
was  introduced  and  the  peritoneal  cavity  washed  out  until  no 
more  fa3cal  or  purulent  matter  ran  I'rom  the  wound.  Then  the 
examination  was  continued,  and  an  opening  was  found  in  the 
ilower  part  of  the  ca3cum  which  freely  admitted  my  index  fin- 
■g  >r.    This  exploration  was  made  with  the  least  possible  dis- 


turbance of  the  adhesions  existing  between  the  abdominal  vis- 
cera. To  one  side  of  tliis  opening  was  plainly  felt  a  ragged 
mass  of  tissue,  measui'ing  about  two  Indies  in  lengtli.  It  wag 
clear,  then,  that  the  case  was  one  primarily  of  inflammation  of 
the  appendix  vormiformis,  or  of  the  (^ajcum  in  close  ])roximity 
to  it,  and  tiiat,  in  consequence  of  this  inflammation,  ulceration 
and  perforation  had  taken  place.  The  abdominal  wound  was 
enlarged  about  an  inch  and  a  half,  passing  to  the  right  of  the 
umbilicus,  to  give  better  access  to  the  region  of^he  appendix. 
The  ca)cum  was  gently  separated  from  restraining  adhesions, 
the  ragged  appendix  was  removed,  and  the  o[)eningin  the  bowel 
closed  with  continued  catgut  sutures,  taking  care  to  bring  the 
opposite  surfaces  of  the  peritonaaum  together,  and  to  turn  all  mu- 
^0118  surfaces  into  the  cavity  of  the  ciBcum.  The  patient  rallied 
from  the  operation  and  did  well  for  twenty-four  hours,  when 
be  suddenly  coUapseil  and  died.  An  autopsy  revealed  a  general 
l)eritonitis.  After  the  operation  there  was  no  movement  of  the 
bowel?,  nor  were  any  firm  adhesions  occluding  the  continuity  of 
the  canal  discovered  at  the  autopsy. 

Another  case  with  a  somewhat  different  history  came  under 
my  observation  a  few  weeks  later.  I  was  called  to  see  a  man 
in  the  western  part  of  the  city,  whom  the  messenger  said  had 
been  sick  for  a  week.  That  he  had  been  having  a  great  deal  of 
stomach-ache.  That  he  had  consulted  a  physician  at  his  office 
several  tijnes,  but  the  medicine  did  not  appear  to  do  him  any 
good,  and  he  had  been  trying  home  remedies  since.  Ilis  wife 
had  been  using  poultices  and  injections,  but  still  the  pain  kept 
up.  lie  liad  had  similar  attacks  before,  but  never  one  so  severe. 
Dr.  D.  L.  Dakin,  of  Detroit,  accompanied  me  to  the  bedside  of 
the  patient,  where  we  found  a  man,  thirty  years  of  age,  a  la- 
borer by  occupation,  suffering  from  fever,  with  a  temperature  of 
103°  F.,  with  tongue  furred,  and  with  pain  in  the  right  side  of 
the  al)domen.  He  repented  the  history  as  above  recited.  A 
physical  examination  of  the  abdomen  revealed  the  right  side 
practically  immobile.  A  firm,  slightly  yielding  mass  could  be 
felt,  reaching  from  the  right  superior  spine  of  the  ilium  to  with- 
in an  inch  of  the  umbilicus,  and  this  mass  was  very  tender  on 
pressure.  The  man  thought  his  trouble  was  caused  by  lifting; 
but  there  was  no  distinct  and  reliable  history  of  the  origin  of 
the  pain.  His  pulse  was  120,  his  respiration  26;  he  had  had  no 
chills,  but  his  fever  had  continued  steadily  all  the  week,  so  his 
wife,  who  had  been  in  constant  attendance  upon  him,  said.  His 
bowels  had  moved  two  or  three  times  every  day  in  consequence 
of  the  medicine  which  had  been  given  him.  On  these  facts  we 
decided  that  the  case  was  one  of  appendicitis,  with  suppura- 
tion. After  putting  the  man  under  the  influence  of  chloroform, 
we  made  an  incision  through  the  abdominal  wall,  over  the  most 
prominent  part  of  the  tumor,  which  was  about  an  inch  internal  to 
the  right  anterior  superior  spinous  process  of  the  ilium,  and  an 
inch  and  a  half  above  it.  This  incision  was  cautiously  carried 
downward  until  the  peritonaeum  was  reached,  when  a  quantity 
of  sero  sanguineous  fluid  oozed  from  the  peritoneal  fat.  Then 
we  made  an  incision  through  the  peritonaeum,  penetrating  the 
doughy  mass  heretofore  described.  A  quantity  of  pus  of  the 
most  foetid  character  was  discharged.  The  opening  was  care- 
fully enlarged,  and  my  finger  explored  an  abscess  cavity  reach- 
ing from  below  the  brim  of  the  pelvis  upward  as  far  as  the  lower 
border  of  the  right  lobe  of  the  liver.  Nowhere  in  this  cavity 
could  a  free  appendix  be  felt;  but  in  its  deeper  portion  the  fin- 
ger (i^tectcd  an  embossed  ridge  which  contained  several  small 
perforations,  and  from  which  small  quantities  of  faecal  matter 
were  discharging,  and  which  was,  I  believe,  the  appendix.  The 
cavity  was  now  packed  carefully  with  iodoform  gauze,  particu- 
lar pains  being  taken  to  compress  the  appendix  ;  an  antiseptic 
dressing  was  applied  over  all  and  held  in  place  by  a  bandage 
over  the  abdomen.    The  next  day  the  patient's  fever  had  en- 


Feb.  25,  1893.] 


WVMAN:  APPENDICITIS. 


217 


tirely  disappeared,  the  pain  likewise  was  gone,  and  lie  expressed 
himsolt'  as  feeling  very  much  improved.  The  dressings  were 
not  disturbed  until  a  week  alter  the  operation,  when  the  gauze 
was  found  sli;:,htly  saturated  with  purulent  fluid.  A  new  dress- 
ing wa.s  then  applied.  Three  weeks  after  the  oi)eration  the  pa- 
tient had  so  far  recovered  that  only  a  slight  granulating  depres- 
sion existed  at  the  site  of  the  incision.  The  abscess  cavity  had 
filled  with  granulation  tissue,  and  five  weeks  after  the  opera- 
tion the  patient  expressed  himself  as  entirely  well,  the  wound 
having  healed.  I  have  seen  him  frequently  since,  and  he  works 
every  day  at  his  occupation  as  a  helper  in  a  lumber  yard,  lifting 
and  straining  as  occasion  requires.  He  says  he  feels  perfectly 
well. 

Another  case,  the  foreign  body  removed  from  which  I  have 
here  to-day  to  show  you,  was  that  of  a  young  man  twenty- 
three  years  of  age,  who  was  employed  in  electrical  work. 
Aft^r  lifting  heavily  in  aiding  some  men  in  putting  a  large 
dynamo  on  a  truck,  he  felt  a  pain  in  bis  right  inguinal  region, 
which  continued  sharp — lancinating  in  character — so  that  he 
was  unable  to  work  the  rest  of  the  afternoon  and  went  to  his 
room.  The  next  day  he  called  a  physician,  who  recognized  a 
point  of  great  tenderness  about  midway  of  a  line  drawn  from 
the  umbilicus  to  the  anterior  spine  of  the  ilium.  The  patient 
had  fever,  his  bowels  moved  regularly,  but  be  did  not  get  better 
after  anodynes  were  administered.  A  week  elapsed  before  I 
was  called  in  consultation  by  my  colleagues,  Dr.  Bell  and  Dr. 
Meddaugh,  of  Detroit.  Then  we  found  a  swelling  deep  in  the 
right  inguinal  region,  reaching  almost  to  the  umbilicus  and 
nearly  to  the  inferior  border  of  the  last  rib.  There  was  a 
marked  bulging  of  the  right  lumbar  region,  and  the  whole  ab- 
domen was  exceedingly  tender.  So  severe  was  the  suffering 
and  so  great  the  tension  in  the  right  side  that  the  patient  lay 
on  his  back  in  bed  with  tiie  limbs  widely  separated.  He  could 
not  bear  to  have  his  feet  placed  side  by  side,  so  great  was  the 
pain  tlie  action  caused  him.  He  was  given  chloroform,  and  I 
made  an  incision  over  the  most  pi-ominent  part  of  the  tumor, 
which  was  immediately  above  the  spine  of  the  ilium,  and,  after 
)  a  deep  dissection  of  the  abdominal  wall,  I  reached  the  perito- 
naeum, which  I  incised  freely,  evacuating  a  large  quantity  of 
pus  inixed  with  fijecal  matter.  Introducing  my  finger,  I  ex- 
plored carefully  the  cavity  in  the  region  where  the  appendix 
should  be  found,  and  discovered  a  date  seed  measuring  three 
quarters  of  an  inch  in  its  longest  diameter,  by  a  quarter  of  an 
inch  in  its  greatest  transverse  diameter  and  a  little  less  in  its 
smallest  diameter.  This  was  partially  imbedded  in  inflamed 
tissue.  After  its  removal  1  made  a  careful  search  to  find  the 
opening  from  which  it  had  escaped,  but  failed.  A  drainage- 
tube  was  inserted  in  the  wound  and  the  cavity  loosely  packed 
with  iodoform  gauze.  The  patient  continued  to  suffer  from 
fever  for  ten  days,  but  his  pain  was  entirely  relieved.  Then 
the  fever  began  to  subside,  he  began  to  eat,  his  bowels  moved 
regularly  every  day,  and  he  made  an  uninterrupted  recovery. 
The  wound  granulated  perfectly  without  interfering  in  any  way 
with  the  functions  of  the  alimentary  canal. 

A  case  presenting  a  somewhat  characteristic  history  is  that 
of  a  young  girl,  and  the  specimen  from  her  case  I  have  with 
me.  She  was  employed  in  one  of  the  factories  in  the  city,  was 
fifteen  years  of  age,  had  always  enjoyed  good  health,  with  the 
exception  of  occasional  attacks  of  colic,  which  were  supposed 
bj  her  mother  to  be  due  to  some  irregularity  in  the  develop- 
ment of  her  menstrual  functions.  She  had  been  somewhat  ir- 
regular in  that  respect,  but  had  been  well  enough  to  perform 
her  duties  comfortably.  She  had  been  tick  a  week  when  I  was 
called  to  her  case  by  Dr.  Lo  Blanc,  of  Detroit.  Her  attack 
'started  soon  after  lifting  a  barrel  which  contained  some  scraps 
of  iron ;  then  she  had  pain  in  the  abdomen,  wfaich  gradually 


increased — so  much  so  that  she  was  obliged  to  go  to  her  homo 
and  bed.  Her  mother  made  hot  applications,  thinking  the  pain 
indicated  the  approach  of  catamenia,  and  gave  her  hot  wiiisky 
and  water  to  drink.  This  provoked  vomiting.  The  voniiting 
and  pain  continued,  unrelieved  by  the  administrations  of  the 
mother,  and  Dr.  Le  Blanc  was  called.  He  made  a  careful  ex- 
amination of  the  abdomen,  failed  to  find  any  point  more  tender 
than  other  points,  could  detect  no  ditt'erence  in  the  deep  struc- 
tures of  the  abdomen  between  the  two  sides,  and  prescribed  for 
the  nausea.  The  cathartics  which  had  bem  given  had  acted 
freely,  and  there  were  frequent  passages  of  g;!S  from  the  bow- 
els. There  were  no  evidences  of  obstruction  of  the  bowels. 
The  matter  ejected  from  the  stomach  was  of  a  simple  bilious 
character  and  contained  much  mucus,  but  the  morphine  which 
the  doctor  administered  hypodermieally,  while  it  relieved  the 
pain,  did  not  stop  the  vomiting,  and  the  patient  gradually  grew 
weaker.  When  I  was  called  in  consultation  1  made  a  very 
careful  bimanual  examination  of  the  contents  of  the  pelvis  and 
abdomen,  but  failed  to  detect  any  localizing  condition.  This 
was  done  with  the  patient  under  the  influence  of  an  auDBsthetic, 
which  was  made  necessary  by  the  general  tenderness  of  the 
abdomen.  She  had,  during  the  preceding  twenty-four  hours, 
been  obliged  to  micturate  much  more  frequently  than  natural, 
but  the  urine  contained  no  excess  of  mucus,  and  it  was  appar- 
ent that  the  irritability  of  the  bladder  was  due  to  some  exciting 
process  within  the  peritoneal  cavity.  Believing,  from  the  fact 
that  the  symptoms  developed  immediately  after  a  strain,  that 
there  was  a  foreign  body  in  some  ])art  of  the  alimentary  canal 
which  the  strain  had  disturbed  and  which  had  caused  a  perfo- 
ration, I  opened  the  abdomen  by  a  section  in  the  median  line, 
running  from  the  umbilicus  to  the  symphysis  pubis.  The  pei-i- 
tonteum  appeared  natural  oh  its  external  aspect,  but,  on  divid- 
ing it,  a  quantity  of  serous,  purulent  matter  was  discharged.  A 
few  coils  of  intestine  which  rolled  into  the  wound  were  deeply 
dyed  a  dark-red  color.  Sweeping  the  finger  about  in  the  peri- 
toneal cavity,  no  adhesions  were  discovered  at  first,  but,  on  ex- 
ploring more  cautiously  in  the  region  of  the  appendix,  a  slight 
adhesion  was  detected  between  that  organ  and  a  loop  of  small 
intestine.  Retractors  were  introduced  into  the  wound,  which 
was  continued  upward  about  an  inch  to  give  better  access  to 
the  region  of  the  appendix,  and  the  examination  with  the  finger 
was  continued.  The  appendix  was  found  to  contain  a  firm, 
solid  body.  The  adhesions  between  the  appendix  and  the  loop 
of  intestine  were  very  easily  separated,  and  did  not  occupy 
over  a  quarter  of  an  inch  in  extent.  Aside  from  this  the  ap- 
pendix was  entirely  free  in  the  peritoneal  cavity.  It  was,  with 
the  CEecum,  brought  up  into  the  wound.  A  catgut  ligature  was 
carried  about  its  base,  and  it  was  removed  with  scissors,  with 
the  foreign  body  in  it,  precisely  as  you  see  the  specimen  in  the 
bottle  which  I  submit  for  your  inspection.  'With  my  eye  I 
could  detect  no  perforation,  but  there  were  several  dark  spots 
like  fly  specks  upon  its  lower  surface.  The  mesentery  of  the 
appendix  was  deeply  congested,  but  no  perforations  could  be  de- 
tected in  it.  The  abdominal  cavity  was  washed  out,  a  drain- 
age-tube was  inserted,  and  the  abdominal  wall  closed.  The 
patient,  however,  did  not  improve  materially  ;  nausea  kept  up, 
and  she  died  in  collai)se  tweuty-four  hours  after  the  operation. 
The  autopsy  revealed  no  obstruction  to  the  continuity  of  the 
canal,  nor  were  there  any  adhesions  to  be  found  in  any  part  of 
the  peritoneal  cavity,  nor  was  there  any  plastic  lymph  thrown 
out;  only  a  deep-red  congestion  of  the  intestinal  |)eriton!Bum 
in  the  region  of  the  appendix  was  discovered.  Death  was  evi- 
dently the  result  of  absorption  into  the  general  circulation  of 
poisons  which  entered  by  way  of  the  peritoneal  cavity.  I  took 
the  specimen  to  my  office  and  examined  it  more  minutely.  I 
poured  into  its  cavity,  around  the  foreign  body,  about  half  a 


218 


SONDERN:   THE  CENTRIFUGAL  APPARATUS. 


[N.  Y.  Mkd.  Jocb.. 


draclim  of  mercury.  This  fluid  at  once  made  its  apjiearance  at 
he  small  spots  like  fly-specks  heretofore  described,  and  quickly 
ran  out  of  the  appendix.  The  cavity  of  this  organ  had  been 
ulcerated  by  tlie  presence  of  the  foreign  body,  which  is  evi- 
dently a  peanut  which  had  been  swallowed  without  mastica- 
tion. Through  the  openings  in  this  specimen  of  diseased  ap- 
pendix I  have  thrust  broom  straws  to  indicate  their  situation. 
It  is  probable  that  the  foreign  body  set  up  a  simple  inflamma- 
tion of  the  mucous  lining  of  the  appendix  first,  and  those 
inflammatory  processes  incident  thereto  extended  gradually  to 
the  peritoneal  investment  of  the  organ,  and  the  pressure  inci- 
dent to  straining  in  lifting  was  the  exciting  cause  of  the  ])erfo- 
rations,  through  which  small  quantities  of  fajcal  matter  or 
intestinal  gases  passed  freely  into  the  peritoneal  cavity,  causing 
the  changes  already  described,  and  the  constitutional  phenome- 
na indicated  by  vomiting,  subnormal  temperature,  rapid  pulse, 
and  the  patient's  death. 

I  have  recited  these  cases  for  the  purpose  of  showing 
simply  one  set  of  features  which  may  accompany  this  pe- 
culiar disease.  I  could,  were  it  not  for  wearying  you,  relate 
yet  other  cases  which  would  no  doubt  prove  equally  inter- 
esting, but  these  suffice  to  show  that  the  disease  known  as 
appendicitis  may  be  characterized  by  a  great  diversity  of 
phenomena,  all  of  which  indicate  clearly  the  necessity  for 
early  surgical  interference. 

I  do  not  believe  that  it  is  good  surgery  to  remove  the 
appendix  when  it  is  encountered  in  a  suppurating  cavity  to- 
which  it  is  so  firmly  adherent  that  its  removal  can  not  be 
accomplished  without  jeopardizing  the  integrity  of  that  por- 
tion of  the  peritoneal  cavity  which  has  not  been  infected 
by  inflammation-producing  organisms.  Nor  do  I  think 
that  it  would  be  good  surgery  to  refuse  to  remove  an  ap- 
pendix that  is  free  and  practically  insure  the  patient — in 
case  of  a  successful  issue  to  the  operation — from  the  dan- 
gers of  a  subsequent  faecal  fistula.  I  have,  in  other  in- 
stances, had  some  experience  in  operating  under  the  idea 
that  the  appendix  should  be  removed  in  all  cases,  and  have, 
in  accordance  with  that  doctrine,  broken  down  adhesions 
which  interfered  with  the  removal  of  the  diseased  organ  ; 
but  the  uniformly  fatal  results  in  those  cases  have  led  me 
to  adopt  the  more  conservative  plan  indicated  by  the  treat- 
ment followed  in  the  cases  recited  in  this  paper. 

An  objection  to  the  so-called  medical  treatment  is  found 
in  the  great  danger  of  recurrent  attacks.  Children  are  par- 
ticularly prone  to  relapse. 

The  danger  in  appendicitis  may  be  summarized  as  fol- 
lows :  (1)  General  peritonitis;  (2)  fascal  infection  by  the 
absorption  of  fecal  gas,  etc.,  from  the  peritonaeum ;  (3) 
faecal  fistula. 

The  surgical  treatment  should  be  undertaken  just  as 
soon  as  a  diagnosis  can  be  made. 


Meharry  Medical  College. — The  seventeenth  annual  commencement 
of  Mehairy  Medical  Department,  Central  Tennessee  College,  Nashville, 
was  held  at  the  Gospel  Tabernacle  on  the  7th  instant,  in  the  presence 
of  an  audience  of  more  than  three  thousand  people.  There  were  thirty- 
Bix  graduates  in  medicme,  two  in  dentistry,  and  six  in  pharmacy.  Dur- 
ing the  past  session  a  hundred  and  twenty  students  in  medicine,  seven 
in  dentistry,  and  twenty-one  in  pharmacy  were  enrolled.  About  half 
the  educated  colored  physicians  of  the  Southern  States  are  said  to  be 
graduates  of  this  institution. 


THE  VALUE  OF 
THE  CENTRIFUGAL  APPARATUS  FOR 
DIAGNOSTIC  PURPOSES. 
Bt  FREDERIC  E.  SONDERN,  M.  D„ 

ATTENDING  PHYSICIAN  TO  OUT-PATIENT  DEPARTMENT,  MOUNT  SINAI  HOSPITAL' 

Centrifugal  force,  used  for  the  special  purpose  of  ob- 
taining sediments  from  urine,  sputum,  and  pathological 
fluids  in  general,  was  first  described  by  Medical  Candidate 
Thor  Stenbeck,*  and  immediately  promised  to  be  an  im- 
portant adjunct  to  a  thorough  as  well  as  speedy  examina- 
tion of  deposits.  The  apparatus  now  in  the  shops  differs 
but  little  from  that  originally  described  in  minute  detail  by 
Stenbeck,  and  consists  briefly  of  a  small  metal  plate  from 
which  two  or  more  receptacles  are  suspended  perpendicu- 
larly for  the  purpose  of  holding  the  glass  tubes  containing 
the  fluid  to  be  examined,  and  so  hinged  that  when  the  ap- 
paratus is  in  motion  they  assume  a  horizontal  position  ;  the 
whole  is  rapidly  rotated  by  a  series  of  cog-wheels  moved  by 
an  electric  motor,  hand  or  foot  power.  By  hand  power  a 
speed  of  twelve  hundred  to  fifteen  hundred  revolutions  a 
minute  may  be  attained  ;  by  motor,  three  thousand  or  more  ; 
in  the  former,  five  to  fifteen  minutes,  in  the  latter,  two  to 
three  minutes,  will  suffice  to  obtain  the  desired  sediment  in 
most  instances. 

It  was  first  brought  to  my  attention  by  Dr.  Willy 
Meyer  f  a  year  ago,  and  since  then  I  have  had  the  oppor- 
tunity of  using  it  on  upward  of  two  hundred  different  speci- 
mens in  the  laboratory  of  Professor  A.  Jacobi  as  well  as  in 
my  own,  and  in  most  instances  comparing  the  results  with 
those  obtained  by  the  usual  method  of  sedimentation  in  a 
conical  glass,  and  my  opinions  are  based  on  the  outcome  of 
these  examinations.  As  I  have  since  read,  the  apparatus 
has  been  demonstrated  by  Dr.  Freeborn  \  and  subsequ  ntly 
by  Dr.  Gerster.* 

The  rapidity  with  which  it  enables  the  making  of  an 
accurate  examination  causes  it  to  be  of  singular  utility  to 
the  consulting  practitioner,  and  it  necessarily  yields  a  richer 
and  clearer  microscopical  picture,  as  fermentation  has  not 
had  time  *to  set  in.  These  two  factors — the  time  required, 
and  the  consequent  changes — are  the  principal  objections 
to  the  old  method  of  procedure. 

It  is  true  that  in  the  examination  of  ordinary  nephritic 
urine,  when  time  is  no  object  and  fermentative  changes  are 
slow  to  occur,  the  old  method  of  sedimentation  is,  as  a  rule, 
satisfactory,  and  in  these  specimens  the  only  advantages  in 
the  deposit  obtained  by  the  centrifuge  are  that  it  is  richer 
in  the  quantity  of  elements  sought  for,  and,  as  they  are 
fresh,  it  presents  them  in  a  clearer  and  comparatively  un- 
changed condition ;  this  is  especially  the  case  with  varieties 
of  epithelial  cells. 

In  cases  of  renal  disease,  when  at  times  only  exceedingly 
few  casts  are  to  be  found  in  the  urine,  as  in  some  of  the 
forms  of  chronic  Bright's  disease  and  occasionally  in  amy- 

*  Stenbeck.    Hygeia,  Stockholm,  1891,  40-61. 
\  Willy  Meyer.    N.  Y.  Med.  Jour.,  January  30,  1892. 
■    X  Medical  Record,  February  27,  1892. 

September  10,  1892.  ,  -  , 


Feb.  25,  1893  .J 


SONDEEN:   THE  CENTRIFUGAL  APPARATUS. 


219 


loid  degeneration  of  the  kidney,  especially  when  these  ele- 
ments are  caught  and  held  in  the  mucous  cloud  suspended 
in  the  middle  of  the  conical  glass,  this  new  method  offers 
marked  advantages.  It  has  repeatedly  been  my  experience 
that  three  minutes  have  sufficed  to  produce  a  deposit  com- 
paratively rich  in  renal  elements,  whereas  the  same  urine 
put  into  a  proper  glass  and  specimens  carefully  removed 
witli  a  pipette  at  any  time  from  one  to  forty-eight  hours 
later,  have  failed  to  show  even  one  cast.  If  in  the  latter 
case  they  failed  to  deposit,  or  underwent  disintegration 
owing  to  the  presence  of  peptone,  so  frequently  found  in 
such  specimens,  I  am  unable  to  say. 

The  rapid  method  of  sedimentation  is  of  particular 
service  in  specimens  of  urine  which,  by  virtue  of  their 
character,  almost  immediately  undergo  fermentative  changes, 
even  started  at  times  before  they  leave  the  body,  and  is 
very  frequently  conducive  to  clearing  up  the  diagnosis  of 
otherwise  obscure  genito  urinary  disorders.  In  these  speci- 
mens, on  standing,  as  by  the  old  method,  there  is  not  only 
a  coagulation  of  the  fibrin  entangling  many  of  the  elements 
sought  for,  but  also  the  development  of  bacteria,  various 
fungi,  the  precipitation  of  phosphate  or  urate  salts,  which 
tend  to  cover  these  elements,  to  say  nothing  of  the  total 
disintegration  of  some,  the  maceration  and  consequent 
change  other  more  delicate  structures  undergo,  which  would 
certainly  make  a  diagnosis  of  their  exact  nature  and  the 
possible  determination  of  their  source  difficult  and  mis- 
leading and  probably  impossible.  It  is  oftentimes  difficult 
to  form  a  clear  opinion  of  elements  which  have  been  ex- 
posed to  a  mild  alkaline  fermentation  in  the  bladder  for  a 
short  time,  and  it  is  therefore  easily  understood  how  much 
greater  is  the  difficulty  when  this  specimen  is  set  aside  in  a 
glass  certainly  for  a  number  of  hours  to  deposit  its  sedi- 
ment before  coming  under  the  microscope.  Many  thorough 
trials,  comparing  the  results  obtained  by  both  procedures, 
are  found  convincing  that  by  the  new  method,  used  at  once 
or  soon  after  the  urine  is  voided,  many  cases  of  pyelitis, 
malignant  growths,  etc.,  can  be  distinguished  by  the  char- 
acter of  the  epithelium  and  cellular  structures  in  general 
present,  which  can  not  be  done  with  any  degree  of  certainty 
after  these  elements  have  been  exposed  to  the  changes  due 
to  a  rapid  fermentation  of  the  specimen  on  standing. 

In  cases  of  hasmaturia  and  hemoglobinuria  the  appa- 
ratus is  applicable.  In  the  former  the  cells  are  thrown 
down  very  quickly,  and  when  large  quantities  are  present  the 
method  is  applied  to  the  remaining  decanted,  partly  cleared 
urine  for  a  second  time,  during  which  the  lighter  elements 
looked  for  are  deposited.  When  blood-coloring  matter 
only  is  present,  the  use  of  the  centrifuge  does  not  change 
the  color  of  the  specimen.  The  process  is,  however,  par- 
ticularly adapted  to  those  cases  in  which  there  are  only 
minute  quantities  of  blood,  and  I  have  in  a  number  of  in- 
stances succeeded  in  finding  small  numbers  of  cells  where 
the  guaiac  test  was  employed  with  a  negative  result,  and 
none  were  found  in  the  sediment  obtained  in  the  usual 
manner.  Litten*  has  made  similar  observations  on  speci- 
mens in  which  both  the  spectroscope  and  Heller's  test  were 

*  Litten.    Deutsche,  kl.  Wochenschrift,  1891,  23. 


negative.  In  cases  of  oxaluria,  Litten  *  has  used  the  appa- 
ratus to  determine  the  daily  variations  in  the  amount  of 
this  deposit  before  fermentation  and  consequent  change  of 
reaction,  solubility,  etc.,  could  set  in,  which  would  occur  on 
standing.  I  have  not  had  the  opportunity  of  employing 
the  method  for  this  purpose  and  testing  its  efficacy  by 
comparing  the  results  with  those  of  quantitative  chemical 
analysis. 

The  method  in  question  is  also  of  decided  utility  in  the 
demonstration  of  tubercle  bacilli,  especially  in  those  speci- 
mens of  sputum,  urine,  pleural  exudations,  etc.,  in  which 
there  are  but  few  to  be  found.  The  well-known  method 
for  examining  sputum  for  bacilli  is  quickly  executed,  and 
in  the  majority  of  instances  is  perfectly  satisfactory.  Speci- 
mens in  which  tedious  examinations  over  many  prepared 
slides  reveal  single  bacilli,  few  and  far  between,  are,  how- 
ever, not  rare,  and  it  was  for  these  that  Biedert  f  and  v. 
SehlenJ  recommended  their  respective  methods  of  sedi- 
mentation. The  latter,  which  in  my  opinion  is  preferable, 
is  as,  follows  :  Add  to  a  given  quantity  of  the  fluid  to  be 
examined  a  quarter  to  half  its  volume  of  the  borax-boric- 
acid  solution  (twelve- per-cent.  solution  of  borax  in  hot  dis- 
tilled water ;  on  stirring,  add  a  like  quantity  of  boric  acid ; 
filter  while  hot).  This  mixture  of  suspected  fluid  and  solu- 
tion is  well  agitated  and  then  put  aside  in  a  conical  glass 
for  four  days. 

The  advantage  of  the  centrifuge  is  that  the  same  de- 
posit  of  bacilli  from  the  described  mixture  can  be  obtained 
in  about  as  many  minutes — certainly  a  great  gain  of  time. 
In  two  cases  I  have  found  bacilli  by  this  combined  use  of 
Biedert's  method  and  the  centrifuge  which  could  not  be 
demonstrated  by  the  same  method  of  sedimentation  in  the 
conical  glass.  V.  Jaksch  *  has  described  the  same  ad- 
vantage. 

The  urine  in  cases  of  tubercular  disease  of  the  genito- 
urinary tract  oftentimes  contains  many  bacilli,  and  a  sedi- 
ment obtained  by  the  ordinary  method  usually  reveals 
their  presence ;  in  these  cases  the  sediment  by  centrifuge 
only  shows  a  quantitative  difference.  It  is,  however,  a 
well-known  fact  that  in  some  specimens  of  urine  containing 
but  few  bacilli  and  much  pus,  or  depositing  large  quantities 
of  salts  by  fermentative  change  on  standing,  as  well  as  in 
clear  specimens,  especially  those  of  high  specific  gravity, 
these  few  bacilli  are  frequently  overlooked,  and  here  again 
the  combination  of  v.  Sehlen's  method  and  the  centrifuge  is 
of  singular  value,  and  will  plainly  reveal  thera  if  present, 
which  is  certainly  not  always  the  case  when  centrifugal 
force  is  not  employed.  In  pleuritic  exudations  the  rapid 
sedimentation  is  of  decided  service  in  searching  for  tubercle 
bacilli  or  pneumococci ;  the  advantages  it  has  here  offered 
are  quantitative  difference,  rapidity,  and  lack  of  disturbing 
elements,  such  as  micro-organisms  developed  during  stand- 
ing. Litten  ||  has  examined  specimens  of  this  kind  so  rich 
in  fibrin  that  coagulation  of  the  entire  fluid  occurred  in  a 

*  Litten.    IjOc.  fit. 

t  Hicdei  t.    Bed.  kl.  Wochcmchrlft,  1880,  42,  43. 

X  V.  Schlen.     Clrlbl.  f.  Bad.  u.  Paraxitcnhuiide,  1888,  22,  23. 

*  V.  Jaksch.    Prager.  med.  Wochcnisch.,  1891,  18. 
I  Litten.    Loc.  cit. 


220 


WAGNER:   PAPILLOMATOUS  GROWTHS  OF  PALATE. 


[N.  Y.  Med.  Jo0b,, 


very  short  time,  and  when  a  sediment  could  not  be  obtained 
unless  the  rapid  method  was  employed. 

In  numerous  specimens  of  cystic  fluids  of  different 
kinds,  when  small  quantities  only  were  aspirated  for  exami- 
nation, the  centrifuge  has  yielded  sediments  far  richer  in 
the  elements  looked  for  than  could  otherwise  be  obtained, 
and  has  repeatedly  justified  my  conclusions,  which  would 
have  been  doubtful  at  best,  and  frequently  impossible,  had 
the  old  method  only  been  used. 

Unprejudiced  comparative  tests  with  the  apparatus  in 
question  yield  results  fully  sustained  by  those  of  Litten,* 
V.  Fritsch,f  and  v.  Jaksch,J  and  it  is  difficult  to  understand 
why  Albu  *  should  maintain  that  diagnosis  is  not  facilitated 
by  the  process.  Perhaps  longer  continued  investigations 
with  specimens  to  which  the  method  is,  particularly  appli- 
cable will  alter  his  opinion. 

128  West  Thirty- fodrtii  Street. 


PAPTLLOMATOUS  GROWTHS 
OF  THE  PALATAL  ARCHES  AND  UVULA. 
By  CLINTON  WAGNER,  M.  D., 

BBNIOK  B0BGEON  TO  THE  METROPOLITAN  THROAT  HOSPITAL,  NEW  YORK. 

Papillomatous  growths  of  the  palatal  arches  and  uvula 
are  not  infrequently  overlooked  in  a  careless  or  too  cursory 
examination  of  the  fauces.  The  patient  will  complain  of 
symptoms  which  are  present  in  ordinary  catarrhal  inflam- 
mation of  the  pharynx  and  larynx — viz.,  a  frequent  desire 
to  clear  the  throat,  at  times  a  tickling  sensation,  which  is 
followed  by  a  short,  hacking  cough,  rendering  a  prolonged 
or  continuous  use  of  the  voice  difficult,  and  in  some  cases 
impossible.  An  examination  with  the  laryngoscope  will  re- 
veal nothing  to  account  for  the  symptoms ;  the  cords  will 
appear  healthy  and  perfectly  normal  in  their  action,  and  the 
pharynx  also  healthy,  excepting,  perhaps,  a  slight  hyper- 
semia. 

A  further  examination,  if  the  symptoms  are  caused  by 
the  presence  of  a  growth,  will  disclose  a  small  wart-like 
body  at  the  junction  of  one  of  the  pillars,  usually  the  pos- 
terior, with  the  soft  palate.  At  first  glance  it  may  be  mis- 
taken for  thickening  of  the  mucous  membrane,  or  an  en- 
larged follicle,  but,  upon  touching  it  with  the  probe,  it  may 
be  dislodged,  and  will  be  seen  to  be  attached  by  a  pedicle 
varying  from  a  quarter  of  an  inch  to  an  inch  in  length. 

They  are  sometimes  attached  to  or  a  little  above  the  ex- 
treme point  of  the  uvula,  to  which  they  cling  very  closely, 
but,  when  moved  by  the  probe,  the  pedicle  will  be  seen. 

In  one  case,  that  of  a  well-known  actress  of  this  city,  I  could 
discover  nothing  at  first  glance  to  account  for  the  constant  feel- 
ing of  irritation  she  experienced  in  her  throat,  especially  while 
performing  her  part  on  the  stage.  With  the  rliinoscope  I  de- 
tected a  slight  prominence  on  the  posterior  surface  of  the  uvula. 
Suspecting  a  growth  of  the  character  under  consideration,  I 
moved  it  with  the  probe  and  dislodged  it;  the  pedicle  was  about 
a  third  of  an  inch  in  length. 

*  Litten.    Loc.  cit. 

f  V.  Fritsch.  Loc,  cit. 
J  V.  Jaksch.    Loc.  cit. 

*  Albu.    Berliner  kl.  Woclienschrift,  May  30,  1892. 


Another  case,  eomewhat  similar,  wa'  that  of  a  gentleman 
from  a  Soutlu-rn  State,  a  presiding  judge.  He  stated  that  it  was 
almost  impossible  for  him  to  deliver  a  charge  from  the  bench 
in  consequence  of  a  short,  hacking  cough,  which  was  greatly  « 
aggravated  and  became  almost  continuous  upon  the  attempt  to 
maintain  a  prolonged  use  of  his  voice.  Upon  examination,  I  dis- 
covered a  growth  about  tlie  size  of  a  grain  of  wlicat  clinging  to 
tlio  extreme  tip  of  the  uvula;  upf  n  moving  it  with  my  probe,  I 
found  it  was  attached  by  a  pedicle  quite  three  fourths  of  an  inch 
in  lengtli.  Aa  the  uvula  itself  was  abnormally  long,  the  growth 
actually  touched  the  ejnglottis  when  that  oivan  was  thrown  up- 
ward and  forward  during  phonation.  With  the  removal  of  the 
growth  all  tlie  unpleasant  symptoms  disappeared. 

Failure  to  recognize  the  growth  is  chiefly  owing  to  the 
fact  that  when  the  mouth  is  wide  open,  as  during  the  ex- 
amination for  diagnosis,  retraction  of  the  soft  palate,  uvula, 
and  arches  takes  place,  by  which  the  growth  is  made  to  ad- 
here closely  to  the  surface  from  which  its  pedicle  springs. 
The  only  way  to  avoid  overlooking  such  growths  is  to  at- 
tempt to  move  or  dislodge  with  the  probe  any  unusual  promi- 
nence that  may  be  seen  at  the  places  mentioned. 

Of  the  cases  that  have  occurred  in  my  private  and  hos- 
pital practice,  I  have  had  no  doubt  as  to  the  character  of  the 
growths,  except  in  the  last,  who  consulted  me  a  few  weeks 
ago.  The  patient,  aged  forty-seven,  stated  that  several  years 
ago  he  had  had  a  severe  attack  of  diphtheria,  shortly  after 
which  he  first  felt  the  annoyance  in  his  throat.  Upon  the 
posterior  arch  was  a  growth,  the  largest  of  the  kind  I  have 
ever  seen  ;  the  anterior  surface  or  part  which  presented  to- 
ward the  orifice  of  the  mouth  seemed  hard,  firm,  and  smooth, 
resembling  a  fibroma  rather  than  a  papilloma.  The  pedicle 
in  this  case  was  unusually  broad,  thick,  and  vascular.  Dr. 
C.  Heitzmann,  to  whom  the  tumor  was  referred  for  exami- 
nation under  the  microscope,  reported  it  to  be  a  "  papilloma 
of  an  entirely  benign  type.  The  large  number  of  medullary 
or  inflammatory  corpuscles  at  the  surface  indicates  that  the 
tumor  has  grown  more  rapidly  of  late." 

The  patients  will  generally  report  that  they  have  taken 
cough  mixtures,  inhalations,  gargles,  troches,  sprays,  etc., 
without  relief.  The  operation  for  the  removal  of  the  growth 
is  very  simple,  and  the  aid  of  the  specialist  is  not  required. 
The  tongue  should  be  depressed  upon  the  floor  of  the  mouth, 
the  patient  holding  the  spatula,  the  growth  seized  with  a 
long  forceps  and  gently  drawn  downward  and  forward, 
and  the  pedicle  divided  with  the  scissors  as  closely  as  pos- 
sible to  the  surface  from  which  it  grows.  As  very  little, 
if  any,  hasmorrhage  follows  the  division  of  the  pedicle,  the 
scissors  are  to  be  preferred  either  to  the  cold  wire  snare  or 
galvano-cautery  loop.  The  snare  may  fail  to  remove  the 
entire  pedicle  and  thus  furnish  a  nucleus  for  a  recurrence  of 
the  growth,  and  the  cautery  may,  in  the  event  of  gagging 
or  retching  on  the  part  of  the  patient,  inflict  a  burn  upon 
the  surrounding  tissues  which  will  annoy  the  patient  for 
several  days. 

65  West  Thirty-eighth  Street. 


The  Philadelphia  Neurological  Society. — At  the  next  meeting,  to 
be  held  at  the  Hall  of  the  College  of  Physicians  on  Monday  evening, 
the  2'7th  inst..  Dr.  Charles  L.  Dana,  of  New  York,  will  read,  by  invita- 
tion, a  paper  entitled  Some  Studies  of  the  Nature  and  Symptoms  of 
Shaking  Palsy,  with  the  Report  of  an  Autopsy. 


Feb.  25,  18'J3.J 


WILSON:  TELEPHONIC 


MASS  AO  E  OF  THE  EAR. 


221 


VIBRATORY  MASSAGE  OF  THE  MIDDLE  EAR 
BY  MEANS  OF  THE  TELEPHONE. 
By  HAROLD  WILSON,  M.  D., 

DETROIT,  MlCn. 

Considerable  interest  has  been  excited  during  the  past 
six  or  eight  months  in  what  may  be  called  the  "  vibratory 
treatment  "  of  affections  of  the  middle  ear.  The  ordinary 
methods  of  treating  these  affections,  such  as  the  use  of  the 
Politzer  bag  or  Siegel  speculum,  involve  tiie  forcible  move- 
ment of  the  tympanic  membrane  and  the  small  bones  of  the 
ear  by  mechanical  means.  The  novelty  of  the  new  treat- 
ment consists  in  the  means  by  which  these  vibrations  are 
produced.  The  "  otophone  "  of  Maloney,  making  use,  I  be- 
lieve, of  the  direct  vibrations  of  the  human  voice,  and  the 
phonograph,  as  employed  by  Garey,  utilizing  indirect  voice 
vibrations  and  those  of  mechanical  origin,  are  two  new 
methods  of  obtaining  rapid  vibrations.  Both  of  these 
methods  are  reported  to  have  given  rather  remarkable  re- 
sults in  the  treatment  of  some  forms  of  middle- ear  catarrh, 
relieving  the  tinnitus  and  improving  the  hearing  where  other 
and  recognized  methods  of  treatment  had  failed  to  give  the 
patients  any  particular  help.  The  claims  of  this  new  method 
are  of  so  startling  a  nature  that  it  seems  to  be  worth  a  care- 
ful investigation,  although  its  promoters  have  been  guilty 
of  announcing  their  results  in  a  rather  sensational  fashion. 
The  "  otophone  "  is  a  patented  device,  and  the  phonograph 
is  somewhat  expensive,  and,  although  of  course  also  pat- 
ented, its  use  in  this  connection  is  free  to  the  entire  profes- 
sion. The  object  of  this  communication  is  to  call  attention 
to  a  third  method  by  which  these  rapid  vibrations  may  be 
secured  and  which  may  possibly  be  found  to  be  of  as  much 
therapeutic  value  as  those  mentioned  above. 

The  usefulness  of  this  new  method  of  treatment  de- 
pends, it  is  contended,  upon  the  "  massage  "  given  to  the 
movable  parts  of  the  middle  ear,  by  which  the  mobility  of 
the  small  bones  is  increased  and  the  nutrition  of  the  soft 
parts  so  improved  that  their  normal  functions  become  more 
or  less  restored.  Acting  upon  this  assumption,  the  writer 
has  made  a  few  experiments  with  the  hand  telephone  of 
Bell,  the  diaphragm  of  which  can  be  set  into  powerful  vi- 
bration by  the  interrupted  current  from  an  ordinary  fara- 
daic  coil.  This  instrument  was  connected  with  the  switch- 
board of  an  office  battery  from  which  an  interrupted  current 
of  greatly  varying  interruption  rate  and  intensity  could 
easily  be  obtained  by  adjustments  of  the  interrupter,  and 
variations  in  the  number  of  cells  connected  with  the  induc- 
tion coil.  In  this  way  a  considerable  variety  of  sounds 
could  be  set  up  in  the  telephone,  from  slow  beats  to  a  noise 
that  would  ordinarily  be  considered  deafening.  The  pitch 
of  the  notes  could  be  further  altered  by  using  the  rheostat. 

Now,  if  the  benefits  derived  from  the  use  of  the  phono- 
graph, according  to  Garey,  are  due  to  the  massage  effects 
of  the  vibrations  set  up,  it  seems  probable  that  from  the 
telephone  used  in  the  same  fashion  similarly  beneficia;!  re- 
sults ought  to  follow.  With  this  idea  in  view,  the  writer 
has  used  the  telephone  apparatus  in  the  following  cases, 
with  the  results  stated.  The  modus  operandi  of  its  employ- 
ment was  to  connect  the  hand  telej)hone  with  the  faradaic 


coil  and  have  the  patient  hold  it  close  against  the  ear,  start- 
ing the  current  either  before  or  after  the  instrument  was  in 
position.  Vibrations  of  the  greatest  intensity  were  used  in 
those  cases  where  there  was  the  greatest  impairment  of 
hearing,  and  the  individual  treatments  were  from  five  to 
fifteen  minutes  in  duration. 

Case  I. — F.  G.  E.,  aged  twenty-seven  years.  History  of 
measles  when  ten  years  old,  followed  by  some  deafness.  Had 
enlarged  tonsils,  wliich  were  operated  upon.  Pronounced  deaf- 
ness in  the  riglit  ear  for  a  long  time,  also  some  tinnitus  in  the 
left,  noticeable  only  when  attention  was  directed  to  it,  and  in  a 
quiet  place.  Membrana  tympani  of  right  ear  thickened,  some- 
what retracted,  and  lacking  in  mobility  ;  that  of  the  left  ear  not 
much  changed  from  tlie  normal.  H.  w.  r.  =  0,  1.  =  6  to  8  feet. 
Patient  had  been  under  my  care  for  six  montbs,  having  reported 
to  me  six  or  seven  times  during  that  period,  and  having  used 
the  Politzer  bag  daily  and  taken  various  internal  remedies  in 
the  mean  time.  Tliere  had  been  a  slight  iinprovetnent  in  the 
tinnitus;  the  hearing  remained  practically  the  saine.  On  August 
19th  I  began  tbe  use  of  the  telephone  and  continued  it  every 
other  day  for  about  three  weeks,  at  the  end  of  which  time  no 
perceptible  change  had  taken  place  either  in  the  hearing  or  the 
tinnitus.    Patient  has  not  reported  since. 

Case  II. — Mrs.  R.,  aged  thirty-two  years.  History  of  catar- 
rhal deafness  of  several  years'  standing.  Membrana  tympani, 
left  ear,  whitish;  handle  of  malleus  retracted;  apex  of  light 
spot  only  visible;  II.  w.  =  1.  p.  Right  ear  similar  to  left;  light 
spot  not  so  small;  H.  w.  =  1  inch.  Naso-pharyngeal  catarrh. 
Tinnitus  very  prominent  and  annoying,  particularly  in  the  left 
ear.  Telephone  used  about  three  times  a  week  for  thi'ee  weeks. 
After  tiie  second  treatment  the  patient  dechired  that  tlie  tinnitus 
in  the  left  ear  was  not  so  great,  and  that  it  was  less  here  than 
on  the  right  side.  After  this  no  further  change  was  noted.  At 
the  end  of  the  period  mentioned  the  hearing  was  unaltered  and 
the  use  of  the  telephone  was  discontinued. 

Case  III. — Miss  M.  K.,  aged  fifty-six  years,  September  21st. 
Deafness  for  eight  or  nine  years.  Tinnitus  like  escaping  steam 
during  the  last  few  weeks;  previously  had  noises  like  explosions, 
but  this  condition  was  intermittent.  Both  ears  similaily  affected. 
Some  naso-pharyngeal  catarrh.  H.  w.  =  0,  both  ears ;  voice- 
hearing  reduced  to  ordinary  tones  at  about  two  feet.  Both  ears 
showed  a  small  amount  of  impacted  cerumen,  which  was  re- 
moved by  syringing.  Membrana  tympani  thickened  and  re- 
tracted. Telephone  u<ed  for  tive  minutes.  The  fo'lowing  day 
the  patient  reported  that  the  tinnitus  in  the  left  ear  had  ceased, 
and  that  in  the  right  ear  was  less.  Patient  did  not  report  again 
until  October  3d,  at  which  time  the  ears  had  undergone  no 
further  change.  The  telephone  was  used  for  ten  minutes.  On 
October  8th  tlie  patient  reported  that  following  the  last  treat- 
ment there  was  an  increase  of  the  noise  in  the  right  ear  and  a 
reappearance  of  that  in  the  left  for  a  few  hours,  after  which  the 
noise  subsided  in  both  ears  and  had  not  troubled  her  very  much 
since.  Several  additional  treatments  were  had  at  intervals  of 
three  or  four  days  apart,  with  the  final  result  that  the  tinnitus 
in  the  left  ear  was  practically  relieved  and  that  in  the  right 
considerably  improved.    The  hearing  was  not  improved. 

Cask  IV. — Mrs.  J.  L.,  aged  sixty  one  years,  consulted  me 
NovembLM-  19,  1890,  with  a  history  of  tinnitus  in  the  left  car 
during  the  ])rovious  two  years,  dating  from  a  mild  attack  of 
middle-ear  su[)puration.  The  tinnitus  was  constant,  not  noticed 
when  the  patient  was  busy,  but  quite  distressing  when  she 
was  quiet.  Membrana  tympani  hardly  changed  from  the  normal 
in  appearance.  Various  internal  remedies  and  the  Politzer  in- 
flations wore  employed  more  or  less  often  during  the  ensuing 


222 


LEADING  ARTICLES. 


[N.  Y.  Med.  JonB., 


two  years.  The  patient  reported  to  me  October  1st  of  this 
year.  The  tinnitus  was  still  present.  She  had  been  suffering 
from  a  cro|)  of  small  furuncles  affecting  both  ears  for  several 
weeks.  J  ])rescribed  ])icrate  of  calcium  for  tlie  furuncles,  and 
put  her  upon  the  telephone  vibrations.  After  four  or  five  treat- 
ments the  tinnitus  seemed  to  be  materially  improved,  except  for 
a  temporary  aggravation  after  each  treatment.  The  patient 
wished  to  see  how  much  permanent  effect  would  follow  from 
the  treatment  already  given,  and  has  discontinued  iier  visits,  to 
repoi  t  again  in  a  few  weeks. 

Case  V. — Miss  N.  L.,  aged  thirty-one  years,  consulted  me 
August  1st  for  deafness.  For  a  number  of  years  there  had  been 
a  gradual  loss  of  hearing  in  both  ears  witliout  pain  or  tinnitus. 
There  was  hypertrophic  catarrh  of  the  naso-iiharynx.  The 
membranfB  tympani  were  much  thickened  and  retracted;  mov- 
able on  Valsalva  inflation.  H.  w.  =  J  in. ;  L.  =  14  to  16  in.  Fop 
a  month  tlie  patient  was  under  almost  daily  treatment,  appro- 
priate local  measures  being  directed  to  the  relief  of  the  nasaj 
catarrh,  and  the  telephone  used  sometimes  in  one,  sometimes  in 
both  ears.  Owing  to  the  death  of  her  brother,  she  discontinued 
her  visits  September  1st.  At  that  time  the  condition  of  the 
mucous  membrane  of  the  nose  was  materially  better,  but  there 
bad  been  no  improvement  in  the  Ijearing. 

Reviewing  the  results  obtained  in  these  cases,  it  is  to  be 
noted  that  in  all  except  the  last  no  other  treatment  was  car- 
ried on  at  the  time  the  telephone  was  being  tried  except  the 
removal  of  the  cerumen  in  Case  III  and  the  use  of  picrate  of 
calcium  in  Case  IV.  The  cases  are  too  few  and  the  results 
too  ambiguous  to  enable  us  to  arrive  at  any  definite  opinion 
as  to  the  merits  of  this  form  of  treatment.  Three  patients 
seemed  to  improve  in  regard  to  the  tinnitus,  but  in  none  was 
there  any  benefit  shown  to  the  hearing.  In  one  of  the  cases 
reported  by  Dr.  Garey  improvement  did  not  show  itself  until 
three  months  had  elapsed  after  the  treatment  was  begun. 
It  is  quite  possible  that  in  none  of  the  above  cases  was  it 
continued  long  enough  to  secure  positive  benefit.  They 
are  reported  as  merely  suggestive.  If  vibratory  massage  of 
the  middle  ear  comes  to  be  recognized  as  a  really  valuable 
method  of  treatment,  I  am  convinced  that  the  telephone 
will  be  found  a  convenient  means  of  applying  it.  Whether 
it  will  be  found  competent  to  supply  the  place  of  the  phono- 
graph in  every  respect  for  this  purpose,  clinical  experience 
alone  will  determine. 

One  element  of  possible  value  in  the  use  of  the  phono- 
graph is  the  diversity  of  the  sounds  that  can  be  produced 
with  it.  The  importance  which  this  fact  may  assume  is  in 
the  development  of  the  attentive  faculty  which  it  may  af- 
ford. The  fact  that  hearing  may  be  lost  through  inatten- 
tion is  well  known,  and  it  would  not  be  surprising  that  any 
form  of  treatment  which  cultivated  the  power  of  attention 
might  relieve  some  cases  of  deafness.  At  the  present  time, 
therefore,  it  is  a  matter  of  some  doubt  how  far  the  new 
treatment  is  mechanical  in  its  action  and  how  far  it  is 
psychical. 

96  Miami  Avenue,  October  27,  1892. 


The  Third  Annual  Dinner  of  the  Society  of  the  Alnmni  of  Charity 
Hospital  will  be  held  at  Clark's,  22  West  Tweiity-tliird  Street,  on  Wednes- 
day evening,  March  1st,  at  V  o'clock.  Tickets  may  be  obtained  from 
the  president,  Dr.  Walter  L.  Can,  G  East  Fifty-eighth  Street,  or  the 
Secretary,  Dr.  Alexander  Lyle,  112  East  Eighty-first  Street. 


THB 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

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


NEW  YORK,  SATURDAY,  FEBRUARY  25,  1893. 


THE  MICROCOCCUS  LANCEOLATUS. 

In  the  Bulletin  of  the  Johns  HopMns  Hospital  Dr.  William 
n.  Welch  has  given  a  revision  of  his  earlier  addresses  and 
papers  on  the  bacteriology  of  pneumonia  that  presents  the 
latest  summary  of  our  present  knowledge  of  the  so-called 
pneumococcus.  It  is  manifest,  from  what  Dr.  Welch  has  to  say 
on  the  nomenclature  of  the  coccus,  that  that  organism  has  been 
abundantly  baptized.  Fourteen  or  more  names  have  been  tried 
on  it,  and  of  these  the  most  fitting,  says  Dr.  Welch,  is  Micro- 
coccus  lanceolatus,  designed  by  Foa  and  Bordoni-Cffreduzzi. 
This  name,  with  or  without  the  additional  descriptive  epithet 
ca])sulatu8,  has  at  present  a  wide  currency  among  the  special 
workers  in  that  field.  In  general  scientific  circles  the  names 
Diplococcus  pnenmonicB  and  Pneumococcus  arc  the  best  known. 
The  cliief  objection  to  these  latter  words  and  their  variationg 
is  tliat  they  suggest  that  an  exclusive  relationsliip  exists  be- 
tween the  coccus  and  acute  croupous  pneumonia,  whereas  this 
same  organism  is  an  undoubted  causative  element  in  epidemic 
cerebro- spinal  meningitis  and  many  other  affections  independent 
of  pneumonia.  It  is  quite  probable  that  the  Micrococcus  pyo- 
genes tenuis  of  Rosenbach  is  identical  with  the  lanceolate  form, 
as  was  first  pointed  out  by  Neumann.  Dr.  Welch  is  inclined  to 
the  opinion  that  this  organism  is  more  properly  designated  as 
a  bacillus  than  as  a  coccus,  but  present  usage  is  so  overwhelm- 
ingly in  favor  of  calling  it  a  coccus  that  he  has  found  it  prefera- 
ble to  go  with  the  majority.  It  would  appear  from  what  he 
says  that  he  had  seriously  considered  the  propriety  of  bringing 
in  a  name  of  his  own  coinage,  but  had  desisted,  for  he  says 
"certainly  one  ought  to  hesitate  before  adding  a  new  name  to 
the  already  long  and  confusing  list  of  synonyms  applicable  to 
this  organism." 

This  last  .contribution  of  Dr.  Welch's  is  a  mine  of  informa- 
tion, partly  derived  from  a  painstaking  study  of  the  work  of 
his  fellow-experts  in  bacteriology  and  partly  from  original  re- 
search :  it  is  the  most  complete  resume  of  the  subject  in  the 
language. 


BILATERAL  PARALYSIS  FOLLOWING  PNEUMONIA. 

Professoe  von  Krafft-Ebing  has  presented  before  tlie 
Vienna  Medical  Society  a  case  of  rare  paralysis  of  the  upper 
extremities  consequent  on  the  action  of  the  toxines  of  pneumo- 
nia. As  reported  in  the  Semaine  medicale,  the  patient,  a  man 
of  thirty-eight,  was  taken  with  a  loss  of  sensibility  of  the  arms 
as  far  down  as  the  elbows,  following  an  attack  of  pneumonia 
in  July  last;  the  skin  was  liyperiBsthetic  from  the  elbow  to  the 


I  Feb.  'i5,  1893.] 


MINOR  PARAGRAPHS. 


223 


finger-tips.  At  tlie  end  of  twelve  tla_vs  sensibility  retiirnetl,  but 
paralysis  persisted,  and  to  it  were  added  dyspncca,  dvspliagia, 
auditory  disturbances,  and  some  pain  in  the  muscles  of  the 
neck,  back,  and  lower  extremities.  Of  these  symptoms  dys- 
phafcia  continued  the  longest,  the  others  disappearing  in  tlie 
course  of  two  weeks.  The  dysphagia  gradually  subsided, 
however,  along  with  the  paralysis,  and  there  remained  only 
marked  atrophy  of  the  muscles  of  the  shoulders,  arms,  and 
hands.  This  was  more  evident  on  the  left  than  on  the  right 
side.    The  reflexes  were  impaired. 

In  considering  the  fetiology  of  these  conditions.  Dr.  von 
KrafFt-Ebing  expressed  the  opinion  that  tbey  could  not  be  re- 
ferred to  a  cerebral  lesion.  Further,  they  could  not  well  be 
traced  to  a  poliomyelitis  anterior  acuta,  because  of  the  anicsthe- 
sia  for  twelve  days,  of  the  comparatively  mild  course  of  the  af- 
fection, and  of  the  absence  of  trophic  change.  lie  believed  that 
it  was  a  case  of  toxic  po?t-pneumonic  polyneuritis,  due  to  the 
action  of  the  toxines  of  pneumonia  on  the  brachial  nerves.  lie 
pointed  out  that  there  had  been  present  in  this  case  the  Sbrillar 
twitcliings  usually  believed  to  pertain  to  an  affection  of  the 
trophic  centers;  this  fact,  therefore,  may  be  held  to  show  that 
thefe  twitchings  may  also  be  produced  when  the  peripheral 
nerves  are  affected. 


MINOR  PARAGRAPHS. 

A  JOURNAL  FOR  MEDICAL  WOMEN. 

We  have  received  the  first  number  of  the  Womaii's  Medical 
Jownal,  a  monthly  of  fourteen  pages  of  reading  matter,  "  de- 
voted to  the  interests  of  women  physicians."  E.  M.  Roys- 
Gavitt,  M.  D.,  is  the  editor-in-chief,  Claudia  Q.  Murphy  the 
managing  editor,  and  Margaret  L.  Ilackedorn  the  business  man- 
ager. The  salutatory  editorial  opens  as  follows  :  "  There  is  an 
early  Christian  legend  that  says  that  when  one  of  the  saints  ap- 
plied for  a  home  in  a  monastery  the  prior  refused  him  entrance, 
on  the  plea  that  the  monastery  was  already  filled  and  there  was 
no  room  for  another  novice.  Undeterred  by  this  announcement, 
the  pilgrim  toi>k  a  glass  of  water  which  was  well  filled  and  in 
reply  placed  a  rose  leaf  in  it  without  spilling  a  drop.  It  is  need- 
less to  say  he  was  admitted.  This  story  is  not  without  it6  moral. 
They  may  say,  and  say  truly,  that  the  field  of  medical  journal- 
ism is  well  filled,  and  that  there  is  no  room  for  another  journal. 
We  beg  to  present  ourselves,  even  as  the  pilgrim  to  the  monas- 
tery, with  a  rose  leaf  in  our  hands."  We  have  heard  this  story 
told  somewhat  differently — a  candidate  for  admission  into  the 
French  Academy  was  sl^own  a  cup  of  tea  full  to  the  brim,  but 
not  a  word  was  spoken  ;  taking  the  act  to  im[)ly  that  there  was 
no  more  possibility  of  the  number  of  the  immortals  being  in- 
creased than  there  was  of  his  adding  more  tea  to  the  cup  with- 
out making  it  run  over,  the  candidate  laid  a  tea  leaf  on  the  liquid 
and  gained  his  point.  Whichever  may  be  the  original  version, 
if  eitberof  them  is,  and  whether  the  ladies  having  this  new  jour- 
nal to  conduct  come  before  the  profession  with  tta  leaves  or 
with  rose  leaves  in  their  l)ands,  we  welcome  them  to  the  edi- 
torial ranks.    Tlie  journal  is  published  in  Toledo,  Ohio. 


MRS.  MAYBRICK'S  CASE. 

The  action  of  the  British  Home  Secretary  in  declining  to 
sanction  a  visit  from  Sir  Spencer  Weils  to  Mr!*.  May  brick  seems 
as  unwise  and  ungenerous  as  ever,  if  nothing  better  can  be  said 


of  it  than  the  following  bald  statement  on  information,  pub- 
lished in  the  British  Medical  Journal  for  February  11th :  "  Mrs. 
Maybrick  was  ill  in  the  prison  at  Woking;  she  had  both  pul- 
monary and  internal  htemorrhage.  It  was  stated  by  the  officials 
that  l.er  illness  was  feigned,  that  she  had  pricked  her  gums  and 
cheeks  with  needles,  and  that  she  liad  wounded  herself  with  a 
tin  knife.  Her  mother,  the  Baroness  de  Rocques,  desired  that 
an  independent  surgical  opinion  should  be  obtained  on  the  truth 
or  mi-taken  nature  of  this  charge.  She  was  especially  desirous 
tb.at  Sir  Spencer  Wells's  opinion  should  be  obtained  because  he 
had  successfully  operated  about  twenty  years  ago  upon  her  own 
mother,  grandmother  of  Mrs.  Maybrick;  and  Sir  Spencer  Wells, 
while  declining  any  opinion  as  to  the  guilt  or  innocence  of  the 
prisoner,  expressed  willingness  to  see  her  and  report  upon  the 
evidence  as  to  her  state  of  health  and  the  question  whether  her 
illness  was  real  or  imaginary,  and  the  symptoms  feigned  or  ex- 
aggerated. TJ[)on  this  understanding  the  Baroness  made  the 
formal  application  to  the  Home  Secretary  which  led  to  Mr. 
Lushington's  reply. 


WOUNDS  MADE  WITHOUT  INJURY  TO  OVERLYING 
CLOTHING. 

In  the  Lancet  for  January  21st  Mr.  Hulke  reported  the  case 
of  a  man  with  a  lacerated  wound  resembling  a  stab,  that  had 
been  inflicted  without  injury  to  the  clothing  that  covered  the 
part.  In  the  same  journal  for  February  4th  Mr.  Sidney  Spokes 
tells  of  his  having  been  called  about  ten  years  ago  to  see  a  man 
who  had  an  incised  wound  of  the  scrotum  through  which  the 
right  testicle  was  protruding,  the  wrinkled  skin  and  contracted 
dartos  closely  surrounding  the  spermatic  cord.  The  man's  story 
was  that,  having  on  a  pair  of  corduroy  trousers,  in  one  of  the 
pockets  of  which  there  was  a  purse  with  a  metal  border  and 
clasp,  he  had  fallen  and  been  trodden  on  by  a  cart-horse  in  such 
a  manner  as  to  force  the  metallic  part  of  the  purse  against  his 
genitals.  On  examining  the  man's  trousers,  Mr.  Spokes  found 
that  not  even  the  pocket  was  injured,  and  consequently  he 
doubted  the  story,  but  it  was  substantiated  to  his  satisfaction. 
Well  attested  instances  of  this  sort  are  of  important  medico-legal 
significance. 


THE  AMERICAN  MEDICAL  ASSOCIATION  AND  THE  MEDICAL 
SOCIETY  OF  THE  STATE  OF  NEW  YORK. 

The  Journal  of  the  American  Medical  Association  reprints 
a  recent  paragraph  of  ours  on  matters  connected  with  the  Medi- 
cal Society  of  the  State  of  New  York's  repeal  of  its  code  of 
ethics,  and  adds:  "  In  this  action  of  the  New  York  State  medi- 
cal society  there  seems  to  be  a  rolling  back  and  away  of  the 
clouds  and  mists  that  have  obscured  the  relations  of  that  or- 
ganization with  the  American  Medical  Association.  We  look 
hopefully  to  the  committee  appointed  by  the  American  Medical 
Association  at  its  last  meeting  to  report  for  the  approval  of  and 
adoption  by  that  organization  a  code  of  ethics,  constitution  and 
by-laws  that  will  be  acceptable  and  provide  an  organic  law  that 
n  ill  make  possible  a  unification  and  membership  in  one  body  of 
every  practitioner  of  rational  medicine  in  this  country." 


THE  GOVERNMENT  OF  VENEZUELA  AND  THE  PAN- 
AMERICAN  MEDICAL  CONGRESS. 

SeSor  p.  EzEQniEi,  Ro.TAS,  the  Venezuelan  Minister  of  For- 
eign xVffairs,  has  forwarded  on  behalf  of  his  Government,  through 
the  United  States  Charge  d' Affaires  at  Caracas,  a  formal  accept- 
ance of  the  invitation  issued  pursuant  to  the  joint  resohition  of 
the  United  States  Congress  to  the  various  governments  of  the 
Western  Ilemisphoro  to  send  official  delegates  to  the  Pan-Amer- 


MINOR  PARAGRAPHS.— ITEMS.— . 

 *  


■PROCEEDINGS  OF  SOCIETIES.        [N.  Y.  Mkd.  Joto., 


ican  MeJical  Con<!;ress.  The  selection  of  df]<'gateB  has  ridt  yet 
been  made,  but  we  learn  that  the  names  will  be  forwarded  at 
the  earliest  possible  moment. 


BANDAGING  THE  EXTREMITIES  IN  COLLAPSE. 

Mant  regard  the  procedure  of  bandaging  the  extremities  in 
collapse  as  a  modern  pro(!ednre.  But  Alexander  of  Tralles  ad- 
vised ligatures  to  the  arms  and  hands  for  the  relief  of  purging, 
and  Garcia  il'Oi  ta,  in  his  work  on  tiie  simple  dings  of  India 
(printed  in  1503),  states  that  the  Hindoo  treatment  for  the 
cramps  and  purging  of  cholera  was  to  ])ut  a  tight  baud  around 
the  head  and  to  bandage  the  legs  very  tightly. 


ITEMS,  ETC. 

Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Ilealth  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  February  21,  1893 : 


DISEASES. 

Week  ending  Feb.  14. 

Week  ending  Feb.  21. 

Cases. 

Deaths. 

Casee. 

Deaths. 

26 

16 

25 

5 

6 

3 

11 

5 

1G8 

16 

203 

20 

Cercbro-spinal  meningitis. . . . 

0 

0 

2 

2 

07 

2 

100 

12 

lOG 

35 

129 

34 

0 

0 

1 

3 

The  Lebanon  Hospital  was  dedicated  on  Wednesday  afternoon,  the 
22d  inst.  The  Lebanon  Hospital  Association  of  the  City  of  New  York 
was  incorporated  July  17,  1890.  After  considering  the  question  of  the 
location  of  the  hospital  very  carefully,  the  association  bought  the  Ursu- 
line  Convent  building  and  property,  and  also  two  adjoining  corner  lots 
on  Westchester  Avenue,  corner  of  150th  Street.  This  purchase  com- 
prises a  block  of  forty  city  lots,  a  five-story  brick  structure  about  two 
hundred  feet  square,  and  several  smaller  buildings,  and  is  located  in 
the  center  of  a  largo  district  that  until  now  has  been  entirely  destitute 
of  any  hospital  service.  The  building  has  been  equipped  for  the  care 
of  a  small  number  of  patients,  and  on  February  23d  was  to  be  open  to 
receive  and  care  for  the  sick  poor. 

St.  Luke's  Free  Hospital,  Chicago. — An  orthopaedic  service  has  been 
established  in  the  hospital,  and  Dr.  John  Ridlon  has  been  appointed 
attending  orthopasdic  surgeon. 

The  Death  of  Dr.  J.  Frederick  Moors,  of  Brooklyn,  occurred  on  the 
19th  inst.  He  was  a  genial  and  exceptionally  popular  member  of  the 
profession,  and  had  made  a  record  as  a  civil  service  commissioner  and 
sanitary  official  for  many  years  at  various  limes.  He  first  went  into  the 
health  service  of  the  city  as  far  back  as  1873.  He  was  a  sanitary  in- 
spector at  the  time  of  his  last  illness.  Dr.  Moore  was  a  graduate  of 
the  University  of  the  City  of  New  York,  of  the  class  of  1861.  He 
had  been  invalided  for  several  months  by  reason  of  the  inroads  made 
upon  his  health  by  multiple  sarcomatous  growths.  He  leaves  a  son 
who  is  a  practitioner  in  Brooklyn. 

Army  Intelligence. —  Official  Lint  of  Changex  in  the  Stalionx  and 
Duties  of  Offucrs  scrvwg  in  the  Medical  Department,  United  States 
Amy,  from  February  12  to  Fchrnary  IS,  1S9S : 

Kimball,  James  P.,  Major  and  Surgeon,  is  granted  leave  of  absence  for 

three  months,  on  surgeon's  certificate  of  disability,  with  permission 

to  leave  the  Department  of  Texas. 
Ware,  Isaac  P.,  First  Lieutenant  and  Assistant  Surgeon,  is  granted 

leave  of  absence  for  one  month. 
SuiTii,  Joseph  R.,  Colonel  and  Assistant  Surgeon-General,  is  granted  two 

months'  leave,  with  permission  to  leave  the  United  States. 
MiDDLETON,  J.  V.  D.,  Major  and  Surgeon,  will,  in  addition  to  his  present 

duties  as  post  surgeon  of  the  Presidio  of  San  Francisco,  Cal,  perform 


the  duties  of  medical  director,  Department  of  California,  during  the 
absence  of  Colonel  Joseph  R.  Smith,  Assistant  Surgeon-General. 
Reynolds,  Fuedekick  P.,  First  Lieutenant  and  Assistant  Surgeon,  is  re- 
lieved from  duty  at  Fort  Monroe,  Virginia,  and  as.signed  to  duty  at 
West  Point,  N.  Y.  Par.  1,  2,  and  4  of  S.  0.  34,  A.  G.  0.,  February 
14,  1893. 

Swift,  Euge.me  L.,  Captain  and  Assistant  Surgeon.  The  suspension  of 
the  order  assigning  him  to  Fort  Yates,  North  Dakota,  is  removed. 

Society  Meetings  for  the  Coming  Week : 

Monday,  February  27th:  Medical  Society  of  the  County  of  New  York; 
Boston  Society  for  Medical  Improvement ;  Lawrence,  Mass.,  Medi- 
cal Club  (private);  Cambridge,  Ma^s.,  Society  for  MeJical  Improve- 
ment; Baltimore  Medical  Association;  Philadelphia  Neurological 
Society. 

Tuesday,  February  2Slh:  New  York  Dcrmatological  Society;  Buffalo 
Obstetrical  Society ;  Boston  Society  of  Medical  Sciences  (private). 

Wednesday,  March  1st:  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) ;  Bridgeport,  Conn.,  Medical  Association ; 
Penobscot,  Me.,  ('ounty  Medical  Society  (]5angor). 

Thursday,  Marth  2d:  New  York  Academy  of  Medicine;  Brooklyn 
Surgical  Society ;  Society  of  Physicians  of  the  Village  of  Canandai- 
gua ;  Boston  Medico-psychological  Association ;  Obstetrical  Society 
of  Philadelphia ;  United  States  Naval  Medical  Society  (Washington), 

Friday,  March  Sd:  Practitioners'  Society  of  New  York  (private); 
Baltimore  Clinical  Society. 

Saturday,  March  J^'h :  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.  30G. — The  gentleman's  address  is  No.  2134  Hancock  Street, 
Philadelphia. 

No.  397. — 1.  Baker  Brown's  Sterility;  its  Causes  and  Treatment, 
London,  1871 ;  J.  M.  Duncan's  Fecundity,  Fertility,  Sterility,  and  Allied 
Topics,  Edinburgh,  1866,  and  New  York,  1871 ;  and  the  same  author's 
Gulstonian  Lectures  On  Sterility  in  Woman,  London,  1884.  2.  We 
have  not  been  able  to  ascertain.  3.  We  can  not  entertain  the  notion 
that  the  device  mentioned  has  any  efficacy  at  all. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Meeting  of  February  7,  1893. 

The  President,  Dr.  M.  Allen  Stakk,  in  the  chair. 

Subacute  Unilateral  Bulbar  Palsy.— Dr.  Alfeed  Wieneb 
presented  a  lad,  aged  seventeen  years,  whose  family  history  was 
negative,  and  who  had  bein  in  good  health  up  to  two  years 
ago,  when  he  had  a  severe  attack  of  perityphlitis,  from  which 
he  recovered  after  five  weeks  of  illness.  He  had  sntfL-red  from 
Ciitarrhal  pharyngitis,  more  or  less,  ever  since  childb<'od.  A 
year  ago  last  spring  the  glands  on  both  sides  of  his  neck,  in  the 
region  of  the  sterno-cleido-mastoid  muscles,  began  to  enlarge. 
In  the  summer  of  the  following  year  an  abscess  formed  in  one 
of  these  filands  on  the  right  side,  and  this  was  opened.  SooD 
afti-r  this  the  remaining  glands  began  to  create  so  much  discom- 
fort that  those  on  the  right  side  were  removed,  together  with 
a  large  portion  of  the  sterno-cleido-mastoid  muscle.  On  Sep- 
tember 1st  of  the  same  year  the  glands  on  the  left  side  were 
removed.  These,  under  the  microscope,  proved  to  be  tubeicu- 
lar.    In  the  latter  part  of  NoTember,  1892,  it  was  noticed  that 


Feb.  25,  1893.] 


PROCEEDINGS  OF  SOCIETIES. 


225 


the  patient's  tongue,  on  protrusion,  deviated  to  the  right  side. 
This  was  followed  by  hoarseness  and  difficulty  in  swallowing, 
and  laier  on  by  distinct  atrophy  of  the  middle  half  of  the 
tongue.  An  clecti'ical  and  lai-yngoscopic  examination  showed 
that  there  was  complete  unilateral  palsy  on  the  right  side,  in- 
volving the  tongue,  the  soft  palate,  the  pharynx,  and  the  larynx, 
together  with  paralysis  of  the  sterno-eleido  mastoid  and  of  the 
upper  portion  of  the  trapezius.  The  lesion  in  this  case,  the 
speaker  said,  might  occupy  a  point  just  external  to  the  exit  of 
the  pneumiigastric  and  spinal  accessoi-y  nerves  from  the  skull, 
or  be  situated  on  the  surface  of  the  medulla,  or  be  nuclear.  All 
the  facts  in  this  case  lent  support  to  the  view  that  the  lesion 
was  a  tubercular  one,  situated  at  the  nuclei  of  the  nerves  which 
governed  these  palsied  parts.  These  groups  of  cells  formed  the 
conjoined  nuclei  of  the  spinal  acces-sory,  vagus,  and  hypoglossal 
nerves,  and  a  very  localized  lesion  in  this  part  of  the  medulla 
was  sufficit-nt  to  atfect  them.  The  involvement  of  the  trapezius 
and  sterno-cleido  mastoid  muscles  was  probably  due  to  injury 
to  the  nerve  supplying  them,  while  the  laryngeal  symptoms 
might  be  accounted  for  by  paralysis  of  the  stylo-hyoid  muscle 
(due  to  pressure  from  an  enlarged  gland),  or  by  tlie  antagonistic 
action  of  the  muscles  on  the  left  side  of  the  throat  over  the 
paralyzed  muscles  on  tlie  right  side. 

Complete  Atrophy  of  the  Tongue,  with  other  Nuclear 
Symptoms. — Ur.  Geoege  W.  Jaooby  presented  a  woman,  aged 
thirty  years,  married  nine  years.  She  had  had  three  childrt-n 
and  two  miscarriages.  During  the  past  fourteen  months  she 
had  not  menstruated.  Her  mother  had  died  of  pulmonary  tu- 
berculosis a(  tlie  age  of  thirty-eight.  Her  husband's  sistei-  had 
recently  died  of  consumption,  and  during  her  illness  the  patient 
had  nursed  her.  During  December,  1802,  the  patient  was  treat- 
ed for  loss  of  sight,  which  had  come  on  gradually  in  both  eyes, 
reducing  vision  to  such  an  extent  that  she  required  some  one  to 
lead  her.  This  loss  of  sight  was  found  to  be  due  to  a  slight 
atrophy  of  both  optic  nerves,  and  under  internal  treatment  the 
'  symptom  disii|i[)eared.  The  patient  had  also  suffered  from  vio- 
'  lent  headaches,  which  disappeared  with  the  loss  of  sight.  Three 
weeks  ago  she  noticed  difficulty  in  swallowing  and  speaking. 
She  vomited  every  morning  on  rising,  even  without  eating. 
At  a  ))revious  examination  it  had  been  found  that  the  tongue 
deviated  tovvaid  the  lett,  and  there  was  marked  atrophy  of  that 
side  of  the  tongue.  The  uvula  hung  to  the  lett,  and  there  was 
paralysis  of  the  left  side  of  the  soft  p  ilate.  The  patient  had 
enlarged  glands  in  the  neck.  There  was  at  present  complete 
atropny  of  the  tongue  and  of  the  soft  palate.  There  was  also 
motor  ocular  paralysis  on  the  left  side,  involving  the  internal 
and  external  muscles.  The  speaker  presented  the  case  as  one 
of  progressii'e  nuclear  paralysis. 

Dr.  B.  Saohs  said  he  had  seen  Dr.  Wiener's  patient  some 
time  ago.  The  idea  ot  a  peripheral  lesion  was  considered  for  a 
short  time  only,  and  the  conclusion  was  soon  arrived  at  that 
the  basilar  site  was  the  more  probable  one.  The  lesion  was  no 
noubt  of  tubercular  origin.  A  chronic  nuclear  condition  must  be 
excluded,  on  account  of  the  rapid  progress  of  the  symptoms  and 
because  they  hal  remained  strictly  unilateral.  Dr.  Jacoby's 
j  case  he  coi)si(iere<l  a  very  interesting  one,  although  he  felt 
rather  inclined  to  doubt  the  diagnosis,  because  of  the  r;i])id 
progress  of  the  symptoms.  They  seemed  to  indicate  tiie  pres- 
ence of  some  active  lesion,  either  spci-itic  or  tubercular. 

Modifications  of  P.espiration  in  the  insane. — Dr.  Theo- 
dore H.  Kellogg  read  a  paper  on  this  subject.  He  gave  a 
systematic  description  of  the  various  forms  of  rc'^piratory 
changes  found  in  the  insane.  To  facilitate  the  study  of  these 
modifications  he  grouped  them  as  follows:  a.  Mollifications  of 
respiration  as  regarded  frequency,  depth,  rhythm,  and  sound. 
6.  (1)  Spasmodic  expiratory  modifications,  such  as  occurred  in 


laughter,  crying,  sneezing,  coughing,  and  snoring;  (2)  spas- 
modic inspiratory  modifications,  as  in  singultus,  chasmus,  and 
laryngeal  crises,    c.  Dyspnceic  modifications. 

Dr.  William  M.  Leszynsky  presented  a  new  form  of  elec- 
trode to  be  employed  for  diagnostic  purposes. 

Sarcoma  of  the  Cervical  Spinal  Cord.— Dr.  0.  A.  Heeteb 
read  the  history  of  the  case,  and  presented  some  photographs 
and  microscopical  specimens  to  illustrate  it.  The  patient  was  a 
merchant,  twenty-nine  years  old.  He  had  been  in  good  health 
until  the  beginning  of  this  illness,  barring  occasional  attacks  of 
chills  and  fever,  and  repeated  and  prolonged  colds,  which  ended 
in  cough  lasting  for  several  weeks.  He  had  never  used  alcohol, 
and  his  habits  had  always  been  in  every  respect  exemplary. 
The  family  history  was  negative.  In  May,  1891,  the  patient  no- 
ticed a  loss  of  sensation,  beginning  as  numbness,  in  the  ulnar 
side  of  the  little  finger  of  the  right  hand.  This  sensory  loss 
soon  extended  to  the  entire  little  finger,  and  thence  to  the  ring 
finger  and  the  ulnar  side  of  the  middle  finger.  At  the  same 
time  there  was  an  upward  extension  of  ancesthesia  along  the 
hand.  In  three  months  from  the  onset  the  anassthesia  had 
passed  up  the  ulnar  side  of  the  forearm  and  arm  and  had 
reacht  d  outward  over  the  hand  as  far  as  the  thumb.  The  pa- 
tient also  began  to  have  pain  on  the  ulnar  side  of  the  right 
forearm  and  hand,  slight  and  occasional  at  h'rst,  afterward  very 
severe  and  of  increased  duration.  This  was  followed  by  loss  of 
povvei',  first  in  the  flexors  of  the  fingers,  then  in  those  of  the- 
forearm.  About  five  months  after  the  first  symptoms  we^ 
noted  there  developed  atrophy  of  the  first  dorsal  interosseus. 
This  wasting  soon  extended  to  the  muscles  of  the  thumb  and 
hypothenar  eminence  and  to  the  flexors  of  the  forearm.  About 
the  eighth  month  the  pain  abated  very  much.  During  the  pe- 
riod of  severest  pain  the  entire  right  arm  became  oederaatous. 
An  electrical  examination  made  in  June,  1892,  showed  a  loss  of 
faradaic  irritability  in  the  right  arm,  in  all  the  extensors  and 
flexors  of  the  wrist,  and  in  the  interossei.  The  tactile  sense 
and  the  sense  of  pain  were  entirely  lost  along  the  ulnar  border 
of  the  arm  to  the  axilla,  and  were  greatly  impaired  along  the 
radial  border  as  high  as  the  shoulder.  The  temperature  sense 
(which  was  only  roughly  tested)  appeared  to  be  quite  lost  in  the 
arm.  There  was  almost  an  entii'e  loss  of  the  muscle  sense;  the 
patient  had  no  sense  whatever  of  the  position  of  the  fingers, 
hand,  and  arm.  The  surface  of  the  right  arm  was  much  colder 
than  that  of  the  left.  It  was  pale  in  color.  In  the  left  hand 
and  arm  power  and  sensation  were  apparently  normal.  Both 
legs  were  a  little  weak.  Equilibrium  was  maintained  without 
any  difficulty.  The  knee-jerks  were  increased,  the  exaggera- 
tion being  more  pronounced  on  the  right  side.  The  power  of 
the  sphincters  was  unimpaired.  There  was  no  vertebral  de- 
formity, and  there  was  no  tenderness  on  pressure  over  any  of 
the  cervical  or  upper  dorsal  spines.  Sight  was  unimpaired. 
The  pupils  reacted  normally  to  light  aud  during  accommoda-. 
tion.  The  right  palpebral  fissure  was  distinctly  smaller  than 
the  left,  and  the  ri^ht  lid  drooped  a  little.  An  examination  of 
the  chest  showed  dullness  on  percussion  over  the  u[)])er  part  of 
the  right  side.  The  temperature  was  101°  F.,  the  pulse  100, 
the  respiration  about  30.  In  the  course  of  two  weeks  after  this 
exauiination  the  right  leg  became  mucti  weaker  than  before,  and 
pain  and  numbne-s  extt-nded  grailually  down  the  entire  li-ft 
arm.  Loss  of  power  was  also  detected  in  the  left  leg.  There 
was  temporary  retention  of  urine.  In  July,  1892,  a  tense 
swelling  was  observed  over  the  outer  end  of  the  right  clavicle 
and  extending  down  into  the  axilla  over  the  front  of  the 
shoulder.  In  the  course  of  two  weeks  this  tumor  gri  w  to  the 
size  of  a  child's  head,  became  very  tense,  and  was  covered  by 
greatly  distended  veins.  The  patient  grew  worse  rapidly.  In- 
continence of  urine  and  fajces  set  in,  aud  the  breathing  became 


226 


PROOEEDINOS 


OF  SOCIETIES. 


[N.  Y.  Med.  Joot., 


labored  owing  to  paralysis  of  tbe  thoracic  muscles.  There  was 
total  loss  of  sensibility  extending  as  high  as  the  crest  of  the 
ilium  on  each  side,  with  impairment  of  sensibility  bilater.'dly  os 
high  as  the  third  rib.  Large  bed-sores  appeared,  and  on  Sep- 
tember 12,  1892,  sixteen  months  after  tlie  beginning  of  the 
symptoms,  the  patient  died  from  exhaustion  and  respiratory 
failure. 

A  partial  autopsy  was  made  and  a  mass  removed  from  the 
clavicle  and  another  from  the  upper  and  posterior  part  of  tlio 
thoracic  wall.  A  number  of  tumors  occupied  the  posterior  and 
inner  aspects  of  the  right  upper  part  of  the  chest,  displacing  the 
lung.  Some  of  these  masses  appeared  to  grow  from  the  clavicle, 
others  from  the  vertebra>,  but  their  relations  could  not  be  dis- 
tinctly made  out.  The  specimen  obtained  from  the  spinal  cord 
was  five  inches  long,  and  extended  from  tbe  seventh  cervical  to 
the  seventh  dorsal  segments,  both  inclusive.  Sections  were 
made  from  the  seventh  cervical  and  the  first,  second,  and  third 
dort^al  segments.  The  tumor  involved  at  this  level  nearly  the 
entire  right  half  of  the  cord  and  encroached  anteriorly  upon  its 
left  anterior  column.  Posteriorly,  it  did  not  jia-s  quite  to  the 
posterior  iiorn.  The  ganglion  cells  in  the  region  of  the  tumor 
had  undergone  partial  or  entire  destruction,  and  in  some  in- 
stances had  apfiarently  been  replaced  by  small  groups  of  spindle- 
shaped  connective-tissue  cells.  In  structure  the  tumor  was  an 
exceedingly  vascular  spindle-celled  sarcoma.  Sections  made 
from  the  mass  obtained  from  the  clavicle  and  thoracic  wall 
sftowed  them  to  be  fibro-sarcomata. 

Regarding  the  diagnosis  of  the  case,  the  speaker  said  that^ 
while  the  anatomical  diagnosis  presented  no  difficulties,  the 
pathological  diagnosis  was  made  with  some  hesitation.  The 
presence  of  signs  of  consolidation  over  the  lung,  muco-purulent 
expectoration,  hectic  temperature,  rather  rapid  emaciation,  and 
night-sweats,  all  suggested  a  tubercular  process,  and  the  diag. 
nosis  of  a  secondary  tubercular  tumor  of  tbe  cord  was  thought 
to  be  justified.  The  alternative  diagnosis  was  sarcoma,  but  this 
appeared  improbable.  An  examination  of  the  sputum  was  not 
made.  Twenty  six  cases  of  sarcoma  of  the  spinal  cord  collected 
by  the  speaker  and  compared  with  cases  of  massive  tuhercle  of 
the  cord  had  brought  out  a  number  of  facts,  some  of  them  of 
practical  interest.  They  were:  1.  Sarcoma  of  the  spinal  cord 
occurred  with  about  equal  frequency  in  the  two  sexes ;  of  the 
twenty-six  ca^es,  fourteen  had  been  in  females  and  twelve  in 
males.  2.  Sarcoma  of  the  spinal  cord  was  essentially  a  disease 
of  adult  life;  of  twenty-one  cases,  only  two  had  occurred  before 
the  twentieth  year,  and  seventeen  between  the  ages  of  twenty 
and  fifty  years.  Massive  tubercle,  on  the  contrary,  was  a  dis- 
ease of  adolescent  and  early  adult  life ;  fifteen  out  of  twenty- 
four  occurred  between  the  fifteenth  and  thirty-fifth  years  and 
five  before  the  fifth  vear.  Tlie  etiological  factors  in  ihe  pro- 
duction of  sarcoma  of  the  s[)inal  cord  were  practically  unknown. 
In  one  case  only  (following  a  fall  on  the  ice)  had  it  appeared  to 
exert  any  influence,  and  even  there  the  influence  might  be  ques- 
tioned. 4.  In  three  cases  of  sarcoma  the  first  symptoms  had 
appeared  during  pregnancy.  5.  Pain  appeared  to  be  the  earliest 
and  most  prominent  sy  mpti  un  in  four  fifths  of  the  cases.  Speaking 
generally,  the  early  symptoms  of  sarcoma  of  the  cord  were  main- 
ly of  an  irritative  and  not  of  a  destructive  nature.  In  sarcoma 
the  course  of  the  disease  was  in  general  much  slower  than  in 
tubercle.  In  all  the  cases  the  diagnosis  had  been  confirmed  by 
autopsy,    (ilioma  had  been  excluded. 

Di-.  Sachs  said  he  had  been  much  interested  in  Dr.  Ilerter's 
attempts  at  diagnosis  bet^^•een  sarcoma  and  luliercleof  the  cord. 
The  rapid  progress  and  greater  destructiveness  of  the  latter  dis- 
ease was  i)robably  the  most  important  symptom.  In  a  case  that 
had  come  under  his  observation  eight  years  before,  he  hail  diag- 
nosticated probable  sarcoma  and  found  tubercle,  and  in  that  case 


the  solitary  lesion  of  the  cord  had  positively  been  the  original 
def>osit  of  the  disease.  Tumors  of  the  cord  were  of  extreme 
rarity. 

Dr.  Mary  Putnam  Jacobi  referred  to  a  ca^e  of  sarcoma  of 
the  cord  in  a  child,  reported  by  Dr.  Gee  {St.  Bartholomfw^a  IIo»- 
pital  Reports),  in  which  the  diagnosis  had  been  confirmed  by 
autopsy.  In  a  case  reported  by  her  last  autumn  the  symptoms 
had  very  closely  resembled  those  in  Dr.  Gee's  case.  There  was 
a  predominance  of  the  irritative  over  the  destructive  symptoms, 
and  there  were  unilateral  paralytic  symptoms.  She  liad  made  a 
diagnosis  of  sarcoma  of  the  cord,  and  before  death  a  large  tumor 
appeared  in  the  cervico-dorsal  region.  No  autopsy  was  per- 
mitted. 

Dr.  Frederick  Peterson  stated  that  sarcoma  in  general  was 
more  cotnmon  under  the  age  of  thirty  than  above  that  age. 

The  President  said  that,  while  sarcoma  in  general  was  more 
commonly  met  with  in  persons  under  the  ago  of  thirty,  yet 
sarcoma  in  the  nervous  system  was  decidedly  more  frequent  in 
adult  life.  He  had  recently  collected  600  cases  of  tumor  of  the 
brain  (300  in  adults  and  300  in  children),  and  among  these  there 
were  34  cases  of  sarcoma  in  children  and  157  in  pdults.  He 
agreed  to  Dr.  Sachs's  statement  that  tumors  of  the  s[)inal  cord 
were  very  rare.  He  had  been  much  interested  in  the  collec- 
tion of  cases  made  by  Dr.  Herter,  and  thought  it  woidd  be  well 
to  carry  the  investigation  further  and  determine  how  many 
of  these  cases  would  have  been  suitable  for  operative  interfer- 
ence. 

Dr.  Gr^me  M.  Hammond  referred  to  the  symptoms  of  Dr. 
Herter'a  patient  on  the  side  of  the  body  opposite  to  that  invaded 
by  the  growth.  These,  he  thought,  might  have  been  due  to 
degenerative  changes  in  the  opposite  side  of  the  cord,  caused 
by  a  cutting  off"  of  the  blood  supply,  or  the  commissure  fibers 
might  have  been  interfered  with  enough  to  produce  the  symp- 
toms. 

Dr.  Herter  stated  that  there  had  been  only  partial  interfer- 
ence with  the  nutrition  of  the  opposite  side  of  the  cord.  As 
regarded  an  operation,  he  had  not  seen  the  patient  until  a  very 
late  day,  and  it  had  seemed  to  him  that  the  case  was  not  suita- 
ble for  an  operation.  The  patient  had  been  seen  by  an  eminent 
neurologist  during  the  earlier  stages,  and  had  been  treated  by 
electricity  with  the  idea  that  the  trouble  was  neuralgic. 

Discussion  on  the  Motor  Disturbances  of  the  Heart  of 
Nervous  Origin. — Dr.  Jaooby  read  the  first  paper  on  this  sub- 
.iect.  He  stated  that  in  a  large  number  (probably  in  more  than 
half)  of  the  persons  wlio  consulted  physicians  on  account  of  some 
motor  disorder  of  the  heart  no  anatomical  lesion  was  clinically 
discoverable,  and  no  mechanical  cause  could  be  found.  In  such 
cases  it  was  reasonable  to  seek  for  the  cause  of  the  altered  func- 
tion in  some  disorder  of  the  complicated  nervous  apparatus  of 
the  heart.  The  subject  might  conveniently  be  divided  into  in- 
termittent, irregular,  abnormally  slow  (bradycardia),  and  abnor- 
mally frecjuent  (tachycardia)  heart's  action. 

Intermittency  might  be  true  or  false;  in  the  latter  form  the 
pulse  failed,  but  the  heart  was  regular,  while  in  the  former  the 
heart  beat  was  actually  dropped.  In  irregularity  of  the  heart's 
action  the  number  of  pulsations  varied  from  minute  to  minute, 
or  the  pulsations  varied  in  height  and  tension.  These  forms  of 
arrhythmia  might  be  persistent  or  only  temporary  ;  when  they 
were  persistent,  they  were  probably  due  to  some  organic  dis- 
ease of  the  heart,  whether  it  could  be  detected  or  not;  when 
they  were  temporary,  they  were  either  dependent  upon  defect- 
ive blood  mixture  or  purely  neurotic.  Toxic  influences  asso- 
ciated with  sexuiil  excesses  and  with  the  excessive  use  of  tea, 
coffee,  tobacco,  and  alcohol  he  had  found  to  be  potent  in  the 
production  of  arrhythmia.  Intermittency  might  be  due  to  even 
the  moderate  use  of  alcohol. 


Feb.  25,  1893.] 


BOOK  NOTICES. 


227 


Slowness  of  the  pulse,  or  bradycardia,  was  a  term  applied 
in  cases  wbere  tlie  pulse  fell  below  60  or,  according  to  some 
writers,  below  40.  A  slow  pulse  should  be  regarded  as  a  symp- 
tom only,  and  might  be  due  to  a  variety  of  causes.  If  we  made 
use  of  the  term  bradycardia  at  all,  we  should  limit  it  to  cases 
in  which  the  infreciuency  of  the  pulse  was  due  to  a  disorder  of 
innervation.  A  slight  reduction  in  the  frequency  of  the  pulse 
was  very  common  in  disturbances  of  the  digestive  tract. 

In  paroxysmal  tachycardia  the  attack  was  always  sudden  in 
its  onset  and  usually  unexpected.  The  pulse  was  increased  from 
normal  to  from  180  to  240,  or  even  to  300,  according  to  some 
observers.  There  was  no  irregularity  of  rhythm  or  intermit- 
tence.  The  heart  beat  in  a  strong  and  energetic  manner,  and 
in  direct  contrast  to  its  action  was  the  extreme  diminution  of 
arterial  tension.  The  cessation  of  the  attack  was  as  sudden  as 
its  onset.  The  paroxysms  varied  in  duration  from  a  few  min- 
utes to  several  hours,  and  occasionally  lasted  even  for  days. 
The  intervals  between  the  attacks  were  irregular.  During  an 
attack  the  excretion  ot  urine  was  generally  diminished ;  it  might 
be  followed  by  the  passage  of  a  large  quantity  of  clear,  limpid 
urine.  The  r&tiology  of  these  cases  was  obscure.  Psychic  in- 
fluences, fright,  errors  of  diet,  and  bodily  exertion  had  all  been 
assigned  as  causes.  It  was  an  affection  of  adult  life;  this  we 
could  say  positively,  and  the  best-established  causes  were  bodily 
and  cerebral  overwork. 

The  author  referred  to  the  pathology,  and  gave  a  brief  re- 
view of  the  various  theories  put  forth  regarding  the  nervous 
mechanism  of  the  heart.  The  assumption  that  we  were  deal- 
ing with  a  bulbar  neurosis  appeared  to  him  to  be  the  most  prob- 
able one. 

Dr.  John  Winters  Brannan  said  that  some  years  ago,  when 
he  was  led  to  investigate  the  subject  of  the  pathology  of  tacliy- 
cardia,  he  had  been  inclined  to  believe  that  it  was  due  to  a  bul- 
bar neurosis,  but  he  had  afterward  rather  favored  the  sugges- 
tion made  by  West,  to  which  Dr.  Jacoby  had  referred,  that  the 
cause  of  the  trouble  was  to  be  found  in  the  heart  muscles.  Up 
to  four  years  ago,  only  four  autopsies  had  been  recorded,  and 
in  all  of  these  the  nervous  system  had  been  found  intact;  in 
only  two  had  the  heart  muscles  been  examined,  and  in  both 
cases  an  extensive  development  of  fibrous  tissue  had  been  found 
in  the  wall  of  the  left  ventricle.  This,  as  some  observers  had 
said,  might  have  been  due  to  the  rapid  cardiac  action.  In  an- 
other case,  where  tiie  disease  had  existed  only  three  months, 
there  had  been  an  extensive  development  of  fibrous  tissue 
throughout  the  wall  of  the  left  ventricle,  in  the  trabeculje,  and 
in  the  papillary  muscles.  The  only  objection  to  that  theory 
lay  in  the  fact  that  there  were  so  many  cases  of  myocarditis 
without  any  history  of  tachycardia.  This  had  been  accounted 
for  by  the  explanation  that  certain  regions  of  the  heart  muscles 
were  tolerant,  while  other  regions  were  intolerant,  and  that 
with  the  latter  there  was  tachycardia.  The  intolerant  regions 
were  especially  found  in  the  interventricular  wall  and  the  pap- 
illary muscles. 

Dr.  Jacobi  referred  to  Gaskell's  experiments  in  connection 
with  this  subject.  She  stated  that  the  suggestion  made  that  an 
apparently  functional  disorder  might  constitute  the  precursor 
of  a  more  serious  condition  seemed  to  her  extremely  interesting 
and  important.  Such  a  case  had  recently  been  brought  to  her 
observation.  The  patient  was  a  woman  who,  for  three  years, 
during  the  period  of  the  menopause,  was  supposed  to  be  very 
hysterical.  She  suffered  from  insomnia,  night  terrors,  and 
other  syinptoms  that  were  considered  purely  neurasthenic,  as 
no  organic  disease  was  found.  She  finally  had  an  attack  of 
hajmorrliage  in  the  pons. 

Dr.  Heeter  referred  to  a  case  of  paroxysmal  tachycardia 
that  he  had  had  under  observation  for  two  years.   The  man  was 


a  sexual  neurasthenic  and  suffered  from  intestinal  indigestion. 
Each  attack  lasted  four  or  five  hours  and  was  generally  induced 
by  some  indiscretion  of  diet.  The  urine  passed  after  such  an 
attack  contained  in  a  large  amount  the  products  of  intestinal 
putrefaction.  It  was  an  interesting  question  whether  the  at- 
tacks were  due  to  such  poisonous  substances  or  perhaps  to  me- 
chanical causes,  such  as  the  distention  of  the  colon  or  other 
parts  of  the  intestinal  tract. 

Dr.  A.  D.  EocKWELi,  was  of  the  opinion  that  functional  dis- 
eases of  the  heart  sometimes  led  up  to  organic  diseases,  but  not 
very  often.  These  functional  heart  troubles  ofttimes  gave  more 
misery  than  a  serious  organic  disease.  If  there  was  disturbed 
rhythm  of  the  heart  which  was  paroxysmal  in  character,  with 
intervals  of  normal  pulse  beat,  the  condition  was  apt  to  be  a 
functional  one,  and,  per  contra,  where  the  rhythmic  disturbance 
was  constant  and  associated  with  profound  circulatory  inter- 
ference, indicated  by  syncope  or  vertigo,  one  was  pretty  safe  in 
diagnosticating  organic  disease. 

Dr.  Leszynsky  had  seen  three  attacks  of  tachycardia  in  a 
young  physician.  Each  attack  had  been  brought  on  by  over- 
indulgence in  alcohol  and  tobacco.  The  pulse  rate  varied  from 
180  to  200,  and  each  attack  lasted  for  two  or  three  days.  The 
patient  had  had  no  attack  now  for  five  years.  As  regarded 
slow  pulse,  he  was  acquainted  with  two  persons,  both  members 
of  the  same  family,  in  whom  that  symptom  was  very  pro- 
nounced. 

Dr.  L.  Stieglitz  referred  to  a  marked  case  of  tetany  he  had 
seen  in  Dr.  Hoffman's  clinic  at  Heidelberg.  The  patient  was  a 
girl,  aged  eighteen,  who  had  attacks  of  tachycardia  with  the 
pulse  ranging  from  180  to  220.  With  tetany  there  was  often 
associated  disease  of  the  thyreoid  gland,  and  this  was  also  the 
case  in  Basedow's  disease,  where  the  pulse  was  rapid.  The 
tachycardia  might  possibly  be  due  to  some  toxic  influence  of 
the  blood. 


i00k  Notices. 


A  Treatise  on  Diseases  of  the  Eectum,  Anus,  and  Sigmoid  Flex- 
ure. By  Joseph  M.  Mathews,  M.  D.,  Professor  of  Prin- 
ciples and  Practice  of  Surgery,  and  Clinical  Lecturer  on 
Diseases  of  the  Rectum,  Kentucky  School  of  Medicine, 
Louisville.  With  Six  Cliromo-lithographs  and  Numerous 
Illustrations.  New  York:  D.  Appleton  &  Co.,  1892.  Pp. 
xvi  to  537. 

The  many  friends  of  Dr.  Mathews  throughout  the  country 
have  looked  forward  to  the  appearance  of  this  work  with  much 
interest.  It  is  really  the  only  new  work  of  importance  upon 
these  subjects  that  has  been  brought  out  during  the  past  two 
years,  and  merits  a  close  consideration  as  embodying  the  latest 
utterances  of  one  who  has  had  a  large  experience  in  this  field 
and  devoted  much  study  to  it.  To  those  who  have  followed  the 
writings  of  the  author  for  the  past  ten  years  much  that  the 
present  book  contains  will  seem  familiar  reading.  It  is  never- 
theless interesting  to  know  that  larger  experience  and  wider 
observation  have  not  changed  the  views  of  this  conscientious 
worker  in  the  field  of  rectal  diseases. 

Dr.  Matiiews  maintains  his  title  to  priority  as  a  rectal  spe- 
cialist in  the  United  States,  and  certainly  he  deserves  credit  for 
what  he  has  done  to  elevate  this  branch  of  surgery.  He  paints 
a  very  roseate  future  for  those  who  contemplate  entering  upon 
this  line  of  work  in  the  assertion,  "no  class  of  disi-ases  yields 
so  promptly  to  treatment  as  diseases  of  the  rectum."  We  are 
inclined  to  believe  that  those  who  are  led  into  this  field  by  such 


228 


BOOK  NOTICE^. 


[N.  T,  Mbd.  Joob^ 


an  assurance  of  rapid  results  will  ere  long  lose  faith  in  their 
prophet,  for  surely  many  of  the  disorders  of  this  organ  are 
obstinate  and  difficult  to  cure. 

Those  who  expect  to  find  the  book  a  scientific,  systematic 
treatise  upon  the  rectum  and  anus  will  be  disappointed,  for  the 
author  plainly  avers  that  he  has  written  only  to  record  his  own 
personal  experience,  thathe  has  not  taken  the  opinions  of  otliers 
as  his  guide,  but  has  related  facts  as  they  appeared  to  him  in  the 
cases  he  has  been  called  on  to  treat.  Consequently  there  is  very 
little  said  in  the  book  upon  minute  anatomy,  pathology,  or  the 
varying  doctrines  concerning  the  mooted  points  in  rectal  dis- 
orders. The  chapters  upon  hysterical  rectum,  diseases  of  the 
sigmoid  flexure,  antiseptics  in  rectal  surgery,  and  tlie  anatomy 
of  the  rectum  in  relation  to  the  reflexes  are  novel,  although 
these  matters  have  all  been  more  or  less  written  upon  by  special- 
ists. The  article  on  the  hysterical  or  nervous  rectum  the  author 
says  he  has  written  especially  to  oppose  Dr.  Goodell's  views 
upon  this  subject.  The  description,  he  says,  which  the  latter  has 
given  of  the  nervous  rectum  is  a  complete  word  picture  of 
ulceration  of  the  rectum,  and  he  believes  that  all  the  symptoms 
described  by  Dr.  Goodell  are  due  to  some  local  cause  which  is 
generally  overlooked  by  the  practitioner.  The  author  is  doubt- 
less correct  in  this  view  of  a  majority  of  these  cases,  but  it  is  a 
question  whether  he  does  not  confirm  the  doctrines  of  Goodell 
in  his  article  on  the  rectal  reflexes. 

The  article  upon  constipation  is  one  of  the  most  original  in 
the  book.  The  author  finds  the  chief  cause  for  this  common 
complaint  in  contraction  or  irritability  of  the  external  sphinc- 
ter muscle.  Many  readers  will  here  learn  with  us  for  the  first 
time  what  an  important  thing  this  little  muscle  is.  Writers 
upon  these  subjects  generally  teach  that  it  is  a  comparatively 
unimportant  part  of  the  rectal  anatomy,  and  that  it  is  a  matter 
of  small  moment  if  it  should  be  cut  or  torn  in  an  operation. 
The  author  of  the  present  work,  however,  assigns  to  it  a  role 
of  far  greater  importance  than  that  of  the  internal  sphincter. 
He  dilates  it  for  constipation,  he  contracts  it  for  procidentia, 
he  soothes  it  for  neuralgia,  and  he  stimulates  it  for  atony.  The 
sigmoid  flexure  is,  according  to  the  author,  another  seat  of  the 
evil  in  constipation,  and  when  such  is  the  case,  and  the  disease 
is  not  malignant,  he  advises  the  daily  use  of  a  moderate-sized 
bougie,  to  be  followed  by  the  injection  of  olive  oil  and  iodo- 
form. Most  practitioners  would  hesitate  to  use  large  quanti- 
ties of  the  latter  drug  in  the  intestinal  tract,  but  the  author  says 
he  has  never  seen  any  evil  effects  follow  its  use. 

The  section  devoted  to  fistula  is  perhaps  the  most  satisfac- 
tory in  the  book.  The  author  does  not  consume  time  and  space 
by  a  long  and  confusing  division  of  the  subject,  but  discusses  it 
in  a  practical  manner  and  is  quite  modest  regarding  his  original 
work  in  this  field.  lie  still  adheres  to  the  practice  of  thrusting 
the  director  through  the  mucous  membrane  at  the  highest  point 
of  the  fistulous  tract,  whether  there  is  any  pathological  opening 
there  or  not,  and  cutting  the  intervening  tissues  through,  hold- 
ing that  such  incision  will  necessarily  include  the  pathological 
opening  into  the  gut,  if  there  should  be  one  at  a  lower  point. 
The  fallacy  of  this  theory  is  evident  to  any  one  who  is  familiar 
with  the  tortuous  tracts  of  fistulae  in  the  lower  portion  of  the 
rectum.  Many  failures  in  the  treatment  of  fistula  are  due  to  this 
very  fact  that  the  opening  into  the  gut  and  a  part  of  the  fistulous 
tract  remain  untouched  by  this  method.  This,  however,  is  the 
only  objectionable  portion  of  this  article,  and  its  concise  practi- 
cal teachings  may  well  be  studied  by  the  oldest  in  our  profes- 
sion. 

The  section  upon  hasmorrhoids  is  not  quite  so  satisfactory,  as 
the  author  is  so  wedded  to  the  ligature  operation  that  he  fails  to 
appreciate  the  advantages  of  others.  His  objections  to  the  AVhite- 
head  operation  are  well  founded,  but,  so  far  as  the  ligature  and 


the  clamp-and-cautery  operations  are  concerned,  be  has  evi- 
dently not  had  sufficient  experience  with  them  to  form  just 
conclusions  with  regard  to  them.  For  example,  he  says  the 
pain  following  the  clamp-and-cautery  operation  is  excruciating, 
owing  to  the  burning  of  the  cutaneous  and  mnco  cutaneous  tis- 
sues about  the  anus.  Those  who  use  this  method  most  fre- 
quently never  burn  these  external  tissues,  but  trim  them  away 
with  scissors,  and  only  apply  the  cautery  to  the  mucous  and 
submucous  ])arts.  If  any  bleeding  occurs  at  the  points  where 
the  scissors  have  been  used,  it  is  in  sight  and  easily  arrested  by 
pressure  forceps.  Hence  it  may  truly  be  said  that  after  the 
anaesthesia  there  is  scarcely  any  pain  to  this  operation.  The 
author  is  certainly  very  skillful  in  the  ligature  operation,  but, 
more  than  this,  fortunate  to  have  done  it  in  a  thousand  cases 
without  ulceration,  contraction,  or  other  unhappy  sequence. 

The  author  has  not  been  infected  with  the  excision  fever  as 
yet,  and,  though  he  believes  that  colotomy  is  of  little  service  in 
cancer  of  the  rectum,  he  yet  questions  whether  the  results  jus- 
tify the  risks  taken  in  excision  by  either  the  Kraske  or  the 
proctotomy  methods. 

The  chapter  on  diseases  of  the  sigmoid  flexure  is  new  and 
interesting,  and  we  have  no  doubt  that  the  author  is  correct  in 
the  opinion  that  many  of  the  symptoms  of  rectal  disorders  are 
due  to  diseases  of  this  portion  of  the  colon.  Malformations  of 
the  rectum  occupy  the  last  chapter  of  the  book,  and  the  author 
concludes  by  saying  that  operations  for  these,  "  whether  by  dis- 
sections in  situ,  punctures,  or  either  one  of  the  colotomies,  are 
generally  unprofitable  and  dangerous." 

Much  might  be  said  in  criticism  of  this  work  as  a  treatise  on 
rectal  diseases,  but  the  author  has  forestalled  us  by  disclaiming 
any  such  position  for  it.  There  are  many  repetitions,  and 
there  is  much  faulty  English  in  the  work  which  it  would  be 
well  to  eliminate  in  succeeding  editions.  However,  in  the 
hands  of  students  and  general  practitioners,  for  whom  it  is  in- 
tended, it  will  be  not  only  useful,  but  an  exceedingly  safe  guide. 
The  printing,  cuts,  and  lithographs  in  the  work  can  not  be  too 
highly  commended  ;  and  the  same  may  be  said  of  the  diagnos- 
tic tables  and  the  indexing. 

BOOKS,  ETC.,  RECEIVED. 

Diseases  of  the  Skin  :  their  Description,  Pathology,  Diagno- 
sis, and  Treatment,  with  Special  Reference  to  the  Skin  Erup- 
tions of  Children.  By  H.  Radciiffe  Crocker,  M.  D.  (Lond.), 
Fellow  of  the  Royal  College  of  Physicians  of  London,  etc.  Sec- 
ond Edition,  revised  and  enlarged.  With  Ninety-two  Wood- 
cuts. Philadelphia  :  P.  Blakiston,  Son,  &  Co.,  1893.  Pp.  xxxii- 
33  to  987.    [Price,  $5.] 

Handbook  of  Materia  Medica,  Pharmacy,  and  Therapeutics, 
including  the  Physiological  Action  of  Drugs,  the  Special  Thera- 
peutics of  Disease,  Ofiicial  and  Practical  Pharmacy,  and  Minute 
Directions  for  writing  Prescriptions.  By  Samuel  O.  L.  Potter, 
A.  M.,  M.  D.,  M.  R.  C.  P.  Lond.,  Professor  of  the  Theory  and 
Practice  of  Medicine  in  the  Cooper  Medical  College  of  San  Fran- 
cisco, etc.  Fourth  Edition,  revised.  Philadelphia:  P.  Blakis- 
ton, Son,  &  Co.,  1893.    Pp.  xii-17  to  781.    [Price,  $4.] 

Lectures  on  Mental  Diseases,  designed  especially  for  Medical 
Students  and  General  Practitioners.  By  Henry  Putnam  Stearns, 
A.  M.,  M.  D.,  Physician  Superintendent  of  the  Hartford  Retreat, 
Lecturer  on  Mental  Diseases,  Yale  University,  etc.  With  Illus- 
trations. Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1893.  Pp. 
xviii-9  to  636.    [Price,  $3.] 

The  Food  Inspector's  Handbook.  By  Francis  Vacher.  Lon- 
don :  The  Record  Press,  1892.    Pp.  ix-140. 

Reflex  Amblyopia.  By  J.  Walter  Park,  M.  D.,  of  Harris- 
burg,  Pa.  [Reprinted  from  the  Annals  of  Ophthalmology  and 
Otology.] 


Feb.  25,  1893.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


229 


Abscess  around  the  Rectum.  A  Lecture  at  the  Clinic  for 
Diseases  of  the  Rectum,  at  the  Now  York  Post-graduate  Hospi- 
tal. By  Charles  B.  Kelsey,  M.  D.  [Reprinted  from  the  Thera- 
peutic Gazette.^ 

Piperazin  in  the  Treatment  of  Stone  in  the  Kidney  ;  Report 
of  Cases.  By  David  D.  Stewart,  M.  D.,  Philadelphia.  [Re- 
printed from  the  Therapeutic  Gazette.'] 

The  Forthcoming  Report  of  the  Bureau  of  Education  on  Pro- 
fessional Education  in  the  United  States.  By  Bayard  Holmes, 
B.  S.,  M.  D.,  Chicago.  [Reprinted  from  the  Journal  of  the 
American  Medical  Association.] 

Report  of  the  Trustees  of  the  Boston  City  Hospital  on  the 
Advisability  of  establishing  Cottage  or  Branch  Hospitals  in  the 
Several  Wards  of  the  City. 

Roosevelt  Hospital,  New  York.  Twenty-first  Annual  Re- 
port.   From  January  1,  1892,  to  December  31,  1892. 


|l£p0rts  on  i\t  "^xa^nm  of  ^ttndm. 


ORTHOPEDIC  SURGERY. 

By  henry  ling  TAYLOR,  M.  D. 

Flat  Foot. — F6r6  and  Demantke  {Jour,  de  Vayiatom.  et  de 
phyaiolog.,  p.  431,  1891)  give  an  interesting  study  of  flat  foot  as 
a  stigma  of  degeneration.    In  an  investigation  of  the  epileptics 
of  the  Bicetre  Hospital  they  found,  among  171  patients,  that  66 
had  double  flat  foot  and  31  flat  foot  on  one  side  only.  These 
patients,  however,  are  of  two  classes :  First,  those  referred  to 
the  hospital  through  the  bureau  for  insanity,  and,  second,  those 
sent  for  convulsive  disorders  from  the  general  hospitals.   In  the 
number  above  mentioned  there  were  106  epileptics  referred  for 
mental  disorder;  of  these,  63  had  flat  foot — iT  on  both  sides,  16 
jji   on  one  side;  of  the  65  epileptics  of  the  second  class,  34  had 
[|  flat  foot — 19  bilateral  and  15  unilateral;  that  is,  there  were  110 
ii!  flat  feet  in  the  first  category,  or  103  in  the  100,  and  53  in  the 
I!   second,  or  81  in  the  100.    Thus  the  flattening  of  the  plantar 
I   arch  shows  itself  most  often  in  individuals  who  have  most 
\   physical  and  mental  defects.    The  authors  enumerate  twelve 
1 1  classes  of  physical  anomalies  which  they  have  observed  among 
)j  the  subjects  of  flat  foot,  among  them  facial  asymmetry,  anoma- 
lies of  the  eye  and  ear,  spinal  deformities,  the  presence  of  the 
retro-anal  fossa,  imperfect  development  of  the  thorax,  hernia, 
phimosis,  anomalies  of  the  fingers  and  toes,  etc.    They  call  at- 
tention to  the  fact  that  flat  foot  does  not  always  imply  func- 
tional trouble,  since  many  mountaineers  with  flat  foot  are  ex- 
cellent walkers.   Lately,  drafted  men  with  flat  feet  are  accepted 
by  the  French  military  authorities,  unless  the  deformity  is  of  a 
severe  grade. 

Redard  (Gaz.  med.  de  Paris,  32,  p.  373,  1892)  describes  a 
variety  of  scoliosis  accompanied  by  flat  foot;  the  worse  foot  is 
.  on  the  side  of  the  lumbar  convexity,  and  the  pelvis  slopes  to- 
ward the  same  side,  most  frequently  the  left.  The  author  main- 
tains that  the  scoliosis  is  due  to  the  pelvic  obliquity,  and  finds 
this  variety  in  twelve  per  cent,  of  his  cases  of  lateral  cui'vature. 
The  treatment  consists  in  rectifying  the  flat  foot. 

In  an  excellent  essay  on  the  subject  by  John  Dane,  A.  B. 
{Boston  Med.  and  Surg.  Jour.,  Oct.  27,  Nov.  3  and  10,  1892), 
tracings  are  studied  from  the  feet  of  four  hundred  children  from 
nine  days  to  fourteen  years  of  age.  These  show  that  "  at  birth 
the  foot  does  not  seem  to  be  flat,  as  is  the  general  opinion." 
"From  one  to  eighteen  months,  arch  distinct;  sexes  alike;  one 
foot  better  than  the  other.    From  eighteen  months  to  three 


years,  arch  mostly  lost ;  exceptions  are  females.  From  three 
to  four  years,  arch  building  up;  unequal  in  two  feet;  femalea 
tending  to  form  earlier.  From  four  years  upward,  arch  estab- 
lished ;  sexes  alike;  both  feet  equal."  For  flat  foot  " general 
tonic  and  hygienic  treatment  is  of  the  flrst  importance."  Spe- 
cial exercises  are  walking  with  toes  pointing  directly  forward 
(Whitman);  rising  on  toes  and  slowly  rotating  heels  outward- 
Broad,  flat-laced  boots  with  a  slight  inward  curve  and  low- 
heel  shoes  should  be  worn.  For  the  mechanical  treatment  the 
author  recommends  Whitman's  plates,  for  which  he  takes  a 
mold  in  warm  dental  sheet-wax,  from  which,  after  oiling,  a 
plaster  mold  can  be  taken.  He  points  out  that  the  good  to  be 
derived  from  any  form  of  plate  is  strictly  negative.  It  prevents 
the  arch  from  further  breaking  down,  but  does  not  bui.d  it  up. 
This  must  be  done  by  manipulation,  special  gymnastics,  and 
general  hygiene. 

Walter  C.  Wood,  M.  D.  {Annals  of  Surgenj,  November,  1892), 
emphasizes  three  features  in  flat  foot:  1.  Partial  dislocation  at 
the  medio-tarsal  joint.  2.  Abduction  of  forefoot,  from  length- 
ening of  internal  border.  3.  Some  flat  feet  are  rigid,  others 
not.  In  recent  cases  rigidity  is  due  to  muscular  spasm,  later  to 
spasm  and  adhesions  between  tendinous  structures;  in  old 
cases  to  changes  in  bony  surfaces.  The  writer  has  observed  un- 
favorable results  from  Ogston's  operation.  He  favors  Thomas's 
method  of  building  up  the  inner  side  of  sole  three  eighths  to 
half  an  inch  in  mild  and  moderately  severe  cases.  For  severe 
cases  he  advises  forcible  reduction  under  an  anaesthetic,  Whit- 
man's spring,  and  massage. 

Clubfoot.  —  The  literature  of  clubfoot  has  increased  so 
rapidly  of  late  as  to  make  a  selection  embarrassing.  At  the 
last  session  of  the  American  Orthopisdic  Association  in  New- 
York  last  September,  out  of  a  total  of  thirty-three  papers  pre- 
sented, seventeen  were  on  clubfoot. 

Dr.  A.  B.  Judson  {Boston  Med.  and  Surg.  Jour.,  Sept.  22, 
1892)  has  made  a  clear  presentation  of  the  advantages  of  leverage 
continuously  applied  to  the  inner  side  of  the  foot,  and  progres- 
sively modified  to  meet  the  requirements  of  the  case.  He  lays 
special  emphasis  on  the  relation  of  the  weight  of  the  body  to 
the  pathology  and  treatment  of  this  affection,  urging  that  the 
reduction  of  the  deformity  be  efl'ected  in  infancy,  before  the 
weight  of  the  body  in  walking  is  added  to  the  resistance  to  be 
overcome,  and  that  the  foot  be  held  in  an  overcorrected  posi- 
tion by  the  continuously  acting  leverage  apparatus,  so  that  the 
child  may,  as  it  were,  stamp  his  foot  straight,  the  body  weight 
acting,  under  these  circumstances,  as  an  aid  in  correction. 

Dr.  A.  II.  Freiberg  {Medical  News,  Oct.  29,  1892,  p.  477) 
gives  an  interesting  account  of  the  ideas  and  methods  of  Pro- 
fessor Julius  \Yolff,  of  Berlin,  whose  clinic  he  has  personally  fol- 
lowed. Two  indications  are  recognized  in  the  treatment  of 
clubfoot.  "First,  we  must  bring  the  foot  into  proper  relation 
with  the  rest  of  the  extremity  and  the  body ;  and,  secondly,  we 
must  retain  it  there  in  functional  activity  for  a  sufficiently  long 
time  to  enable  the  bones  to  undergo  the  necessary  metamor- 
phosis as  a  result  of  their  function."  The  author  points  out  that 
all  the  bones  of  the  foot  are  involved  to  a  greater  or  less  de- 
gree; and  "Julius  Wolff  has  shown  that  the  shape  of  every 
bone,  as  well  as  its  internal  architecture,  are  the  expressions  of 
the  static  demands  upon  it.  He  has  also  shown  that  we  are  no 
longer  to  consider  the  bones  as  mere  levers  of  an  inert  material, 
but  as  living  tissues,  and  as  capable  of  accommodating  them- 
selves to  different  changes  as  are  our  other  tissues." 

It  follows  that  any  appliance  for  the  purpose  in  hand  must 
be  of  a  more  or  less  permanent  character.  Wolff  uses  plaster 
of  Paris,  but  in  a  manner  quite  different  from  most  operative 
surgeons — Kouig,  for  example,  who  forces  the  foot  rapidly  into 
shape  at  from  one  to  three  sittings,  with  considerable  violenoe 


230 


REPORTS  OK  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jodb., 


to  resisting  parts.  By  Wolff's  metliod  tlic  reduction  is  gradiKil 
and  is  bnmght  about  by  a  large  number  of  sittings  at  intervals 
of  a  few  days,  and  no  violence  is  used.  Slight  deformities  are 
treated  without  tenotomy  ;  in  the  severe  forms  tenotomy  of  the 
lieei  cord  and  sometimes  of  the  plantar  fascia  is  practiced. 
Great  pains  are  taken  with  the  technique  of  the  phister  dress- 
ing, and  gradual  correction  is  effected  without  removing  the 
plaster,  by  cutting  a  wedge  of  plaster  from  the  dressing  on  the 
outer  side  of  the  ankle  Joint,  prolonging  the  cut  over  the  front 
of  the  joint,  and  fixing  the  foot  in  the  improved  position  by  an 
additional  plaster  bandage.  Tliis  is  repeated  as  often  as  neces- 
sary, and  correction  is  complete  within  four  weeks;  the  cast  is 
then  strengthened  and  the  patient  is  allowed  to  walk  in  shoes 
fitted  over  the  dressing.  The  patient  wears  the  cast  for  weeks 
or  years  under  surgical  observation.  Wolff  denies  that  forcible 
redressement  or  bloody  operations  are  necessary.  The  writer 
reports  an  ideal  result  in  a  case  of  Wolff's,  now  twenty-eight 
years  old,  which  was  treated  eight  yeais  ago. 

Dr.  Bilhaut  {AmiaJes  orthopedic,  April  1  and  Oct.  15,  1892) 
believes  that  congenital  clubfoot  should  be  treated  early  by 
careful  and  not  too  rapid  manual  redressement,  without  tenoto- 
my, and  retained  in  a  gutta-percha  splint  and  kept  in  position 
and  under  observation  for  a  considerable  time.  lie  reports  a 
successful  case  where  treatment  was  begun  at  the  age  of  four 
days.  He  believes  operative  procedures  unnecessary  except  in 
neglected  cases. 

Lateral  Curvature.— Dr.  F.  Beely,  of  Berlin  (reprint  from 
Trans,  of  the  American  Orthopaedic  Assoc.,  1891),  gives  an  analy- 
sis of  the  osseous  deformities  in  scoliosis  resulting  from  the  pres- 
sures and  strains  falling  upon  the  bodies  of  the  vertebrai  and  their 
arches.  The  changes  occur  according  to  the  law  that  traction 
and  pressure  act  as  stimulants  to  the  deposition  of  bony  tissue, 
while  macroscopic  growth  takes  place  in  the  direction  of  least 
resistance.  In  concluding,  he  calls  attention  to  the  fact  that  in 
many  cas3s  of  scoliosis  the  sulcus  paraspinosus  is  in  the  dorsal 
region,  shallow  and  broad  on  the  concave  side,  deep  and  nar- 
row oa  the  convex  side.  In  the  lumbar  region,  with  the  curve 
reversed,  the  groove  is  shallow  and  broad  on  the  convex  side, 
and  deep  and  narrow  on  the  side  of  the  concavity. 

Dr.  Messner,  of  Wiesbaden,  describes  the  unilateral  atrophy  of 
the  thorax  and  curvature  of  the  spine  following  infantile  paralysis 
{Centralhlatt  fur  Chirurgie,  No.  44,  1892).  In  a  hundred  and 
fifty-six  cases  of  lateral  curvature  the  author  found  eight  due  to 
infantile  paraly^is.  Paralytic  scoliosis  becomes  fixed  very  late  or 
not  at  all,  owing  to  relaxation  and  stretching  of  the  spinal  liga- 
ments. There  is  no  real  rotation  or  rib  deformity,  according  to 
the  author,  even  in  old  and  severe  cases.  In  tlie  cases  observed, 
the  convexity  of  the  dorsal  curve  was  always  toward  the  sound 
side,  while  the  paralyzed  respiratory  mu.scles  were  on  the  concave 
side.  Tlie  prognosis,  except  in  severe  cases,  is  more  favorable  than 
in  the  ordinary  form  of  lateral  curvature.  The  deformities  should 
usually  be  preventable  by  the  use  of  electricity,  massage,  inunc- 
tions, and  cold  ablutions.  The  indications  for  treatment  are  to 
hold  the  spine  in  position  and  to  strengthen  the  spinal  muscles. 
For  the  first  tiie  author  recommends  a  light  removable  jacket 
applied  during  suspension  ;  for  the  second,  gymnastic  exercises, 
douches,  massage,  electricity,  and  stimulating  inunctions.  The 
exercise  should  be  given  for  an  hour  twice  a  day,  and  elec- 
tricity and  massage  once  daily.  The  author  reports  perfect  cures 
in  three  c.ises,  improvement  in  four. 

Pott's  Disease.— Dr.  John  Ridlon  {Medical  Record,  Sept.  17, 
1892)  reports  two  cases  of  lateral  deformity  of  the  spine  with 
rotation  made  worse  by  exercise  and  improved  by  spinal  sup- 
port. He  concludes  that  I^ott's  disease  was  present  as  the 
causative  factor. 

Dr.  Koyal  Whitman  writes  suggestively  {Medical  News,  Nov. 


19,  1892)  of  the  modification  and  prevention  of  llie  ultimate  de- 
formities of  Pott's  disease,  especially  in  the  middle  region  of  the 
spine.  He  points  out  that  the  mid-dorsal  region  is  specially  un- 
favorable as  regards  the  limitation  of  the  amount  of  the  de- 
formity, on  account  of  the  normal  posterior  curving  of  the 
spine,  the  movements  of  the  ribs  in  respiration,  tlie  movements 
of  the  arms,  and  the  exaggeration  from  compensatory  changes. 
"The  local  deformity  of  Pott's  disease  is  of  slight  importance  as 
compared  with  the  effect  on  the  spine  as  a  whole."  "  Our  efforts  ] 
should  be  directed  to  straightening  the  entire  spine  above  and 
below,  and  thus  to  limit  the  kyphosis  to  the  at  tual  extent  of 
the  disease."  The  author  calls  special  attention  to  the  value  of 
"backward  traction  on  the  shoulders  and  restraint  of  unneces- 
sary motion  of  the  arms,"  and  to  elevation  and  support  of  the 
chin,  in  order  to  throw  the  weight  of  the  head  backward. 
With  disease  between  the  fifth  and  tenth  dorsal,  and  deformity 
moderate,  but  the  head  and  shoulders  carried  forward,  the  au- 
thor uses  the  Taylor  brace  with  tlie  chest  piece  modified  to  bear 
in  front  of  the  shoulders  by  the  hollow  discs,  the  size  of  a  but- 
ter plate  ;  a  fixed  chin-supporter  is  so  adjusted  as  to  tilt  the  head 
back.  Medical  supervision  throughout  the  period  of  growth  is 
often  necessary  in  order  to  get  the  best  results. 

Mr.  W.  J.  Koeckel  gives  an  account  {Amtralian  Medical 
Jour.,  Sept.  15,  1892,  p.  424)  of  Iiis  surgical  experiences  at  the 
National  Orthoptedic  Hospital,  London,  of  which  he  was  for 
seven  years  one  of  the  senior  surgeons.  He  condemns  all  spinal 
supports  for  Pott's  disease  as  inadequate,  including  "  that  hol- 
low mockery  known  as  Sayre's  jacket."  He  uses  a  frame  re- 
sembling in  principle  the  wire  cuirass  to  immobilize  the  entire 
body  "from  the  crown  of  the  head  to  the  soles  of  the  feet." 
He  reports  good  results  in  several  cases  after  one  or  two 
years'  use  of  the  frame.  The  patient  can  be  carried  about,  but 
is  never  removed  from  the  frame. 

Hip  Disease. — Dr.  Lovett  and  Dr.  Morse  {Boston  Med.  and 
Surg.  Jour.,  Aug.  18,  1892)  describe  a  transient  or  ephemeral 
form  of  hip  disease.  The  writers  ascertained  that  in  the  years 
1888  and  1889  a  hundred  and  fifty-six  new  patients  with  hip 
disease  came  to  the  Children's  Hospital,  Boston.  Of  these, 
thirty-eight  made  fewer  than  four  visits  and  disappeared  from 
view.  In  February,  1892,  twenty-four  of  these  thirty-eight 
could  be  traced;  of  these,  eleven  had  hip  disease  of  the  or- 
dinary type,  while  thirteen  had  recovered  without  treatment. 
Of  these,  eigiit  appear  to  have  been  cases  of  simple  acute  syno-  . 
vitis,  but  in  the  remaining  five  the  bone  appears  to  have  been 
involved,  as  trochanteric  thickening  and  shortening  of  the  limb 
could  be  demonstrated  after  recovery,  which  took  place  in  a 
few  weeks  or  months.  The  authors  conclude  that  there  is  a 
transient  form  of  hip  disease  which  may  end  in  spontaneous 
recovery  within  a  few  months,  but  does  not  appear  to  differ 
in  its  symptoms  from  the  usual  form. 

Dr.  Lovett  gives  {Boston  Med.  and  Surg.  Jour.,  Oct.  13, 1892) 
a  clinical  classification  of  hip  disease.  He  finds  four  well-marked 
types : 

{a)  The  destructive  form,  which  is  rapid,  severe,  and  but  lit- 
tle influenced  by  ordinary  treatment ;  there  is  extensive  infil- 
tration of  soft  parts,  and  in  most  instances  the  disease  passes  on 
to  a  fatal  issue.  This  form  is  due  to  a  florid  tuberculosis  of  bone 
or  to  an  acute  infectious  osteomyelitis. 

{!>)  The  painful  form  ;  pain  is  a  prominent  symptom,  and  ex- 
acerbations are  common.  This  is  the  ordinary  form  of  hip  dis- 
ease and  is  due  to  focal  bone  tuberculosis,  where  irritation  sur- 
rounds the  foci,  and  the  tendency  is  to  ])urulent  degeneration. 

(c)  The  painless  or  quiet  form,  due  to  the  fibroid  form  of  focal 
bone  tuberculosis^,  with  little  irritation.  In  these  cases  spasm 
and  atroi)hy  are  prominent  symptoms,  and  the  course  is  slow 
with  a  tendency  to  ankylosis. 


Feb.  25,  1893.J 


^TEW  INVENTION'S. 


231 


{d)  The  transient  or  ephemeral  form,  due  probably  to  a 
focus  of  tuberculosis,  which  is  rapidly  absorbed,  or  is  so  distant 
from  the. joint  as  to  cause  little  or  no  synovial  irritation. 

In  a  discussion  on  coxalgia  and  the  serious  nrticnlar  affec- 
tions of  the  lower  extremity  at  the  Imperio-royal  Medical  Soci- 
ety of  Vienna  (Mercredi  medical,  Paris,  Nov.  23,  1892,  p.  5G8), 
Dr.  Lorenz  stated  that  the  object  of  mechanical  treatment  was 
to  relieve  pain,  thus  enabling  the  patient  to  sleep,  and  to  permit 
tlie  ])atient  to  live  as  much  as  possible  out  of  doors.  Pain  was 
generallydue  to  retlex  spasm  and  was  relieved  bythorou^di  fixa- 
tion ;  extensioii  in  addition  vvas  not  indispensable.  In  cases 
with  little  deformity  the  author  preferred  his  plaster  cuirass, 
consisting  in  a  negative  of  the  posterior  aspect  of  the  trunk  and 
affected  limb ;  to  this  an  extension  apparatus  was  added. 

Dr.  Albert  protested  against  the  indiscriminate  and  routine 
employment  of  either  extension  or  excision.  His  results  were 
less  favorable  (two  cures  in  thirty  cases)  than  Dr.  Lorenz's.  He 
had  obtained  good  results  from  ignipuncture  of  the  superficial 
joints. 

Dr.  Billroth  was  of  the  opinion  that  the  modern  treatment 
was  better  than  the  old.  He  believed  in  preliminary  redresse- 
ment  in  inveterate  cases ;  afterward  he  used  an  immobilizing 
apparatus.  He  said  that  resection  never  gave  a  good  functional 
result.  He  seldom  found  night  pains  or  gonalgia  in  hip  disease, 
and  he  found  early  abduction  in  only  ten  per  cent,  of  the 
cases. 

Mr.  Pollard  and  Mr.  Marshall  give  an  elaborate  report  {Lan- 
cet, July  23,  30,  and  Aug.  6,  1892)  on  37  cases  of  tuberculous 
disease  of  the  hip  joint,  for  which  excision  of  the  joint  was  per- 
formed in  36  cases ;  the  remaining  case  was  an  arthrotomy,  the 
acetabulum  alone  being  diseased. 

The  right  side  was  affected  in  19;  the  left  in  16;  not  re- 
corded, 2.  In  10  cases  the  cause  was  assigned  to  a  fall  or  blow 
on  the  hip.  One  case  occurred  while  a  double  hip  splint  was 
being  worn  on  account  of  disease  of  the  other  hip. 

Duration  of  the  Disease  hefove  Operation. — Less  than  one 
year,  IS  cases  (of  these,  5  less  than  six  months).  Between  one 
and  two  years,  14  cases.  Over  two  years,  10  cases.  Abscess  in 
front  of  the  great  trochanter,  29  cases;  abscess  behind  the  great 
trochanter,  3  cases ;  not  recorded,  1  c:ise.  Four  cases  had  dis- 
charging sinuses  before  operation.  In  35  cases  the  head  of  the 
femur  and  the  acetabulum  were  denuded  of  cartilage  ;  in  5  the 
trochanter  was  also  diseased ;  in  1  the  acetabulum  alone  was 
diseased;  in  1  the  head  of  the  femur  was  removed  as  a  seques- 
trum. The  anterior  incision  was  practiced  thirty-three  times ; 
the  posterior,  four  times. 

Results  of  OperaJice  Interference. — Five  died  before  healing 
of  the  wounds — 2  of  shock,  1  of  iodoform  poisoning,  1  of  collapse 
on  the  eighth  day,  1  of  tubercular  meningitis  in 
eleven  weeks.  Eighteen  wounds  healed  by  pri- 
mary intention.  Fourteen  healed  in  from  three 
to  five  months.  In  26  of  the  32  cases  in  which 
the  patients  survived  the  excision,  or  all  but  6, 
recurrence  of  the  disease  took  place;  of  the 
remaining  6  patients,  1  died  of  diphtheria  four 
weeks  and  a  half  after  the  operation. 

In  12  cases  there  was  recurrence  of  bone  disease.  One  or 
more  secondary  operations  were  performed  in  the  26  relapsed 
cases. 

In  the  patients  that  recovered  from  the  excision,  improve- 
ment of  the  general  health  and  relief  from  pain  were  observed. 

Of  17  completed  cases  they  report  as  follows:  Shortening 
between  one  and  two  inches  in  9;  two  inches  in  5  ;  over  two  in 
3  cases;  average  shortening,  1-85  inch.  Most  had  some  abduc- 
tion, 80  that  the  average  apparent  shortening  was  1-3  inch. 

In  regard  to  motion,  the  cases  resulted  as  follows:  Immobil- 


ity of  joint,  2  cases;  little  mobility,  4  cases;  considerable  mo- 
bility, 11  cases. 

Flushing  with  Barker's  flushing  curette  was  done  in  12  cases; 
1  patient  died  of  shock.  They  remark  that  "  recurrence  of  dis- 
ease appears  to  occur  frequently,  whatever  method  of  treatment 
be  adopted  "  (page  303).  Seven  cases  were  treated  without 
drainage;  in  eight  cases  drainage  was  used  from  eighteen  to 
forty-eight  hours;  in  thirteen  cases  it  was  used  from  four  days 
to  several  weeks. 

There  was  healing  by  primary  union  in  71"4  percent,  of  cases 
treated  without  dramage ;  in  75  per  cent,  of  cases  treated  by 
drainage  up  to  forty-eight  hours ;  and  in  53  per  cent,  of  cases 
treated  by  drainage  longer  than  forty-eight  hours. 

Of  18  wounds  which  healed  by  primary  union,  4  remained 
sound  when  last  seen,  one  year  to  two  years  and  five  months 
after  the  opei-ation ;  1  patient  died  of  intercurrent  disease;  1 
case  was  uncertain;  12  cases  relapsed,  in  5  of  which  there  was 
relapse  of  bone  disease. 

Of  20  cases  (17  completed  cases,  and  3  which  remained 
healed  more  than  a  year  after  primary  union),  16  relapsed ;  5 
patients  had  one  secondary  operation ;  5  had  two  secondary 
operations;  3  had  three  secondary  operations ;  2  had  four  sec- 
ondary operations;  1  had  five  secondary  operations. 

The  authors  remark  that  "  the  results,  if  considered  from  all 
points  of  view,  appear  to  us  to  be  much  less  encouraging  than 
the  advocates  of  the  methods  followed  were  led  to  anticipate 
would  be  the  case." 


[fto  dnbfntions,  tit. 


A  NEW  NEEDLE. 

By  D.  Tod  Gilliam,  M.  D., 
columbus,  ohio. 

All  needles  with  a  handle  are  open  to  one  objection — viz., 
they  are  too  heavy.  Another  serious  objection  to  those  com- 
monly in  use  is  the  difficulty  in  threading,  as  the  process  of 
threading  has  to  be  repeated  every  time  they  are  thrust  through 
the  tissues  and  withdrawn.  If  a  good-sized  eye  is  made,  it  is  at 
the  expense  of  a  cumbersome  and  formidable  instrument — too 
large  to  be  thrust  through  the  tissues  with  impunity.  Then, 
again,  the  eye  of  the  needle  is  its  weak  point,  and  it  is  here  that 
the  needle  almost  invariably  breaks.  If  they  are  constructed 
so  as  to  thread  from  the  side,  they  are  still  more  bulky  and  are, 
apt  to  cut  the  suture  or  ligature,  which  in  the  latter  event  may 


prove  a  serious  matter,  as  I  have  known  disastrous  consequences 
follow  the  ligation  of  an  ovarian  pedicle  with  a  thread  weakened 
in  this  way.  In  order,  as  much  as  possible,  to  obviate  these 
defects,  1  have  had  constructed  for  me  by  Messrs.  George  Tiemann 
&  Co.  the  needle  hei-ewith  shown.  It  differs  from  other  needles 
in  that  it  is  ])rovided  with  an  automatic  steel  spring  eye  which 
disap[)ears  in  passing  through  the  tissues  and  reappears  when 
the  pressure  is  removed.  The  eye,  which  consists  of  tempered 
steel  wire,  is  sprung  into  a  little  slot  on  the  concave  side  of  tlie 
needle  near  its  point,  this  pait  of  the  needle  being  tubular.  On 


232 


MISCELLANY. 


[N.  Y.  Med.  Joto. 


the  principle  that  a  tube  with  its  wall  of  proper  thickness  is 
stronger  than  a  solid  rod  of  equal  diameter,  the  needle  is  not 
weakened,  but,  if  anything,  made  stronger  tlian  a  solid  needle. 
There  is  no  eye  to  weaken  it  at  this  point  or  to  increase  its 
diameter.  The  needle  penetrates  easily,  tlie  spring  yielding 
kindly  to  the  pressure  of  the  tissues  and  springing  oat  again, 
presenting  a  large  eye  immediately  the  pressure  is  removed. 
Should  the  spring  break  or  rust,  or  if  for  any  occasion  it  should 
be  desirable  to  remove  it,  it  can  easily  be  replaced  by  another. 
It  has  a  wide  range  of  application  as  a  suture  and  ligature 
carrier,  and  has  the  advantage  of  being  always  ready,  I  am 
indebted  to  Messrs.  Tiemann  &  Co.  for  suggestions  in  perfect- 
ing the  instrument. 


^  i  s  c  c  1  hi  n  g » 


The  Section  in  Laryngology  and  EMnology  of  the  Pan-American 
Medical  Congress  is  now  thoroughly  orgaui/.ed  with  secretaries  in  all 
the  countries  of  South  America  as  well  as  in  the  United  States  and 
Canada.  The  president,  Dr.  E.  Fletcher  Ingals,  of  Chicago,  is  making 
a  thorough  canvass  to  secure  a  large  number  of  good  papers  for  the 
section,  and,  aided  as  he  will  be  by  the  able  secretaries,  Dr.  Murray 
and  Dr.  Maron  y  Alonso,  and  the  corps  of  honorary  presidents,  he  feels 
assured  of  the  success  of  this  department  of  the  congress.  The  honor- 
ary presidents  are : 

Dr.  Harrison  Allen,  Philadelphia ;  Dr.  Francke  H.  Bosworth,  New 
York;  Dr.  J.  Solis-Cohen,  Philadelphia;  Dr.  D.  Bryson  Delavan,  New 
York ;  Dr.  J.  F.  Dixon,  Portland,  Oregon ;  Dr.  Stephen  Dodge,  Halifax, 
Nova  Scotia ;  Dr.  W.  C.  Glasgow,  St.  Louis ;  Dr.  Frederick  I.  Knight, 
Boston ;  Dr.  George  M.  LefEerts,  New  York ;  Dr.  Alvaro  Ledan,  Villa 
Clara,  Cuba ;  Dr.  John  N.  Mackenzie,  Baltimore ;  Dr.  David  Matto, 
Lima,  Peru ;  Dr.  P.  Emelio  Petit,  Santiago,  Chile ;  Dr.  John  O.  Roe, 
Rochester,  N.  Y. ;  Dr.  Federico  Semeleder,  Mexico,  Mexico ;  Dr.  Charles 
E.  Sajous,  Paris,  France. 

The  secretaries  for  foreign  countries  are :  Dr.  Ovejero,  [Piedad  22] 
Buenos  Ayres,  Argentine  Republic ;  Dr.  H.  Guedes  de  Mello,  Rio  de 
Janeiro,  U.  S.  of  Brazil ;  Dr.  G.  W.  Major,  Montreal,  Canada  ;  Dr.  Felix 
Campuzano,  [Virtudes  33]  Havana,  Cuba  ;  Dr.  Luis  Fonnegra,  [Calle 
10,  N  limero  263]  Bogota,  Colombia  ;  Dr.  Fabricio  Uribe,  Guatemala, 
Guatemala  ;  Dr.  Henri  Goulden  McGrew,  Honolulu,  Hawaii ;  Dr.  Angel 
Gavino,  [Cocheros  15]  Mexico,  Mexico ;  Dr.  J.  Midence,  Leon,  Nicara- 
gua;  Dr.  Eugenios  Cassanello,  [San  Jos6  119]  Montevideo,  Uruguay; 
Dr.  Napoleon  F.  Cordero,  MeriJa,  Venezuela. 

All  physicians  interested  in  this  section  are  requested  to  correspond 
with  one  of  the  secietarics  for  the  United  States,  Dr.  J.  Maron  y  Alonso 
(Spanish-speaking),  Las  Vegas,  N.  M.,  and  Dr.  T.  Morris  Murray  (Eng- 
lish-speaking), "Washington,  D.  C. 

The  Physiological  Action  of  the  Active  Principles  of  Frechites 
Suberecta. — Mr.  R.  B.  Wild  contributes  to  the  February  number  of  the 
Medkal  Chronicle  the  following  abstract  of  an  article  by  Mr.  Ralph 
Stockman,  in  the  Laboratory  Reports  of  the  Royal  Colkr/e  of  Physicians, 
^  Edinburgh,  vol.  iv :  The  Urcchites  suberecta  belongs  to  the  natural 
order  Apocynacece,  and  grows  abundantly  in  Jamaica  and  other  West 
Indian  islands,  where  it  is  known  as  the  "  savanna  flower "  or  "  yel- 
low-flowered nightshade."  It  is  notoriously  poisonous,  and  is  supposed 
to  have  been  the  chief  poison  used  by  "  Obeah  men  "  in  the  time  of 
slavery. 

Bowrey  separated  from  the  leaves  two  active  substances — urecfdtin 
and  urechitoxin.  These  are  both  glucosides,  with  an  intensely  bitter 
taste  when  in  solution ;  the  former  is  insoluble,  the  latter  slightly  solu- 
ble in  water.  Experiments  with  urechitin  showed  that  it  is  a  very  ac- 
tive poison,  similar  in  its  general  action  to  digitalin.  The  isolated 
frog's  heart  in  "  Williams's  apparatus  "  was  killed  in  nine  minutes  by  a 
solution  containing  1  part  in  200,000,  and  in  two  hours  by  a  solution  of 
1  in  10,000,000.    The  blood  pressure  in  rabbits  wag  raised  in  the  early 


stages  of  poisoning,  and  fell  in  the  later  stages  until  the  heart  stopped 
beating.  Rabbits  were  much  less  susceptible  to  the  poison  than  dogs. 
Urechitoxin  also  proved  to  be  a  muscle  and  heart  poison,  but  very 
much  less  active  than  urechitin ;  neither  substance  caused  contraction 
of  the  blood-vessels  of  the  frog  when  locally  applied.  With  regard  to- 
the  marvelous  stories  told  of  the  poisonous  action  of  the  plant,  there  is 
a  certain  admixture  of  truth  and  falsehood — a  full  lethal  do.se  will  be 
fatal  within  a  few  hours  or  a  day  or  two ;  a  single  dose  of  the  poison 
can  not  be  so  administered  as  to  be  fatal  after  the  lapse  of  days  or 
weeks.  On  the  other  hand,  if  repeated  minute  do.ses  be  given,  there 
seems  to  be  no  doubt  that  an  animal  or  man  may  remain  all  the  time 
in  apparently  good  health  and  then  die  suddenly.  The  explanation  of 
the  long-delayed  action  and  sudden  death  in  such  cases  is  to  be  found 
in  the  well-known  accumulative  action  of  digitalin  and  similarly  acting 
bodies ;  the  small  repeated  doses  cause  an  accumulation  of  the  poison 
in  the  heart  muscle  until  a  stage  is  reached  when  the  heart  is  so  thor- 
oughly poisoned  that  death  ensues  from  cardiac  failure. 

It  is  improbable  that  Urechitex  suberecta  will  ever  prove  to  be  of 
value  as  a  cardiac  tonic,  as  it  possesses  in  a  high  degree  the  objec- 
tionable accumulative  properties  which  have  been  so  often  remarked  in 
the  case  of  digitalis. 


JTo  Contribnton  and  Corresi)ondent«. — The  attention  of  all  who  purpone 
favoring  us  with  communications  is  respectfully  called  to  the  follovo- 
ing: 

Authors  of  articles  intended  for  publication  under  the  Jiead  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  rnanmcript  is  sent  to  this  jour- 
nal, a  similar  manuscript  or  any  cdistract  thereof  mxist  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notifed 
of  tJie  fact  at  the  time  the  article  is  sent  to  us  ;  {S)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  vnll  ht 
published  as  promptly  as  our  otlier  engagements  will  admit  of — w» 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  viishes  complied  with  must  be  distinctk 
stated  in  a  communication  accompanying  the  manuscript,  and  n< 
new  conditions  can  he  considered  after  the  manuscript  has  been  put 
into  the  type-setters^  hands.  We  are  often  constrained  to  decline 
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not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  tcith  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  itderest  to  tJie  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  vihether  intended  for  publication  or  not,  must  contain  the 
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tention will  be  paid  to  anonymous  communications.  Hereafter,  cor- 
respondents asking  for  iiiformation  that  we  are  capable  of  giving, 
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under  the  author^  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particidar  cases  or  recommend  indi- 
vidual practitioners. 

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

Newspapers  and  other  pidAicatioits  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  irJeresl 
to  our  readers  will  be  considered  as  doing  them  and  ns  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  communication*  relating  to  the  busineu  of  the  journal  should  be  ad- 
dressed to  the  publishers. 


THE  ]^EW  YORK  MEDICAL  JOURJ^AL,  March  4,  1893. 


dBriginal  Communiratbns. 


THE  PARASITIC  THEORY  OF 
THE  AETIOLOGY  OF  CARCINOMA  * 

By  ROSWELL  PARK,  A.M.,  M.  D., 

BUFFALO,  N.  Y., 

PBOFBSSOR  OF  8UBGERY,  MEDICAL  DEPARTMENT,  UNIVBRSITT  OF  BUFFALO  ; 
ATTBNDINO  SURGEON,  BUFFALO  GENERAL  HOSPITAL,  ETC. 

In  any  discussion  on  cancer  the  question  of  its  jetiology 
should  always  take  precedence  of  that  concerning  its  treat- 
ment, since  the  latter,  to  be  both  rational  and  effective, 
should  be  based  upon  the  former.  It  is  not  my  purpose  at 
present  to  consider  the  numerous  theories  put  forward  in 
time  past  to  explain  its  essential  cause,  but  rather  to  invite 
your  attention  to  a  resume  of  the  latest  and  perhaps  most 
fascinating  explanation  offered  as  to  the  prime  cause  of  this 
dreadful  malady. 

Just  who  is  entitled  to  the  credit  of  having  first  ad- 
vanced the  hypothesis  of  its  parasitic  origin  it  would  be 
hard  to  tell,  but  to  two  English  surgeon-pathologists, 
Hutchinson  and  Paget,  we  are  largely  indebted  for  having 
advanced  the  a  priori  plausibility  of  such  a  view.  In  a 
memorable  address  some  years  ago  the  latter  called  atten- 
tion to  the  parasitic  origin  of  most  of  the  xylomata  or 
woody  tumors  seen  on  so  many  trees,  and  ventured  the  pre- 
diction that  an  analogous  parasitic  origin  would  ere  long 
be  determined  for  many  of  the  tumors  met  with  in  the  ani- 
mal kingdom.  That  we  now  have  a  class  of  infectious 
granulomata,  acknowledged  by  all,  is  not  yet  sufficient 
realization  of  such  a  prophecy. 

Virchow  recognized  as  early  as  1847  certain  peculiar 
bodies  noted  in  and  between  carcinoma  cells,  which  he  then 
supposed  to  be  evidences  of  degeneration.  Their  true  na- 
ture was  not  made  out  till  1888,  when  they  were  identified 
as  belonging  to  the  sporozoa,  although  he  himself  later 
(Virchow's  Archiv,  Bd.  xxxiii)  suggested  the  possibility  of 
their  being  psorosperms. 

Inasmuch  as  the  present  paper  deals  mainly  with  these 
organisms,  it  will  be  proper  to  stop  here  a  moment  to  re- 
hearse a  few  statements  concerning  their  nature  and  place 
in  the  animal  kingdom.  First  of  all,  they  are  distinctly  not 
bacteria,  which  are  vegetable  organisms,  but  belong  to  the 
protozoa  or  unicellular  animal  forms. 

The  GregarinidcE  are  included  in  the  suborder  Endo- 
plastica  and  subclass  Sporozoa,  according  to  Leuckart,  and 
are  described  as  having  ovoidal  or  spheroidal  bodies,  some- 
times with  a  segmental  constriction,  occasionally  with  one 
end  beaked  and  carrying  horny  spines.  They  consist  of  a 
I  dense  ectosarc  and  a  softer  endosarc,  containing  an  endo- 
plast  but  no  contractile  vacuole.  They  are  all  essentially 
i  parasitic.  They  have  neither  oral  aperture  nor  pseudopodia 
They  contain  granular  protoplasm  with  nucleus  and  nucleo- 
lus, and  vary  in  size  even  up  to  a  centimetre  in  diameter. 

The  Coccidia  form  another  subclass  of  the  Sporozoa,  are 


*  Read  before  the  Medical  Society  of  the  State  of  New  York  at  its 
eighty-Beventh  annual  meeting. 


quite  similar  to  the  foregoing,  but  have  a  micropyle  at  one 
end. 

According  to  another  classification,  the  Sporozoa  or 
Cytozoa  are  divided  into  four  subclasses,  as  follows :  Ore- 
garinidea  (by  some  held  to  include  the  coccidia) ;  Coccidi- 
idea  or  Microsporidia ;  Myxosporidia ;  Sarcocystidia  or 
Sarcosporidia. 

But  minutiae  of  classification  aside,  it  is  enough  for  our 
present  purposes  that  the  bodies  in  question  are  exceeding- 
ly minute  forms  of  unicellular  animal  life.  In  1878  Rivolta 
(Dei  parassiti  vegetali,  Turin,  1878)  and  Bollinger  (Vir- 
chow's Archiv,  Bd.  Iviii)  recognized  their  parasitic  nature 
and  identified  them  as  Gregarince  ;  and  they  gave  to  the 
lesions  found  in  fowls  and  pigeons  which  so  closely  resem- 
ble molluscum  the  suggestive  name  epithelioma  gregarino- 
sum.  In  1880  Nedopil,  Herisson,  and  others  thought  to 
characterize  miliary  carcinomatosis  as  an  infectious  disease. 
Neisser,  in  a  study  of  molluscum  contagiosum  ( Vierteljahr- 
schft.  f.  Dermatol.,  1888,  xv,  553),  distinguished  between 
their  spores  and  better  developed  stages.  He  only  studied 
them  in  sections,  his  culture  and  inoculation  experiments 
failing.  He  found  them  in  greatest  number  in  affected  tis- 
sues, but  also  in  uninjured  cells  and  adjacent  tissues. 

L.  Pfeiffer  described,  also  in  1888  {Zeitschft.  f.  Hygiene, 
1888,  iii,  3,  and  iv,  422),  certain  bodies  met  with  in  two 
cases  of  general  carcinosis  and  one  of  sarcoma  of  the  breast, 
and  regaided  them  as  belonging  to  the  Sporozoa.  He  found 
them  in  the  epithelial  cells  of  a  fresh,  warm  melanotic 
growth,  and,  studying  their  developmental  stage,  saw  that 
it  resembled  closely  the  spore  formation  of  the  Micro- 
sporidia. (See  also  Die  Protozoen  als  Krankheitserreger, 
Jena,  1890.) 

Darier,  in  1889,  observed  certain  bodies  which  he  be- 
lieved to  be  coccidia  in  a  hitherto  undescribed  skin  disease 
to  which  he  gave  the  name  psorospermose  folUculaire  vege- 
tante  (Annales  de  derm,  et  de  syph.,  1889,  No.  7),  and  later, 
with  Wickham  [Ctrlbl.  f.  path.  Anat.,  i,  682),  he  attrib- 
uted Paget's  disease  of  the  nipple  to  a  coccidium  which  in- 
vades the  skin. 

It  would  certainly  seem  as  though,  provided  Paget's 
disease  of  the  nipple  is  a  factor  in  the  production  of  cer- 
tain mammary  cancers,  and  that  it  is  a  true  psorosper- 
mosis, the  best  conditions  for  a  study  of  the  parasitic 
nature  of  cancer  would  be  met  with  in  cases  of  this  dis- 
ease. 

Hutchinson,  Jr.  ( Trans,  of  the  Path.  Soc.  of  London,  xli,. 
1890,  214),  and  Wickham  [Archives  de  med.  experimentale, 
1890,  i,  1  ;  Annales  de  dermat.  et  de  syph.,  1890,  i  and  ii)- 
have  both  studied  the  matter  carefully,  the  latter  with  seven 
cases.  Wickham  describes  three  stages  of  the  disease  after 
invasion : 

1.  Thickening  and  disorganization  of  the  epidermis  and 
inflammation  of  the  corium. 

2.  Elevation  of  the  horny  cells,  lively  escape  of  leuco- 
cytes which  crowd  aside  the  epithelial  cells,  proliferation  of 
the  rete  mucosura,  and  the  e[)ithelium  of  the  sweat,  seba- 
ceous, and  milk  glands,  and  finally  extensive  infiltration  of 
the  cutis. 


234 


PARK:   PARASITIC  THEORY  OF  THE  AETIOLOGY  OF  CARCINOMA.    [N.  Y.  Meu.  Joub., 


3.  Stage  of  true  carcinomatous  growth  from  both  the 
superficial  and  glandular  epithelium. 

In  the  beginning  the  parasites  appear  with  or  without 
nuchi,  later  surround  themselves  with  a  double  membrane, 
while  the  contained  protoplasm  differentiates  itself  into  a 
number  of  granules,  and  thus  is  formed  what  he  calls  a 
sporiferous  cyst.  These  he  found  not  only  in  the  epider- 
mis, but  also  in  various  gland  ducts  and  in  the  pearly  bodies. 
In  spite  of  failure  to  cultivate  or  inoculate,  Darier  and  Wick- 
ham  did  not  doubt  their  parasitic  as  well  as  their  pathogenic 
character,  and  felt  that  under  their  influence  not  only  epi- 
thelioma but  other  forms  of  carcinoma  might  develop. 

Malassez  and  Albarrau  foimd  in  two  epitheliomata  of 
the  jaw  peculiar  bodies  having  striking  resemblances  to  the 
coccidiaso  often  found  in  the  livers  of  rabbits  {Soc.de  bioL, 
April,  1889),  and  Vincent  had  a  similar  experience  (Annales 
de  micrographie,  1890,  ii,  p.  10). 

Thoma  found  in  the  nuclei  of  many  cancer  cells  peculiar 
bodies  so  different  from  other  human  cells  that  he  consid- 
ered them  parasitic  and  thought  they  might  be  encapsulated 
coccidia  {Fortschrit.  d.  Med.,  1889,  p.  413). 

Sjorbring,  of  Lund  {ihid.,  p.  529),  studied  their  life  his- 
tory and  found  free  extracellular  as  well  as  intracellular 
and  spore  forms,  and  called  attention  to  their  resemblances 
to  the  organisms  which  produce  pebrine  in  silkworms. 

Steinhaus  examined  thirty  cancers  from  various  sources, 
sometimes  finding  these  bodies,  sometimes  not,  but  consid- 
ered them  parasitic  when  present  (Virchow's  Archiv,  Bd. 
cxxvi,  p.  633). 

Ilacke  described  in  1890  four  cases  of  cancer  in  which 
he  found  coccidia  in  and  among  the  cells,  varying  in  size 
from  two  to  fifty  microns,  the  smaller  intracellular  the  larger 
extracellular,  spherical,  encapsulated,  the  capsule  very  highly 
refractive.  Within  the  cell  they  often  appeared  as  in  a  vacu- 
ole, owing  to  the  shrinking  of  the  surrounding  protoplasm 
during  hardening.  As  they  grew  they  seemed  often  to  fill 
and  destroy  the  cell  {Soc.  de  bioL,  Nov.  8,  1890). 

Van  Heukelom,  of  Leyden,  studied  some  two  hundred 
tumors,  and  came  to  conclusions  essentially  those  of  Thoma 
and  Sjorbring  {Ctrlbl.f.  path.  Anat.,  1890,  p.  704). 

But  these  views  were  not  accepted  without  lively  dis- 
pute. Russell,  Piffard,  Schiitz  {Microscopische  Carcinombe- 
funde,  Frankfort,  1890),  Torok,  and  Tomraasoli,  among  oth- 
ers, after  minute  study  claimed  that  these  so-called  coccidia 
were  onl}'  altered  cells,  simple  masses  of  chromatin,  products 
of  degeneration,  etc.  Klebs  made  implantation  experiments 
without  success,  and  these  bodies  underwent  no  change  or 
increase.  Duplay  and  Cazin,  finding  no  such  changes  as 
they  thought  coccidia  in  their  evolution  should  evince,  con- 
cluded these  bodies  to  be  of  degenerative  origin  and  to  re- 
sult not  only  from  cells  but  from  mitoses. 

Ribbert  made  a  most  exhaustive  study  [Deutsche  med. 
Woch.,  1891,  p.  1179)  of  cell  inclusions  in  cancer,  and  con- 
cluded that  his  results  did  not  permit  his  acceptance  of  the 
parasitic  theory,  and  therefore  held  to  the  degenerative  view 
of  their  nature. 

Ramsay  Wright  {Ctrlbl.f.  allgem.  Path.,  1890,  No.  11) 
and  Russell  {Brit.  Med.  Jour.,  1890,  p.  1297),  while  not  so 
opposed  to  the  parasitic  view,  referred  these  bodies  to  the 


saccharomyces.  Moreover,  the  latter  found  among  them 
certain  granules  which  have  an  affinity  for  fuchsin,  the  so- 
called  "fuchsin  bodies"  (Fuchsinophile),  which  are  also  to 
be  found  in  other  pathological  and  normal  tissues. 

Cornil  {Journal  de  Vanat.  et  de  physiol.,  1891,  No.  1)  and 
Hansemann  (Virchow's  Archiv,  Bd.  cxxiii,  p.  356,  1890) 
think  it  possible  to  mistake  for  coccidia  or  their  spores  va- 
rious stages  of  karyokinetic  cell  division. 

Stroebe  (Ziegler's  Beitrdge,  1891,  xi,  lift.  1)  and  Stein- 
haus {Ctrlbl.f.  allgem.  Path.,  1891,  No.  2)  feel  compelled 
to  admit  the  sporozoan  nature  of  these  bodies,  but  are  not 
convinced  that  they  are  the  true  cause  of  cancer. 

Sudakewitsch  {Wratsch,  1891,  No.  49)  decides  that  "a 
carcinomatous  growth  of  epithelium  in  man,  as  well  as  in 
other  animals,  may  follow  the  immigration  of  parasites  be- 
longing to  the  Sporozoa''''  {Med.  News,  Jan.  7,  1893,  p.  20). 

While  all  these  studies  concerning  coccidia  were  in  prog- 
ress the  bacteriologists  were  by  no  means  idle.  Even  in 
1887  Scheurlen  published  his  address  on  the  aetiology  of 
cancer  {Deutsche  med.  Woch.,  1887,  No.  48,  p.  1033)  and 
described  a  small  spore-bearing  bacillus,  slightly  motile, 
easily  stained,  bleached  by  alcohol,  but  shown  by  Gram's 
method  and  its  spores  by  the  ordinary  stains.  He  found 
that  it  grew  on  agar,  on  potatoes,  and  in  broths.  This  ba- 
cillus was  difficult  to  find  in  sections,  and  its  spores  were 
found  in  only  about  one  cover-glass  preparation  of  cancer 
juice  out  of  three.  lie  also  described  the  appearance  of 
the  spores  in  unstained  preparations  in  words  which  almost 
make  one  who  reads  them  now  think  he  mistook  coccidia 
for  spores.  But  he  cultivated  his  bacillus  and  injected  it 
into  the  mammary  glands  of  dogs  and  found,  as  a  result, 
tumors  whose  most  notable  characteristic  was  cell  prolifera- 
tion. 

His  claim  to  priority,  by  the  way,  was  hotly  contested 
by  Freire  {Deutsche  med.  Woch.,  1888,  No.  1,  p.  14). 

In  a  discussion  following  the  reading  of  Scheurlen's  pa- 
per, A.  Fraenkel  expressed  himself  as  believing  that  cancer 
was  a  parasitic  disease,  but  that  its  prime  cause  might  be- 
long to  a  class  of  organisms  then  little  or  not  at  all  known, 
and  not  bacteria. 

In  a  critique  on  the  so-called  cancer  bacillus  Baumgar- 
ten  makes  some  very  sensible  remarks,  which  should  be 
carefully  noted  by  those  interested  in  the  subject  {Jahres- 
bericht  der  Mikroorganismenlehre,  1887,  iii,  p.  273).  He 
holds  that  cancer,  like  all  true  tumors,  is  an  abnormal  con- 
dition of  original  embryonal  elements,  according  to  views 
enunciated  by  Cohnheim,  and  that,  according  to  these, 
there  is  neither  need  nor  room  for  a  bacillus.  He  argues 
that  we  have  as  much  reason  to  expect,  e.  g.,  a  teratoma  ba- 
cillus. Or,  supposing  that  this  theory  be  held  only  to  con- 
cern a  certain  number  or  proportion  of  cases,  he  still  re- 
gards the  hypothesis  as  untenable,  since  it  has  no  analogies 
either  in  pathological  mycology  or  parasitology.  For,  so 
far  as  we  know,  he  maintains,  all  other  micro-organisms 
cause,  instead  of  cell  and  tissue  proliferation,  rather  exu- 
dative inflammation  and  tissue  necrosis,  the  later  prolifera- 
tion being  protective  when  present. 

I  may,  perhaps,  be  permitted  here  to  digress  for  a  mo- 
ment to  give  an  illustration  of  the  way  in  which  Cohnheim's 


I 


March  4,  1893.]        PARK:  PAEASITIC  THEORY  OF  THE  ETIOLOGY  OF  CARCINOMA. 


235 


views  may  be  made  to  suit  any  purpose.  The  writer  of  an 
editorial  in  a  recent  number  of  ihQ  Journal  of  the  American 
Medical  Association  (Jan.  14,  1893,  p.  49)  epitomizes  them 
to  this  effect :  that  they  constitute  a  theory  that  "  tumors 
are  due  to  exaggerated  growth  of  primary  remnants  of  em- 
bryonal folds  gone  astray  in  various  parts  of  the  body," 
and  states  that  it  has  been  severely  criticised  by  enthusiastic 
believers  in  the  parasitic  origin  of  carcinoma,  although  so 
good  a  bacteriologist  as  Baumgarten,  as  just  stated  above, 
falls  back  on  it  as  an  a  priori  argument  against  this  origin. 
But  this  same  writer  goes  on  to  say  that  it  has  been  shown 
that  embryonal  folds  exist  in  all  multicellular  organisms, 
and  that,  consequently,  invertebrates  would  theoretically 
be  just  as  liable  to  various  forms  of  tumors  as  the  higher 
animals  ;  "  hut  such  a  thing  as  carcinoma  has  never  been  de- 
scribed in  the  inferior  animals  up  to  the  present  time,  although 
they  are  very  liable  to  parasitic  tumors  of  various  kinds." 
(Italics  mine.)  Here  he  shows  a  lamentable  lack  of  knowl- 
edge, since  veterinary  and  pathological  records  and  mu- 
seums are  full  of  instances  such  as  he  denies,  while  that 
prince  of  comparative  pathologists,  J.  Bland  Sutton,  has 
described  numerous  specimens  which  have  come  under  his 
own  observation.  Hence  the  force  of  such  argument  is  at 
once  lost. 

Scheurlen's  position  was  also  speedily  attacked  from 
other  quarters — by  Senger,  A.  Pfeiffer,  van  Ermengem, 
Rosenthal,  Sanquirico,  and  Sanarelli  {Riforma  med.,  1888) 
— all  of  whom  insisted  that  his  cancer  bacillus  was  widely 
diffused  and  harmless,  while  Rosenthal  showed  that  it  fre- 
quented the  nipples  of  healthy  women  and  young  girls. 

Schill,  who  worked  at  this  subject  for  six  years,  ob- 
served something  which  he  described  as  consisting  of  two 
colored  (stained)  points  connected  by  a  hyaline  body,  which 
he  found  in  large  numbers  in  various  cancers,  and  which  he 
cultivated  and  considered  a  fungus  (Deutsche  med.  Woch., 

1887,  No.  48,  p.  1034). 

A  little  later  Nepveu  (Gazette  hebdom.  de  med.  et  de  chir., 

1888,  No.  18)  found  all  sorts  of  organisms  in  breaking 
down  and  ulcerating  cancers ;  and  Hauser  (AfUnchener  med. 
Woch.,  1888,  No.  12)  and  Markara  [Deutsche  med.  Woch., 
1888,  No.  31)  contested  Scheurlen's  hypothesis  on  patho- 
logical grounds. 

Scheurlen,  however,  rejoined  [Deutsche  med.  Woch., 
1888,  No.  30),  with  the  aid  of  Francke,  Lampiasi-Rubino, 
and  Magalhaes,  and  fought  for  the  acceptance  of  his  con- 
tentions, but  apparently  in  vain,  since  to-day  they  are  nearly 
forgotten.  Fatichi  [II  bacillo  di  Scheurlen  e  un  saprofita 
della  pelle,  Firenze,  1889)  cultivated  from  skin  of  normal 
individuals  a  bacillus  which  morphologically,  in  cultures, 
and  in  every  other  way,  resembled  Scheurlen's.  It  is  also 
identical  with  Bordoni-Uffreduzzi's  Bacillus  epidermidis. 

On  the  other  hand,  Koubassoff  professed,  in  1890  [Ctrlbh 
f.  Bakteriol.,  vii,  317),  to  have  found  in  cancerous  tumors 
a  bacillus  different  from  Scheurlen's,  which,  whert  implant- 
ed in  animals,  caused  disseminated  nodules,  histologically 
resembling  cancer,  and  final  death.  No  one  seems  to  have 
confirmed  his  researches. 

Balance  and  Shattuck  [Proc.  of  the  Royal  Soc,  xlviii, 
1890,  p  392)  reported  only  failures  to  find  any  organism  in 


cancers  (also  Brit.  Med.  Jour.,  1887,  Oct.  29,  p.  929).  Since 
1890  scarcely  an  article  has  appeared  on  the  subject  of  can- 
cer bacilli,  and  the  attention  of  all  workers  in  this  field 
seems  to  have  been  concentrated  on  the  Sporozoa  which  are 
alleged  to  cause  the  disease. 

Inasmuch  as  everything  now  points  in  their  direction,  it 
will  be  worth  while  to  refer  briefly  to  methods  for  their 
detection.  Pieces  of  cancer  tissue  should  be  preserved  in 
Flemming's  solution,  which  seems  to  cause  the  organisms 
to  appear  to  better  advantage.  The  stain  which  gives  the 
best  result  is  the  so-called  Ehrlich-Biondi  triple  stain,  whose 
formula  is  simple,  but  whose  happy  combination  seems  diffi- 
cult.   The  directions  given  are  to  dissolve — 

Methyl  green  0'5  in  distilled  water. ...   100  ; 

Acid  fuchsin  0-5  in  distilled  water.  ...     40 ; 

Orange  2*0  in  distilled  water   200. 

These  solutions  to  be  mixed  and  filtered  before  use.  Sec- 
tions are  left  in  it  for  twelve  hours,  then  washed,  dehy- 
drated, cleared,  and  mounted.  With  this  stain  the  nucleus 
of  the  cancer  cell  becomes  green,  the  protoplasm  orange-red> 
the  nucleus  of  the  parasite  red,  and  its  protoplasm  light- 
blue.  Working  with  it.  Puffer,  Walker,  and  many  others 
have  not  hesitated  to  pronounce  the  included  bodies  to  be 
true  parasites. 

At  a  meeting  of  the  London  Pathological  Society  held 
December  20,  1892  [Lancet,  December  31,  1892,  p.  1496), 
Jackson  Clarke  described  a  case  of  epithelioma  of  the  nose 
which  abounded  in  unmistakable  psorosperms.  To  be  sure, 
coccidia  with  stain-resisting  capsules  were  not  found,  but 
every  other  stage  of  rabbit's  coccidia  was  represented.  The 
idea  of  degeneration  was  negatived  by  beautiful  nuclear 
figures  and  by  clear  evidence  of  biological  processes.  Con- 
jugation and  amoeba  formation  were  observed.  Many  large 
psorosperms  lay  within  the  epithelial  cells,  whose  capsules 
were  seen  to  possess  perfect  radial  striation.  He  called  at- 
tention to  the  fact  that  most  writers  had  failed  to  distin- 
guish the  amoebae  from  leucocytes,  and  stated  that  the 
amoeboid  stage  of  the  parasite's  cyclic  existence  afforded 
the  key  to  the  malignancy  of  cancer.  He  had  found  clear 
evidence  of  the  following  processes  : 

1.  A  single  psorosperm,  or  one  formed  by  conjugation 
of  two,  becomes  changed  by  formation  of  a  reticulum 
which  extends  outward  from  the  nucleus  till  it  fills  the 
whole  cell. 

2.  The  reticular  plasmodium,  usually  surrounded  by  a 
capsule,  consisting  of  the  dead  and  distended  host  cell, 
breaks  up  into  rounded  segments  which  keep  the  reticular 
structure,  and  stain  faintly  purple  with  acid  hiematoxylin. 

3.  Within  some  of  these  daughter  psorosperms  fine 
filaments  of  chromatin  appear.  By  breaking  up  of  the 
same,  amoeboid  cells  are  set  free,  which  multiply  bv  division 
and  are  distinguished  from  leucocytes  by  treatment  with 
acid  haematoxylin. 

4.  These  amoeboid  bodies  make  their  way  in  vast  num- 
bers into  connective-tissue  spaces  beyond  the  epithelial 
part  of  the  growth.  In  passage  they  separate  epithelial 
cells  and  thus  facilitate  epithelial  down-growth  and  detach- 
ment of  small  groups  of  cells.  A  considerable  degree  of 
inflammation  is  caused  by  this  tissue  invasion,  with  results 


236 


PARK:  PARASITIC  THEORY  OF  THE  MTIOLOOY  OF  CARCINOMA.    [N.  Y.  Med.  Joub., 


similar  to  those  seen  in  inflammatory  papilloma  (e.  y.,  mu- 
cous tubercles) — i.  e.,  extension  of  epithelial  growth,  new 
formation  of  vessels,  etc. 

5.  Later  most  of  the  amoebae  disappear  and  the  resultant 
inflammation  subsides.  A  small  proportion  enter  epithelial 
cells  and  can  there  be  detected,  with  care,  even  in  their  non- 
nucleated  stage.  Those  that  remain  are  by  this  time  the 
somewhat  familiar  intracellular  psorosperms,  most  abun- 
dant in  and  about  cell  nests.  Arriving  at  a  certain  stage, 
the  cycle  is  renewed  and  a  fresh  extension  of  growth  takes 
place,  sometimes  with  detachment  of  venous  or  lymphatic 
emboli  and  resulting  metastasis.  Clarke  insisted  that  the 
cyclic  life  of  these  parasites  and  their  reaction  on  the  tis- 
sues could  account  for  all  the  phenomena  of  cancer. 

He  remarked  further  that  these  amoeboid  sporozoa  were 
identical  in  structure  with  some  of  the  plasmodia  met  with 
in  ague.  The  cyclic  cause  of  the  disease  corresponds  with 
the  cyclic  life  of  the  parasites.  From  a  psorospermosis  of 
the  spleen  and  lymph  nodes  it  is  but  a  step  to  leucocythse- 
mia  and  sarcoma.  In  a  cystic  scirrhus  he  had  found  the 
cream-like  contents  of  the  cyst  to  consist  wholly  of  amoe- 
boid psorosperms.  Apart  from  the  mystery  of  the  path 
(and  source)  of  infection,  the  nature  of  the  disease  is  now 
revealed. 

During  the  discussion  following  Clarke's  remarks  Mr. 
Shattuck  said  that  though  the  former  had  described  one 
cycle  of  growth  in  man,  it  was  quite  possible  to  have  another 
and  diifering  cycle  outside  the  human  organism — e.  g.,  in 
rabbits,  where  the  appearances  were  often  different.  He 
himself  inclined  to  the  view  held  by  Metschnikoff.  We 
can  not  infect  lower  animals  with  cancer  from  human  be- 
ings, but  are  seeking  now  how  to  cultivate  the  parasite  and 
then  inoculate  animals  with  it.  Instances  of  successful 
inoculation  are  at  present  as  rare  as  the  occurrence  of  cysti- 
cercus  in  man. 

That  indefatigable  worker,  Metschnikoff,  has  recently 
taken  part  in  this  discussion  by  an  argument  entitled  Re- 
marks on  Carcinomata  and  Coccidia  [Revue  generale  de 
sciences  pures  et  appliquees  ;  Jour,  of  the  Am.  Med.  Assoc., 
loc.  cit.).  He  states  that  these  so-called  parasites  have  the 
greatest  analogy  with  the  coccidia ;  be  contrasts  carcinoma 
with  coccidiosis  of  rabbit  liver,  and  sees  between  them  many 
points  of  striking  similarity.  Coccidiosis  is  an  infectious, 
parasitic  disease,  not  contagious,  its  lesions  nodular  in  ar- 
rangement, composed  of  proliferating  epithelium  of  biliary 
ducts,  the  cells  containing  the  parasites  or  Sporozoa  whose 
role  is  now  not  denied.  So,  too,  epithelioma  is  character- 
ized by  epithelial  proliferation  ;  is  not  contagious,  is  nodu- 
lar, and  its  cells  contain  peculiar  bodies  which  certainly 
present  most  accurate  resemblances  to  Sporozoa,  and  he 
concludes  the  researches  reported  to  be  sufficiently  reliable 
to  serve  as  a  starting  point  for  new  studies. 

The  most  elaborate  contribution  to  the  subject  is  that 
of  Podwyssozki  and  Sawtschenko,  of  Kiev,  entitled  Para- 
sitism in  Cancer,  with  Description  of  Certain  Parasitic 
Organisms  found  in  Cancerous  Tumors  [Ctrlbl.  f.  Bak- 
terioL,  1892,  xi,  pp.  493,  532,  559).  In  their  monograph 
they  have  considered  at  length  the  history  of  the  subject. 
They  also  call  attention  to  the  fact  that  a  multitude  of 


analogies  offer  where  epithelial  proliferation  is  due  to  the 
irritation  produced  by  parasites — e.  g.,  besides  the  changes 
in  the  rabbit's  liver  due  to  the  Coccidium  oviforme,  the  le- 
sions in  the  intestinal  mucosa  of  many  animals,  with  inflam- 
matory infiltrate  and  neoplastic  growths  caused  by  the  Coc- 
cidium perforans.  (Full  details  of  these  and  similar  lesions 
are  to  be  found  in  L.  Pfeiffer's  Die  Protozoen  als  Krank- 
heitserreger.)  To  even  summarize  their  most  interesting 
paper  would  be  to  exceed  the  limits  of  this  one  ;  but  some  of 
their  statements  must  be  here  epitomized  or  quoted.  For 
example,  this  :  "  The  more  pronounced  the  intensity  of  car- 
cinomatous proliferation,  the  more  numerous  the  mitoses 
in  the  cancer  cells  ;  the  softer  the  tumor  and  more  marked 
its  tendency  to  degeneration,  the  greater  the  number  of 
parasitic  organisms  in  its  cells.  They  are  best  to  be  found 
in  medullary  growths,  and  especially  in  those  of  the  breast ; 
in  epitheliomata  of  the  lips  and  face  they  do  not  abound." 

They  studied  these  sporozoa  in  more  than  twenty  cases 
of  miscellaneous  cancers,  and  looked  carefully  to  find  in 
them  the  same  biological  characteristics  that  are  found  in 
bodies  whose  protoplasmic  life  history  is  unquestioned, 
such  as  evidences  of  cell  division,  holding  that  the  dispute 
concerning  their  true  nature,  as  illustrated  by  the  papers  of 
Steinhaus  and  Stroebe,  was  due  to  the  failure  of  previous 
investigators  to  produce  convincing  evidence  thereof. 
They  find  the  sporozoa  either  inside  the  cells  or  in  the  in- 
tervening lymph  spaces,  and  furnish  some  beautiful  chromo- 
lithographic  reproductions  of  their  specimens.  These  bodies 
consist  of  cyst-like  cells  (sporocysts)  with  semilunar  nuclei, 
which  undergo  fission,  their  progeny  escaping  and  becom- 
ing disseminated  by  the  lymph  paths. 

They  consider  it  probable  that  the  parasites  display  a 
symbiosis  or  commensalism  with  the  epithelial  cells.  They 
leave  open  the  question  of  just  what  part  the  coccidia  play 
in  the  aetiology  of  cancer,  declining  to  express  convictions 
until  inoculation  experiments  with  cultures  shall  be  made 
possible.  (The  experiments  of  Delepine,  Brit.  Med.  Jour., 
May,  1891,  make  it  probable  that  this  happy  day  is  not  far 
off.)  That  we  have  here  to  do  with  a  true  parasitism  they 
do  not  doubt.  Or,  to  put  it  in  their  own  words,  "  In  a 
question  of  such  extreme  difficulty,  so  acknowledged  by 
zoologists  and  specialists,  as  the  determination  of  species 
of  sporozoa,  it  will  be  the  most  sensible  thing  to  '  go  slow ' 
{zuruckhalten) ;  for  the  immediate  present  it  is  enough  if  we 
can  ascribe  them  their  proper  place." 

Finally,  Foa,  of  Turin,  described  and  figured,  in  August 
of  last  year  {Ctrlbl.  f.  BakterioL,  1892,  xii.  No.  6.  p.  185), 
certain  bodies  found  in  and  about  cancer  cells  which  .stained 
with  hsematoxylin  and  showed  marked  variations  in  size 
and  configuration,  whose  evolutionary  phases,  appearances, 
segmentation,  and  behavior  to  stains  all  stamped  them  as 
parasites.  He,  however,  hesitated  to  insist  that  their  pres- 
ence was  more  than  accidental. 

Foa's  publication,  in  which  he  criticised  some  of  Pod- 
wyssozki's  statements,  has  provoked  a  very  recent  rejoinder 
from  the  latter,  in  which  he  reiterates  his  former  statements 
and  views,  and  promises  further  corroborative  evidence  in 
the  near  future  (ibid..  No.  16,  p.  551). 

Herewith  is  concluded  a  necessarily  incomplete,  because 


March.  4,  1893.] 


BRAISim:  OTITIS 


MEDIA  PURULENTA. 


23T 


brief,  summary  of  our  present  knowledge  bearing  on  one  of 
the  most  important  topics  now  or  ever  before  our  profes- 
sion. Wliile  the  parasitic  theory  is  by  no  means  new,  the 
facts  which  tend  to  substantiate  it  are  of  very  recent  dis- 
covery— so  recent,  in  fact,  that  it  would  be  unseemly  to  ac- 
cept them  as  all-sufficient.  Obviously  they  can  but  consti- 
tute a  mere  foundation  upon  which  we  may  hope  to  build. 
The  other  all-important  yet  subsidiary  topics  of  the  geo- 
graphical distribution  of  cancer,  and  the  influence  of  sex, 
age,  part  involved,  civil  and  sanitary  condition,  injury, 
heredity,  state  of  nutrition,  and  of  preceding  benign  growth, 
must  be  constantly  borne  in  mind.  Many  apparent  contra- 
dictions must  be  explained,  many  conflicting  statements 
reconciled. 

The  proper  position  for  the  real  student,  it  would  seem 
to  me,  is  in  the  middle  ground,  between  skepticism  on  the 
one  hand  and  credulity  on  the  other,  working  and  waiting 
for  the  light  that  we  have  great  reason  to  eagerly  expect, 
and  probably  from  the  direction  indicated  in  the  course  of 
this  paper. 

P'or  my  own  part,  I  can  not  help  feeling  that  we  are  on 
the  eve  of  great  discoveries  in  this  matter,  partly,  perhaps, 
because  I  have  for  years  had  a  growing  conviction  that  can- 
cer— and  syphilis,  too — were  parasitic  diseases,  due  to  either 
unfamiliar  or  yet  unknown  organisms,  and  that  some  new 
technical  method,  or  some  new  application  of  old  methods, 
would  ere  long  furnish  the  key  to  the  mystery.  Whether 
we  have  been  recently  supplied  with  this  by  the  investiga- 
tors quoted  above  is  as  yet  uncertain,  though  probable. 
How  anxiously  impatient,  yet  sanguine,  I  am  you  may  bet- 
ter appreciate  when  you  recall  that  my  home  is  (in  western 
New  York)  in  a  limited  area,  where  the  death-rate  from 
cancer  is  greater  than  in  any  other  part  of  our  continent. 


OTITIS  MEDIA  PUEULENTA 
FOLLOWING  AMPUTATION  OP  THE  UVULA.* 
By  WILLIAM  0.  BRAISLIN,  M.  D., 

BROOKITN. 

In  the  recent  edition  of  his  work  on  the  ear.  Buck  | 
calls  attention  to  the  not  uncommon  happening  of  tubercu- 
lar disease  of  the  middle  ear  in  private  practice,  and  "  among 
the  poorer  classes,"  he  states,  "  it  is  of  almost  frequent  oc- 
currence." 

The  following  case  of  otitis  media,  which  was  of  un- 
doubted tubercular  nature,  is  related,  not  because  it  was 
tubercular,  since  the  writer  shares  the  opinion  quoted  above, 
but  on  account  of  its  seeming  connection  with  a  condition 
of  the  throat  which  demanded  surgical  interference ;  and  also 
to  create  discussion  upon  the  possibility  of  surgical  proced- 
ures in  the  throat  having  a  direct  bearing  upon  the  aetiol- 
ogy of  suppuration  occurring  within  the  tympanum. 

The  patient,  a  man  of  tliirty-five,  a  traveling  salesmen,  has 
been  under  treatment  for  nearly  two  years,  lie  had  been  suf- 
fering from  a  chest  lesion  of  a  tubercular  nature  for  some  time 


*  Read  before  the  Long  Island  Medical  Societj',  December  1,  1892. 
t  A  Manual  of  Dineascs  of  the  Ear,  New  York,  p.  306. 


before  coming  under  observation.  An  examination  of  the  chest, 
made  on  March  30,  1891 — the  date  of  first  consultation — re- 
vealed a  very  extensive  consolidation  of  the  right  lung  and  a 
beginning  lesion  of  the  left  apex. 

On  the  26th  of  June,  1892,  he  was  compelled  to  consult  for 
the  relief  of  symptoms,  chief  of  which  was  a  cough.  This  was 
of  the  most  distressing  character.  He  complained  of  weakness, 
of  dizziness,  and  of  soreness  in  the  epigastric  and  abdominal 
regions,  superinduced  by  the  excessive  use  of  the  abdominal 
muscles,  called  into  play  by  his  constant  eiforts  of  coughing. 
The  cough  was  even  more  severe  on  lying  down.  It  often 
occurred  that  when  he  placed  himself  in  the  recumbent  pos- 
ture the  fit  of  coughing  superinduced  would  result  in  the  stom- 
ach being  emptied  of  its  contents.  An  examination  of  the 
throat  revealed  a  hypertemic  condition  of  the  pharynx,  iu 
marked  contrast  with  the  anaemic  hard  palate,  a  very  consider- 
able grade  of  post-nasal  catarrh,  and  the  uvula  elongated  a  full 
half  inch  beyond  its  normal  length.    The  appetite  was  good. 

An  amputation  of  the  uvula  was  advised  as  a  likely  method 
of  checking  the  severity  of  the  cough.  This  measure  for  his 
relief  was  performed  on  the  following  day.  Nothing  unusual 
resulted  except  the  pain  following  the  operation,  which  was 
excessive,  althoiigli  a  ten-per-cent.  cocaine  solution  had  preTi- 
ously  been  thoroughly  applied.  The  patient  stated  that  "  it  set 
his  teeth  aching." 

The  relief  which  followed  the  procedure  was  marked  and 
prompt,  so  far  as  the  excessive  coughing  and  the  vomiting  were 
concerned.  After  three  days  of  subsequent  treatment,  during 
which  an  unusual  amount  of  pain  was  complained  of,  the  pa- 
tient felt  so  much  better  that  he  started  on  the  road  again  to 
fulfill  pressing  business  contracts. 

This  constitutes  the  history  of  the  case  up  to  the  time 
when  the  ear  trouble  began. 

The  patient  was  next  seen  on  the  2Yth  of  September — three 
months  later.  lie  then  stated  that  his  right  ear  had  been  dis- 
charging for  six  weeks.  He  said  that  the  pain  which  resulted 
from  the  removal  of  the  uvida  had  "settled  itself  in  his  right 
ear,"  and  then  had  gradually  worn  away;  but  that  after  some 
time  the  ear  had  begun  to  discharge  without  any  pain  and  ap- 
parently "  of  itself." 

On  examination,  the  inner  extremity  of  the  auditory  canal 
was  found  covered  with  a  cheesy-looking  pus,  consisting  of  ac- 
cumulated epithelium,  pus,  and  debris.  On  removal  of  this,  the 
lining  membrane  of  the  canal  was  found  swollen  and  red,  and 
was  extremely  sensitive.  It  was  just  possible  at  this  time  to 
detect  a  perforation  occupying  a  position  in  the  tympanic  mem- 
brane anterior  to  the  handle  of  the  hammer.  Bone  conduc- 
tion was  better  for  the  tuning  fork  on  the  affected  side.  Air 
conduction  was  better  than  bone  conduction  on  both  sides. 
Hearing  distance  for  watch  was  A.  D.  j'j,  A.  8. 

After  a  few  days  of  treatment  the  swelling  of  the  canal  so 
far  subsided  that  it  was  possible  to  see  the  whole  of  the  tym- 
panic membrane.  It  was  then  evident  that  two  slit-like  perfo- 
rations existed  in  the  drum  membrane — one  anterior  and  one 
posterior  to  the  hammer  handle.  The  membrane  was  whitish 
and  o[)aque.  There  was  some  tinnitus  at  times.  The  discharge 
was  thin,  watery,  and  almost  without  odor.  Marked  tenderness 
at  the  contact  of  the  cotton-wool  probe  continued. 

After  a  month  of  very  regular  treatment,  without  any  ap- 
parent improvement,  the  patient  declined  any  further  treatment 
directed  to  the  ear. 

As  to  the  character  of  this  inflammation,  there  does  not 
seem  to  be  a  reasonable  doubt  but  that  the  suppuration  was 
of  a  tubercular  nature.    The  indications  for  this  conclusion 


238 


HINKSON:  SUPRAVAGINAL  HYSTERECTOMY. 


[N.  Y.  Mbd.  Jodb., 


are  the  lack  of  pain  at  the  time  the  discharge  began,  the 
obstinacy  of  the  disease  to  treatment,  notwitlistanding  all 
absence  of  bone  involvtment  in  the  disease  process  or  of 
any  other  of  the  common  causes  of  long-continued  suppu- 
ration, and  the  extensive  tubercular  lesion  already  existing 
in  the  patient's  lungs.  The  marked  tenderness  to  the  ap- 
plication of  remedial  measures,  which  was  a  prominent 
feature  of  the  case,  also  points  to  a  tubercular  variety  of 
otitis  media. 

The  question  to  be  considered  in  this  case  is  whether 
or  not  the  removal  of  the  uvula  had  any  direct  influence 
upon  the  development  within  this  patient's  middle  ear  of  a 
suppurative  inflammation. 

The  soft  palate,  and  with  it  the  uvula,  take  the  part  of 
a  valve  to  close  off  the  naso-pharynx  and  nares  during  the 
expulsory  effort  of  coughing. 

As  was  remarked,  the  soreness  and  pain  immediately  fol- 
lowing the  removal  of  the  uvula  were  very  noticeable.  This 
soreness  and  pain  led  to  an  involuntary  suppression  of  the 
strong  contractions  of  the  levators  of  the  palate,  naturally 
occurring  during  the  expulsory  action  of  coughing,  just 
such  as  occurs  in  the  muscles  of  the  diaphragm  during  an 
attack  of  peritonitis.  The  removal  of  the  uvula  also, 
doubtless,  contributed  to  the  freedom  with  which  coughed- 
up  sputa  entered  the  pharynx  and  thence  the  openings  of  the 
Eustachian  tubes.  It  is  possible,  at  any  rate,  that  such  was 
the  source  of  infection  of  the  middle  ear.  The  onset  of 
the  ear  trouble,  following  so  closely  upon  the  removal  of 
the  uvula,  makes  it  seem  probable  that  had  no  operation 
been  done,  the  middle- ear  disorder  would  not  have  occurred. 

It  is  further  to  be  said,  however,  that  the  removal  of  the 
uvula,  in  the  light  of  its  effects  upon  the  severity  of  the 
cough  and  reflexly  upon  the  general  health  of  the  patient, 
is  not  to  be  regretted,  since  the  present  inconvenience  of 
syringing  the  ear  is  certainly  less  than  the  extremely  de- 
generating effects  of  the  cough  and  the  dependent  vomiting 
in  connection  with  the  already  depressed  state  of  the  pa- 
tient. 

Sexton,*  speaking  of  the  affections  of  the  ear  result- 
ing from  diseased  teeth,  refers  to  a  nervous  connection 
sometimes  seemingly  existing  between  the  two ;  but  he 
properly  lays  much  more  stress  upon  the  evident  and  direct 
connection  arising  from  the  intimate  contact  into  which  the 
tympanum  and  oral  cavity  are  brought  by  means  of  the 
Eustachian  tube. 


SUPKAVAGmAL  HYSTERECTOMY 

PERFORMED  FOR  THE  REMOVAL  OF 
A  SUBPERITONEAL  FIBROCYSTIC  TUMOR  OP  THE  UTERUS. 

By  JOHN  R.  HINKSON,  M.  D., 

BLISSVILLB,  LONG  ISLAND  CITT,  NEW  YORK. 

Mrs.  E.,  aged  fifty,  a  mother  of  five  children,  was  seen  by 
the  writer  on  June  1,  1892,  having  been  called  in  consultation 
by  the  attending  physician.  On  examination,  the  abdomen  was 
found  to  bo  enormously  distended,  and  a  movable  body  could 
be  felt  which  reached  from  the  pubes  to  tlie  ensiforin  appendix. 
There  was  dullness  on  percussion  all  over  the  abdomen. 


*  American  Journal  of  the  Medical  Sciences,  1880,  vol.  Ixxix,  p.  24. 


On  vaginal  examination,  the  cervix  could  not  be  reached  by 
the  finger.  Some  fluctuation  was  detected  on  the  left  side  of 
the  tumor,  while  on  the  right  side  there  was  a  feeling  of  stony 
hardness. 

The  patient  was  very  much  emaciated.  Her  temperature 
was  102°  and  her  pulse  95.  She  complained  of  great  pain  and  of 
inability  to  retain  any  food.  She  was  a  complete  invalid  and  it 
was  with  great  difficulty  that  she  could  move  even  from  one 
room  to  another.    The  urine  contained  considerable  albumin. 

She  gave  the  following  history:  Eleven  years  ago,  while 
living  in  New  York  city,  she  consulted  her  family  physician 
about  a  swelling  which  she  had  noticed  in  the  right  iliac  region 
about  two  years  before  and  which  had  now  grown  to  about  the 
size  of  an  orange.  Her  physician  then  took  her  to  Dr.  Noeg- 
gerath,  who  told  her  that  the  operation  for  the  removal  of  this 
tumor  was  a  very  dangerous  one,  that  the  growth  of  such  tu- 
mors was  very  slow,  and  that  in  about  twelve  years  menstrua- 
tion would  cease  and  the  growth  of  the  tumor  would  be  ar- 
rested. 

Up  to  a  few  months  before  she  was  seen  by  the  writer  she 
suffered  no  pain,  but  the  weight  of  the  tumor  caused  her  con- 
siderable inconvenience.  Menstruation  did  not  cease  until  she 
was  forty-eight  years  of  age,  and  had  always  been  normal.  The 
diagnosis  of  a  uterine  subperitoneal  fibroid  was  made,  and  on 
the  3d  of  June,  1892,  it  was  decided  to  perform  laparotomy  at 
the  patient's  residence. 

Having  etherized  the  patient,  an  incision  four  inches  long 
was  made  in  the  median  line  of  the  abdomen,  allowing  a  quan-  ■ 
tity  of  ascitic  fluid  to  escape,  and,  on  exploration,  the  tumor 
was  found  to  be  free  from  adhesions.    The  incision  was  then'* 
prolonged  upward  to  about  six  inches  above  the  umbilicus,  and  ' 
the  tumor  turned  out  of  the  abdominal  cavity. 

The  tumor  was  found  to  be  cystic  on  the  left  side,  and,  in^ 
order  to  diminii^h  its  size,  an  incision  was  made  from  which  •{ 
three  quarts  of  fluid  escaped.  The  pedicle  was  very  broad  and 
thick  and  was  so  short  that  the  tumor  pressed  tightly  on  the 
abdominal  wall  and  rendered  manipulation  of  the  pedicle  ex- 
tremely difficult.  The  ovaries  were  found  on  either  side  of  the 
tumor.  It  was  first  determined  to  treat  the  pedicle  with  the 
serre-nceud  of  Cintrat,  but,  on  applying  it,  the  instrument  was 
found  totally  inadequate  for  the  purpose,  as  the  wire  gave  way. 
After  this  an  elastic  ligature  was  wound  round  the  pedicle  sev- 
eral times  and  Keith's  clamp  applied.  The  tumor  was  then 
separated  with  the  actual  cautery.  Having  done  this,  the  pedi- 
cle slipped  from  the  grasp  of  the  clamp  and  some  lisemorrhage 
occurred.  On  endeavoring  to  again  a[)ply  the  clamp,  it  was 
found  that  the  instrument  was  too  weak  to  stand  the  strain,  and 
that  it  was  impossible  to  approximate  the  blades. 

The  pedicle,  which  was  composed  of  the  uterus  and  broad 
ligaments,  was  then  grasped  on  either  side  with  Wells's  pedicle 
forceps.  There  was  no  haamorrhage  from  the  uterine  stump,  it 
having  been  arrested  by  the  cautery.  The  pedicle  was  then 
ligatured  in  sections  with  No.  4  braided  silk.  All  haemorrhage 
having  been  arrested,  the  abdomen  was  closed  by  interrupted 
sutures  of  wire  and  the  peritoneal  cavity  drained  by  packing 
with  iodoform  gauze. 

The  patient  did  not  bear  the  operation  at  all  well.  At  times 
the  pulse  became  so  feeble  that  it  was  feared  she  would  die 
on  the  table.  Hypodermic  injections  of  atropine,  whisky,  and 
nitroglycerin  were  used.  After  the  operation  she  recovered 
from  the  ana3sthetic  sufficiently  to  be  able  to  recognize  those 
about  her,  but  the  pulse  continued  very  rapid  and  feeble.  Her 
breathing  became  so  much  embarrassed  that  it  was  necessary 
to  perform  artificial  respiration. 

She  died  four  hours  subsequent  to  the  operation,  having  a 
temperature  of  106°.    The  operation  lasted  two  hours. 


March  4,  1893.] 


STAFFORD:  DILATATION  OF  THE  CERVIX  UTERI. 


239 


On  examination  after  death,  there  was  no  evidence  of  hasm- 
orrhago  having  occurred. 

The  tumor,  after  the  evacuation  of  the  cysts,  weiglied  seven- 
teen pounds  and  a  half. 


DILATATION  OF  THE  CERVIX  UTERI.* 
By  JAMES  STAFFORD,  M.  D., 

ATTENDING  GYN-ECOLOGIST  TO  THE  NORTHERN  DISPENSARY  ; 
ASSISTANT  ATTENDING  '  TN.KCOLOGI8T  TO  BELLEVUE  HOSPITAL, 
OUT-PATIENT  DEPARTMENT  ; 
OLtNICAL  ASSISTANT  IN  GTN^OOLOGT  AT  THE  NEW  YORK  POLYCLINIC  ; 
HEMBER  OF  TUB  SOCIETY  OP  THE  ALUMNI  OF  BELLBVUE  HOSPITAL,  ETC. 

I  WILL  preface  my  remarks  upon  this  subject  by  stating 
that  in  this  paper  I  refer  to  only  slight  stretching  of  the 
uterus,  not  forcible  and  extreme  dilatation,  known  as  divul- 
eion.  Some  physicians  consider  cervical  dilatation  of  but 
minor  importance,  and  prefer  divulsion  in  most  cases ;  but 
when  a  dilatation  is  performed  they  choose  to  do  it  at  the 
bedside  of  the  patient  and  rarely  as  an  office  treatment, 
and  after  the  operation  they  require  the  patient  to  keep  the 
bed  a  certain  length  of  time  before  being  allowed  to  sit  up. 
Others  believe  the  operation  to  be  an  important  one  ;  and  one 
that,  if  done  under  thoroughly  aseptic  and  antiseptic  pre- 
cautions, may  in  many  cases  be  safely  performed  upon  the 
office  table  and  afterward  the  patient  be  allowed  to  go  about 
her  duties,  with  instructions  merely  to  observe  quiet  for  a  few 
hours.  As  for  myself,  I  am  in  the  habit  of  doing  the  operation 
!l  in  my  office  except  in  the  case  of  young  unmarried  women 
or  women  who  are  unusually  nervous  and  sensitive  to  pain. 
Among  these  patients  I  advocate  doing  the  operation  at 
their  bedside,  and  even  then  often  prefer  anaesthesia,  divul- 
sion, and  the  use  of  a  drainage-tube  to  dilatation,  as  the 
pessary-tampon  treatment  which  I  generally  use  after  the 
operation  to  improve  the  pelvic  circulation,  and  sometimes 
as  a  support  to  the  uterus,  often  creates  a  fear  and  dread 
in  the  minds  of  these  patients,  so  that  they  are  very  re- 
luctant to  return  for  treatment,  or,  as  frequently  happens, 
seek  the  advice  of  some  other  practitioner,  with  a  hope 
that  his  treatment  of  their  case  will  be  less  painful  and  un- 
pleasant. AVith  the  exception  of  the  classes  of  cases  just 
mentioned,  I  almost  invariably  do  the  operation  upon  my 
Harvard  chair  in  the  office,  and  then  instruct  the  patient 
merely  to  limit  the  amount  of  exercise  during  the  succeed- 
ing twelve  hours ;  and  I  have  yet  to  record  among  a  large 
number  of  patients  so  treated  any  disease  of  the  pelvic 
organs  which  I  could  trace  to  this  operation  as  an  etiologi- 
cal factor. 

As  preparatory  treatment,  pessary  tampons,  saturated 
in  boroglyceride  and  glycerin,  and  copious  antiseptic  douches 
should  be  used  for  at  least  three  days,  and  for  a  longer 
period  should  there  be  much  attendant  uterine  congestion. 

The  operation  may  be  done  with  the  patient  either  in 
the  dorsal  or  in  Sims's  position.  When  the  dorsal  posi- 
tion is  selected,  the  external  genitals  should  be  rendered 
thoroughly  aseptic  and  the  vagina  be  thoroughly  cleansed 
with  an  antiseptic  douche.  As  an  additional  precaution, 
the  patient  should  then  be  turned  upon  the  side,  a  Sims 


*  Read  before  the  Society  of  the  Alumni  of  Bellevue  Hospital, 
October  5,  1892. 


speculum  be  introduced,  and  the  vagina  and  vaginal  portion 
of  the  cervix  be  washed  off  with  cotton  pledgets  soaked  in 
a  1-to- 3,000  corrosive-sublimate  solution.  The  dorsal  posi- 
tion should  then  be  resumed  and  a  digital  examination  made 
to  ascertain  the  location  of  the  os  and  fundus  uteri. 

The  uterine  probe,  guided  by  the  finger  in  the  vagina, 
having  been  used  to  determine  the  patency  and  course  of 
the  cervical  canal,  the  dilators  are  inserted  to  a  distance 
corresponding  to  the  index  on  the  instrument,  or,  if  there 
is  no  index,  to  a  depth  corresponding  to  the  measure- 
ment made  from  the  length  of  the  canal  as  ascertained 
by  the  probe.  The  remainder  of  the  treatment  is  so  like 
that  used  in  the  left  semi-prone  position  that  I  will  not  di- 
late upon  it  here,  but  state  my  objections  to  the  dorsal  po- 
sition. This  position  seems  far  less  practicable  than  the 
left  semi-prone,  as  the  parts  are  less  likely  to  be  as  asep- 
tic. Unless  the  vagina  is  large  or  the  perineum  torn  or 
unusually  elastic,  the  manipulations  will  be  more  unpleas- 
ant to  the  patient  and  difficult  for  the  operator.  As  less 
traction  is  made  upon  the  perinaeum  by  this  method  in  ex- 
treme anterior  positions  of  the  uterus,  it  will  be  more  diffi- 
cult to  introduce  the  instrument,  for  the  handles  of  the 
dilator  can  not  be  depressed  enough  to  make  the  instru- 
ment so  nearly  approach  a  parallel  to  the  axis  of  the  cervi- 
cal canal,  hence  there  would  be  more  traumatism  to  the 
parts.  Lastly,  the  operation  is  done  by  the  touch  to  a 
great  extent,  unaided  by  the  eye  ;  and  as  the  portion  of  the 
dilator  which  enters  the  uterus  must  necessarily  come  in 
contact  not  only  with  the  examining  finger  but  with  thar 
vaginal  wall  before  entering  the  uterine  cavity,  there  is 
always  a  certain  amount  of  danger  of  conveying  sepsis  to 
the  endometrium. 

I  much  prefer  the  left  semi-prone  position.    Having  in- 
troduced the  Sims  speculum,  I  render  the  vagina  and 
vaginal  portion  of  the  cervix  aseptic  by  means  of  pledg- 
ets of  absorbent  cotton  saturated  in  a  1 -to- 3,000  solution 
of  corrosive  sublimate.    The  position  of  the  fundus  uteri 
and  the  course  of  the  cervical  canal  having  been  ascertained, 
as  in  the  dorsal  position,  the  patient  is  prepared  for  opera- 
tion.   As  an  extreme  antiseptic  precaution,  aside  from  the 
soap  and  water  and  the  l-to-20  carbolic  solution,  I  usually 
place  the  uterine  portion  of  the  dilator  in  a  ninety-five-per- 
cent, solution  of  carbolic  acid,  and  wash  this  off  in  a  1-to- 
3,000  corrosive-sublimate  solution  just  previous  to  their  in- 
sertion.   To  introduce  the  dilator  I  grasp  the  lower  handle 
with  the  right  hand  and  endeavor  to  make  the  uterine  por- 
tion correspond  to  the  axis  of  the  cervical  canal  as  it  is 
being  inserted.  At  the  time  of  introduction  of  some  dilators 
it  is  necessary  to  make  traction  upon  the  cervix  ;  but  I  con- 
sider this  procedure  in  most  instances  inadvisable,  and  believe 
that  in  a  majority  of  those  cases  where  traction  is  used  it 
is  not  so  much  a  mistake  of  the  operator  as  the  use  of  a 
faulty  dilator.    The  objection  to  making  traction  upon  the 
cervix  as  the  instrument  is  introduced  is  that  the  dilator 
may  become  engaged  in  the  cervical  folds  at  the  angle  of 
flexion  near  the  internal  os,  and  thus  the  operator  deceive 
himself  by  elongating  and  stretching  the  lower  cervix,  and 
in  reality  not  cause  the  instrument  to  enter  the  uterine 
cavity  at  all. 


240 


STAFFORD:  DILATATION  OF  THE  CERVIX  UTERL 


[N.  Y.  Med.  Jotm., 


Such  accidents  are  said  to  happen,  and  I  should  not  be 
surprised  if  they  did  occur  much  more  frequently  than  is 
usually  supposed,  and  perhaps  this  is  a  reason  why  an  ex- 
ceedingly valuable  operation,  through  no  fault  of  its  own, 
but  at  the  hands  of  operators  performing  it  imperfectly, 
has  not  reached  that  degree  of  importance  among  the  pro- 
fession which  it  justly  deserves.  If  traction  is  used  at  the 
time  of  introduction  of  the  instrument,  it  should  not,  if 
avoidable,  be  continued  through  the  dilatation,  as  it  is  pref- 
erable to  have  the  cervix  relaxed  at  this  time ;  and  then 
again,  if  the  traction  were  kept  up,  an  unnecessary  degree 
of  stretching  would  be  done  at  the  external  os. 


As  before  stated,  traction  upon  the  cervix  at  the  time  of 
operation  may  be  avoided  in  most  instances  by  the  choice 
of  a  proper  instrument.  I  prefer  dilators  in  which  the 
cervical  portion  is  as  small  as  is  consistent  with  the  pres- 
sure to  be  exerted  upon  them  and  which  are  perfectly 


smooth,  as  they  are  thus  more  effectually  made  aseptic. 
It  is  well  to  have  them,  if  such  can  be  obtained,  of  a 
curve  approaching  a  parallel  to  the  axes  of  the  uterine  and 
vaginal  canals,  as  in  these  cases  the  fundus  uteri  does  not 
have  to  be  changed  so  much  in  position  to  facilitate  their 
introduction,  and  thus  the  beak  of  the  instrument  is  less 
likely  to  become  engaged  in  the  cervical  folds  at  the  angle 
of  flexion.  I  never  use  a  compression  screw  or  other  me- 
chanical appliance  upon  the  handles  of  the  instrument  to 
produce  the  dilatation,  as  I  consider  that  the  amount  of 
force  exerted  should  be  carefully  measured  by  the  operator 
and  that  it  can  be  done  in  no  way  so  exactly  as  by  the  grip 


of  the  hand.  I  do  not  care  for  dilators  which  are  serrated 
upon  the  cervical  portion,  as  I  consider  this  unnecessary ; 
besides,  such  instruments  have  to  be  made  unusually  broad 
to  furnish  the  requisite  amount  of  strength,  and,  as  it  is  the 
uterine  canals  which  are  stenosed  that  require  the  opera- 
tion, this  would  be  an  argument  against  the  instrument. 

Before  a  regular  meeting  of  this  society  in  P'ebruary  of 
this  year  I  showed  a  steel  dilator  which  I  had  recently 
devised,  and  which  I  considered  met  the  indications  in 
this  operation  more  nearly  than  any  other  instrument  I 
have  had  the  pleasure  of  seeing  or  seen  described.  I  will 
not  weary  you  with  a  second  lengthy  description  of  this 
instrument,  but  simply  present  it  for  your  inspection  and 
state  that  its  chief  advantage  lies  in  its  vagino- uterine  curve. 
This  curve  approaches  so  nearly  the  angle  of  the  uterine  to 
the  vaginal  canals  that  it  is  an  easy  matter  to  insert  them. 
The  curve  also  renders  the  instrument  much  less  likely  to 
become  caught  in  the  cervical  folds,  requires  less  force  to 
be  exerted  in  its  introduction,  and  consequently  causes  less 
pain  to  the  patient  and  traumatism  to  the  endometrium 
and  perimetrium.  After  performing  a  dilatation,  I  usually 
apply  to  the  endometrium,  through  a  cervical  shield  upon  a 
uterine  applicator,  a  ninety-five-per-cent.  solution  of  car- 
bolic acid.  I  withdraw  first  the  shield  and  then  the  appli- 
cator, thus  making  the  application  to  both  body  and  neck 
of  the  uterus,  which  acts  not  only  as  a  guard  against  sepsis, 
but  also  as  a  stimulant  to  the  parts.  The  treatment  is  com- 
pleted by  the  insertion  of  a  pessary  tampon  which  has  been 
saturated  in  a  solution  of  boroglyceride  and  glycerin. 

Among  the  conditions  where  dilatation  has  proved  a 
useful  treatment  are  primarily,  and  most  important  of  all,  a 
majority  of  the  cases  of  imperfect  uterine  drainage  ;  second- 
ly, imperfect  development  of  the  uterus ;  and  lastly,  cases 
of  sterility  in  wuich  the  uterus  is  of  normal  size  and  there 
is  no  interference  with  drainage. 

The  subject  of  obstructed  uterine  drainage  is  a  broad 
one,  and  patients  whose  symptoms  are  chiefly  due  to  this 
cause  are  very  numerous.  A  large  percentage  of  gynteco- 
logical  patients  seeking  relief  from  their  dysmenorrhcea,  from 
their  leucorrhoea,  from  their  nervous  condition,  from  their 
sterility,  fi'om  their  many  pelvic  pains,  are  representatives  of 
this  class ;  and  when  drainage  has  been  accomplished  the  con- 
gestion and  endometritis  subside  and  there  is  marked 
improvement.  To  cases  of  obstructed  drainage  with  an 
attendant  subacute  or  chronic  catarrhal  endometritis, 
and  sometimes  with  subinvolution  or  chronic  conges- 
tion, the  operation  of  dilatation  is  preferably  adapted^ 
except  in  some  extremely  rigid  uteri  in  which,  without  the 
use  of  anaesthesia,  it  is  very  difiicult  to  introduce  the  instru- 
ment, as  well  as  painful  to  the  patient ;  and  in  patients  of  a 
somewhat  similar  character,  who  have  previously  had  dila- 
tation, but  in  whom  the  symptoms  have  returned  within  a 
moderate  length  of  time,  owing  in  many  cases,  no  doubt,  to 
the  fact  that  the  rigidity  of  the  uterus  rendered  the  opera- 
tion so  painful  that  a  sufficient  degree  of  stretching  could 
not  be  tolerated.  In  the  treatment  of  these  latter  two  classes, 
and  cases  requiring  operations  within  the  uterine  cavity, 
divulsion  is  usually  resorted  to.  Certain  cases  of  posterior 
displacement  of  the  uterus  fail  to  drain,  not  so  much  because 


March  4,  1893.] 


SWAm:   TUMOR  OF  TEE  LARYNX. 


241 


of  stenosis  of  the  cervical  canal  as  because  of  a  faulty  position 
of  the  fundus  uteri.  To  improve  drainage  in  these  cases 
the  pessary  tampon  is  well  adapted,  the  uses  of  which  I 
related  in  an  article  read  before  this  society  in  March  last.* 

When  a  marked  endocervicitis  exists  w^ith  imperfect 
drainage,  it  should  be  treated  first,  and,  if  necessary,  the  og 
externum  dilated,  as,  if  an  instrument  were  introduced  into 
the  uterine  cavity  before  this  inflammation  and  discharge  had 
subsided,  sepsis  would  be  very  likely  to  be  carried  in  upon 
it  and  unfavorable  symptoms  result.  Hence  it  is  prefer- 
able to  wait  until  the  cervical  canal  has  been  drained  and 
the  endocervicitis  subsided,  as  then  the  instrument  may  be 
inserted  past  the  internal  os  with  comparative  safety. 
Uterine  congestion  from  exposure  to  cold  or,  as  occasion- 
ally happens,  from  over-exercise  of  the  parts,  although  often 
treated  by  means  of  the  dilator,  may,  I  think,  be  often  as 
effectually  benefited,  and  with  a  hope  of  as  early  and 
permanent  a  cure,  by  the  application  of  pessary  tampons 
saturated  in  boroglyceride  and  glycerin,  the  osmotic  action 
of  the  glycerin  diminishing  the  congestion  and  improving 
the  pelvic  circulation  and  the  muscular  tone  of  the  uterus. 
Consequent  upon  the  diminished  uterine  congestion  the 
cervical  canal  becomes  more  patent,  drainage  improves^ 
and  in  a  different  way  cervical  dilatation  is  performed  with- 
out a  resort  to  steel  dilators. 

Many  patients  at  the  menopause  suffering  from  hot  flashes 
globus  hystericus,  and  a  general  train  of  nervous  symptoms^ 
who  are  referred  to  the  specialist  upon  nervous  diseases,  who 
endeavors  to  combat  these  symptoms  by  a  resort  to  drugs, 
electricity,  etc.,  will,  if  examined,  be  found  to  be  suffering 
from  chronic  endometritis  and  obstructed  drainage,  the 
uterus  often  enlarged  instead  of  atrophied,  and  the  endo- 
metrium very  hyperaesthetic  to  the  introduction  of  the 
probe.  A  resort  to  drainage  and  applications  of  carbolic 
acid  to  the  endometrium  will  diminish  the  inflammation 
and  cause  a  disappearance  of  many  of  the  reflex  symptoms, 
so  that  it  will  often  be  surprising  how  marked  will  be  the 
improvement  from  but  a  short  course  of  treatment. 

Imperfect  development  is  now  recognized  as  an  impor- 
tant factor  in  the  production  of  laceration  of  the  cervix 
and  uterine  diseases.  A  large  percentage  of  infantile  uteri 
are  quite  sharply  anteflexed  and  often  have  stenosed  canals, 
which  cause  dysmenorrhoea.  By  a  resort  to  occasional  dila- 
tation, which  should  in  many  instances  be  of  both  the  body 
and  neck  of  the  uterus,  in  conjunction  with  other  therapeu- 
tic measures  generally  used  in  these  cases,  the  uterus  be- 
comes larger  and  menstruation  more  abundant,  painless,  and 
more  regular.  The  acute  flexion  becomes  less  pronounced, 
and,  in  short,  an  organ  is  developed  capable  of  performing 
{  its  functions  in  a  physiological  manner. 
I  Another  set  of  cases  in  which  the  dilator  proves  of 
service  are  those  of  sterility  not  due  to  imperfect  develop- 
ment or  to  stenosis  of  the  cervical  canal.  The  occasional 
stretching  of  the  cervix,  often  without  the  application  of 
carbolic  acid  afterward,  just  before  the  insertion  of  a  pes- 

*  Med.  Record,  h.\)x\\  30,  1892.     For  the  illustration  of  tlic  in- 
strument in  situ  I  am  indebted  to  my  friend  Mr.  Bert  Wilder,  an  artist 
for  Harpers'  Weekly,  and  for  the  diagram  of  the  instrument  to  the  VV. 
j  F.  Ford  Surgical  Instrument  Company,  the  manufacturers. 


sary  tampon,  seems  to  produce  an  altered  condition  in  the 
parts  which  favors  conception,  and  by  this  plan  of  treat- 
ment I  have  rendered  fertile  some  women  of  many  years' 
sterility.  One  I  recall,  a  nullipara  eight  years  married,  who, 
after  reciving  this  plan  of  treatment  for  about  two  months, 
became  pregnant.  It  is  probable  that  the  tampons  stimu- 
late a  more  perfect  ovulation  and  improve  the  condition  of 
the  endometrium ;  but  that  the  dilator  is  of  material  addi- 
tional service  I  have  no  doubt. 

I  do  not  consider  it  wise  to  do  a  dilatation  upon  pa- 
tients having  an  acute  endometritis  or  perimetritis,  and,  if 
it  is  necessary  to  effect  drainage,  it  is  better  to  use  some 
other  plan  of  treatment. 

As  to  the  time  of  doing  a  dilatation,  I  prefer  the  in- 
terim of  two  weeks  between  the  menstrual  epochs,  and  am 
not  an  advocate  of  a  too  frequent  repetition  of  the  operation, 
as,  by  so  doing,  congestion  and  slight  inflammatory  conditions 
resulting  from  abrasions  may  obstruct  drainage  and  produce 
a  general  endometritis  and  perhaps  perimetritis.  Hence  it 
is  preferable  to  dilate  infrequently,  and  I  would  advise  not 
doing  more  than  two  dilatations  in  one  intermenstrual  pe- 
riod. The  object  in  dilating  at  the  time  stated  is  to  take 
the  uterus  when  it  is  in  a  quiescent  state — that  is,  when  its 
sinuses  contain  but  a  moderate  amount  of  blood  and  the 
endometrium  is  the  least  congested  physiologically,  as,  by 
so  doing,  less  harm  from  traumatism  is  likely  to  occur,  less 
reactionary  symptoms  result,  and  at  this  time  your  force  is 
exerted  more  upon  the  muscular  wall  of  the  uterus  than  in 
forcing  blood  out  of  the  congested  endometrium,  and  risk- 
ing the  greater  danger  of  doing  harm  to  the  tissues  near 
the  menstrual  epoch.  When  the  cervical  canal  is  fairly  well 
open  and  the  object  is  more  to  stimulate  the  parts,  one  need 
not  be  so  particular  in  detail ;  but  in  cases  of  imperfect 
drainage,  by  heeding  the  above-mentioned  precautions,  un- 
favorable results  will  in  most  instances  be  avoided. 

157  Madison  Avenoe. 


A  CASE  OF  TUMOR  OF  THE  LAEYNX.* 
By  H.  L.  SWAIN,  M.  D., 

NEW  HAVEN,  CONN. 

I  HAVE  to  present  to  you  to-day  the  simple  clinical  re- 
port of  a  case  of  tumor  in  the  larynx  which,  from  the  un- 
usual features  occurring  in  it,  is  made  more  interesting  than 
the  common  run  of  such  cases,  and  I  trust  in  the  relation 
of  my  experience  sufficient  may  be  found  to  make  up  for 
the  apparent  simplicity  of  the  title.  The  facts  of  the  his- 
tory are  these  : 

Mr.  X.,  fifty  years  old,  presented  himself  in  the  latter  part 
of  June,  1890,  complaining  of  hoarseness  and  trouble  in  breath- 
ing, latter  only  of  a  week's  duration.  He  was  evidently  labor- 
ing hard  to  breathe,  both  inspiration  and  expiration  liaviiig  tl)at 
peculiar  sound  which  is  always  indicative  of  obstruction  in  the 
larynx  or  at  its  opening.  Complete  aphonia  existed  and  speak- 
ing was  exceedingly  difficult  and  tiresome  to  patient.  Had 
never  bad  any  pain  in  larynx.  He  stated  that  he  had  been 
somewhat  hoarse  for  nearly  a  year  past  witii  a  gradual  increase, 

*  Read  before  the  American  Laryngological  Association  at  it.s  four 
teenth  annual  congress. 


212 


8WAIN:    TUMOR  OF  THE  LARYNX. 


[X.  Y.  Med.  Jour., 


and  liad  from  time  to  time  severe  attacks  of  cougliinf.^  during 
which  lie  was  quite  sure  he  felt  something  moving  in  his  wind- 
pipe. Suddenly,  about  a  week  ago,  he  was  attacked  with  dysp- 
noea after  a  severe  coughing  fit,  and  since  that  time  lias  not  been 
able  to  speak  out  loud  or  to  breathe  with  any  comfort  or  free- 
dom. His  physician  had  examined  his  throat  and  told  him  to 
consult  a  i-pecialist  without  delay,  sending  him  some  fifteen  or 
twenty  miles  to  the  city.  "While  talking  he  had  an  attack  of 
coughing,  during  which  he  got  very  red  and  cyanosed. 

Proceeding  to  the  examination  of  patient,  I  found  nothing 
out  of  order  with  the  exterior  portions  of  the  throat ;  the  larynx 
was  large  and  well  developed  without  any  sign  of  disease  any- 
where. Glands  in  neck  not  at  all  enlarged.  A  slight  pijaryn- 
gitis  presented  itself  on  illuminating  the  throat,  and  the  epiglottis 
was  normal  and  fairly  erect.  Filling  up  the  entire  glottis  and 
moving  up  and  down  between  the  cords  during  breathing  was  a 
pedunculated  tumor,  which  appeared  easily  movable,  firm  and 
smooth  in  consistence,  the  small,  narrow  pedicle  being  attached 
in  and  a  little  above  the  anterior  commissure  of  the  vocal  cords. 
Neither  of  the  latter  were  visible,  although  the  posterior  portion 
of  the  arytsenoids  was  easily  so.  On  applying  cocaine,  besides 
the  strangulation  which  was  produced — and  the  latter  was  se- 
vere— it  was  noticed  that  the  tumor  was  decidedly  dense  and 
firm.  The  diagnosis  was  made  of  a  fibromyxoma,  lying  on  and 
between  the  vocal  cords,  and  immediate  operation  was  deemed 
necessary. 

Without  suspecting  the  breadth  of  the  j)edicle,  which  seemed 
very  narrow  as  well  as  reasonably  thin,  still  an  idea  of  possible 
spasm  of  the  glottis,  in  case  of  failure  in  extracting  the  mass, 
came  like  a  specter  to  my  mind,  and,  before  making  any  serious 
attempts  at  removal,  a  few  instruments  for  the  purpose  of  mak- 
ing a  rapid  tracheotomy  were  put  in  readiness  for  immediate 
action.  Then  several  unsuccessful  attempts  were  made  with 
various  forceps,  but  they  one  and  all  slipped  off.  Despairing  of 
these,  the  cold  noose  was  tried,  and  on  the  third  attempt  secured 

a  firm  hold.  An  ordi- 
nary amount  of  trac- 
tion, such  as  would 
be  appropriate  to  the 
size  and  nature  of  the 
tumor  had  it  occurred 
in  tlie  nose  or  naso- 
pharynx, was  brought 
to  bear  without  any 
success.  A  second 
pull  with  more  force 
followed,  but  the  pa- 
tient still  held  on  his 
end.  As  the  noose 
was  pulled  well  home 
at  the  very  first,  more 
force  still  was  exer- 
cised and  muscle  con- 
quered, bringing  out 
tiie  tumor  which  you 
here  see  in  nature 
and  in  photograph.  Appalled  at  the  >ize  of  the  tumor — which 
has,  of  course,  shrunk  greatly  after  two  ye;irs'  sojourn  in  alco- 
hol—as also  at  the  breadth  of  the  pedicle,  the  patient,  who  had 
been  previou-ly  told  what  to  do,  was  speedily  got  on  to  (louch 
with  head  depending  so  that  blood  need  not  get  into  the 
trachea.  Several  generous  mouthfuls  of  blood  were  raised  and 
then  the  hfBinorrhage  ceased,  the  exceedingly  tractable  patient 
having  meanwhile  got  very  red  in  the  face.  The  examination 
showed  the  laceration  where  the  tumor  had  been,  leaving  a 
clear  wound,  which  was  not  perceptibly  bleeding.    The  vocal 


\ 


Fig.  1.— Tuiii": 


larynx. 


cords,  which  1  had  feared  might  have  been  injured,  were  intact, 
and  the  patient  spoke  quite  clearly. 

After  warning  the  patient  of  the  danger  of  after-bleeding  he 
was  sent  home,  to  return  in  two  days.  To  my  great  relief,  he  ad- 
dressed me  with  a  fine,  clear,  bass  voice,  and  with  scarcely  a  trace 
of  hoarseness.    Talking  still  hurt  him  and  bis  throat  and  neck 


Fig.  2. — Ed^e  of  tumor. 
Natural  pize. 


Fig.  3. — Side  of  tumor. 
Natural  kIzc. 


were  sore  and  lame.  Otherwise  nothing  untoward  had  happened. 
Only  once  or  twice  did  he  cough  up  any  blood.  Inspection  showed 
a  wound  from  the  tubercle  of  the  epiglottis  down  between  and  be- 
low the  vocal  cords,  the  same  healing  nicely.  Later  he  seemed  lia- 
ble to  a  recurrence  of  the  growth,  and  I  had  to  noose  off  a  small 
projection  and  cauterized  the  base.  This  was  some  two  months 
after  the  first  operation,  during  which  time  he  was  twice  cau- 
terized thoroughly.  When  last  seen  there  seemed  to  be  a  con- 
siderable projection,  and  it  was  by  no  means  certain  what  the 
outcome  would  be.  I  then  lost  sight  of  the  patient  until  June 
4tli  of  this  year,  when  I  wrote  to  him  asking  him  how  he  was. 
His  answer  was  in  the  presentation  of  himself,  and  I  found  him, 
save  for  some  hypertrophic  trouble  in  the  nose,  entirely  in 
order.  His  larynx  was  without  trace  of  any  kind  of  trouble  save 
a  slight  general  congestion  of  the  entire  mucous  membrane,  per- 
haps a  tririe  more  pronounced  in  the  seat  of  the  old  trouble. 
No  cicatrix  was  visible.  He  has  no  other  ditficulty  in  using  his 
voice  than  what  his  chronic  laryngitis  would  account  for.  He 
therefore  has  been  two  years  without  recurrence.* 

In  looking  back  over  this  one  case,  a  few  interesting 
points  seem  worthy  of  separate  comment.  First,  the  kind 
of  tumor — a  fibromyxoma — is  one  of  the  rarities  of  our 
clinical  experience.  Second,  the  size  of  tumor  is  unique  in 
my  own  experience,  especially  as  removed  in  toto.  Only 
once  in  removing  a  large  papilloma,  piece  by  piece,  did  I 
ever  meet  so  large  an  excrescence.  Thirdly,  the  breadth 
of  the  pedicle,  together  with  its  toughness  and  situation, 
rendered  two  dangers  imminent  in  its  removal  by  evulsion 
— namely,  those  of  rupturing  the  attachment  of  the  vocal 
cords  and  of  serious  haemorrhage,  and  yet  this  character  of 
pedicle  and  tumor  renders  evulsion  in  general  decidedly  the 
best  method.  Fourthly,  when  it  is  considered  that  this  tumor 
was  between  the  vocal  cords  and  lay  its  whole  length  in  the 
larynx,  how  was  it  possible  for  the  patient  to  breathe  at  all  ? 
Surely  his  larynx  must  have  been  unusually  roomy  and  the 
tumor  freely  movable,  or  this  would  not  have  been  the  case. 
What  would  be  very  easily  possible  with  a  small  tumor 
was  also  the  case  with  this  large  one — namely,  that  by  in- 
spiration the  tumor  was  actually  made  to  sink  down  before 
the  air  could  enter  the  windpipe  and  the  tumor  would 
have  to  be  forced  back  again  as  the  air  went  out.  As  this 
was  the  case,  it  seemed  to  me  that  the  patient  was  in  very 

*  I  am  indebted  for  the  photographs  which  show  the  tumor  to  Pro- 
fessor M.  ('.  White,  who  kindly  made  them  for  me,  and  they  help  to 
make  more  graphic  this  simple  clinical  history. 


March  4,  1893.J 


RIGKETTS:  INTERNAL  URETHROTOMY. 


243 


imminent  danger  as  regards  life.  How  easy  it  would 
have  been  for  a  piece  of  mucus,  a  particle  of  food,  or  float- 
ing body  in  air  to  produce  a  fit  of  coughing  and  spasm  of 
glottis  !  Then  the  tumor  might  have  become  wedged  in 
between  the  cords,  perhaps  have  swollen  the  merest  trifle, 
and  then,  not  being  dislodged,  the  patient  must  have  suffo- 
cated. All  this  seemed  so  very  possible  that  I  held  myself 
as  almost  holding  the  man's  life  in  my  hands  and  deemed 
it  wise  to  rid  him  immediately  of  the  obstruction,  or,  were 
I  not  successful,  to  put  him  somewhere  where  he  could 
receive  immediate  attention  by  skilled  hands  in  case  of 
emergency.  This  brings  me  by  easy  gradation  to  the  fifth 
interesting  point — namely,  the  operation.  The  exceedingly 
fine  point  must  here  be  drawn  which  of  two  methods  to 
choose — per  naturae  vias,  or  by  external  incision — to  get  at 
the  impediment.  In  deciding  this  point  the  question  natu- 
rally arises.  How  sure  are  you  of  the  size  of  the  tumor  with 
which  you  are  dealing  1  In  general  we  are  apt  to  conceive 
the  growth  to  be  much  larger  than  is  the  real  case,  but  at 
least  in  the  case  before  us  the  reverse  was  true.  What 
guarantee  have  we  that  the  upper  part  of  a  given  tumor, 
visible  to  us  and  blocking  effectively  further  insight  into 
the  larynx,  is  the  full  size  of  the  tumor,  and  how  far  does 
the  tumor  extend  downward  ?  As  one  can  plainly  see  from 
the  side  view  of  the  tumor  compared  with  one  taken  from 
the  upper  end,  a  great  disparity  may  exist.  Fortunately, 
this  shape  of  tumor  and  its  situation  is  rare,  so  that  we 
usually  can  judge  tumors  to  be  what  they  seem  as  regards 
size ;  but,  as  in  this  case,  could  a  much  larger  tumor  have 
been  safely  removed  by  the  method  adopted  ?  For  a  small 
tumor  of  this  kind  it  would  seem,  as  in  the  nose  and  other 
situations,  that  the  cold  snare  removed  the  growth  cleaner, 
got  more  of  the  pedicle,  and  was  less  liable  to  troublesome 
haemorrhage  and  return  of  growth,  than  is  the  case  with  the 
hot  snare,  which  cuts  off  only  that  which  is  grasped,  or  the 
forceps,  which  is  open  to  the  same  objections.  In  the  case 
of  the  larynx  one  has  also  to  think  of  the  danger  of  the  hot 
wire  to  other  tissues.  The  only  point  against  the  cold 
snare  is  that  if  a  tumor  is  very  large  or  with  a  broad  pedi- 
cle, too  much  force  must  be  brought  to  bear,  and  the  dan- 
ger of  rupture  of  important  parts  must  be  considered.  To 
remove  such  a  tumor  by  pieces  would  be  almost  impossible 
from  the  firm,  smooth  surface  which  they  present.  Another 
thing  must  be  borne  in  mind  in  objecting  to  the  cold  snare  : 
that  if  a  greater  resistance  is  to  be  overcome  than  is  possible 
or  deemed  wise,  how  are  you  to  extricate  yourself  ?  Surely 
not  easily.  And  meanwhile  how  is  the  patient  breathing  ? 
Offhand,  then,  one  would  say  immediately.  Do  a  thyreotomy, 
open  the  larynx,  remove  the  tumor,  and  sew  the  parts  to- 
gether again.  But  then  comes  a  doubting  Thomas  who 
asks  what  proportion  of  successes  attend  your  operation  of 
splitting  the  larynx  ?  Do  the  majority  of  patients  remain 
possessors  of  clear  voices  ?  Are  you  able  with  the  knife  to 
remove  a  tumor  of  this  kind  as  thoroughly  as  by  evulsion 
and  not  cut  other  parts,  and  are  not  your  chances  of  a  re- 
currence very  much  greater  than  by  the  other  methods  ? 
And,  finally,  can  you  forget  that  the  tracheotomy  and  other 
disturbance  necessary  to  the  external  opening  subject  your 
patient  to  the  not  very  remote  danger  of  lung  troubles  and 


secondary  hajraorrhage  ?  These  doubts  confronting  one, 
with  the  acknowledged  dangers  of  the  other  methods,  what 
is  one  to  do  ? 

In  answering  the  question  for  myself,  I  adopted  the 
method  as  in  the  history  read.  Were  I  ever  to  be  con- 
fronted again  with  a  tumor  of  the  same  or  less  size,  dis- 
tinctly pedunculated,  and  in  an  adult,  I  should  again  elect 
the  cold  snare.  In  children,  or  in  cases  of  tumor  with  a 
broad  base,  or  more  upon  either  cord,  or  larger  in  size, 
within  the  cavum  laryngis,  the  external  operation  seems 
the  more  expedient  and  decidedly  safer. 


INTERNAL  URETHROTOMY: 

AN  ABSTRACT  OF  THE  RESULTS  OF  THIRTY-SIX  OPERATIONS. 
By  B.  MERRILL  RIOKETTS,  M.  D.,  Pn.  B., 

CINCINNATI,  OHIO. 

The  operation  of  itself  I  consider  a  simple  one,  and  if 
sepsis  is  guarded  against,  febrile  disturbance  will  not  occur. 
The  complications  that  arose  in  these  thirty-six  cases  were  : 

1.  Urethral  fever. 

2.  Orchitis. 

3.  Perforation  into  the  rectum. 

Of  the  first,  I  have  had  three  cases  where  the  tempera- 
ture reached  102°  and  which  subsided  within  seventy-two 
hours.  We  know  that  the  simple  introduction  of  a  cathe- 
ter or  sound,  hard  or  soft,  will  cause  a  rise  in  temperature 
which  is  usually  of  short  duration,  and  we  have  reason  to 
believe  that  this  rise  of  temperature  is  due  to  septicaemia. 

In  the  second  class — orchitis — it  is  interesting  to  note 
that  inflammation  of  the  testicle  did  not  occur  until  after 
the  eleventh  day  in  one,  thirteenth  in  another,  and  fourteenth 
in  another.  The  eleventh  began  while  the  patient  was  still 
confined  to  his  room.  The  thirteenth  began  four  days  after 
the  patient  had  returned  to  his  duties,  which  were  those  of 
a  commercial  traveler.  This  great  length  of  time  I  believe 
will  exclude  the  primary  operation  as  being  the  cause  of  the 
orchitis. 

In  two  of  the  cases — the  first  and  the  second — there  was 
no  introduction  of  the  sound  after  the  withdrawal  of  the 
urethrotome.  In  the  third,  however,  the  sound  was  intro- 
duced every  third  day  ;  possibly  the  introduction  of  the 
sound  in  this  ca&e  caused  the  orchitis. 

In  the  third — perforation  into  the  rectum — I  feel  that 
there  is  a  ray  of  hope  of  my  not  being  responsible  when  we 
consider  the  possibility  of  there  having  existed  a  recto-ure- 
thral  fistula.  The  urethra  was  serpentine  and  only  admitted 
a  No.  17  French  sound  with  great  difficulty.  I  advised  an 
internal  urethrotomy,  and  my  attempt  to  do  the  operation 
under  the  influence  of  chloroform  was  thwarted.  The  pa- 
tient was  allowed  to  come  from  under  the  influence  of  the 
chloroform  and  informed  of  the  difilculty.  On  the  next  day 
I  was  successful,  but,  before  adjusting  the  instrument  with 
my  finger  in  the  rectum,  I  found  that  its  point  and  ray 
finger  came  together.  The  bladder  was  entered  without  dif- 
ficulty, the  operation  done,  and  a  No.  30  French  sound  in- 
troduced with  ease,  and  the  patient  returned  to  his  work, 
that  of  a  bookkeeper,  on  the  following  Saturday. 
The  Trinidad,  137  Broadway,  January  2,  1893. 


244 


LEADING  ARTICLES. 


[N.  Y,  Mei>.  Jooh., 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine, 

Published  by  Edited  by 

D.  Applbton  &  Co.  Prank  P.  Foster,  M.  D. 


NEW  YORK,  SATURDAY,  MARCH  4,  1893. 


THE  CORONER  SYSTEM  IN  NEW  YORK  STATE. 

In  1877  a  committee  of  the  Massachusetts  Medical  Society 
presented  a  report  on  the  existing  coroner  system  in  that  State. 
The  committee  stated  that  the  system  was  a  remnant  of  past 
and  obsolete  usages,  that  it  was  wholly  unsuited  to  the  needs 
of  the  times,  that  the  powers  pertaining  to  the  office  of  coroner 
were  unrestricted  and  dangerous  and  had  been  perverted,  and 
finally  that  the  manner  in  which  inquests  were  conducted  was 
too  frequently  objectionable  and  too  often  permitted  criminals 
to  escape.  The  committee  further  stated  that  the  inspection  of 
the  body,  the  autopsy,  and  the  inquiry  into  the  cause  of  death 
should  be  intrusted  to  the  medical  profession,  while  the  neces- 
sity for  a  further  inquest,  and  its  conduct  when  decided  upon, 
should  be  committed  to  the  legal  profession  with  its  courts  and 
detectives.  In  otiier  words,  the  determination  of  what  caused 
the  death  belonged  to  the  medical  profession,  and  that  of  who 
caused  the  death  belonged  to  the  magistrates  and  the  courts. 
As  a  result  of  the  united  efforts  of  the  medical  and  legal  pro- 
fessions, a  law  was  passed  by  the  Legislature  of  that  State, 
abolishing  the  old  office  of  coroner  and  substituting  therefor  a 
system  of  medical  examiners,  and  the  system  has  been  in  satis- 
factory operation  since  July  1,  1887. 

The  economical,  efficient,  and  practical  change  wrought  in 
Massachusetts  has  attracted  the  attention  of  various  States,  and 
a  bill  was  introduced  into  the  New  Y'ork  State  Assembly  in 
1879  providing  for  the  limitation  of  the  functions  of  coroners 
and  for  the  creation  of  medical  examiners.  This  bill  failed,  as 
have  several  similar  bills  introduced  at  subsequent  sessions  of 
the  Assembly. 

A  bill  has  been  introduced  into  the  present  Assembly  pro- 
viding for  the  abolition  of  the  office  of  coroner  in  the  city  and 
county  of  New  York,  transferring  the  medical  portion  of  the 
investigation  now  made  by  the  coroner  to  the  jurisdiction  of 
the  board  of  health,  and  providing  that  the  legal  part  of  the 
investigation  shall  be  made  by  the  police  justices  without  the 
aid  of  a  jury.  The  board  of  health  is  authorized  to  appoint 
three  "  inquest  physicians,"  at  a  salary  not  to  exceed  tiiree 
thousand  dollars  a  year  each,  and  it  is  to  be  the  duty  of  these 
physicians  to  make  duplicate  rei)orts  of  all  inquests,  one  copy 
to  go  to  the  board  of  health  and  one  to  the  District  Attorney's 
office.  This  is,  in  the  main,  the  scope  of  the  bill,  and  the  local 
profession  has  been  asked  to  support  it. 

We  do  not  question  the  sincerity  of  the  gentleman  that 
framed  the  bill,  but  the  first  section — that  of  abolishing  the 
ofiSce  of  coroner — is  unconstitutional ;  section  ten  of  the  con- 


stitution of  the  State  of  New  York  requires  that  there  should 
be  a  coroner.  The  bill  is  objectionable  in  tiiat  it  does  not  apply 
to  the  entire  State,  where  improvement  in  existing  conditions 
is  more  to  be  desired  than  in  this  city.  And  it  would  seem  to 
be  impracticable  because  each  of  the  four  city  coroners  has  a 
physician,  and  these  four  officials  have  as  much  to  do  as  they 
can  attend  to,  so  that  a  smaller  number  could  not  attend  to  the 
work,  and  a  greater  number  would  probably  be  required  in  a 
few  years  from  now.  The  proposed  compensation  is  not  suffi- 
cient to  attract  desirable  men,  while  the  fact  that  the  office 
is  an  elective  one  would  probably  interfere  with  the  success  of 
any  proposed  change.  There  are  certain  ill-defined  matters  in 
the  bill  that  might,  were  it  otherwise  satisfactory,  be  euscepti- 
ble  of  amendment. 

Nothing  but  a  constitutional  amendment  can  secure  in  this 
State  a  coroner  system  similar  to  that  of  Massachusetts,  where 
the  medical  examiners  are  appointed  by  the  Governor  instead 
of  being  elected. 


THE  WATER  SUPPLY  OF  NEW  YORK  CITY. 

The  necessity  for  obtaining  a  supply  of  pure  water  for  the 
city  of  New  York  attracted  attention  in  the  early  part  of  this 
century,  but  not  until  1831  was  any  active  step  taken  to  im- 
prove the  system  of  water  companies  and  wells  then  in  exist- 
ence. In  December,  1831,  a  report  was  made  to  the  board  of 
aldermen  relative  to  introducing  into  the  city  of  New  York  a 
supply  of  wholesome  water,  accompanied  by  a  request  for  an 
act  empowering  the  city  to  raise  money  to  execute  this  work. 
But  the  State  Legislature  did  not  act  in  the  premises  until  Feb- 
ruary, 1833.  The  Croton  aqueduct  was  built,  and  water  from 
that  source  was  supplied  to  the  city  in  1842. 

With  the  growth  and  increased  population  of  the  city 
heavier  demands  were  made  upon  the  old  aqueduct,  and  its  in- 
sufficiency required  the  construction  of  the  recently  completed 
aqueduct.  While  the  latter  has  ameliorated  the  scarcity  of 
water,  it  has  not  improved  the  quality  of  the  water  furnished ; 
and  the  growth  of  population  occupying  the  Croton  watershed, 
affording  as  it  does  opportunities  for  the  contamination  of  the 
water  supply,  is  a  matter  of  serious  import  to  the  city. 

The  larger  portion  of  the  Croton  waterslied  lies  in  this 
State,  but  a  small  portion  extends  on  the  east  into  Connecticut, 
the  area  being  more  than  three  hundred  square  miles.  Croton 
Lake  was  found  insufficient  to  supply  the  needs  of  the  city 
more  than  a  quarter  of  a  century  ago,  and  twenty  years  ago  a 
storage  reservoir  was  constructed  at  Boyd's  Corners  that  has  a 
capacity  of  some  three  billion  three  hundred  million  gallons. 
This  has  been  supplemented  by.  the  Middle  Branch,  Sodom,  and 
Bog  Brook  reservoirs,  while  additional  reservoirs  are  being 
constructed  on  the  west  branch  of  Cioton  River,  on  Muscoot 
River,  and  on  Titicus  River. 

The  Health  Department  of  the  City  of  New  York  published 
in  its  annual  report  for  the  year  1891  a  valuable  and  compre- 
hensive report  of  an  investigation  of  the  sanitary  condition  of 
the  Croton  watershed,  including  maps  that  indicated  the  prin- 


March  4,  1893.J 


LEADING  ARTICLES. 


245 


oipal  sources  of  contamination  of  the  various  water  courses  in- 
cluded in  the  shed.  Mr.  E.  W.  Martin  and  Mr.  A.  L.  Beebee, 
the  chetnists  of  the  department,  stated  that  with  but  few  excep- 
tions the  streams,  lakes,  and  reservoirs  showed  more  or  less 
marked  evidence  of  sewage  contamination,  that  the  condition 
of  affairs  as  found  by  their  investigation  to  exist  on  the  Croton 
watershed  was  of  a  most  serious  character  and  required  imme- 
diate attention,  that  there  was  danger  of  the  progressive  de- 
terioration of  the  water  supply,  and  that,  under  existing  condi- 
tions, such  deterioration,  while  it  might  be  gradual,  was,  in 
their  opinion, S'inevitable. 

The  presentation  the.se  gentlemen  made  of  the  necessity  that 
prompt  and  efiScient  means  be  taken  to  remove  the  sources  of 
contamination  already  existing  on  the  watershed,  and  to  pre- 
vent subsequent  pollution  from  new  sources,  has  resulted  in  tlie 
introduction  into  the  present  Legislature  of  an  act  to  provide  for 
the  sanitary  protection  of  the  sources  of  the  water  supply  of 
the  city  of  New  York  by  the  city's  acquisition  of  such  lands, 
tenements,  etc.,  in  the  counties  of  "Westchester,  Putnam,  and 
Dutchess,  as  may  be  necessary  for  such  purpose,  and  also  for 
the  sanitary  protection  of  these  lands  when  they  are  acquired. 

While  we  are  not  prepared  'to  say  what  the  legal  obstacles 
or  objections  to  such  a  bill  are,  if  any  exist,  it  seems  probable 
that  they  may  be  corrected  by  amendment.  From  a  sanitary 
standpoint,  especially  with  the  threatened  invasion  of  a  cholera 
epidemic  during  the  coming  summer,  it  is  most  desirable  that 
the  Legislature  should  provide  a  means  by  which  the  health 
department  of  the  city  may  make  the  necessary  rules  and  regu- 
lations for  the  sanitary  protection  of  the  sources  of  the  water 
supply.  It  is  to  be  hoped  that  the  State  will  not,  as  Hamburg 
did,[recognize  the  evil  after  the  city  isjattacked  ;  and  the  medi- 
cal profession  should  further  the  aim  of  the  health  department 
in  this  matter  and  urge  the  enactment  of  legislation  that  will 
protect  our  water  supply. 


"  POLITICS." 

The  New  York  Academy  of  Medicine,*after  a  decidedly  ac- 
rimonious debate,  at  the  special  meeting  held  February  24th> 
revoked  its  action  taken  at  the  previous  regular  meeting,  re- 
appointed the  National  Quarantine  Committee,  and  instructed 
the  committee  to  take  such  action  as,  in  its  judgment,  would 
further  the  establishment  of  a  satisfactory  system  of  national 
quarantine.  By  adopting  this  course  the  Academy  has  done 
more  than  merely  throw  the  weight  of  its  influence  on  the  side 
of  the  advocates  of  national  control  of  quarantine  methods; 
it  has  asserted  the  principle  that  a  scientific  body  owes  the 
country  active  service  as  well  as  advice  whenever  its  scientific 
knowledge  may  help  avert  a  common  danger  or  advance  the 
common  welfare.  We  say  this  without  the  slightest  intention 
of  committing  the  t/oMrartV  to  participation  in  the  ostricli-likc 
feeling  of  security  that  a  national  quarantine  adminis-tration, 
even  the  best  that  can  he  devised,  will  prove  all-powortul  for 
the  preservation  of  the  public  health. 


The  Academy's  position  is  defined,  and  the  stormy  meeting 
at  which  it  was  settled  is  a  thing  of  the  past.  We  have  no  in- 
tention of  criticising  the  proceedings  of  that  meeting;  we  wish 
only  to  call  attention  to  the  use  of  the  word  "politics  "  and  to 
the  abuse  thereof.  The  fact  that  the  word  has  two  entirely 
different  meanings  has  been  a  source  of  confusion  in  many  a 
discusi-ion,  and  it  was  the  cause  of  much  trouble  at  the  Acade- 
my's meeting. 

In  its  good  sense,  politics  is  something  which  every  Ameri- 
can must  take  part  in  ;  it  is  one  of  the  duties  of  citizenship  to 
do  so.  Politics  has  nothing  to  do  with  parties  or  factions,  with 
campaigns  or  "  machines,"  with  personal  ambitions  or  petty 
schemes;  it  may  be  defined  as  "applied  patriotism."  In  its 
bad  sense,  it  means  partisan  trickery,  the  outgrowth  of  selfi.sh- 
ness,  not  of  patriotism.  If,  as  was  feared  by  those  who  op- 
posed the  motion  carried  at  the  meeting,  there  was  danger  that 
its  adoption  would  introduce  the  last  variety  of  "politics" 
into  the  Academy,  it  would  be  a  misfortune,  for  the  methods 
of  the  lowest  class  of  unscrupulous  politicians  are  not  worthy 
of  a  learned  body.  We  do  not  believe  that  there  is  much  dan- 
ger that  last  week's  proceedings  can  have  any  such  deplorable 
consequences. 

For  the  Academy  to  degrade  itself  by  adopting  the  "  poli- 
tics" of  the  slums  or  pursuing  the  methods  of  the  corrupt  lob- 
byist would  surely  be  bad;  but  for  it  to  refrain  from  exerting 
its  power  to  the  utmost  in  the  cause  of  public  safety  would  be 
far  worse.  If  the  most  influential  medical  organization  in  the 
country  refuses  to  advocate  measures  of  great  importance  to 
the  whole  nation,  for  fear  of  becoming  involved  in  "politics," 
that  organization  is  disgraced  in  the  eyes  of  all  loyal  citizens. 
The  Academy  can  not  avoid  taking  part  in  "politics "in  its 
higher  meaning,  and,  if  it  does  its  duty,  need  not  fear  contami- 
nation from  the  baser  sort  of  "politics." 


THE  TEN-MENUTE  PAPER. 

The  ten-minute  paper  has  recently  become  a  marked  fea- 
ture in  the  work  of  the  New  York  Academy  of  Medicine.  The 
Section  in  Pajdiatrics  was  early  among  the^ promoters  of  this 
innovation,  and  during  the  past  year  has  carried  out  the  idea 
very  thoroughly.  The  result  has  been  a  marked  increase  in 
the  attendance  at  the  meetings,  a  large  number  of  concise, 
pithy,  and  interesting  papers,  and  a  wide  publication  of  the 
proceedings.  The  instructions  to  writers  of  papers  formulated 
by  the  chairman.  Dr.  Nortbrup,  contained  a  number  of  apt  sug- 
gestions and  were  somewhat  as  follows:  L  Hippocrates  and 
Galen  may  be  passed  with  very  slight  notice,  as  they  have  been 
for  some  time  dead  and  their  opinions  are  somewhat  obsolete. 
2.  Scratch  |out  the  formal  introduction  and  begin  where  the 
subject  matter  really  begins.  3.  Condense  the  body  of  the 
paper.  4.  End  the  paper  where  the  subject  matter  cuds,  mak- 
ing its  action  like  that  of  the  piston  syringe— begin,  spatter, 
stop.  As  a  result  of  this  policy  the  papers  have  been  unusually 
practical  and  to  tlie  point. 


246 


MINOR  PARAGRAPHS. 


[N.  T.  Med.  Johb., 


The  genius  for  sticking  to  tlie  text  is  as  rare  among  doctors 
as  among  clergymen.  It  requires  courage  as  well  as  genius  to 
write  a  paper  upon  one  subject  with  a  total  omission  of  all 
one's  pet  theories  upon  extriineous  matters.  Even  the  most 
extreme  hobby-rider  is  rarely  content  with  one  hobby  at  a 
time,  but  leads  along  a  train  of  colts  of  his  own  breeding, 
which  he  is  prone  to  mount  at  intervals  to  show  off  their 
superior  points.  A  really  good  hobby-rider  is  a  rarity.  Suc- 
cessful papers,  almost  without  exception,  are  those  written 
with  one  definite  atid  predominating  thought,  upon  which 
every  fact  is  brought  to  bear  and  toward  which  every  argu- 
ment is  ilirected.  For  the  ordinary  society  paper,  conclusions 
alone  are,  as  a  rule,  sufficient,  with  pertinent  facts  so  marshaled 
as  to  give  them  proper  support.  The  various  minute  details  of 
the  stages  by  which  these  conclusions  are  reached  are  usually 
uninteresting  and  had  better  be  touched  upon  lightly  or  omitted 
entirely.  It  is  not  alleged  that  every  paper  can  be  made  a  ten- 
minute  paper,  but  it  is  a  fact  that  a  large  proportion  of  the 
papers  read  at  society  meetings  and  published  in  the  journals 
could  be  profitably  condensed  from  twenty-five  to  seventy-five 
per  cent.  An  expert  member  of  an  editorial  staff,  by  remorse- 
lessly stripping  away  the  padding,  is  usually  able  to  make  an 
abstract  that  will  present  all  the  author's  ideas  and  conclusions 
in  one  tenth  the  space  of  the  original  paper.  Many  a  man  who 
has  had  something  of  real  value  to  say  has  first  smothered  the 
life  out  of  it  with  padding  and  then  dug  a  grave  for  it  and 
buried  it  in  the  midst  of  a  five-column  paper  comi)iled  from 
some  text-book.  It  would  be  far  better  for  medical  literature 
if  every  man  would  content  himself  with  writing  what  he 
really  knew  instead  of  writing  what  he  did  not  know.  One 
new  fact  discovered,  one  new,  live,  practical  idea,  is  a  sufficient 
subject  for  one  paper,  though  it  may  be  a  short  one.  Two  or 
three  subjects  for  a  single  paper  will  render  it  weak  or  actually 
inert.  A  shot-gun  is  adapted  to  small  game,  but  large  game  is 
only  brought  down  with  a  rifle.  A  single  paper  upon  a  live 
subject,  if  it  hits  the  mark  squarely,  will  do  more  to  establish 
a  man's  reputation  Mian  ten  diluted  and  watery  compilations. 


MINOR  FARAORAPES. 

VARIETIES  OF  OBSTRUCTED  RESPIRATION. 

At  a  meeting  of  the  Section  in  Paediatrics  of  the  New  York 
Academy  of  Medicine  held  on  February  9th,  Dr.  Dillon  Brown, 
discussing  the  subject  of  obstructed  respiration,  said  that 
obstruction  in  the  naso  pharynx,  trachea,  or  bronchi  was 
sometimes  mistaken  for  laryngeal  croup.  Obstruction  in  the 
naso-pharynx  was  sometimes  very  difficult  to  distinguish  from 
laryngeal  obstruction.  In  both  conditions  there  were  noisy 
respiration,  dyspnoea,  recession  of  the  chest  wall,  croupy  cough, 
restlessness,  and  cyanosis.  The  difierence  lay  chiefly  in  the  char- 
acter of  tiie  respiratory  sound,  which  was  stertorous  and  rattling 
in  naso-pharyngeal  diseases,  while  the  voice  was  clear,  although 
it  might  have  a  nasal  quality.  The  diagnosis  could  usually  be 
made  by  ocular  examination  of  the  pharynx  and  nares,  but  digi- 
tal examination  was  sometimes  necessary.  "When  diphtheria 
involved  both  the  larynx  and  the  pharynx  it  might  be  very  diffi- 


cult to  determine  in  which  locality  lay  the  chief  cause  of  the 
dyspnuia.  The  caliber  of  the  trachea  was  so  great  that  an  in- 
tense type  of  inflammation  oi'  a  very  large  foreign  body  wa» 
necessary  to  cause  serious  interference  with  respiration.  Tra- 
cheal obstruction  was  characterized  by  expiratory  dyspnoea  in 
contradistinction  to  the  in8|)irat()ry  dyspntiia  of  obstruction  in 
the  higher  portions  of  the  air  passages.  In  bronchial  oiistruc- 
tion  the  respiratory  sounds  were  diminished  only  on  the  side  to 
which  the  obstructed  bronchus  belonged.  Laryngeal  obstruc- 
tion was  characterized  by  hoarseness  or  aphonia,  by  hard, 
brassy,  croupy  respiration,  and  by  marked  downward  move- 
ment of  the  larynx  with  each  inspiration.  This  latter  symptom 
was  one  of  great  diagnostic  importance.  Suprasternal  reces- 
sion was  also  a  common  and  important  symptom.  Inspiratory 
and  expiratory  dyspnoea  and  recessions  of  the  chest  wall  were 
symptoms  of  less  constant  occurrence  in  the  earlier  stages. 


THE  TREATMENT  OF  ELONCxATION  OF  THE  LIGAMENTUM 
PATELLJ-;. 

According  to  the  Medical  Week  for  February  17th,  Mr.  W. 
J.  Walsham  re{)orted  at  the  Royal  Medical  and  Chirurgical  So- 
ciety of  London,  on  February  14th,  two  similar  cases  of  knee 
trouble  characterized  by  elongation  of  the  ligamentum  patellse. 
There  were  pain  and  difficulty  in  walking  and  liability  to  fall 
suddenly,  on  account  of  the  patella  slipping  over  one  or  the 
other  condyle;  the  jiatella  could  be  dislocated  laterally  on  to 
either  condyle,  and  with  the  knee  bent  at  an  angle  of  90°  it 
could  be  pushed  up  on  the  condyles  of  the  femur  so  that  its  an- 
terior surface  looked  upward  instead  of  forward.  The  elon- 
gated ligament  was  shortened  by  transplanting  the  tubercle  of 
the  tibia  about  an  inch  down  the  shaft.  The  wound  healed  by 
first  intention,  and  when  each  patient  was  last  seen  the  knee 
joint  appeared  normal.  Mr.  Keetley  had  treated  such  a  case 
successfully  by  excision  of  a  wedge  of  bone  from  the  patella  and 
shortening  the  aponeurosis  on  the  inner  side,  and  Mr.  Greig 
Smith  had  shortened  the  ligament  by  passing  a  kangaroo  ten- 
don through  its  whole  length  and  pulling  it  so  tight  as  to 
pucker  up  the  ligament,  which  he  then  secured  by  a  second 
suture.  The  unsatisfactory  results  following  instrumental  treat- 
ment suggest  recourse  to  operative  measures,  and  Mr.  Wal- 
sham's  operation  or  the  excision  of  a  portion  of  the  ligament 
would  seem  to  be  the  most  promising  procedure. 


APPENDICITIS  VERSUS  TYPHLITIS. 

At  a  recent  meeting  of  the  London  Clinical  Society  Sir  Dyce 
Duckworth  protested  against  the  use  of  the  term  appendicitis 
by  one  of  the  speakers,  stating  that  the  term  was  of  American 
origin,  and  had  not  been  accepted  in  England.  He  believed 
that  inflammation  of  the  vermiform  appendix  should  be  desig- 
nated by  the  term  typhlitis,  and  stated  that  appendicitis  would 
not  figure  in  the  next  edition  of  the  Nomenclature  of  the  Royal 
College  of  Physicians.  The  word  appendicitis  is  a  hybrid  and 
therefore  objectionable.  Ecphyaditis  is  to  be  preferred,  but 
appendicitis  has  become  popular,  and,  with  all  the  objection 
that  can  lie  against  it,  it  is  to  be  preferred  to  typhlitis,  because 
the  latter  does  not  mean  disease  of  the  vermiform  appendix, 
but  of  the  ciBcum. 


J^ALSE  RENAL  BALLOTTEMENT. 

At  a  recent  meeting  of  the  Paris  Societe  de  chirurgie,  reported 
in  the  Union  medicale,  M.  Le  Dentu  spoke  of  certain  observations 
that  supported  M.  Tuffier's  reflections  on  the  occurrence  of  so- 


March  4,  1893.] 


MINOR  PARAGRAPHS.— ITEMS. 


247 


called  renal  ballottement  in  hepatic  afi'ections.  In  three  cases 
there  had  been  calculi  in  the  gall-bhidder,  induration  of  that 
organ,  and  adhesions  around  it,  and  in  another  case  tliere  had 
been  inHainination  of  the  peritoneal  coat  of  the  liver.  In  all 
these  four  cases  renal  ballottement  had  been  elicited,  but  surgi- 
cal intervention  had  shown  that  there  was  no  renal  disease. 
Not  only  prolapse  of  the  kidney,  but  also  enlargement  of  the 
liver  or  a  tumor  beneath  it  might  give  rise  to  the  sign,  although 
tumors  under  the  liver  tended  rather  to  come  into  relation  with 
the  anterior  wall  of  the  abdomen,  while  renal  tumefactions 
were  disposed  toward  the  iliac  fossa.  At  tlie  same  meeting  M. 
Reclus  told  of  an  inflammatory  tumor,  consequent  on  perfora- 
tion of  a  vermiform  appendix  that  was  very  long  and  directed 
upward,  that  had  given  rise  to  the  same  false  renal  ballottement 


"  ACHILLODYNIA." 

Professor  E.  Albert  rejjorts  in  the  Wiener  medicinische 
Presse  for  January  8th  a  peculiar  disorder  in  which  there  is 
pain  at  the  insertion  of  the  tendo  Achillis  that  prevents  the  pa- 
tient's standing  or  walking,  though  no  pain  is  experienced  when 
he  is  sitting  or  lying.  There  is|s]ight  swelling  about  the  inser- 
tion of  the  tendon,  though  there  is  but  little  tenderness  on 
pressure.  The  condition  does  not  seem  to  be  dependent  upon 
any  constitutional  disorder,  and  has  defied  treatment  by  hot  or 
cold  appjications,  iodine,  and  mercury.  It  differs  from  Raynal's 
"peritendinous  cellulitis  of  the  tendo  Achillis  "  in  that  there 
are  no  nodular  thickenings  in  the  substance  of  the  tendon,  ps  in 
that  disease.  There  has  been  no  evidence  of  partial  rupture  or 
detachment  of  the  tendon  in  the  cases  that  have  been  observed. 


DUBOISINE  IN  THE  TREATMENT  OF  MANIACAL  EXCITEMENT 
AND  OF  PARALYSIS  AGITANS. 

De.  Fbedeeiok  Peterson,  in  a  recent  paper  on  the  treat- 
ment of  the  insane,  speaks  of  the  advantage  of  administering 
sulphate  of  duboisine  to  quiet  maniacal  excitement,  and  be- 
lieves it  preferable  to  hyoscyamine.  Professor  E.  Mendel,  of 
Berlin,  recommends  it  in  paralysis  agitans  to  quiet  the  trem- 
bling. It  is  administered  hy|)odermically,  in  doses  of  from  one 
three-hundredth  to  one  two-hundredth  of  a  grain,  its  effects 
last  from  three  to  five  hours,  and  it  is  less  toxic  and  more 
efficacious  than  hyoscine. 


A  NEW  PLATE  FOR  INTESTINAL  ANASTOMOSIS. 

Dr.  F.  Btron  Robinson,  of  Chicago,  has  invented  a  plate 
consisting  of  a  central  metallic  disc  which  firmly  holds  together 
two  raw- hide  plates  of  the  size  desired.  No  sutures  are  re- 
quired to  be  used  with  the  plate.  The  metallic  disc  is  made 
small  enough  to  pass  readily  through  the  ileo-csecal  valve,  and 
adhesion  from  firm  pressure  is  relied  on.  The  object  of  the 
plate  is  to  secure  an  ample  anastomotic  aperture  without  sutures 
and  by  means  that  will  not  interfere  with  fascal  circulation 
after  breaking  down. 


THE  ACTION  OF  COLD  APPLICATIONS  ON  THE  BLOOD. 

TnE  Medical  Week  states  that  at  a  recent  meeting  of  the  Im- 
perio-Royal  Medical  Society  of  Vienna,  Professor  Winternitz  said 
that  he  had  observed  that  the  leucocytes  in  the  blood  increased 
to  twice  or  even  three  times  their  original  number  after  cold- 
water  applications.  The  great  importance  of  a  largo  number 
of  leucocytes  in  assisting  recovery  from  infectious  diseases  being 


admitted,  the  advantages  possessed  by  cold  water  over  other 
antipyretics  will  readily  be  appreciated. 


THE  ALKALINE  NITRATES  IN  MALARIAL  POISONING. 

In  the  Pester  medieinisch-chirurgiscJie  Presse,  according  to 
an  abstract  in  the  Union  medicale,  Dr.  Buro  reports  excellent 
results  from  the  use  of  sodium  nitrate  and  potassium  nitrate  in 
intermittents,  whether  quotidian,  tertian,  or  quartan.  The 
sodium  salt  is  to  be  preferred,  because  it  is  less  toxic  and  mora 
soluble.  The  ordinary  hypodermic  dose  is  from  fifteen  to 
twenty  grains,  given  at  the  onset  of  a  paroxysm  or  in  an  inter- 
mission. 


ANOTHER  FOUR-YEAR  MEDICAL  COLLEGE. 

The  Woman's  Medical  College  of  Pennsylvania  now  requires 

all  new  matriculates  to  attend  four  annual  courses  of  lectures, 
of  seven  months  each,  before  being  eHgible  for  the  medical  de- 
gree. This  makes  the  fifth  or  sixth  college  in  the  United  States 
that  has  adopted  this  high  standard.  It;  is  to  be  hoped  that 
many  others  will  soon  follow  in  the  same  path. 


MR.  BURDETT'S  HOSPITALS  AND  ASYLUMS  OF  THE 
WORLD. 

We  regret  to  learn  from  the  public  press  that  Mr.  Henry  C. 
Burdett,  the  author  of  that  magnum  opus,  The  Hospitals  and 
Asylums  of  the  World,  the  first  two  volumes  of  which  were  fa- 
vorably reviewed  in  the  Journal  during  the  past  year,  has  been 
compelled  to  rewrite  a  large  part  of  the  third  and  fourth  vol- 
umes because  of  the  loss  of  much  of  his  copy  in  consequence  of 
the  failure  of  his  publishers. 


"  ORGANOPATHY." 

De.  John  Aulde  suggests  in  the  American  Therapist  that 
the  method  of  treating  disease  by  administering  to  the  patient 
an  extract  or  tincture  of  the  organ  of  a  healthy  animal  corre- 
sponding to  the  organ  affected  might  with  propriety  be  called 
"  organopathy." 


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  28,  1893  : 


DISEASES. 

Week  ending  Feb.  21. 

Week  ending  Feb.  88. 

Cases. 

Deaths. 

Cases. 

Deaths. 

25 

5 

11 

4 

11 

5 

11 

6 

203 

20 

180 

15 

2 

2 

1 

3 

100 

12 

109 

5 

129 

34 

105 

33 

7 

3 

15 

S 

Medico-masonic. — The  Lancet  related  that  a  recent  meeting  of  ^scu- 
lapius  Lodge,  No.  2410,  was  held  at  the  Caf6  Royal,  Regent  Street,  at 
which  the  W.  M.  (Deimty  Inspector-General  Belgrave  Ninui.s,  M.  D.)  pre- 
sided, suppoi  teii  by  the  otlicers  of  the  lodge  and  a  number  of  brethren. 
After  the  minutes  of  the  last  mooting  had  been  road  and  coufirmed  Bro. 
Surgcou-Captaiu  R.  Ashton  Bostock,  L.  R.  C.  P.  Loud.,  M.  R.  C.  S.,  wa* 


24:8 

unanimously  elected  a  joining  member.  Bro.  W.  Arbuthnot  Lane, 
M.  S.  Lond.,  F.  R.  C.  S.  Eng.,  was  admitted  to  the  third  degree. 

The  Bafifalo  Academy  of  Medicine. — At  the  next  meeting  of  the 
Surgical  Section,  on  Tucsiiay,  tlic  1th  inst..  Dr.  Ernest  Wende  will 
speak  on  The  Causes  and  Theories  of  Syphilis,  Dr.  Carlton  C.  Frederick 
on  Syphilis  and  Marriage,  and  Dr.  William  H.  Heath  on  the  Treatment 
of  Syphilis. 

The  French  Congress  of  Surgery. — The  seventh  session  of  the  con- 
gress will  open  on  Monday,  April  Sd,  in  the  great  amphitheatre  of  the 
Paris  faculty  of  medicine,  under  the  presidency  of  M.  Laniiclongue. 

The  Late  Professor  Hardy. — In  the  Union  medicale  we  find  an  in- 
teresting aecouut  of  the  obsequies  of  the  distinguished  dermatologist 
Professor  Hardy,  which  took  place  at  the  Madeleine  on  the  25th  of 
January.  The  throng  jjresent  represented  not  only  the  medical  profes- 
sion, but  the  whole  Parisian  population.  The  deceased  was  eighty 
years  old,  and  for  forty  years  he  had  served  in  the  Hopital  Saint- 
Louis. 

The  Death  of  Dr.  William  W.  Dawson,  of  Cincinnati,  is  announced 
in  the  Journal  of  the  American  Medical  Ansociation  as  having  taken 
place  on  February  16th.  The  deceased  was  a  trustee  of  the  American 
Medical  Association,  and  had  been  its  president. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army,  from  February  19  to  February  25,  1893  : 

By  the  authority  of  an  act  of  Congress,  approved  February  2,  isit8, 
FiNLF.Y,  .James  A.,  Captain  and  Assistant  Surgeon,  is,  by  direction 
of  the  President,  placed  upon  the  retired  list  of  the  army,  to  date 
from  February  16,  1893,  the  date  of  his  acceptance  of  his  appoint- 
ment under  the  provisions  of  said  act. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  February  25,  1893 : 
Stone,  E.  P.,  Passed  Assistant  Surgeon.   Ordered  to  the  Naval  Hospital, 

Chelsea,  Mass. 

Gravatt,  C.  U.,  Surgeon.  Detached  from  the  Naval  Hospital,  New 
York,  March  1st,  and  granted  three  months'  leave. 

Society  Meetings  for  the  Coming  Week : 

Monday,  March  6th :  New  York  Academy  of  Sciences  (Section  in 
Biology) ;  German  Medical  Society  of  the  City  of  New  York  ;  Mor- 
risania  Medical  Society  (private) ;  Brookl\Ti  Anatomical  and  Surgical 
Society  (private) ;  Utica  Medical  Library  Association  ;  Coming,  N. 
Y.,  Academy  of  Medicine  ;  Boston  Society  for  Medical  Observation  ; 
St.  Albans,  Vt.,  Medical  Association  ;  Providence,  R.  I.,  Medical 
Association  (annual) ;  Hartford,  Conn.,  Medical  Society  ;  South  Pitts" 
burgh,  Pa.,  Medical  Society  ;  Chicago  Medical  Society. 

Tuesday,  March  7th:  New  York  Obstetrical  Society  (private);  New 
York  Neurological  Society  ;  Elmira  Academy  of  Medicine  ;  Buffalo 
Academy  of  Medicine  (Surgical  Section) ;  Buffalo  Medical  and  Sur- 
gical Association  ;  Ogdensburgh  Medical  Association  ;  Hudson,  N.  J., 
County  Medical  Society  (Jersey  City) ;  Androscoggin,  Me.,  County 
Medical  Association  (Lewiston)  ;  Essex,  Mass.,  South  District  Medical 
Society  (annual — ^Salem) ;  Baltimore  Academy  of  Medicine. 

Wednesday,  March  Sfh:  New  York  Surgical  Society  ;  New  York  Patho- 
logical Society;  Metropolitan  Medical  Society  (private) ;  American 
Microscopical  Society  of  the  City  of  New  York ;  Medical  Societies 
of  the  Counties  of  Albany  and  Montgomery  (quarterly),  N.  Y. ; 
Pittsfield,  Mass.,  Medical  As.sociation  (private) ;  Worcester,  Mass., 
District  Medical  Society  (Worcester) ;  Philadelphia  County  Medical 
Society. 

Thursday,  March  9th :  New  Y''ork  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,  Mass.,  Medical  Club  (private);  Pathological 
Society  of  Philadelphia. 

Friday,  March  10th:  Yorkville  Medical  Association  (private);  Brook- 


[N.  Y.  Med.  Jocr. 

.) 

lyn  Derraatological  and  Genito-ui  inary  Society  (private) ;  German 
Medical  Society  of  Brooklyn  ;  Medical  Society  of  the  Town  of  Sau- 
gerties. 

Saturday,  March  11th  :  Obstetrical  Society  of  Boston  (private). 


^tiin^  to  tbc  (^bitor. 

THAT  "ELECTRICAL  NOVELTY"  ONCE  MORE. 

January  25,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

.Sir:  A  friend  has  just  called  my  attention  to  Mr.  George 
Quarrie's  comments  {New  York  Medical  Journal,  December  24, 
1892)  on  a  letter  of  mine,  in  the  New  York  Medical  Journal  of 
November  12,  1892,  criticising  an  article  of  his  upon  his  "Elec- 
trical Novelty." 

In  his  fir.st  article  Mr.  Quarrie  told  us  that  our  "feet  soles" 
were  "the  most  highly  organized  nerve  surface  of  any  in  our 
body,"  and  on  this  fact  (?)  based  his  principal  argument  for  his 
novel  shoe.  I  quoted  from  Dr.  Flint's  Physiology,  to  disprove 
bis  fact.  He  does  not  deny  the  disproof,  but  he  says  "  it  is 
qnite  irrelevant." 

Irrelevant !  Let  us  see.  Mr.  Quarrie  virtually  founded  his 
case  on  the  following  passages  in  his  first  article  :  , 

"  I  ask  any  man,  before  he  decides  tliis  question  for  himself, 
to  consider  for  a  moment  the  wonderful  construction  of  his  own 
feet  soles.  Why  are  they  provided  by  the  Creator  with  that 
marvelous  cluster  of  cutaneous  nerve  endings  which  so  distin- 
guishes them  from  any  other  part  of  his  body  ?  Why  have  we 
here  those  myriads  of  little  nerve  feelers  brought  right  out  into 
the  papillae  of  the  skin,  so  that,  if  free  to  do  so,  they  would  have 
actual  contact  with  the  earth  as  we  walk  on  it." 

Further  on  he  distinctly  declares  that  our  "  feet  soles"  are 
"  the  most  highly  organized  nerve  surface  of  any  in  our  bodies." 

To  this  I  replied  : 

"  The  '  nervous  papilliB  '  of  the  palmar  surface  of  the  hands 
and  fingers  are  more  than  four  limes  as  numerous  as  on  the 
plantar  surface  of  the  feet.  And  of  the  four  hundred  papillaB 
in  a  square  surface  of  a  little  more  than  one  twelfth  of  an  inch, 
on  the  third  phalanx  of  the  index  finger,  only  one  hundred  and 
eight  are  nervous — '  nerve  feelers,'  as  Mr.  Quarrie  calls  them. 
To  the  same  area  on  the  great  toe,  in  a  corresponding  locality, 
there  are  only  thirty-four  tactile  corpuscles — nervous  papillae — 
and  '  seven  or  eight  in  the  skin  on  the  middle  of  the  surface  of 
the  feet.'  "    (Flint's  Physiology,  p.  514.) 

Now,  it  is  this  quotation  from  Dr.  Flint  which  knocks  the 
foundation  from  Mr.  Quarrie's  theory  and  topples  the  whole 
superstructure  to  the  ground,  that  Mr.  Quarrie  says  is  "irrele- 
vant." Instead  of  frankly  acknowledging  his  mistake,  he  affects 
to  regard  the  exposure  and  refutation  of  it,  not  only  as  irrele- 
vant, but  injurious. 

Mr.  Quarrie  quotes  me  correctly  as  saying  that  "this  horny 
substance  (the  thickened  epidermis)  is  one  of  the  most  non-con- 
ductive of  all  the  animal  tissues."  And  he  says  :  "  Now  this  is 
an  important  point."  Important  if  true  ;  and  one  sees  that  Mr» 
Quarrie  does  not  presume  to  dispute  it.  If  he  would  have  us 
infer  anything  to  the  contrary,  he  has  given  us  no  reason  to  do 
so.  This  horny  substance  of  the  skin  is  one  of  the  most  non- 
conductive  of  the  animal  tissues,  whether  "  riddled  by  sweat 
ducts  "  or  with  buckshot ;  and  Mr.  Quarrie  can  not  get  round 
that  fact  by  showing  that  copper,  iron,  or  water  is  a  conductor. 

Mr.  Quarrie  says :  "  I  mentioned  the  fact  that  Nature  had 
placed  a  great  nervous  concentration  in  the  soles  of  our  feet." 


ITEMS.— LETTERS  TO  THE  EDITOR. 


March  4,  1893.] 


LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES. 


249 


I  did  not  notice  such  a  mention.  I  can  not  now  find  it  in 
his  article.  It  is  not  there.  If  it  had  been,  I  should  not  have 
known  what  it  meant.  Nor  can  I  now  conceive  of  any  fact  or 
condition  to  which  the  expression  "  nervous  concentration  "  can 
be  applied.  Perhaps  Mr.  Quarrie,  not  wishing  to  repeat  his 
blunder,  adopts  this  expression  as  a  substitute  for  the  passages 
above  quoted.  If  so,  the  reader  can  now  see  the  difference  be- 
tween what  he  did  say  and  what  he  now  says  he  said  ;  and  he 
can  also  see  that  there  is  no  possible  sense  in  which  it  can  be 
true  in  respect  to  the  "  organized  nerve  surface  "  of  our  bodies 
— the  "nerve  feelers"  of  the  feet  being  to  those  of  the  hands 
as  thirty-four  is  to  one  hundred  and  eight.  Will  Mr.  Quarrie 
now  own  up  ? 

I  should  be  glad  to  return  Mr.  Quarrie's.compliment  by  char- 
acterizing his  letter  as  a  "  labored  "  one.  Had  he  bestowed  as 
much  labor  upon  it  as  the  subject  deserves,  we  should  not  have 
been  treated  to  such  expressions  as  "  nervous  concentration," 
"  electricity  of  low  tension  "  (a  term  discarded  by  electricians 
for  its  ambiguity,  and  utterly  meaningless  here),  nor  should  we 
have  had  Dr.  Flint's  "groove  between  rows  of  papilla?"  con- 
verted into  "groove  in  the  papillae";  nor  should  we  have  heard 
of  "the  shape  of  moisture";  nor  have  been  told  that  the  simple 
proposition  that  "the  soles  of  a  man's  feet  are  non-conductive 
to  electricity"  was  "self-contradictory."  The  proposition  may 
not  be  true,  whoever  asserts  it :  but,  true  or  false,  it  would  take 
a  finer  analytical  faculty  than  any  Mr.  Quarrie  has  manifested 
in  this  discussion  to  point  out  the  elements  of  self-contradiction 
in  it. 

Further,  if  Mr.  Quarrie  had  read  the  whole  of  the  book  from 
which  he  ventures  to  quote  (Sylvanus  B.  Thompson's  Electricity 
and  Magnetism),  he  would  have  learned  that  the  difference  be- 
tween high  and  low  tension  [intensity]  electricity  was  one  of  de- 
gree only  Cpi'ge  5^8,  London  edition,  1884),  and  that  "pure  water 
will  hardly  conduct  at  all,  and  is  for  the  feeble  electricity  [low 
intensity  ]  of  the  voltaic  battery  almost  a  perfect  insulator,  though 
for  the  high-potential  electricity  of  the  frictional  machines  it  is 
a  fair  conductor."    (Page  30.) 

Now,  is  the  electricity  (the  currents  of  muscular  contraction) 
that,  according  to  Mr.  Quarrie,  escapes  through  our  "  feet  soles," 
the  "  high-potential  electricity  of  the  frictional  machines,"  or  is 
it  the  "feeble  electricity  of  the  voltaic  battery,"  or  only  "natu- 
ral [!J  electricity  ?  " 

It  is  surprising  that  Mr.  Quarrie  does  not  see  that  his  own 
quotations  from  Thompson  are  fatal  to  his  assumption. 

I  hardly  need  to  say  that  I  am  not  assailing  Mr.  Quarrie's 
"  novel  shoe,"  but  only  the  science  (?)  by  which  he  would  fain 
recommend  it.  If  his  shoe  is  good  for  anything,  it  proves  that 
Mr.  Quarrie  is  a  better  shoemaker  than  electrician,  physiologist, 
or  anatomist.  Nor  need  I  say  that  there  is  no  intention  to  in- 
jure or  insult  Mr.  Quarrie  in  making  these  criticisms.  If  there 
is  any  injury,  it  is  purely  incidental  to  the  truth,  which  Mr. 
Quarrie  ought  to  be  willing  to  accept.  If  Mr.  Quarrie  had  sub- 
mitted his  articles  to  an  expert  physiologist,  an  expert  electri- 
cian, an  expert  logician,  and  an  expert  grammarian  for  revision 
before  publication,  he  would  not  have  incurred  the  criticism 
which  .seems  so  to  nettle  him.  R.  C.  Rutiieefoud. 


SUMMER  DIARRHffiA. 
137  East  Ninetkekth  Street,  February  21,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sik:  Once  more  Dr.  Illoway,  of  Cincinnati,  has  made  cer- 
tain statements  concerning  my  investigations  regarding  Cholera 
Infantum  and  the  Weather  {Medical  Record,  March  24,  1888), 
in  a  recent  letter  published  in  your  issue  of  February  18th,  simihir 


to  his  critical  remarks  upon  the  same  subject  in  his  j)aper  on 
Summer  Complaint  {New  York  Medical  Journal,  September  10, 
1892),  and  once  more  I  beg  of  you  to  permit  me  to  say  a  few 
words  in  defense.    It  will  be  the  last  time. 

1.  My  critic  insists  upon  it  (in  the  face  of  my  published 
work  and  my  previous  public  correction)  that  "  Seibert  con- 
cludes, from  a  comparison  of  monthly  means  [of  temperature], 
that  a  continued  minimal  temperature  of  not  less  than  60°  F.  is 
necessary  for  the  occurrence  of  summer  diarrhoea,  and  that 
when  the  daily  mijiimal  tem2Jerature  is  below  60°  F.  it  loses 
its  epidemic  character." 

Answer. — The  untruthfulness  of  this  peculiar  statement  is 
written  on  its  face.  How  can  any  one  gain  daily  minimal  tem- 
perature observations  from  monthly  means? 

2.  From  the  fact  that  I  did  compare  the  monthy  means 
of  temperature  and  the  frequency  of  this  disease  in  the  first 
half  of  my  report  (leaving  the  comparison  of  the  three  weather 
observations  of  each  day  of  ten  years  for  tlie  second  and  more 
important  half).  Dr.  Illoway  deduces  "that  he  who  runs  can 
read  in  this  paragraph  that  we  must  not  pay  too  much  attention 
to  daily  temperatures,"  etc. 

Answer. — "Daily  temperatures"  are  not  even  mentioned 
once  in  the  first  half  of  my  work!  If  the  ability  to  run  is  es- 
sential for  the  misinterpretation  quoted,  then  I  can  at  least 
guess  at  how  such  a  thing  is  possible,  although  it  is  new  to  me 
that  some  people  need  their  feet  to  do  their  thinking. 

To  finally  illustrate  how  clearly  my  critic  understands  some  of 
the  valued  additions  to  modern  science,  I  will  state  the  fact  that 
in  his  long  article  on  Summer  Complaint,  covering  fifty-six 
pages  and  a  half  of  a  reprint,  he  speaks  of  sterilization  of  milk 
but  once — in  his  last  foot-note  :  "  This  [sterilization]  from  my 
standpoint  becomes  unnecessary,"  and  later  on:  "The  superior- 
ity of  my  method  is  still  further  enhanced  by  the  knowledge 
afforded  us  by  the  valuable  investigations  of  Leeds  and  Davis, 
that  the  nutritive  value  of  milk  is  destroyed  by  sterilization,'''' 
and  then  proceeds  to  inform  us  that  he  orders  '■'■all  milk  to  be 
boiled  for  half  an  hour  in  a  covered  vessel " !    Poor  Soxblet! 

A.  Seibeet,  M.  D. 


^r0cctbmcj;s  of  Societies. 


MEDICAL  SOCIETY  OF  THE  STATE  OF  NEW  YORK 

Eighty-seventh  Annual  Meeting,  held  in  Albany  on  Tuesday, 
Wednesday,  and  Thursday,  February  7,  8,  and  9,  1893. 

The  President,  Dr.  Lewis  S.  Pilchee,  of  Brooklyn,  in  the  Ch.air. 

{Vontinued  from  page  SOI.) 

Certain  Forms  of  Septicaemia  resulting  from  Abortion 

was  the  title  of  a  paper  read  by  Dr.  Andeew  F.  Curkier,  of 
New  York.  The  forms  of  septicaemia  to  be  considered,  ho  said, 
were  not  exclusively  peculiar  to  abortion,  but  might  follow  the 
termination  of  the  pregnant  state  whether  that  had  occurred  at 
term  or  [)rematurely.  Modern  antiseptic  midwifery  had  reached 
nearly  ideal  conditions  in  its  care  of  the  parturient  woman  and 
her  offspring  at  term.  Assistance  was  almost  always  available 
to  a  woman  at  such  a  time,  and  if  she  entered  a  maternity  hos- 
pital nothing  was  lacking,  as  a  rule,  which  would  minister  to 
her  safety  and  recovery.  How  different  was  the  situation  with 
reference  to  abortion!  Abortion  was  an  unnatural  process, 
while  parturition  at  term  was  natural"  and  physiological.    It  sig- 


250 


PROCEEDINOS  OF  SOCIETIES. 


fN.  Y.  Med.  Jouu  , 


ni6e(l  tbe  interposition  of  disease  or  violence  and  tlie  disturb- 
ance to  a  greater  or  lesser  degree  of  the  equilibriutn  of  natural 
forces.  It  was  regarded  by  many  women  as  too  trivial  a  matter 
to  require  the  attention  of  a  physician,  and  was  attended  with 
carelessness  and  neglect.  It  was  probably  responsible  for  more 
of  the  serious  disease  which  affected  the  pelvic  viscera  of  women 
than  any  otlier  cause. 

Septiciomia  in  the  light  which  had  been  shed  upon  it  by  bac- 
teriology signified  that  poisonous  elements  were  circulating  in 
the  blood  which  were  distributed  more  or  less  extensively  over 
the  body  and  caused  serious  and  often  fatal  consequences. 
These  elements  had  been  found,  isolated,  and  cultivated,  and  the 
culture  fluids  had  been  successfully  used  in  reproducing  the  jjhe- 
Doinena  of  the  disease,  microbes  similar  to  those  which  were  in- 
jected being  found  in  the  white  blood-corpuscles,  the  blood- 
vessels, and  the  subcutaneous  tissues  contiguous  to  the  point  of 
inoculation.    Such  experiments  had  repeatedly  been  performed 
upon  animals,  and  Garre,  Bumm,  Bockhardt,  and  Schimmel- 
busch  had  performed  them  upon  their  own  persons.    In  septi- 
caemia following  abortion  the  products  of  conception  had  not 
been  completely  removed  or  there  had  been  decomposition  and 
absoi'ption  or  the  introduction  of  poisonous  elements  from  with- 
out. The  intensity  of  the  disease  in  a  given  case  would  be  regu- 
lated by  the  virulence  of  the  poison,  the  resistance  of  the  indi- 
vidual, and  the  efficiency  of  treatment.  Two  varieties  of  bacteria 
were  principally  efficient  in  septicaemia — the  Streptococcus  py- 
ogenes mireus  and  the  Staphylococcus  pyogenes  aureus.  They 
might  be  of  variable  activity,  might  modify  each  other's  action, 
and  might  be  modified  by  the  action  of  other  bacteria  which, 
under  normal  conditions  of  the  body,  might  be  harmless  para- 
sites {e.  g.,  the  Bacterium  coli  commune).  The  resisting  power  of 
the  body  was  a  very  variable  quantity,  differing  with  tempera- 
ment and  disposition  and  modified  by  its  surroundings.  The 
cases  of  the  disease  might  be  divided  into  mild,  severe,  and  un- 
controllable varieties  or  groups,  the  first  always  ending  in  more 
or  less  complete  recovery,  the  second  often  terminating  fatally, 
the  third  being  almost  invariably  fatal.    In  the  first  group  the 
abortion  occurred  most  frequently  at  the  third  or  fourth  month 
of  gestation,  after  more  or  less  pain  and  haemorrhage,  and  was 
followed  in  a  few  hours  by  clots  and  portions  of  the  fcEtal  envel- 
opes. Blood  and  membranous  tissue  continued  to  be  discharged 
for  the  next  three  or  four  days.    Then  came  chilliness,  consti- 
pation, sallowuess  of  the  skin,  and  an  anxious  facial  expression. 
The  uterus  was  enlarged,  soft,  and  sensitive,  the  os  patulous,  and 
the  uterine  discharge  offensive.    The  general  condition  resem- 
bled that  of  the  continued  fevers  of  mild  type.  If  the  surround- 
ings were  favorable  and  the  treatment  was  intelligent,  includ- 
ing curettage,  gauze,  drainage  of  the  uterus,  and  the  judicious 
use  of  salines,  calomel,  and  tonics,  prompt  recovery  would 
ensue.    In  another  class  of  mild  cases  in  which  the  patient 
was  neglectful  of  herself,  the  surroundings  were  bad,  and 
the  treatment  was  inefficient  and  unskillful,  there  might  be 
recovery  after  an  experience  with  endometritis  or  salpingitis, 
and  the  conditions  would  be  favorable  for  much  subsequent 
trouble.    In  the  second  group  of  cases  the  symptoms  were 
more  serious  than  in  the  first,  the  result  was  fatal  for  some  of 
them,  while  for  others  there  was  partial  recovery,  with  more 
or  less  diseased  pelvic  organs.    In  these  cases  there  might  be  a 
history  of  precedent  abortions  with  resulting  induration  of  the 
uterine  tissue,  or  of  criminal  operation  or  serious  disease,  such 
as  cancer,  tubercle,  or  syphilis,  or  the  patient  might  have  been 
so  weakened  by  other  diseases,  by  work,  or  by  worry  that  little 
resistance  could  be  offered  to  the  inroads  of  septicemia.  The 
course  of  the  disease  might  be  febrile  or  not;  there  might  or 
might  not  be  suppuration  ;  there  might  be  steady  progress  to  a 
fatal  issue,  remissions  with  final  recovery,  or  remissions  ending 


in  death.    It  was  difficult  or  iiiii)ossiiile  to  delineate  exact  types 
of  the  disease,  for  there  would  be  modifications  in  almost  every 
case,  but  it  was  possible  to  discriminate  one  form  in  which  the 
toxic  and  another  in  which  the  inflammatory  element  predomi- 
nated.   In  the  toxic  cases  there  was  an  initial  chill  without  high 
temperature,  but  with  a  small  and  quick  pulse  and  frequent  and 
shallow  respiration.    The  facial  expression  was  anxious  and  the 
skin  sallow.    There  was  tenderness  of  the  uterus  and  its  sur- 
roundings, and  there  might  be  induration  in  the  groins  and  at 
the  vaginal  vault.    The  odor  of  the  breath  was  disagreeable,  but 
the  author  had  never  noticed  that  it  was  sweetish  ;  the  mouth 
and  tongue  were  dirty.    The  stomach  and  intestines  were  para- 
lyzed, the  abdomen  was  distended  and  sensitive,  but  the  pain 
was  not  the  cutting  pain  of  acute  peritonitis.    There  was  no 
appetite,  and  the  vomiting  was  distressing.    When  bile  was 
vomited  for  any  length  of  time,  he  had  always  observed  a  fatal 
termination.    There  were  insomnia,  delirium,  and  muscular 
trembling  and  twitching.    Treatment  must  be  energetic  from 
the  beginning,  and  include  curettage,  uterine  and  vaginal  irri- 
gation, oxygen  inhalation,  alcohol,  fluid  nourishment,  and  tur- 
pentine enemata.   The  latter  were  often  of  the  greatest  value, 
but  must  not  be  used  too  often  or  in  too  great  concentration. 
Such  treatment  might  cause  the  disappearance  of  the  grave 
symptoms,  and  convalescence  and  recovery  might  ensue,  or 
foci  of  infection  might  be  rekindled  and  death  follow  quickly. 
In  the  inflammatory  cases  the  symptoms  were  severe,  but  they 
were  less  insidious  than  in  the  toxic.    There  were  well  marked 
evidences  of  peritonitis  or  of  cellulitis,  with  rapidly  extending 
induration  in  the  pelvis  and  abdominal  wall.    The  temperature, 
pulse,  and  respiration  were  febrile,  and  fluctuation  might  be 
expected  in  the  vagina,  the  rectum,  or  the  gluteal  or  inguinal  re- 
gion. Incision  and  irrigation  might  be  followed  by  relief  and  re- 
covery, or  tbe  issue  might  be  pyaemia  and  death.    In  the  third 
group  of  cases  there  might  be  sepsis  and  death  within  a  few 
hours  or  days,  or  there  might  be  extensive  suppurative  processes 
resulting  fatally  in  a  longer  or  briefer  period,  according  to  the 
patient's  endurance.    The  former  were  absolutely  hopeless;  the 
latter  nearly  so.    Successful  abdominal  sections  in  the  suppura- 
tive cases  had  been  reported,  but  they  were  rare.    The  forego- 
ing observations  had  been  made  on  the  basis  that  septicaemia 
was  a  disease  or  condition   to  which   peritonitis,  cellulitis^ 
lymphangeiitis,  and  phlebitis  were  subsidiary.    This  was  in  ac- 
cordance with  bacteriological  manifestations,  and  simplified 
much  that  had  before  been  vague  and  confusing. 

The  Relative  Value  of  Certain  Obstetrical  Operations.— 
Dr.  E.  II.  Gran'din,  of  New  York,  gave  a  general  review  of 
embryotomy,  tbe  Caesarean  section,  and  symphyseotomy.  In 
all  cases,  whatever  the  operation,  the  paramount  importance  of 
asepsis  was  presupposed.  Of  the  greatest  importance  also  was 
an  accurate  knowledge  of  pelvimetry,  and  this  should  be  pos- 
sessed by  every  one  who  practiced  obstetrics.  Examinations  as 
to  the  diameters  of  the  pelvis  and  the  relations  of  the  fcetus  to 
them  were  usually  performed  in  too  perfunctory  and  superficial 
a  way  to  be  of  practical  value.  Information  of  this  character 
should  all  be  obtained  before  the  beginning  of  labor,  and  both 
external  and  internal  measurements  of  the  pelvis  should  be 
made.  Such  information  would  enable  one  to  make  an  intelli- 
gent choice  of  operative  procedures,  and  would  obviate  the 
necessity,  which  has  so  often  arisen  under  past  methods,  of 
making  a  woman  the  subject  first  of  one  experiment  and  then 
of  another.  The  choice  of  operations  was  now  such  that  it 
would  seldom  be  necessary  to  perform  the  destructive  opera- 
tions. 

The  Limitations  of  Embryotomy.— In  a  paper  with  this 
title  Dr.  J.  Clifton  Edgae,  of  New  York,  said  that  the  term 
'  was  intended  to  comprehend  every  operation  by  which  the 


March  4,  1893.] 


PROCEEDINGS  OF  SOCIETIES. 


251 


foetus  was  diminislied  in  size,  wiietber  by  cutling  or  by  crush- 
ing. However  successful  operators  in  this  country  or  elsewhere 
mljl'ht  hiive  been,  it  must  always  heafhnittcd  that  the  Ciesarean 
section  was  attended  with  f^reater  danger  to  the  mother  tlian 
embryotomy.  Statistics  of  craniotomy  were  given  showing 
that  in  skillful  hands  this  operation  usually  resulted  favorably. 
The  crushing  operations  upon  the  skull  within  the  uterus  were 
always  to  be  avoided  if  possible,  and  a  foi-ni  of  operation  less 
dangerous  for  tlie  mother  was  to  be  preferred.  The  instruments 
for  such  operations  were  very  cumbersome  and  powerful,  and 
there  were  few  men  who  had  used  them  sufficiently  often  to  be 
proficient  with  them.  The  importance  of  pelvimetry  with 
reference  to  the  operative  procedures  of  obstetrics  was  very 
great;  especially  important  was  it  that  one  should  always  know 
the  measurement  of  the  conjugate  diameter  before  labor  began. 
The  statistics  of  several  of  the  obstetrical  operations  were  better 
in  European  than  in  American  maternities.  This  was  attribut- 
able to  more  extensive  training  and  to  greater  familiarity  with 
the  instruments  to  be  used. 

Embryotomy  on  the  dead  foetus  was  always  justifiable  where 
indications  for  the  CiEsarean  section  were  wanting.  On  the 
living  foetus  it  would  also  always  be  justifiable  in  certain  rare 
cases  in  which  for  good  reasons  the  Csesarean  section  was  to  be 
rejected.  Symphyseotomy  was  an  operation  that  diminished 
the  dangers  attending  the  Cfesarean  section.  It  could  fairly  be 
said  that  with  existing  methods  of  operation  the  indications  for 
producing  the  death  of  the  fcetus  had  never  been  so  rare  as 
now.  In  general,  embryotomy  upon  the  dead  foetus  was  indi- 
cated where  the  danger  to  the  motlier  was  increased  by  the 
practice  of  any  other  method,  where  the  diameters  were  too 
small  for  the  forceps  or  version,  where  the  pelvic  canal  was  ob- 
structed by  disease,  and  where  the  condition  of  the  mother 
called  for  rapid  delivery. 

On  the  living  foetus  embryotomy  was  indicated  in  certain 
cases  in  which  rai)id  delivery  was  called  for  in  the  mother's 
behalf,  and  in  cases  of  monsters,  etc. 

The  Limitations  of  the  Csesarean  Section.— Dr.  Robert 
A.  Murray,  of  New  York,  read  a  paper  in  which  he  said  that 
the  results  of  the  improved  Csesarean  section  had  been  excel- 
lent, and  the  chances  were  all  in  the  patient's  favor  if  the  diag- 
nosis, time,  and  all  other  necessary  conditions  were  satisfied. 
Success  would  also  be  dependent  upon  the  condition  that  the 
operator  be  an  accomplished  obstetrician  or  surgeon.  The 
speaker  was  in  favor  of  the  method  of  incising  the  uterus  in 
situ.,  as  its  removal  from  the  body  might  introduce  undesirable 
complications.  Suitable  cases  were  those  in  wliich  the  conju- 
gate diameter  was  under  two  inches  and  three  quarters,  in 
which  the  pelvis  was  much  deformed,  or  in  which  cancer  or 
other  serious  disease  was  present.  The  statistics  of  Harris  and 
others  seemed  to  show  that  the  average  weight  of  children  born 
in  this  country  was  greater  than  the  average  of  those  who  were 
born  in  the  maternities  of  Europe.  This  was  perhaps  one  rea- 
son why  the  success  of  European  operators  was  somewhat  better 
than  that  of  Americans.  It  was  not  conceded  tliat  the  skill  of 
American  operators  was  inferior  to  th;it  of  others.  The  abso- 
lute indication  for  an  operation  existed  in  all  pelves  with  a  con- 
jugate under  two  inches  and  a  half;  the  relative  indication 
could  not  as  yet  be  stated  in  precise  terms.  Concerning  sym- 
physeotomy, a  severe  labor  might  result  even  in  cases  in  which 
the  separation  of  the  pubic  bones  amounted  to  throe  inches. 

The  Anatomical  Limitations  of  Symphyseotomy.— Dr. 
J.  E.  Kelly,  of  New  York,  read  a  pa{)er  in  whicli  he  said  that 
the  anatomical  consideration  of  the  subject  had  special  refer- 
ence to  the  cartilages  and  muscles.  The  yleldmg  of  the  carti- 
lages after  section  was  followed,  as  the  foetus  advanced,  by 
rotation  of  the  pubic  bones  upon  the  o^sa  innorainuta.  After 


the  tissues  had  been  divided  to  the  symphysis  the  section 
should  be  made  downward  and  behind  the  symphysis,  rather 
than  upward  and  backward.  By  this  method  there  was  less 
danger  of  injuring  the  vessels,  which  ran  immediately  under  the 
symphysis.  The  increase  in  space  which  was  gained  by  the 
operation  was  least  in  the  antero -posterior  diameter  of  the  pel- 
vis. As  to  the  joints,  the  separation  was  least  at  the  sacro-iliac 
synchondrosis.  An  extreme  separation  of  three  inches  at  the 
symphysis  was  attended  by  a  separation  at  the  synchondrosis  of 
only  three  sixteenths  of  an  inch.  The  damage  to  other  struc- 
tures by  the  operation  was  not  serious.  The  elasticity  of  the 
muscles  and  ligaments  of  the  pelvis  during  labor  could  be 
counted  upon  as  contributing  at  least  half  an  inch  to  all  the 
diameters  as  obtnined  by  pelvimetry.  The  operation  could  be 
divided  into  four  stages:  the  preparation  of  the  surface,  division 
of  the  tissues  down  to  the  symphysis,  division  of  the  cartilage 
and  division  of  the  infrapubic  ligament.  The  changes  in  the 
bones  and  joints  which  followed  the  operation  as  labor  pro- 
gressed were  very  clearly  demonstrated  by  carefully  constructed 
models. 

The  Clinical  Limitations  of  Symphyseotomy  was  the  title 
of  a  i)aper  by  Dr.  Chaeles  Jewett,  of  Brooklyn.  The  opera- 
tion had  been  performed  in  sixty-eight  recorded  cases  since 
1886.  It  had  been  done  in  America  nine  times  in  the  last  four 
months.  Of  the  sixty-eight  mothers,  sixty-five  had  been  saved. 
Very  few  injuries  had  been  reported,  and  recovery  had  usually 
been  as  rapid  as  after  the  Cesarean  section.  In  the  reported 
cases  there  had  been  all  grades  of  deformity,  the  conjugate 
diameter  ranging  from  two  inches  and  a  half  to  three  inches 
and  three  quarters.  The  operation  was  applicable  in  flat  pelves 
to  diameters  as  low  as  two  inches  and  a  half.  The  field  of  the 
operation  began  where  the  indications  for  the  forceps  and  ver- 
sion ended.  The  use  of  the  forceps  in  badly  deformed  pelves 
was  often  destructive  to  the  children.  An  indication  which  had 
not  often  been  mentioned  was  to  be  found  in  impacted  mento- 
posterior face  cases.  The  operation  resulted  in  a  general  gain 
in  the  pelvic  capacity.  In  cases  in  which  there  was  ankylosis 
at  the  sacro-iliac  synchondrosis,  symphyseotomy  was  contra- 
indicated.  The  operation  was  one  which  could  be  performed 
by  the  general  practitioner  more  readily  than  the  Cfesarean  sec- 
tion, the  latter  being  more  suitable  for  the  skilled  abdominal 
surgeon.  Symphyseotomy  required  very  little  time  in  its  per- 
formance, and  was  especially  indicated  in  neglected  and  pro- 
tracted labors,  in  which  Csesarean  section,  as  a  last  resort, 
would  usually  result  fatally.  The  technique  of  the  operation  as 
performed  in  the  author's  case  was  narrated,  and  the  absence  of 
difficulty  attending  it  remarked  upon. 

The  discussion  of  the  foregoing  papers  was  opened  by  Dr. 
E.  P.  Davis,  of  Philadelphia.  He  approved  of  the  recommen- 
dations in  regard  to  the  routine  practice  of  pelvimetry.  It 
involved  no  exposure  of  the  individual,  and  only  three  measure- 
ments were  essential.  At  the  same  examination  the  condition 
of  the  foetal  heart  and  the  relation  of  the  foetal  to  the  maternal 
proportions  should  he  ascertained. 

He  agreed  to  the  recommendation  that  embryotomy  in  case 
of  monsters  was  always  ap[)ropriate.  The  Ca3sarean  section  was 
preferable  when  possible  to  destructive  operations,  if  for  no 
other  reason  than  that  the  latter  involved  the  use  of  dangerous 
instruments  with  the  use  of  which  very  few  were  familiar. 
Porro's  operation  was  to  be  preferred  to  the  Csrsarean  section 
alone  in  cases  compli(5ated  with  cancer  or  with  inulti[)le  fibroid 
tumors.  There  was  some  danger  that  the  risinj:  enthusiasm  for 
symphyseotomy  would  obscure  the  indications  for  the  Cfesarean 
section.  The  danger  of  serious  hromorrhage  after  symjjhyseoto- 
my  was  not  imaginary.  He  believed  it  would  be  found  that 
cases  in  which  there  was  great  disproportion  between  the  sizo 


252 


BOOK  NOTICES. 


[N.  Y.  Med.  Johh., 


of  the  foetus  and  the  dimensions  of  the  pelvis  would  more  fre- 
quently furnish  indications  for  symphyseotomy  than  cases  of 
flat  pelvis. 

Dr.  riowAKD  A.  Kei.ly,  of  Baltimore,  showed  Galbiati's 
knife  for  the  performance  of  syinpliyseotomy,  also  some  tin 
models  by  Harris  of  modificat  ions  of  Gaibiati's  instrument,  more 
suitable  than  the  latter  for  American  practice.  He  would  never 
perform  embryotomy  in  pelves  with  a  conjugate  under  five  cen- 
timetres. He  had  seldom  seen  the  generally  contracted  pelvis ; 
the  deformities  in  thi-i  country  were  usually  the  simple  flat  or 
rhachitic  pelvis,  lie  did  not  feel  certain  that  symj)hyseotomy 
would  necessarily  result  in  a  perfectly  strong  symphysis.  That 
point  needed  to  be  more  closely  studied.  The  ancients  had  be- 
lieved that  the  joints  of  the  pelvis  separated  during  latjor,  and 
the  ancient  work  of  Severus  upon  this  subject  had  suggested  to 
Sigault  the  operation  of  symphyseotomy.  Oojjies  of  the  works 
of  both  these  authors  were  shown. 

Practical  Antisepsis  and  Asepsis. — Dr.  Howakd  A.  Kelly, 
of  Baltimore,  illustrated  the  methods  in  use  in  his  work  at  the 
Johns  Hopkins  University  Hosi)ital. 

Epitaphs  from  the  Tombstones  of  Medical  History.— Dr. 

Joseph  11.  Hunt,  of  Brooklyn,  sliowed  under  this  title  the  j)or- 
traits  of  many  of  the  classical  autliors  in  medical  science,  also 
curious  and  interesting  pictures  from  their  works.  The  crude- 
ness  of  the  ancient  ideas  concerning  anatomy,  physiology,  and 
patliology  was  shown  and  furnished  an  unusually  interesting 
exhibition. 

Microphotographic  Demonstrations  of  the  Biological 
Characters  of  the  Cholera  Spirillum  were  given  by  Dr 
George  M.  Sternberg,  of  the  army.  The  reaction  of  the 
cholera-spirillum  culture  in  tubes  under  the  sulphuric-acid  test 
was  also  demonstrated  and  commented  upon. 

(To  he  condnned.) 


Diseases  of  the  Shin:  their  Description,  Pathology,  Diagnosis, 
and  Treatment,  with  Special  Reference  to  the  Skin  Erup- 
tions of  Children.     By  H.  Radcliffe   Crocker,  M.  D. 
(Lond.),  Fellow  of  the  Royal  College  of  Physicians  of  Lon- 
don, etc.     Second  Edition,  revised  and  enlarged.  With 
Ninety-two  Woodcuts.     Philadelphia:  P.  Blakiston,  Son, 
&  Co.,  1893.    Pp.  xsxii-33  to  987.    [Price,  $5.] 
The  author  has,  in  preparing  this  new  edition  of  his  excel- 
lent text-book,  made  a  slight  addition  to  the  title  by  his  an- 
nouncement of  special  reference  to  the  skin  eruptions  of  chil- 
dren ;  but  in  his  revision  he  has  made  the  material  addition  of 
some  two  hundred  and  thirty-five  pages  of  text  and  sixteen  illus 
trations.    An  inspection  of  the  volume  will  show  that  he  has 
kept  en  rapport  with  the  progress  in  dermatology  and  has  fur- 
nished his  readers  with  the  latest  and  most  definite  informa- 
tion. 

In  tlie  section  on  semeiology  he  calls  attention  to  the  prob- 
ably important  influence  the  vaso-motor  centers  exercise  on  the 
distribution  of  eruption?,  and  suggests  the  more  careful  study 
of  this  subject  from  a  neurological  standpoint. 

In  the  chapter  on  aetiology  brief  sections  have  been  incor- 
porated on  the  influence  of  race  and  of  the  circulation  in  caus- 
ing skin  diseases. 

The  section  oti  treatment  now  includes  a  notice  of  antipy- 
rine,  more  extensive  but  not  laudatory  remarks  on  the  utility 
of  ichthyol,  and  a  reference  to  the  iodol  compounds. 


Many  additional  titles  of  diseases  figure,  such  as  erythema 
ab  igne,  erythema  searlatiniforme  desquamativum,  erythema  in- 
duratiim,  epidemic  exfoliative  dermatitis,  zoster  atypicus  gan- 
graenosus  et  hystericus,  hydroa  vacciniforme,  seu  aestivale,  pity- 
riasis rubra  pilaris,  tylosis  palmts  et  planta),  Darier's  disease, 
angeioma  serpiginosuin,  phagedaena  tropica,  dysidrosis  of  the 
face,  seborrhieic  dermatitis,  adenoma  sebaceum,  and  actinomy- 
cosis. 

The  author  has  very  sensibly  substituted  the  word  nodule 
for  tubercle,  because  the  latter  may  be  confounded  with  patho- 
logical tubercle.  And  he  uses  the  word  follicular  instead  of 
lichenoid  in  describing  the  syphilide  in  which  the  hair  follicle 
is  the  seat  of  the  lesion. 

A  modification  of  Morris's  very  satisfactory  classification  of 
vaccination  eruptions  has  been  adopted  in  the  work. 

In  the  new  section  on  Morvan's  disease  the  author  briefly 
reviews  the  literature  of  the  subject,  calling  attention  to  the 
fact  that  a  case  of  anaesthetic  leprosy  had  been  recently  reported 
that  presented  all  the  symptoms  described  by  Morvan.  Zam- 
baco'a  recent  researches  have  demonstrated  the  fact  that  Mor- 
van's disease  is  nothing  but  anaesthetic  leprosy. 

Many  of  the  sections  have  been  rewritten  to  make  them  ac- 
cord with  more  recent  experiment.  Thus,  in  that  on  lupus  the 
employment  of  tuberculin  in  treating  these  cases  is  considered, 
and  the  author  thinks  there  is  a  small  field  for  its  use.  In  the 
appendix  of  formulae  the  process  of  administering  this  prepara- 
tion is  fully  described.  The  section  on  alopecia  has  been  en- 
larged commensurately  with  the  importance  of  that  subject. 

The  first  portion  of  the  appendix  contains  an  analysis  of 
twelve  thousand  cases  of  diseases  of  the  skin  treated  in  dispen- 
sary and  private  practice,  from  which  an  idea  may  be  obtained 
of  the  frequency  with  which  the  various  forms  of  skin  disease 
occur. 

We  can  say  of  this,  as  we  did  of  the  first  edition,  that  it  is 
one  of  the  most  thorough  treatises  on  diseases  of  the  skin  that 
we  know  of,  and  it  is  in  every  way  worthy  of  commendation. 


The  Chronic  Disorders  of  the  Digestive  Tube.  By  W.  W.  Van 
Valzah,  a.  M.,  M.  D.  New  York:  J.  H.  Vail  &  Co.,  1893. 
Pp.  iv-151. 

In  this  brochure  the  author  presents  tlie  substance  of  sev- 
eral papers  previously  contributed  to  medical  journals.  He 
urges  the  im])ortance  of  a  careful  investigation  into  the  physical 
condition  of  the  digestive  organs  as  a  preliminary  to  systematic 
treatment,  the  latter  to  be  mainly  by  general  hygiene,  a  nitro- 
genous diet,  and  the  free  use  of  water  taken  internally  to  wash 
out  the  alimentary  canal  and  promote  tissue  change  aud  elimi- 
nation. 

Drugs  are  not  ignored,  but  occupy  a  secondary  position  in 
the  therapeusis  of  these  disorders. 

A  chapter  oa  seasickness  is  added.  The  author  classes  this 
disorder  as  a  vertigo  of  sensory  origin,  and  believes  that  a 
healthy  digestion  before  and  during  the  voyage  is  the  best  pre- 
ventive. 

Influenza:  its  Pathology,  Symptoms,  Complications,  and  Se- 
quels; its  Origin  and  Mode  of  Spreading;  and  its  Diagnosis, 
Prognosis,  and  Treatment.     By  Julius  Althaus,  M.  D., 
M.  R.  C.  P.  Lond.,  Senior  Physician  to  the  Hospital  for  Epi- 
lepsy and  Paralysis,  Regent's  Park.    Second  Edition,  much 
enlarged.    London  :  Longmans  &  Co.,  1892.    Pp.  xii-407. 
The  interest  evoked  by  the  recent  epidemic  of  grippe  is 
shown  not  only  by  the  call  for  a  second  and  enlarged  edition  of 
Dr.  Althaus's  valuable  treatise,  but  in  a  still  more  striking  man- 
ner by  his  references  to  five  hundred  and  eight  separate  papers 


March  4,  1893.] 


BOOK  NOTICES.— REPORTS  ON  THE  PROGRESS  OP  MEDICINE. 


253 


in  difiFerent  languages  which  have  appeared  on  this  subject  in 
the  last  three  years.  Dr.  Althaus  believes  that  Pfeiffer's  bacil- 
lus is  the  cause  of  grippe,  which  is  contagious  by  actual  contact 
or  by  means  of  fouiites.  Its  progress  follows  the  established 
lines  of  human  intercourse  at  the  rate  of  the  usual  modes  of 
communication ;  its  spread  has  nothing  to  do  with  meteorological 
conditions,  as  it  advances  independently  of  climate,  season, 
wind,  and  weather.  It  affects  large  masses  of  human  beings 
simultaneously:  first,  because  of  its  short  incubation  (two 
days);  second,  because  human  beings  are  exceedingly  suscepti- 
ble to  the  poison  ;  third,  because  it  is  propagated  not  only  by 
those  who  are  ill  in  bed,  but  by  many  ambulatory  patients  who 
have  it  in  a  mild  form.  The  author  assumes  that  a  poisonous 
albuminoid,  grippo-toxine  secreted  by  the  bacillus  of  grippe  cir- 
culates in  the  blood  and  causes  the  symptoms  of  the  feverish 
attack.  In  a  d:iy  or  two  an  antidote,  anti-grippo-toxine,  is 
formed  in  the  patient's  serum,  and,  according  as  it  is  abundantly 
or  sparingly  produced,  there  will  be  a  crisis  or  only  a  pseudo- 
crisis,  the  latter  followed  by  a  more  protracted  course.  The 
protean  symptoms,  complications,  and  sequels  are  fully  de- 
scribed, and  the  principles  which  should  guide  the  diagnosis, 
prognosis,  and  treatment  are  carefully  explained. 

BOOKS,  ETC.,  RECEDTED. 

Bnrdett's  Hospital  Annual  and  Year  Book  of  Philanthropy, 
1893.  Containing  a  Review  of  the  Position  and  Requirements 
and  Chapters  on  the  Cost  of  Management  of  the  Voluntary 
Charities,  and  an  Exhaustive  Record  of  Hospital  Work  for  the 
Year.  Edited  by  Henry  C.  Burdett,  Author  of  Hospitals  and 
Asylums  of  the  World,  etc.  London  :  The  Scientific  Press 
(Limited),  1893.    Pp.  cxciv'536.    [Price,  5s.] 

Various  Forms  of  Hysterical  or  Functional  Paralysis.  By 
H.  Charlton  Bastian,  M.  A.,  M.  D.,  F.  R.  S.,  Fellow  of  the  Royal 
College  of  Physicians,  etc.  Philadelphia :  J.  B.  Lippincott  Co., 
1893.    Pp.  xi-199.    [Price,  $2.25.] 

The  Twelve  Tissue  Remedies  of  Schussler,  comprising  the 
Theory,  Therapeutical  Application,  Materia  Medica,  and  a  Com- 
plete Repertory  of  these  Remedies.  Homceopathically  and  Bio- 
chemically considered.  By  William  Boericke,  M.  D.,  Late  Pro 
fessor  of  Materia  Medica  and  Therapeutics  in  the  Hahnemann 
Hospital  College  of  San  Francisco,  and  Willis  A.  Dewey,  M.D., 
Professor  of  Materia  Medica  in  the  Hahnemann  Hospital  College 
of  San  Francisco.  Third  Edition,  rewritten  and  enlarged. 
Philadelphia:  Boericke  and  Tafel,  1893.    Pp.  10-13  to  384. 

The  Treatment  of  Hay  Fever  by  means  of  Cocaine  Phenate. 
By  D.  Braden  Kyle,  M.  D.,  of  Philadelphia.  [Reprinted  from 
the  Medical  News.] 

Phenate  or  Carbolate  of  Cocaine  as  a  Local  Anaesthetic.  By 
D.  B.  Kyle,  M.  D.,  of  Philadelphia.  [Reprinted  from  the  Thera- 
peutic Gazette.] 

Pott's  Disease,  with  Special  Reference  to  Treatment  in  the 
Upper  Dorsal  and  Cervical  Region.  By  Arthur  J.  Gillette, 
M.  D.,  St.  Paul,  Minn.  [Reprinted  from  the  Northwestern  Lan- 
cet.] 

Extraction  of  Steel  from  the  Interior  of  the  Eye  with  the 
Electro-magnet.  By  Alvin  A.  Hnbbell,  M.  D.,  Buffalo,  N.  Y. 
[Reprinted  from  the  Buffalo  Medical  and  Surgical  Journal.] 

Ueber  das  Wesen  und  die  Behandlung  der  Perity[)hlitiden. 
Vortrag,  gehalten  an  der  Versammlung  schweizerischer  Aerzto 
am  28.  Mai  1892  in  der  Aula  der  Universitiit  Genf.  Von  Pro- 
fessor Dr.  Sahli,  in  Bern.  [Separatabdruck  aus  dem  Correspon- 
demhlatt  fur  schweizer  Aerzte.] 

Beitriige  zur  Kenntniss  der  Metastasenbildung  maligner  Tu- 
moren  nach  statistischen  Zusammenstellungen,  aus  den  Sektions- 
protokollen  des  bernischen  pathologischen  Instituts.  Inau- 
gural-Dissertation zur  Erlangung  der  DoktorwOrde  der  hohen 


medizinischen  Fakultat  der  Universitat  Bern  vorgelegt  von  Mai 
Mtiller,  prakt.  Arzt  in  Bern. 

Ueber  den  Einfiuss  von  Ruhe,  roassiger  Bewegung  und  kor- 
perlicher  Arbeit  auf  die  normale  Magenverdauung  des  Menschen. 
Inaugural-Dissertation  zur  Erlangung  der  Doktorwilrde  einer 
hohen  medizinischen  Fakultat  der  Universitat  Bern  vorgelegt 
von  Wilhelm  Spirig,  Arzt. 

Transactions  of  the  Medical  Society  of  Virginia.  Twenty- 
third  Session.    Alleghany  Springs,  Va.,  1892. 

Oils  and  Fats  in  Surgical  Dressings.  By  C.  M.  Hobby,  M.  D., 
Iowa  City,  Iowa.  [Reprinted  from  the  Transactions  of  the  Iowa 
State  Medical  Society.] 

Additional  Notes  on  Forcible  Overcorrection  in  the  Treat- 
ment of  Rigid  Flat  Foot.  By  Royal  Whitman,  M.  D.,  New 
York.    [Reprinted  from  the  Annals  of  Surgery.] 

A  New  Measurement  in  the  Study  of  Fever.  By  Louis  F. 
Bishop,  M.  D.,  New  York.  [Reprinted  from  the  Medical  News.'\ 


^cjjorts  0n  tijc  |]rogrcss  of  S^^tiinnc. 

OPHTHALMOLOGY. 

Bt  CHARLES  STEDMAN  BULL,  M.  D. 

Temporary  Blindness  during  Lactation.— Nettleship  (A'<jy. 
Lond.  Oj)hlh.  Hasp.  Rep.,  xiii,  2)  refers  to  instances  of  women 
who  become  blind,  or  nearly  blind,  shortly  but  not  immediately 
after  the  birth  of  a  child,  in  circumstances  which  can  not  be 
explained  either  by  loss  of  blood  or  renal  disease,  and  which 
can  also  be  readily  distinguished  from  mere  failure  of  accommo- 
dation due  to  enfeebled  health.  He  has  never  seen  such  a  case 
during  the  time  of  the  blindness,  but  the  after-appearances  ob- 
served by  him  seem  to  point  with  more  or  less  certainty  to  the 
previous  occurrence  of  optic  neuritis,  resembling  that  form  of 
neuritis  seen  in  chronic  anoamia. 

The  Operative  Treatment  of  Chronic  Glaucoma.— Collins 

{Roil.  Lond.  Ophth.  IIosp.  Rep.,  xiii,  2)  infers  that  an  iridectomy 
may  remedy  the  increased  tension  due  to  apposition  of  the  root 
of  the  iris  to  the  posterior  surface  of  the  cornea  in  the  follow- 
ing ways:  1.  When  this  apposition  is  recent,  very  slight  means 
are  sometimes  suiiicient,  the  escape  of  the  aqueous  and  a  drag 
on  the  iris  being  enough.  2.  In  some  recent  and  acute  cases 
the  iris  tears  away  from  its  extreme  root,  thus  leaving  a  large 
portion  of  the  filtration  area  free  for  drainage,  even  if  the  re- 
mainder of  the  iris  retains  its  faulty  position.  3.  In  some  cases 
a  permanent  gap  is  maintained  in  the  walls  of  the  globe  by  the 
prolapse  of  a  fold  of  the  iris  in  the  wound.  This  iris  tissue 
subsequently  either  becomes  stretched  and  atrophied  or  rup- 
tures periodically,  thus  allowing  the  aqueous  to  ])ass  through  it 
into  the  subconjunctival  tissue,  and  become  absorbed  by  the 
lymphatics  and  vessels.  By  these  means  a  new  channel  of  exit 
for  the  aqueous  is  formed.  He  emphasizes  the  advisability  of  per- 
forming iridectomy  for  chronic  glaucoma  in  the  early  stages  of 
the  disease,  before  the  apposition  of  the  root  of  the  iris  to  the 
cornea  has  resulted  in  adhesion. 

The  Prognosis  of  Chorioidal  Sarcoma.— (Jriilith  {Ophth. 
Rev.,  December,  1891)  gives  an  analysis  of  twenty-three  cases,  the 
histories  of  which  he  has  been  enabled  to  trace.  Of  these  pa- 
tients, fourteen  were  alive  from  three  to  ten  years  and  a  half 
after  operation.  Six  died  from  extension  of  sarcoma  to  in- 
ternal organs.  Three  more  died,  but  not  certainly  from  sarcoma 
of  other  organs.  An  examination  of  the  ages  of  the  patients 
seemed  to  ])oint  very  decidedly  to  a  better  prognosis  for  the 
youthful  than  for  those  of  more  advanced  years.    The  average 


254 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


N.  V.  Mrd.  Joni'. 


of  the  recoveries  wat;  38-3  years ;  of  the  fatal  cases,  52'1  years. 
He  thinks  that  local  recurrence  means  that  some  bud  of  the  pro- 
cess iiad  been  left  in  tlie  orbit,  while  metastasis  implios  the  pres- 
ence in  the  circulation  of  tumor  cells.  Tiie  two  processes  are 
quite  distinct. 

Myopia  the  Result  of  Constitutional  Disease.— Batten 
(Ophth.  Rev.,  January,  1892J  lujre  calls  attention  to  the  frequent 
association  of  myopia  with  vascular  disease,  as  evidenced  by 
the  following  conditions:  1.  Spontaneous  hajmorrhage,  such  as 
epistaxis,  menorrliagia,  and  retinal  extravasations.  2.  Capillary 
congestion.  3.  Cardiovascular  disease,  with  high  arterial  ten- 
sion, cardiac  hypertrophy,  and  valvular  disease.  The  tendency 
to  haemorrhage  in  myopia  is  recognized  as  a  local  condition,  but 
Batten  insists  that  there  is  a  general  tendency  to  haemorrhage, 
occurring  as  well  in  other  parts  of  the  body.  He  considers 
epistaxis  a  common  accompaniment  of  myopia,  as  also  menor- 
rhagia,  which  sometimes  takes  the  place  of  epistaxis  in  the 
male.  He  considers  as  evidence  of  capillary  congestion  the  full, 
red  lips  and  rather  high-colored  cheeks  frequently  observable 
chiefly  in  young  myopes.  The  heart  shows  signs  of  enlarge- 
ment of  very  variable  degrees,  which  is  probably  due  to  both 
dilatation  and  hypertrophy. 

The  Corneal  Reflex  of  the  Ophthalmoscope  as  a  test  of 

Fixation  and  Deviation.— Priestley  Smith  {Ophth.  Rev.,  Febru- 
ary, 1892)  says  that  in  a  large  majority  of  cases  the  corneal  reflex 
will  be  seen  to  stand  a  little  nearer  to  the  inner  than  the  outer 
side  of  the  pupil.  Furthermore,  the  corneal  reflexes,  whether 
central  or  slightly  eccentric,  will  be  seen  to  stand  quite  sym- 
metrically in  the  two  eyes,  and  neither  of  them  will  change  its 
position  in  relation  to  the  pupil,  as  the  light  is  transferred  back- 
ward and  forward  from  one  eye  to  the  other.  In  a  minority  of 
instances,  on  the  other  hand,  a  want  of  symmetry  in  the  positions 
of  the  reflexes  will  be  observed.  Sometimes  binocular  fixation, 
though  true  at  the  first  moment,  will  be  abandoned  after  a  few 
seconds,  one  or  the  other  eye,  or  each  in  turn,  making  a  slight 
deviation,  while  the  other  continues  to  fix.  The  ophthalmoscope, 
as  a  bright  fixation  object,  is  more  likely  than  a  candle  to  reveal 
the  signs  of  excessive  or  insufficient  converging  power,  or  of 
other  latent  difficulty  in  binocuhir  fixation.  If,  as  the  light  is 
moved  from  one  eye  to  the  other  and  back  again,  the  illuminated 
eye  always  fixes  the  mirror,  and  the  other  always  takes  up  the 
deviation,  we  know  that  both  eyes  have  the  power  of  fixation, 
though  not  of  fusion.  If,  on  the  other  hand,  one  eye  persist- 
ently fixes  the  mirror  and  the  other  persistently  deviates,  in  spite 
of  the  repeated  injunction  to  look  at  the  liglit,  we  know  that  the 
deviating  eye  ha?  little  if  any  power  of  direct  fixation,  and  will 
be  found  to  have  very  imperfect  central  vision.  This  observa- 
tion divides  cases  of  convergent  squint  into  two  groups:  Those 
in  which  it  may  be  possible  to  restore  true  binocular  fixation, 
and  those  in  which  it  will  almost  certainly  be  impossible.  If 
both  eyes  appear  to  fix  the  mirror  properly  when  the  light  is 
thrown  on  one  eye,  whereas,  when  it  is  transferred  to  the  other 
the  latter  shifts  its  position  so  as  to  show  a  slightly  displaced 
reflex,  we  may  expect  to  find  a  pronounced  absolute  central 
scotoma  in  the  latter.  A  paralytic  deviation  is  distinguished 
from 'a  concomitant  deviatioti  by  the  fact  that  the  asymmetry  of 
the  reflexes  increases  or  diminishes  when  the  patient  is  made  to 
turn  his  eyes  in  different  directions.  In  cases  of  diplopia  pre- 
enting  no  obvious  deviation  of  the  eye,  the  corneal  reflexes 
give  a  positive  objective  indication  which  is  of  much  value. 
The  immediate  result  of  a  strabismus  operation  can  sometimes 
be  ascertained  more  conveniently  by  means  of  an  ophthalmo- 
scope and  lamp  than  in  any  other  way. 

An  Instrument  for  the  Determination  of  Convergence 
Power  and  the  Position  of  Rest  of  the  Eyes.— Siraub  (Ophth. 
Rev.,  April,  1892)  has  devised  a  simple  instrument  for  testing 


rapidly  the  latent  position  of  the  eyes  on  distant  and  near  fixa- 
tion. It  consists  of  a  small,  oblong  mirror  (16  ctm.  x4  ctm.)  at- 
tached to  a  narrow  ribbon,  furnished  with  a  centimetre  scale. 
This  rihbon  is  about  1'5  ctm.  long  and  has  a  flat  black  ruler 
fiistened  at  the  other  end.  The  instrument  is  to  be  applied  as 
follows:  A  small  ink  spot  being  made  on  the  bridge  of  the  pa- 
tient's nose  between  the  eyebrows,  he  must  be  seated  op[)osite 
the  observer,  with  his  back  to  a  window.  The  observei'  holds 
the  mirror  with  the  left  hand  against  his  own  forehead,  with 
its  long  axis  horizontally,  so  that  the  patient  can  look  in  it. 
The  mirror  must  then  be  turned  on  a  horizontal  axis,  enabling 
the  patient  to  see  the  ink  spot  on  his  nose,  or  a  spire,  tree  top, 
part  of  a  house  opposite,  or  any  other  distant  object  which  lias 
been  pointed  out  to  him  before  taking  his  seat.  While  the  pa- 
tient is  accommodating  his  eyes  to  various  distances,  the  ob- 
server is  near  enough  to  make  the  usual  test  for  squint  by 
means  of  the  ruler  held  in  tlie  right  hand  and  used  alternately 
to  cover  the  i-ight  and  left  eye.  Meanwhile  the  rihbon,  placed 
behind  the  patient's  ear,  measures  the  distance  from  the  eye  to 
the  mirror — i.  e.,  half  the  distance  for  which  the  eye  is  accom- 
modated, if  the  ink  spot  is  flxed.  Each  eye  is  covered  and  un- 
covertd  fre(]uently.  The  patient  will  sometimes  continue  to 
converge  at  first,  and  only  after  several  coverings  and  uncover- 
ings  the  innervation  of  the  covered  eye  gives  way,  and  the  eye 
enters  into  what  might  be  termed  the  relative  position  of  rest. 
The  Operative  Treatment  of  Infantile  Ectropion.— 

ScotVs  (Ophth.  h'ec,  April,  1892)  method  of  operating  consists 
in  replacing  the  everted  eyelid  and  retaining  it  in  its  proper 
position  by  the  introduction  of  a  wire  splint,  as  follows: 
Cleanse  the  eyebrow  and  both  surfaces  of  the  eyelid  thorough- 
ly, and  place  a  spatula  under  the  lid  in  order  to  protect  the  eye- 
ball. Arm  a  half-curved  needle  with  a  moderately  thick  silver- 
wire  suture,  and  pass  it  in  the  substance  of  the  lid  from  the 
eyebrow  downward,  emerging  on  the  free  palpebral  margin 
between  the  eyelashes  and  conjunctiva.  Enter  the  needle  again 
on  the  lid  margin  at  a  point  about  four  millimetres  distant  from 
the  point  of  emergence,  pass  it  upward  in  the  substance  of 
the  lid  parallel  to  the  first  part  of  the  suture,  and  bring  it  out 
on  the  eyebrow  four  millimetres  distant  from  the  first  point  of 
enti'ance.  No  traction  should  be  made  on  the  lid  now,  but  the 
piece  of  silver  wire  exposed  on  the  edge  of  the  lid  should  fit 
closely  against  it.  Then  fasten  the  free  ends  of  the  suture  by 
twisting  them  together  over  a  small  piece  of  India  rubber  or 
catgut.  Mold  the  eyelid  into  its  proper  shape  by  bending  the 
silver  wire  in  the  lid  over  the  surface  of  the  spatula.  Two 
sutures  may  be  employed — one  toward  either  extremity  of  the 
lid.  The  silver  wire  should  remain  in  the  lid  for  at  least  a 
week. 

The  Relative  Frequency  of  Myopia  among  Christians 
and  Jews. — Stephenson  (Ophth.  Rev.,  April,  1892),  from  an 
examination  of  the  Christian  and  Jewish  children  in  the  Lon- 
don Central  Foundation  Schools,  draws  the  following  data:. 

1.  Of  the  total  number  of  Jews,  10'63  per  cent,  were  myopic. 

2.  Of  the  Christians,  1'97  per  cent,  were  myopic.  3.  The  per- 
centage of  frequency  of  myopia  in  the  Jewish  boys  was  more 
than  six  times  greater  than  in  the  Christian  boys.  4.  There 
were  nearly  three  and  a  half  times  as  many  myopes  among 
Jewesses  as  among  Christian  girls.  5.  The  Jews  showed  a 
larger  percentage  of  myopes  than  the  Jewesses.  6.  There 
were  fewer  myopes  among  Christian  boys  than  among  Chris- 
tian girls,  the  percentage  difference  between  the  two  classes 
amounting  to  only  0-64. 

Changes  in  the  Retina  due  to  Long-continued  Lodg- 
ment of  a  Metallic  Chip  on  its  Surface. — Priestley  Smith 
(Ophth.  /^co.,  July,  1892)  reports  the  case  of  a  lad,  aged  seventeen, 
who  was  struck  in  the  left  eye  by  a  fragment  of  bell  metaU 


March  4,  1893.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


255 


Four  weeks  after  the  injury  a  small  linear  cicatrix  was  visible 
in  the  cornea  close  to  its  nasal  margin,  and  behind  this  a  black 
point  in  the  iris  indicated  an  aperture  made  by  the  chip.  The 
lens  was  clear.  The  chip  of  metal  was  seen  lying  on  the  retina 
some  distance  from  the  nasal  side  of  the  disc  and  on  a  higher 
level.  There  was  a  corresponding  scotoma  in  the  field.  There 
was  no  pain  or  any  other  si-mptom,  and  V.  =  y^.  Four 
months  later  the  foreign  body  had  slightly  shifted  its  position, 
and  one  month  later  the  chip  dropped  directly  downward  through 
an  angle  of  45°.  Its  former  position  was  marked  by  a  gray 
opaque  patch  on  the  retina,  around  which  was  a  cloudy  zone, 
bordered  by  faint  pigmentary  discoloration.  Two  scotomata 
now  existed  in  the  field.  Thirteen  months  after  the  accident 
the  position  of  the  chip  was  unchanged,  but  its  surface  was  less 
lustrous.  On  the  main  arteries  and  veins  of  the  retina  were 
numerous  minute  shining  points  like  specks  of  gold  leaf. 

Operation  for  the  Radical  Cure  of  Stricture  of  the  Lac- 
rymalDuct,  with  Description  of  a  Stricturotome.— Thomas's 
{Ophth.  Rev.,  September,  1892)  instrument  is  five  centimetres 
and  a  half  long.  The  shank  is  of  untempered  steel  and  four 
centimetres  long.  The  cutting  blade  is  seven  millimetres  long 
and  three  millimetres  wide,  the  whole  terminating  in  a  conical 
tip,  blunt  at  the  point,  and  equal  to  the  blade  in  length.  The 
conical  tip  serves  as  guide  and  dilator  for  the  cutting  blade,  and 
as  a  protector  of  the  soft  parts  during  the  introduction  and 
withdrawal  of  the  instrument.  The  danger  of  making  a  false 
passage  is  also  obviated  by  this  conical  tip.  The  first  step  in 
the  operation  consists  in  slitting  the  canaliculus,  which  is  done 
more  readily  with  a  small  director  and  Beer's  knife  than  with 
a  Weber's  knife.  An  obstructing  ledge  of  tissue  is  usually 
found  at  the  inner  end  of  the  groove  formed  from  the  lower 
canaliculus,  and  this  may  be  divided  later  by  the  stricturotome. 
j  A  Bowman's  probe  is  then  to  be  inserted  to  locate  the  stricture. 
I  The  stricturotome  is  then  introduced,  and,  the  tip  being  engaged 
in  the  stricture,  continuous  pressure  is  to  be  made  and  the  cone 
carried  through  the  stricture.  Incision  is  then  made,  com- 
pletely dividing  the  stricture  in  at  least  three  different  direc- 
tions. As  after-treatment,  a  large  leaden  style,  eight  to  ten 
millimetres  in  circumference,  with  the  upper  extremity  bent  at  a 
right  angle,  is  then  introduced.  This  is  removed  every  day  or 
two  and  the  passage  washed  out,  and  at  the  end  of  a  few  weeks 
it  is  removed  altogether. 

Ophthalmoplegia. — Arusaignas  (Rev.  gen.  cfophihal.,  May 
30,  1892)  divides  the  subject  of  ophthalmoplegia  into  internal 
(ciliary  muscle,  sphincter  iridis,  and  dilatator  pupillae),  external 
(recti  and  oblique  muscles  and  levator  palpebrae),  and  mixed, 
where  both  internal  and  external  muscles  are  involved.  The 
affection  may  be  unilateral  or  bilateral,  partial  or  total.  Di- 
vided, according  to  the  seat  of  the  lesion,  there  is:  1.  Nuclear 
ophthalmoplegia.  2.  Fascicular  ophthalmoplegia.  3.  Basal  oph- 
thalmoplegia. 4.  Orbital  ophthalmoplegia.  The  cause  of  ocular 
paralyses  has  to  do  with  the  seat  of  the  lesion,  the  cause  of  the 
lesion,  and  the  nature  of  this  cause.  In  addition  to  the  four 
I   varieties  mentioned  above,  we  sometimes  speak  of  cortical 

(ophthalmoplegia,  cortico-peduncular  ophthalmoplegia,  and  pe- 
ripheral or  terminal  ophthalmoplegia.  The  cause  of  the  lesion 
may  be  direct  or  indirect  traumatism ;  compression  of  the  nerve 
or  of  the  nuclei;  degeneration  of  the  nuclei,  as  in  polio-encepha- 
litis superior  ;  or  more  or  less  complete  destruction  of  the  nu- 
clei. The  nature  of  the  cause  maybe  a  haemorrhage,  a  gumma, 
a  cyst,  or  a  malignant  tumor.  The  treatment  of  any  case  of 
ophthalmoplegia  should  always  bo  directed  to  the  cause. 

Endarteritic  Changes  in  the  Ocular  Vessels.— Gamier 
(Ctrlbl.  f.  prakt.  Aug.,  January,  1892)  refers  to  and  indorses 
the  statement  of  Thoma  that  the  localized  nodular  connective- 
tissue  formations  in  the  intima  occur  at  the  points  where  the 


blood  current  has  become  slower.  The  diminished  elasticity  of 
the  middle  muscular  layer,  and  its  consequent  localized  widen- 
ing of  the  lumen  of  the  vessel,  precede  this  formation  of  new 
connective  tissue.  Where  a  vessel  bifurcates  or  gives  off"  lateral 
branches,  these  changes  in  the  intima  of  the  arteries  are  apt  to 
occur,  and  hence  we  should  expect  to  find  them  at  the  points 
of  perforation  of  the  sclera  by  the  ciliary  vessels,  and  in  the 
vortices  of  the  veins,  where  we  do  actually  find  a  nodular  en- 
dophlebitis.  In  the  eye  the  primary  diffuse  endarteritis  of  the 
central  vessels,  visible  with  the  ophthalmoscope,  is  probably  a 
symptom  of  general  angeio-sclerosis.  The  changes  in  the  intra- 
ocular fluids  may  alter  the  nutrient  relations  of  the  walls  of  the 
ocular  vessels  and  mechanically  diminish  their  power  for  work. 
The  central  vessels  of  the  retina  will  present  these  changes  in 
diseases  of  the  retina,  and  the  ciliary  vessels  will  show  them  in 
diseases  of  the  uveal  tract.  Secondary  diffuse  endarteritis  is 
met  with  in  the  eye,  especially  in  the  capillary  zone,  and  is 
often  found  connected  with  permanent  increased  tension.  Here 
the  connective  tissue  is  gradually  changed  into  hyaline  masses* 
which  permanently  narrow  the  lumen  of  the  vessels. 

A  New  Operation  for  Congenital  Ptosis.— Birnbacher 

{Ctrlbl.  f.  prakt.  Aug.,  May,  1892)  has  devised  the  following 
operation:  An  incision  is  made,  convex  upward,  through  tiie 
skin  of  the  upper  lid,  parallel  to  the  upper  tarsal  border,  from, 
end  to  end  of  the  lid.  The  upper  edge  of  the  tarsus  is  dissected 
free,  and  three  strong  silk  sutures,  each  armed  with  two  needles, 
are  passed  through  the  upper  tarsal  border  so  as  to  make  three 
loops  about  equal  distances  apart,  but  the  loops  are  not  tied. 
The  two  needles  of  the  middle  loop  are  thrust  upward  beneath 
the  skin  and  brought  out  close  together  in  the  eyebrow.  The 
two  lateral  loops  then  lie,  respectively,  obliquely  inward  and 
outward,  so  that  the  points  of  exit  lie  farther  apart  from  each 
other  than  the  points  of  exit  of  the  loop  at  the  upper  tarsal  bor- 
der. All  three  loops  are  then  stretched  over  little  rolls  of  iodo- 
form gauze  and  tied,  the  tension  of  the  knots  being  so  measured 
that  in  closure  of  the  lids  the  ciliary  margins  of  the  two  lids 
just  touch  each  other.  The  wound  in  the  skin  is  then  united 
with  fine  sutures.  The  loops  may  remain  from  twenty  to 
twenty-five  days.  After  their  removal  the  cicatricial  bands  in 
the  lid  show  their  former  position.    The  effect  is  excellent. 

A  Case  of  Corneal  Neoplasm.— S  imon  (Ctrlbl.  J.  prakt. 
Atig.,  July.  1892)  reports  a  case  of  interest  in  a  laborer  whose 
right  eye  had  been  burned  by  lime  twelve  days  before.  There 
was  great  chemosis,  loss  of  epithelium  on  the  cornea,  and  two 
small  abscesses  in  the  cornea.  The  whole  cornea  was  eventu- 
ally destroyed.  Three  years  later  he  came  to  have  the  eye  enu- 
cleated. There  was  then  a  solid,  white,  conical  tumor,  with 
smooth  surface,  which  occupied  nearly  the  entire  site  of  the 
former  cornea.  There  was  no  pain,  some  slight  irritation,  and 
perception  of  light.  The  eye  was  enucleated,  and,  after  hard- 
ening, carefully  examined.  The  conjunctiva  and  sclera  were 
normal.  The  tumor  was  covered  by  a  prolongation  of  the  nor- 
mal conjunctival  epithelium,  but  greatly  thickened.  The  tumor 
showed  a  dense  fibrous  structure,  with  numerous  round  and 
fusiform  cells,  and  might  very  properly  be  called,  from  the  ar- 
rangement of  tliese  cells,  a  fibro-sarcoma. 

The  Anomalies  of  Convergence.— Van  Milligen  (Ann. 
(foculiatique,  January,  1892)  prefaces  his  conclusions  on  this 
subject  by  some  remarks  drawn  from  his  own  observations. 
He  considers  that  voluntary  convergence  may  be  preserved  in 
spite  of  the  complete  absence  of  visual  convergence  and  even 
of  binocular  vision.  Paralysis  of  visual  and  voluntary  conver- 
gence is  usually  consecutive  to  chronic  alcoholism  with  alco- 
holic amblyopia.  Patients  with  alcoholic  amblyopia  can  not 
converge  for  a  point  five  or  even  ten  centimetres  from  their 
eyes,  and  in  these  patients  there  is  entire  absence  of  the  sense 


256 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Mbd.  Jodb., 


of  binocular  vision.  His  conclusions  are  as  follows:  1.  There 
are  cases  of  paresis  of  convergence  met  with  in  patients  who 
possess  all  the  factors  necessary  to  a  perfect  equilibrium,  a 
normal  refraction  and  accommodation,  and  an  intact  sense  of 
binocular  vision,  but  in  whom  there  is  a  defective  central  inner- 
vation localized  in  the  center  for  convergence.  2.  There  are 
cases  of  paresis  of  accommodation,  unilateral  or  bilateral,  with- 
out paresis  of  convergence,  which  proves  that  the  centers  for 
these  two  functions  are  distinct  from  eacli  other.  3.  There  are 
cases  in  which  the  refraction  and  accommodation  are  intact, 
but  in  which  binocular  vision  is  suppressed,  convergence  is 
abolished,  and  the  sense  of  the  need  of  fusion  is  lacking.  These 
facts  indicate  that  conscious  fixation  originates  in  the  visual 
sphere,  and  tends  in  the  direction  of  the  center  of  convergence. 
4.  There  are  cases  in  which  the  vision  is  abolislied,  but  the 
voluntary  convergence  is  still  jjreserved,  which  would  seem  to 
indicate  that  the  center  for  convergence  is  connected  with  the 
motor  cortex,  independently  of  the  visual  centers. 

The  Connection  between  Irregular  Contraction  of  the 
Ciliary  Muscle  and  Astigmatism.— G.  J.  Bull  {Anii.  d'ocu- 
listique,  February,  1892)  criticises  the  work  of  Dobrowolsky, 
and  considers  that  a  series  of  errors  has  induced  the  latter  to 
believe  that  the  action  of  the  lids  exerts  no  influence  in  the  cor- 
rection of  astigmatism,  and  that  the  accommodation  neutralizes 
the  eflFects  of  cylindrical  glasses,  whereas  actually  tliis  neutrali- 
zation comes  from  the  act  of  winking,  and  his  conclusions  are 
therefore  illogical.  Ilis  cases  of  astigmatism,  examined  with 
the  stenopeic  slit,  only  prove  that  the  accommodation  produced 
no  other  etiect  than  the  increase  of  the  crystalline  curvature 
equally  in  all  the  meridians.  Landesberg's  cases  prove  nothing 
but  the  fact  that  the  accommodation  may  increase  or  diminish 
the  astigmatism.  He  concludes  that  the  statements  of  neither 
Dobrowolsky,  Lanilesberg,  nor  Martin  have  advanced  any  satis- 
factory proof  that  the  action  of  the  ciliary  muscle  may  cause  a 
variation  in  the  astigmatism. 

Secondary  Modifications  in  the  Motor  Apparatus  of  the 

Eyes  in  Strabismus.— Parinaud  {Ann.  d'ocuUstique,  March, 
1892)  considers  that  permanent  squint  may  remain  for  a  varying 
length  of  time  in  the  condition  of  a  simple  nervous  trouble,  and 
exhibits  the  two  following  peculiarities:  1.  The  discordant  con- 
dition of  the  optic  axes  persists  to  the  same  extent,  or  almost 
so,  in  all  the  directions  of  the  visual  glance.  In  spite  of  the  ab- 
normal condition  of  convergence  or  divergence,  the  association 
of  movements  is  preserved  in  all  lateral  directions.  2.  The  sec- 
ondary deviation  of  the  sound  eye  is  equal  to  the  primary  devi- 
ation of  the  squinting  eye,  when  the  sound  eye  is  covered  and 
the  squinting  eye  forced  to  fix.  The  fixity  of  the  squinting 
deviation  of  nervous  origin  may  be  explained  either  by  the  new 
relations  of  convergence  and  accommodation,  or  by  the  altera- 
tion of  the  centers  of  innervation  of  convergence.  The  modifi- 
cations of  the  visual  field  constitute  a  secondary  phenomenon  ; 
they  are  the  effect  and  not  the  primary  cause  of  the  deviation. 
They  do  not  explain  the  degree  of  the  deviation.  They  are  not 
solely  produced  by  the  shortening  or  elongation  of  certain  mus- 
cles, but  mainly  by  the  retraction  of  the  fibrous  tissues  of  the 
eye,  especially  the  capsule  of  Tenon.  The  phenomena  of  re- 
traction which  are  produced  in  the  squinting  eye  may  be  com- 
l)ared  to  those  observed  in  other  parts  of  the  body. 

A  Refraction  Ophthalmoscope  with  Cylindrical  Glasses 
and  a  Mirror  with  Variable  Focus.— Parent  (Ann.  d'ocu- 
listique,  March,  1892)  has  devised  a  modification  of  his  former 
instrument,  in  which  each  cylinder  is  mounted  in  a  toothed 
ring,  and  a  geared  wheel,  set  in  motion  by  a  steel  shank  with 
swollen  ends,  causes  all  the  cylinders  to  turn  equally  and  simul- 
taneously. The  degree  of  rotation  of  the  cylinder  or  the  direc- 
tion of  its  axis  is  indicated  by  a  needle.    The  mirror,  by  a  play 


of  two  lenses  (—  D.  0-25  and  +  D.  0-25),  has  a  varying  focus, 
which  actually  realizes  all  the  mirrors,  from  the  plane  mirror 
to  the  concave  mirror  of  eight  centimetres  focus.  The  mirror 
also  presents  at  its  center  alternate  silvered  and  transparent 
bands,  which  form  a  sei  ies  of  stenopeic  slits. 

Curetting  the  Lacrymal  Sac  without  Cutaneous  Incis- 
ion.— Terson  (Ann.  d'oculistique,  April,  1892)  advises  the  fol- 
lowing method  of  operation:  After  injecting  a  few  drops  of  a 
solution  of  cocaine  into  the  lacrymal  sac,  the  upper  canaliculus 
is  freely  divided,  and  the  entire  passage  down  to  the  end  of  the 
nasal  duct  is  opened  by  a  Bowman's  probe  No.  4.  Then  a 
small  cutting  fenestrated  curette  is  pushed  into  the  lacrjmo- 
nasal  canal  up  to  the  handle.  Tiie  curette  is  then  drawn  up- 
ward, cutting  sharply  through  the  lining  membrane,  and  again 
pushed  down  and  drawn  up,  always  revolving  the  handle  each 
time  until  the  entire  inner  surface  of  the  canal  has  been  thor- 
oughly scraped. 

Atrophy  of  the  Optic  Nerve  during  Pregnancy ;  Prema- 
ture  Artificial  Delivery.— Valude  (Ann.  d'oculistique,  April, 
1892)  reports  an  interesting  case  of  this  nature  occurring  in  a 
patient  aged  thirty.  Her  first  pregnancy  had  occurred  nine 
years  before.  Following  her  confinement,  at  every  succeeding 
menstrual  epoch  there  had  been  a  marked  amblyopia  in  both 
eyes,  worse  in  the  left  eye,  which  lasted  during  the  menstrual 
epoch  and  then  rapidly  disappeared.  This  condition  remained 
unchanged  up  to  the  beginning  of  her  second  pregnancy,  when 
the  left  eye  suddenly  became  and  grew  increasingly  much  worse. 
The  left  eye  grew  steadily  worse  during  the  pregnancy,  and  at 
the  end  of  the  second  month  the  rigiit  began  to  fail.  The  oph- 
thalmoscope showed  a  white  optic  disc  in  the  right  eye,  where 
there  was  only  perception  of  light,  and  a  slightly  pale  optic  disc 
in  the  left  eye,  with  vision  of  one  tenth.  Premature  delivery 
was  advised  and  performed  successfully,  with  restoration  of 
normal  vision  to  the  right  eye,  but  no  effect  on  the  left  eye. 

Contribution  to  the  Study  of  Hsemorrhagic  Glaucoma.— 

Valude  and  Dubief  (Ann.  d''oculistique,  August,  1892),  in  a  nnm- 
ber  of  cases  of  so-called  hemorrhagic  glaucoma,  have  observed 
that  certain  retinal  lesions  are  absolutely  constant,  but  that  the 
changes  in  the  uveal  tract  and  oi)tic  nerve  are  very  variable. 
In  all  these  cases,  by  whomsoever  reported,  there  has  always 
been  a  profound  hyaline  or  fibrous  degeneration  of  the  retinal 
vessels,  and  the  existence  of  retinal  vacuoles  of  varying  size  and 
distribution,  sometimes  filled  with  fibrinous  exudation,  some- 
times empty.  These  vacuoles  form  a  lesion  which  is  the  result 
of  a  primordial  vascular  change,  the  hyaline  degeneration.  In 
some  cases  the  chorioid  presents  the  signs  of  inflammatory  in- 
filtration, but  often  it  is  perfectly  healthy.  The  obliteration  of 
the  iris  angle  and  Fontana's  spaces,  which  is  characteristic  of 
acute  and  subacute  glaucoma,  is  in  these  cases  very  often  en- 
tirely absent.  The  same  is  true  of  the  posterior  channel  of  fil- 
tration in  these  cases  of  hsemorrhagic  glaucoma.  In  all  of  the 
cases  examined  there  were  evidences  of  general  arterio-scle- 
rosis.  These  cases  begin  with  retinal  haemorrhages,  and  after  a 
varying  lapse  of  time  there  begins  a  condition  of  increased  ten- 
sion, which  may  end  in  positive  glaucoma.  The  authors  think 
that  these  are  not  cases  of  glaucoma. 

Muscular  Advancement.— Howe  {Amer.  Jour,  of  Ophthal.., 
May,  1892)  makes  use  of  a  clamp  which  consists  of  a  pair  of 
forceps  an  inch  long  with  crossed  branches,  the  clamp  por- 
tion about  a  quarter  of  an  inch  long,  turned  at  right  angles, 
and  provided  with  three  teeth,  which  fit  corresponding  de- 
pressions on  the  opposite  branch.  After  the  tendon  of  the 
muscle  is  exposed,  the  smooth  blade  of  the  forceps  is  passed 
under  the  muscle  and  its  end  firmly  clamped,  leaving  .suflScient 
space  without  difficulty.  In  introducing  the  stitches  Howe  uses 
a  modification  of  the  loop  suture,  which  he  calls  the  B-shaped 


March  4,  1893.] 


REPORTS  OK  THE  PROGRESS  OF  MEDICINE. 


257 


loop.  A  stitch  is  first  introduced  at  the  same  place  and  in 
the  same  manner  as  in  Prince's  operation,  and  then,  being  tied 
in  the  center  at  the  point  nearest  the  cornea,  the  needle  is 
again  placed  under  the  conjunctiva  at  that  point,  and  this  end 
of  the  thread  is  tied  with  the  other  end  of  the  same  suture. 
Thus  one  loop  is  divided  into  two  and  looks  like  a  B.  In 
order  to  draw  the  muscle  forward,  two  stitches  are  used.  One 
passes  from  the  upper  edge  of  the  muscle  and  corresponding 
part  of  the  conjunctiva  through  the  upper  part  of  the  B-shaped 
loop.  The  lower  stitch  is  passed  in  the  same  way  through  the 
lower  edge  of  the  muscle  and  through  the  lower  part  of  the 
B  loop.  Then,  by  tying  the  corresponding  ends  of  these  two 
stitches  above  aud_  below,  the  muscle  is  brought  securely  into 
the  desired  position. 

Elevations  along  the  Margin  of  the  Lens.— Topolanski 
{Kl.  Mon.f.  Aug.,  March,  1892)  describes  the  microscopical  ap- 
pearances in  lenses  which  had  previously  been  described  oph- 
thalmoscopically  by  both  Magnus  and  himself.  He  concludes 
that  the  lens  is  not  always  perfectly  smooth  at  its  margin,  but 
often  shows  little  undulatory,  or  rather  tent-like,  elevations. 
These  elevations  are  the  result  of  the  pulling  action  of  the 
zonula.  The  capsule,  capsular  endothelium,  and  lenticular 
fibers  all  take  part  in  their  formation.  They  appear  first  as 
substance  or  tissue  elevations,  but  subsequently  change  into 
an  actual  lifting  of  the  parts  involved  oiF  or  away  from  the  rest 
of  the  lens. 

The  Pathogenesis  and  Diagnosis  of  Ophthalmoplegia. — 

Sauvineau  {Rec.  d'ophthal.,  April,  1892)  considers  three  classes  of 
ophthalmoplegia  of  cerebral  origin:  1.  Nuclear,  of  which  there 
are  two  varieties — one  bilateral  and  frequent,  the  other  uni- 
lateral. 2.  Supranuclear.  3.  Cortical.  After  their  exit  from 
the  peduncles,  the  motor  nerves  of  the  eye  may  be  injured  or 
diseased  in  their  course  at  the  base  of  the  brain  (basilar)  or  in 
the  orbit  (orbital).  Finally,  the  primary  lesion  may  involve 
simultaneously  the  terminal  branches  of  the  nerves  in  the  orbit, 
the  nerve  trunks  at  the  base  of  the  brain,  and  the  roots  in  the 
peduncles.  These  cases  he  calls  ophthalmoplegia  by  peripheral 
neuritis.  In  bilateral  nuclear  ophthalmoplegia  we  have  gradual 
abolition  of  the  movements  of  the  eye,  attacking  successively 
the  difl:'erent  muscles,  incomplete  ptosis,  and  absence  of  reflex 
«erebral  phenomena.  The  motility  of  the  eyes  is  much  easier 
in  the  morning  than  in  the  evening,  and  this  fact  is  character- 
istic of  a  lesion  occupying  the  nerve  cells  of  the  nuclei. 

Nuclear  ophthalmoplegia  may  appear  under  three  forms — 
interior,  exterior,  and  mixed,  a.  Ophthalmoplegia  externa 
must  be  nuclear  except  in  the  acute  form,  where  the  lesion  is 
situated  above  the  nuclei.  5.  Ophthalmoplegia  interna  must 
be  nuclear  if  we  exclude  an  orbital  or  peripheric  cause,  c.  In 
•ophthalmoplegia  mixta  a  nuclear  cause  is  very  difiScult  to  dis- 
tinguish from  a  basilar  cause,  and  the  diagnosis  must  be  made 
by  aid  of  concomitant  symptoms.  In  the  chronic  form  of 
nuclear  ophthalmoplegia  the  protuberantial  nuclei  are  first  at- 
tacked. This  polio-encephalitis  superior  corresponds  to  the 
primary  lesion  of  the  bulbar  nuclei,  which  causes  labio-glosso- 
laryngeal  paralysis,  and  to  that  of  the  cells  of  the  anterior  horns 
■of  the  spinal  cord.  The  nuclei  may  be  involved  secondarily  in 
a  spinal  or  cerebro-spinal  affection,  or  in  general  systemic 
diseases,  as  syphilis  or  diabetes.  The  subacute  form  is  met 
with  in  infectious  diseases  and  in  the  various  forms  of  general 
systemic  poisoning.  In  the  acute  form  the  lesion  (hemorrhagic 
softening)  does  not  involve  the  protuberantial  nuclei,  or  does  so 
secondarily.  The  lesion  attacks  the  gray  substance  beneath  the 
ependyma,  which  forms  the  walls  of  the  third  ventricle,  aque- 
duct of  Sylvius,  and  fourth  ventricle.  It  is  probable  that  the 
acute  form,  under  the  name  of  hajmorrhagic  polio-encephalitis, 
is  not  of  nuclear  origin. 


Unilateral  nuclear  ophthalmoplegia  must  be  distinguished 
from  the  ophthalmoplegia  of  basilar  or  orbital  origin,  and  it 
the  paralysis  is  complete,  the  diagnosis  is  very  difficult.  It  is 
easy  if  the  paralysis  is  exclusively  external  or  internal.  Supra- 
nuclear lesions  affecting  either  the  co-ordinating  centers  or  the 
fibers  uniting  these  centers  to  the  nuclei  cause  paralysis  of  the 
associated  and  conjugate  movements  of  the  eyes. 

Cortical  ophthalmoplegia,  met  with  in  various  neuroses,  es- 
pecially in  hysteria,  involves  voluntary  movements  of  the  eyes 
exclusively. 

Basilar  ophthalmoplegia  is  usually  unilateral.  It  is  always 
total  and  mixed.  Amblyopia  or  complete  amaurosis  in  the  eye 
on  the  paralyzed  side  is  strong  evidence  of  a  basilar  cause,  and 
the  same  is  true  of  optic  neuritis.  Another  valuable  corrobo- 
rative symptom  is  imilateral  olfactory  paralysis.  Another  is 
anaesthesia  of  the  frontal  branch  of  the  trifacial.  The  usual 
causes  of  basilar  ophthalmoplegia  are  basilar  meningitis,  menin- 
geal haemorrhage,  lesions  of  vessels,  and  neoplasms  of  various 
kinds. 

Orbital  ophthalmoplegia  is  generally  due  to  a  lesion  of  the 
nerves  themselves  or  of  their  terminal  branches.  It  is  always 
unilateral  and  mixed,  and  is  accompanied  by  pain  and  by  more 
or  less  exophthalmia. 

Peripheral  ophthalmoplegia  is  due  to  nerve  lesions  situated 
in  those  parts  of  the  nerves  below  the  nuclei.  This  variety  is 
very  rare  in  infectious  diseases  and  very  common  in  tabes.  It 
is  characterized  by  its  curability  and  by  the  existence  of  spasms 
of  the  associated  muscles  (retraction  of  the  levator  palpebrae  of 
the  diseased  eye  and  spasm  of  the  associated  muscles  of  the 
sound  eye). 

A  Hitherto  Unknown  Alteration  in  the  Lens  occurring 
during  Accommodation.  —  Tscherning  {Arch.  (Vophthal., 
March,  1892)  has  discovered  that  toward  the  end  of  the  act  of 
accommodation  the  lens  undergoes  a  displacement  downward. 
This  displacement  of  the  lens  actually  centers  the  eye,  but  the 
axis  was  always  two  degrees  lower  than  the  visual  line. 

A  Case  of  Primary  Tuberculosis  of  the  Conjunctiva  fol- 
lowed by  Death  from  Pulmonary  Tuberculosis,— Motais  {Rec. 
d^ophthal.,  April,  1892)  reports  a  case  of  this  kind  in  a  little  girl 
aged  eight.  The  upper  lid  of  the  left  eye  was  much  swollen  and 
purple  in  color;  ocular  conjunctiva  slightly  injected ;  no  dis- 
charge. The  inner  surface  of  the  npper  lid  was  covered  with 
granules  the  size  of  the  head  of  a  pin,  grayish  or  rosy  in  color, 
and  some  of  them  semi-transparent.  Two  spots  of  erosion,  with 
grayish  base  and  looking  something  like  an  ulcerated  chancre, 
were  found,  one  at  the  center  and  the  other  at  the  external  angle. 
A  portion  of  the  conjunctiva  was  removed  and  introduced  into 
the  anterior  chamber  of  the  eyes  of  two  rabbits  and  two  guinea- 
pigs.  Between  the  fifteenth  and  twenty-third  days  small  tumors 
appeared  in  the  iris  of  all  four  animals,  grew  rapidly  in  size,  and 
the  animals  emaciated  rapidly.  These  tumors  all  contained  the 
tubercle  bacillus.  Subsequently  many  glands  in  the  little  girl 
became  involved,  and  she  died  of  pulmonary  phthisis  ten  months 
later. 

Papillitis  and  Retrobulbar  Neuritis  as  a  Result  of  In- 
fluenza.— Antonelli  {Rec.  iVop/it/iuL,  June,  1892)  is  of  the  opin- 
ion that  papillitis  caused  by  influenza  occurs  between  the  third 
and  fourteenth  day  following  the  inception  of  the  disease.  It 
is  always  at  first  accompanied  by  a  certain  frontal  and  peri- 
orbital pain  which  often  lasts  a  number  of  days.  Voluntary 
movements  of  the  eyes  as  well  as  all  pressure  evoke  pain. 
Vision  fails  rapidly,  and  sometimes  entirely  in  twenty-four 
hours. 

Retrobulbar  neuritis  caused  by  influenza  is  more  frequent 
than  papillitis.  It  commences  usually  during  the  period  of  con- 
valescence, and  is  often  accompanied  by  dull  pain  deep  in  the 


258 


NE  W  IN  VENTIONS—MISGELLA  NY. 


[N.  Y.  Med.  Jocb  , 


orbit.  Vision  is  apt  to  fail  very  rapidly,  but  rarely  reaches  ab- 
solute blindness,  and  it  may  be  restored  to  the  normal  standard. 

Scraping  the  Lacrymal  Sac— Wecker  {Arch,  d'ophthal, 
November-December,  1891)  believes  that  the  indications  for 
scraping  the  lacrymal  sac  are :  1.  In  order  to  rapidly  cure  cases 
of  old  dacryocystitis  in  persons  who  have  cataracts  ready  for 
operation.  2.  To  shorten  the  usual  treatment  in  laborers  and 
workmen.  3.  To  prevent  grave  lesions  of  the  cornea  in  patients 
who  live  at  a  great  distance  from  specialists  and  surgeons,  and 
who  consequently  can  not  undergo  the  ordinary  treatment  for 
dacryocystitis. 

He  divides  the  upper  canaliculus  as  far  as  the  caruncle.  He 
then  passes  a  tine  cutting  bistoury  into  the  sac  as  far  as  the  be- 
ginning of  the  nasal  duct,  and  then  cuts  through  tlie  anterior 
wall  of  the  sac.  The  lips  of  the  wound  are  then  held  apart,  the 
sac  and  duct  washed  out  with  a  sublimate  solution,  and  the  en- 
tire inner  surface  of  the  sac  is  then  scraped  with  a  sharp  cutting 
spoon,  until  the  mucous  membrane  is  removed.  The  sac  is  then 
again  irrigated  and  the  wound  closed  by  two  or  three  deep 
sutures. 

(7b  be  corUinued.) 


^tfaj  fnfamtions,  etc. 


A  NEW  ABDOMINAL  DRAIN-TUBE  OF  ALUMINIUM. 

By  F.  Byron  RobIxNso.n,  B.  S.,  M.  D., 

CtnCAGO. 

The  tube  is  made  of  aluminium  so  as  to  avoid  the  danger  of 
breaking  in  the  abdominal  cavity.  It  is  open  at  the  bottom  and 
perforated  with  holes  in  the  sides  for  two  thirds  of  the  distance 


from  the  bottom  upward.  The  cost  of  the  tube  will  probably 
be  three  times  that  of  glass,  but  a  tube  will  last  many  years. 
It  is  manufactured  by  Truax,  Greene,  &  Co.,  of  Chicago. 


Germany  and  the  Paa- American  Medical  Congress. — The  following 
open  letter  from  Professor  Czernj',  of  Heidelberg,  was  published  in  the 
Deutsche  medicinische  Wochennchnft  for  January  12th: 
"To  Claudius  H.  Mastin,  M.  D.,  LL.  D.,  Mobile,  Ala.,  President  of  the 

American  Surgical  Association,  in  reference  to  the  Pan-American 

Medical  Congress. 
"  Honored  Sir  and  Colleague  : 

"You  were  kind  enough  to  extend  to  me,  December  3,  1892,  a  per- 
sonal invitation  to  attend  the  Pan-American  Medical  Congress,  to  be 
held  at  Washington,  September  5  to  8,  1893.  According  to  the  pre- 
liminary announcement,  and  to  your  communications,  the  congress,  in 
connection  with  the  Columbian  Exposition  at  Chicago,  will  offer  so  many 
attractions  that  I  exceedingly  regret  not  to  be  able  to  accept  so  amiable 


an  invitation  extended  to  me  by  one  of  the  most  prominent  members  of 
the  body  of  American  pliy.sicians. 

"As  the  rea.sons  which  prevent  me  from  attending  might  be  of  in- 
terest to  the  German  physicians,  you  will  certainly  pardon  my  desire  to 
make  these  reasons  more  generally  known  in  this  manner. 

"At  the  first  glance  one  might  have  been  impressed  with  the  idea 
that  the  Pan-American  Congress  was  intended  to  be  a  rival  to  the  lon"- 
prepared  International  Medical  Congress,  which  is  to  be  held  at  Rome, 
from  September  24  to  October  1,  1893.  However,  as  at  the  former  in- 
ternational expositions  almost  always  contemporary  medical  and  scien- 
tific congresses  took  place,  it  appears  but  just  that  the  American  physi- 
cians should  also  avail  themselves  of  the  opportunity  of  meeting  on 
their  own  continent.  But  since  the  physicians  of  all  civilized  countries 
are  united  in  the  humane  endeavor  to  rather  mitigate  than  to  increase  ^ 
difficulties  between  nations  and  continents,  where  such  exist,  I  there- 
fore think  any  intention  to  injure  the  International  Congress  by  the 
Pan-American  must  be  entirely  excluded. 

"  Perhaps  the  meeting  of  the  International  Congress  might  be  post- 
poned eight  days,  which,  for  several  reasons,  would  be  more  desirable. 
With  earnest  intentions  and  favorable  weather  it  ought  to  be  possible 
to  make  the  trip,  with  the  modem  fast  steamers,  from  Washington  to 
Rome,  from  September  9th  to  September  23d.  It  would  not  be  a  bad 
idea  if  the  members  who  desire  to  make  the  journey  would  do  so  jointly, 
directly  from  Washington  to  Rome,  on  a  steamer  chartered  expre.'idy  for 
that  purpose,  in  order  to  bring  the  greetings  of  the  rising  capital  of  the 
promising  West  to  the  old  metropolis  of  European  civilization. 

"A  more  serious  consideration  to  visit  the  Pan-American  Congress 
is  entertained  by  me  regarding  the  question  of  languages.  In  section 
9th  of  your  programme  it  says :  '  The  languages  of  the  congress  shall 
be  Spanish,  French,  Portuguese,  and  English.'  The  German  language 
is  probably  excluded  because  it  is  nowhere  official  language  in  America. 
If  this  consideration  should  have  prevailed,  then  the  Dutch  and  Dan- 
ish languages  ought  to  have  been  permitted,  since  these  languages  are 
in  official  use  in  America.  Be  this  as  it  may,  /  do  not  think  that  the 
physicians  of  Germany  can  take  part  in  the  proceedings  of  iJie  Pan- 
Ameriean  Medical  Congress  if  they  are  not  permitted  to  read  their  pa- 
pers in  German,  while  any  other  language  but  the  English  is 
Hh  admitted  at  the  congress.  It  must  be  remembered  that  also  at 
Hf  the  International  Congress  '  remarks  are  permitted  in  any  other 
H  language,  if  any  of  the  members  are  willing  to  translate  them 
R       into  one  of  the  four  official  languages.' 

"I  shall  not  mention  the  work  done  continually  for  the 
El  science  of  medicine  in  the  German  language,  but  I  desire  to 
K  refer  to  the  great  number  of  prominent  American  physicians 
Ip  who  have  received  the  best  part  of  their  education  in  Ger- 
man schools  and  to  the  numerous  German  physicians  who 
practice  with  success  in  America,  and  who  have  added  so  much 
to  the  great  reputation  in  which  American  medical  literature  is  at 
present  held  in  the  whole  world.  Indeed,  I  am  inclined  to  believe 
that  North  and  South  American  physicians  will  frequently  be  able  to 
communicate  with  each  other  in  the  German  language,  learned  by  them 
in  our  universities.  If  I  am  not  mistaken  in  this,  I  certainly  think 
that  the  executive  committee  of  the  Pan-American  Medical  Congress 
should  pass  a  resolution  which  would  enable  German  physicians  to 
visit  the  congress,  provided  a  participation  on  our  part  is  at  all  desired. 

"  I  shall  be  exceedingly  gratified  if  my  suggestions  should  find  fa- 
vor on  the  other  side  of  the  ocean ;  and  if  I  should  be  thus  enabled, 
dear  sir  and  colleague,  to  personally  enter  into  friendly  relations  with 
you  in  Washington. 

"  With  best  wishes  and  the  compliments  of  the  season,  I  am, 
"  Yours  most  respectfully, 

"  Dr.  Czerny, 

Honorary  Member  of  the  American  Surgical  Association. 
"  Heidelberg,  December  28,  1892." 

The  following  reply  has  been  made  by  Secretary-General  Reed  : 

"Cincinnati,  February  14,  1893. 

"  Professor  v.  Czerny,  Heidelberg. 

"  My  dear  Doctor  :  My  distinguished  colleague.  Dr.  C.  H.  Mastin, 
has  referred  to  me  for  official  reply  your  open  letter  addressed  to  him 


March  4,  1893. J 


MISCELLANY. 


259 


and  published  in  the  Deutsche  medirinltche  Wochcmchrift  for  January 
12th  of  this  year. 

"  A  careful  reading  of  your  valued  communication  lead.s  me  to 
the  conclusion  that  you,  in  common  with  other  distinguished  German 
savants,  hesitate  in  accepting  an  invitation  to  attend  the  Pan-American 
Medical  Congress,  (1)  because  the  (Jerraan  profession  is  not  officially 
invited  by  the  executive  committee  to  become  a  constituent  part  of  the 
congress,  (2)  because  the  German  language  is  not  one  of  the  official 
languages  of  the  congress,  and  (3)  because  a  general  participation  on 
the  part  of  yourself  and  confreres  might  be  construed  into  disloyalty 
to  the  International  Medical  Congress  which  is  to  meet  in  Rome  in  the 
same  month. 

"  In  reply  I  beg  to  state  that  the  occasion  for  holding  a  medical 
congress  in  the  United  States  in  1893  is  the  fact  that  a  large  number  of 
physicians  will  be  in  this  country  in  attendance  upon  the  World's  Co- 
lumbian Exposition.  This  attendance  will  be  largely,  although  not  by 
any  means  exclusively,  from  the  countries  of  the  Western  Hemisphere. 
It  would  have  been  very  desirable  indeed  to  have  arranged  an  organiza- 
tion which  would  have  embraced  all  the  countries  of  the  world.  The 
medical  profession  of  the  United  States,  however,  acknowledges  alle- 
giance to  the  World's  Internatioiial  Congress  which  is  to  meet  in  Rome. 
To  have  attempted  an  organization  in  Germany  or  any  other  European 
countries  in  the  interest  of  the  American  meeting  would  have  been  in 
violation  of  our  loyalty  to  the  International  Congress,  while  an  official 
invitation  to  the  Government  and  medical  societies  of  Germany  and 
other  European  countries  to  send  delegates  to  the  Washington  meeting 
would  have  been  almost  equally  inimical  to  the  interests  of  the  Rome 
Congress.  It  was  therefore  resolved  that  the  organization  should  be 
limited  to  the  American  countries,  and  that,  while  it  was  desirable  to 
secure  the  attendance  of  our  distinguished  confreres  from  Europe  as 
guests,  invitations  to  that  end  should  be  strictly  personal  in  character, 
and  should  be  issued  by  the  general  officers  and  presidents  of  sections 
at  their  discretion. 

"  The  languages  chiefly  spoken  by  the  peoples  of  the  various  con- 
stituent countries  of  the  congress  are  Spanish,  Portuguese,  and  Eng- 
lish, and  these  were  accordingly  selected  by  the  committee  as  the  offi- 
cial languages  of  the  congress.  French,  which  is  the  language  of 
important  colonies  and  communities,  was  subsequently  added  at  the 
instance  of  our  confreres  in  Brazil,  who  employ  it  largely  in  scientific 
communication,  as,  indeed,  do  a  large  proportion  of  the  physicians  of 
both  the  English-  and  Spanish-speaking  countries.  Danish  and  Dutch 
are  not  included,  simply  for  the  reason  that  it  is  extremely  [difficult?], 
indeed  practically  impossible,  to  deal  with  them  satisfactorily  in  a  liter- 
ary way  in  this  country.  It  was  hoped  that  delegates  from  countries 
and  colonies  speaking  other  than  Spanish,  Portuguese,  English,  and 
French  would  furnish  their  remarks  on  paper  in  one  of  the  official  lan- 
guages. This  was  so  thoroughly  understood  by  the  committee  and  has 
become  such  a  well-established  usage  at  international  congresses  that  it 
was  not  deemed  necessary  to  state  it  explicitly ;  but  I  shall  communi- 
cate the  suggestion  which  you  kindly  make  to  the  executive  committee, 
when  I  have  no  doubt  it  will  be  made  definite  in  the  by-laws. 

"  As  early  as  December,  1891,  I  opened  correspondence  by  telegraph 
with  the  president  of  the  XI  International  Congress,  and  subsequently 
with  Professor  Maragliano,  of  Genoa,  the  secretary-general,  asking  that 
the  date  of  the  Rome  meeting  be  arranged  so  as  to  permit  us  to  send 
delegates  from  Washington.  The  date  of  the  International  Congress 
was  accordingly  changed  from  the  IVth  to  the  24th  of  September, 
which  will  give  us  sixteen  days  in  which  to  go  from  Washington  to 
Rome.  Arrangements  were  begim  in  February  of  last  year  for  a  spe- 
cial sailing  of  a  steamer  September  9th,  direct  to  Italy,  by  way  of  the 
Azores  and  Gibraltar,  to  take  those  desiring  to  attend  the  Rome  meet- 
ing, a  special  reduced  rate  being  accorded  for  the  occasion.  My  pres- 
ent correspondence  indicates  that  a  large  number  will  avail  themselves 
of  this  privilege.  It  is  highly  gratifying  to  note  that  the  expediency 
of  this  plan  has  occurred  quite  independently  to  one  so  conversant  with 
affairs  as  yourself. 

"  Permit  me  to  say  in  conclusion  that  our  European  confrkres  who 
may  honor  the  Pan-American  Medical  Congress  with  their  presence  will 
be  accorded  every  linguistic  privilege,  that  arrangements  have  already 
been  made  for  their  return  to  Italy  in  time  for  the  International  Con- 


gress, and  that  in  the  event  of  their  coming  they  will  be  greeted  with 
a  most  cordial  American  welcome. 

"  Very  sincerely  yours, 

"  Charles  A.  L.  Reed, 

"  Secretary-General  P.- A.  M.  C." 

Researches  on  the  Production  of  Perfume  in  Flowers. — In  its  Feb- 
ruary issue  the  American  Journal  of  Pharmacy  Te^v'mti  from  the  Phar- 
maceuticalJournal  and  Transactions  for  January  7th  an  adaptation  from 
the  Comptes  rendus  de  P  Academic  des  sciences  of  an  article  on  this  sub- 
ject, by  M.  E.  Mesnard,  as  follows : 

"  The  insufficient  nature  of  the  micro-chemical  methods  usually  em- 
ployed has  so  far  prevented  an  exact  knowledge  being  obtained  of  the 
matter  in  which  the  perfume  of  flowers  is  produced.  I  have  applied 
to  this  class  of  researches  a  general  method  which  has  served  in  the 
localization  of  fixed  oils.  The  section  being  placed  in  a  drop  of  pure 
glycerin  is  arranged  upon  a  round  cover  glass,  which,  being  then  in- 
verted, serves  as  a  cover  to  a  small  chamber  formed  by  cementing  a 
glass  ring  to  an  object  slide.  In  the  interior  of  the  chamber  is  fixed 
another  ring  of  smaller  diameter  and  somewhat  less  in  height,  thus 
forming  with  the  first  an  annular  space  in  which  the  reagent  may  be 
placed.  By  adopting  this  arrangement  the  light  passing  through  the 
central  part  of  the  cell  is  not  modified.  The  inner  ring  will  further 
serve  to  support  a  very  small  cover  glass,  upon  which  sections  may  be 
arranged  which  require  to  be  exposed  to  the  action  of  the  reagent  for 
some  length  of  time,  as  occasionally  happens  in  the  case  of  the  fixed 
oils.  The  reagent  invariably  employed  is  pure  hydrochloric  acid,  the 
hydrated  vapors  from  which  are  readily  absorbed  by  the  glycerin.  In 
this  way,  by  a  gentle  and  easily  regulated  action,  I  obtain  complete  hy- 
dration of  sections  in  the  presence  of  an  acid.  When  they  have  been 
exposed  for  a  short  time,  the  essential  oils  appear  as  minute  spherical 
drops  of  a  fine  transparent  golden  yellow.  If  the  action  be  prolonged 
the  drops  disappear,  being  transformed  into  diffusible  products.  The 
tendency  of  the  globules  is  not  seen  in  the  fixed  oils,  so  that  it  provides 
a  means  of  distinguishing  these  two  classes  of  products. 

"  Jasmin. — In  this  flower  the  essence  is  situated  in  the  row  of  epi- 
dermal cells  on  the  upper  side  of  the  petals  and  sepals.  Some  exist 
also  in  the  corresponding  layer  on  the  under  surface,  where  the  sepals 
are  colored  by  a  violet  pigment.  If  the  evolution  of  the  cell  contents 
in  flowers  at  different  stages  of  development  be  followed,  at  first  noth- 
ing but  chlorophyll  is  found  in  the  tissue  ;  tannin  appears  next,  or 
rather  intermediate  glucosides,  difficult  to  identify  by  means  of  the 
ordinary  tests  for  these  substances.  These  glucosides  furnish  the  tan- 
nin and  pigments  of  the  lower  surface  of  the  sepals.  The  hydrochloric- 
acid  vapors  distinguish  all  the  tannoid  compounds  intermediate  between 
the  chlorophyll  and  tannin  or  pigments  on  the  one  hand,  and  between 
the  chlorophyll  and  essential  oil  on  the  other.  The  explanation  of 
these  facts  seems  to  be  as  follows :  Whereas  upon  the  lower  surface 
of  the  bud,  which  was  exposed  to  the  action  of  light  and  the  oyxgen  of 
the  air,  the  tannoid  compounds  were  slowly  oxidized  and  gave  rise  to 
tannin,  upon  the  upper  surface  which  was  hidden  in  the  bud  these 
agencies  were  inoperative,  and  the  same  compounds  were  converted  into 
essential  oil,  which  oxidizes  in  contact  with  the  air  and  produces  the 
sensation  of  perfume. 

"  Poses. — The  essence  in  roses  is  found  in  the  papilliform  epidermal 
cells  on  the  upper  surface  of  the  petals,  scarcely  ever  on  the  lower  side. 
The  origin  of  the  essence  is  easily  recognized  as  being  the  same  as  in 
the  preceding  case.  The  delicacy  and  the  special  odor  of  the  essence 
furnished  by  each  variety  of  roses  seems  to  depend  upon  the  more  or 
less  complete  transformation  of  the  intermediate  taimoid  compounds 
derived  from  the  chlorophyll. 

"  Violets. — The  essence  is  here  similarly  situated.  It  is  necessary, 
however,  before  applying  reagents  to  the  sections  in  this  instance,  to 
immerse  them  in  tungstate-of-sodium  solution  for  some  minutes,  in 
order  to  precipitate  the  tannin.  The  essential  oil  then  appears  bright 
red. 

"  Tuberose. — In  tjiis  case  the  essential  oil  is  found  upon  the  lower 
surface  of  different  parts  of  the  perianth.  The  intermediate  cells  con- 
tain a  fixed  oil.  Tannin  is  scarcely  perceptible.  Here,  then,  in  conse- 
quence of  the  abundance  of  chlorophyll  in  the  first  place,  of  the  almost 


260 


MISCELLANY. 


[N.  Y.  Med.  Joue. 


complete  absence  of  tannin,  and  also,  probably,  of  the  presence  of  fixed 
oil  which  has  swept  it  toward  the  periphery,  the  essential  oil  is  carried 
toward  the  lower  surface.  The  intense  odor  of  the  tuberose  only  com- 
mences to  reveal  itself  when  the  oil  is  enabled  to  form  itself  into  small 
drops  under  the  influence  of  the  reagent. 

"  Orange. — The  reagent  discloses  the  presence  of  several  distinct 
essences  in  orange  blossoms.  First  there  is  that  of  the  secretory  sacs, 
which  occur  on  the  lower  surface  of  the  petals  or  sepals.  This  is  not 
essence  of  neroli,  as  is  generally  supposed,  but  an  essence  analogous  to 
that  of  petit-grain.  By  skillfully  eliminating  these  sacs  in  an  unopened 
bud,  the  agreeable  odor  of  the  flower  when  it  afterward  expands  is  in 
no  degree  injured.  Essential  oil  is  still  found  in  the  epidermis  on  both 
surfaces  of  the  petals,  and  likewise  upon  the  periphery  of  the  petaloid 
filaments  of  the  stamens.  By  systematically  preventing,  in  various 
ways,  the  liberation  of  the  perfume  in  these  diiferent  regions,  I  have 
been  able  to  assure  myself  that  the  odor  from  the  upper  surface  of  the 
petals  alone  corresponds  to  the  finest  neroli.  The  odor  of  the  flower 
then  is  a  mixture. 

"  The  conclusions  to  be  drawn  from  these  researches  are : 

"  1.  That  the  essential  oil  is  generally  found  localized  in  the  epi- 
dermal cells  of  the  upper  surface  of  the  petals  or  sepals,  though  it  may 
exist  upon  both  surfaces,  especially  if  the  floral  organs  are  comi)letely 
hidden  in  the  bud.  The  lower  surface  generally  contains  tannin  or  pig- 
ments derived  from  it. 

"  2.  The  chloro])hyll  seems,  in  every  case,  to  give  rise  to  the  essen- 
tial oil.  This  transformation  is  readily  comprehended  if  it  be  admitted, 
as  is  generally  understood,  that  the  floral  organs  are  but  modified  leaves 
found  performing  a  new  function.  The  chlorophyll  being  thus  diverted 
from  its  original  purpose,  may  be  transformed  into  tannoid  compounds 
or  into  essential  oils. 

"  3.  The  liberation  of  perfume  in  the  flower  only  becomes  percepti- 
ble when  the  essential  oil  is  sufficiently  freed  from  the  intermediate 
compounds  which  have  given  rise  to  it.  Its  formation  is  to  some  ex- 
tent in  inverse  proportion  to  that  of  the  tannin  and  pigments  in  the 
flower.  This  will  explain  why  flowers  with  green  petals  pos.^ess  no 
odor,  why  white  flowers  or  roses  are  most  frequently  odoriferous,  why 
the  Composiice  which  are  so  rich  in  tannin  have  a  characteristic  dis- 
agreeable odor,  and  why  the  cultivated  white  lilac  and  forced  roses  ac- 
quire a  very  fine  perfume." 

The  Preparation  of  Kumyss. — The  following  is  taken  from  an  arti- 
cle published  m  the  February  number  of  the  Therapeutic  Gazette  : 

"The  original  kumyss  is  the  Russian,  made  from  mare's  milk,  which 
is  used  for  the  obvious  reason  that  it  is  less  rich  in  casein  and  fatty 
matter  than  cow's  milk,  and  therefore  far  more  easy  of  digestion. 

"Mare's  milk  contains  approximately  1'70  percent,  of  casein  and 
1"40  per  cent,  of  fatty  matter,  whereas  cow's  milk  contains  4'55  of 
casein  and         of  fatty  matter. 

"  Cow's  milk  is  probably  universally  used  in  England,  and  it  answers 
the  purpose  admirably  in  most  instances,  but  a  better  preparation  is  ob- 
tained by  diluting  with  water  to  reduce  the  percentage  of  casein,  etc. 

"Mare's  milk  contains  S'^S  of  milk  sugar,  cow's  milk  only  5'35;  it 
is  therefore  necessary  to  add  some  of  this  to  our  preparation.  The 
following  formula  answers  very  well.    Take  of — 


Fresh  milk   1  xij  ; 

Water   3  iv  i 

Brown  sugar   3  ijss. ; 

Compressed  yeast   gr.  xxiv ; 

Milk  sugar. ...    3  iij. 


"  Dissolve  the  milk  sugar  in  the  water,  add  to  the  milk,  rub  the 
yeast  and  brown  sugar  down  in  a  mortar  with  a  little  of  the  mix- 
ture, then  strain  into  the  other  portion.  Strong  bottles  are  very  essen- 
tial, champagne  bottles  ))eing  frequently  used,  and  the  corks  should  fit 
very  tightly;  in  fact,  it  is  almost  necessary  to  use  a  bottle  machine  for 
the  purpose,  and  once  the  cork  is  properly  fixed  it  should  be  wired 
down.  Many  failures  have  resulted  because  the  corks  did  not  fit  prop- 
erly, the  result  being  that  the  carbonic-acid  gas  escaped  as  formed  and 
left  a  worthless  preparation.  It  is  further  necessary  to  keep  the  prepa- 
ration at  a  moderate  temperature,  and,  to  insure  the  article  being  prop- 
erly finished,  the  bottles  are  to  be  gently  shaken  each  day  for  about  ten 


minutes  to  prevent  the  clotting  of  the  casein.  It  is  as  well  to  take  the 
precaution  of  rolling  a  cloth  round  the  bottle  during  the  shaking  pro- 
cess, as  the  amount  of  gas  generated  is  great,  and  should  the  bottle  be 
of  thin  glass  or  contain  a  flaw,  it  may  give  way.  Some  few  days  elapse 
before  the  fermentation  passes  into  the  acid  stage,  and  when  this  has 
taken  place  the  preparation  is  much  thicker.  It  is  now  in  the  proper 
condition  for  allaying  sickness,  being  retained  by  the  stomach  when 
almost  everything  else  is  rejected." 

The  New  York  Academy  of  Medicine. — The  regular  order  for  the 
meeting  of  Thursday  evening,  the  2d  inst.,  was  a  paper  entitled  Clinical 
Notes  on  the  Diagnosis  and  Treatment  of  Pleurisy,  by  Dr.  Beverley 
Robinson. 

At  the  ne.xt  meeting  of  the  Section  in  Ptediatrics,  on  Thursday  even- 
ing, the  9th  inst,  the  subject  of  catarrhal  pneumonia  will  be  discussed 
— its  bacteriology  by  Dr.  Henry  Koplik,  its  pathology  by  Dr.  Francis 
Delafield,  its  symptomatology  by  Dr.  Joseph  E.  Winters,  and  its  treat- 
ment by  Dr.  A.  Jacobi. 

At  the  next  meeting  of  the  Section  in  Genito  urinary  Surgery,  on 
Tuesday  evening,  the  14th  inst.,  Dr.  G.  K.  Swinburne  will  report  a  case 
of  syphilitic  re-infection. 


To  Contribntors  and  Correspondents. —  The  attention  of  all  who  purpote 

favoring  us  with  communications  is  respectfully  called  to  the  follow- 
ing : 

Authors  of  articles  intended  for  publication  under  tlie  head  of  "  original 
contributions  "  are  respectfully  informed  that,  m  accepting  such  arti- 
cles, we  alivays  do  so  with  the  understanding  that  (he  following  condi- 
tions are  to  be  observed :  (i)  when  a  rnanwicript  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  he 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (S)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly' 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters^  hands.  We  are  often  constrained  to  decline 
articles  which,  although  t/iey  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,  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  tlie  aimoer  to  his  note 
is  to  he  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  cmifidejdial.  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  notiJU 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet- 
ings wUl  be  inserted  when  they  are  received  in  time. 

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

All  communications  intended  for  the  editor  should  he  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  JN^EW  YORK  MEDICAL  JOURNAL,  March  11,  1893. 


©riginal  Communications. 


THE  INTIMATE  NERVOUS  CONNECTION  OF  THE 

GENITO-URINARY  ORGANS  WITH  THE 
CEREBRO-SPINAL  AND  SYMPATHETIC  SYSTEMS. 
By  FRED  BYRON  ROBINSON,  M.  D., 

CHICAGO. 

Every  observing  physician  sees  a  very  close  connection 
between  the  genital  organs  and  the  nervous  system.  Tins 
is  not  strange  when  one  looks  at  existing  facts  and  the 
long-continued  effects  of  evolutionary  forces.  Of  all  in- 
stincts of  the  animal  race,  the  sexual  instinct  is  the  most 
dominant.  The  sexual  instinct  has  an  all-pervading  influ- 
ence in  every  species  of  animal.  It  governs  their  action. 
It  forms  habits  on  their  lives.  It  induces  new  phases  of 
existence.  All  through  the  stages  of  animal  evolution, 
every  other  instinct  must  bend  to  the  sexual  instinct. 
Physical  and  mental  forces  wonderfully  combine  to  make 
this  sexual  instinct  the  most  effectual  in  its  consummation. 
The  sexual  instinct  dominates  the  most  powerfully  in  males, 
and  hence  the  physical  and  mental  vigor  of  the  best  animals 
in  the  race  survive.  The  cow  in  rut  is  served,  from  sheer 
physical  and  mental  vigor,  by  the  most  powerful  bull.  In 
herds  of  animals  the  sexual  instinct  dominates  most  vigor- 
ously in  the  finest  males,  and  they  toss  aside  the  weak 
males,  to  become  the  parent. 

The  main  study  of  zoology  is  reproduction.  The 
weapons  of  offense  and  defense  possessed  by  males  are 
primarily  to  cultivate  and  defend  the  sexual  instinct.  The 
horns  of  bulls,  the  powerful  heels  of  stallions,  the  eagle's 
talons,  and  the  claws  of  powerful  feet,  are  the  weapons  to 
defend  and  to  carefully  cultivate  the  sexual  instinct — the 
dominant  instinct  of  animal  life.  When  we  pass  on  to  man, 
the  sexual  instinct  is  rather  heightened  than  diminished. 
But  in  man  the  sexual  instinct  is  couched  in  a  more  subtile 
place  than  physical  tenements  ;  secretly  in  the  depths  of 
man's  mental  forces  lies  his  sexual  instinct.  As  man  has 
gained  the  ascendency  of  animal  life  by  his  wits  alone,  so 
bv  his  wits  alone  can  be  studied  his  sexual  instincts.  Thus 
in  the  lowest  form  of  physical  existence  sexual  instincts 
dominate,  yet  in  the  higher  forms  of  mental  existence  the 
sexual  instincts  are  still  more  powerfully  dominant.  From 
such  premises,  patent  to  all  observers,  it  is  quite  obvious 
that  evolutionary  forces  have  through  long  ages  established 
a  very  close  connection  between  the  nervous  system  and 
the  genitals — -the  organs  which  gratify  the  sexual  instinct. 
Forces  (mental  or  physical)  acting  through  eons  of  ages 
will  establish  very  definite  matters.  Here  I  should  like 
to  lay  down  a  few  distinct  propositions  so  that  the  ideas 
in  this  little  communication  may  be  more  clearly  under- 
stood. The  first  idea  is  that  an  ideal  nervous  system 
consists  of  (1)  a  ganglion  cell,  (2)  a  conducting  cord,  and 
(3)  a  peripheral  apparatus.  The  second  idea  is  that  the 
increase  of  man's  intelligence  is  not  by  the  increase  of  gan- 
glion cells,  but  by  the  increase  of  conducting  cords.  Chi- 
cago and  New  York  may  each  represent  a  ganglion  cell. 


and  a  single  railroad  may  represent  the  conducting  cord. 
Now,  when  there  was  but  one  railroad  between  New  York 
and  Chicago,  but  little  business  could  be  done  on  account 
of  the  limited  amount  of  commerce  which  the  single  road 
could  accommodate.  Chicago  and  New  York,  as  the  ganglia 
cells,  could  dispose  of  far  more  business  than  the  single  road 
could  transmit.  But  when  the  railroads  multiplied  between 
the  two  centers,  the  business  increased  just  in  proportion  to 
the  number  of  roads  or  conducting  lines.  Now,  one  could 
infer  that  the  industrious  work  of  ages  of  natural  forces 
would  have  established  numerous  lines,  and  vigorous  lines, 
of  connection  between  the  genitals  and  the  nervous  system. 
The  facts  which  dissection  show  are  positive  in  demon- 
strating the  widespread  and  intimate  connection  of  the 
genitals  with  the  cerebro-spinal  and  sympathetic  systems. 

The  ganglion  cells  can  receive  and  dispose  of  far  more 
mental  work  than  a  few  conducting  cords  can  transmit  j 
so  that  the  progress  and  advance  toward  a  higher  nervous 
system  and  a  higher  intelligence  is  an  increase  in  the  con- 
ducting cords  or  lines  to  transmit  intelligence  or  ideas. 
Also  a  well  developed  periphery  is  an  absolute  necessity  for 
the  purpose  of  collecting  ideas  to  transmit.  An  increasing 
sensitive  periphery  is  required  to  perceive  forces  and  com- 
prehend ideas  so  that  they  can  be  sent  to  the  central  gan- 
glia. Now,  the  number  of  conducting  cords  which  attach 
the  genitals  to  the  nervous  centers  is  simply  enormous. 
Besides,  the  nerve  periphery,  situated  in  the  external  geni- 
tals, is  highly  sensitive  and  highly  developed,  so  that  it 
quickly  perceives  and  quickly  transmits  the  slightest  sensa- 
tion, and  also  evolutionary  forces  through  the  ages  seem 
to  increase  the  sexual  instinct  with  the  progress  of  intelli- 
gence and  mental  growth. 

I  base  my  remarks  on  several  years  of  careful  dissection 
of  many  cadavers  and  animals.  If  one  carefully  dissects  the 
body  of  a  man  he  will  note  the  extensive  cerebro-spinal 
nerves  supplying  the  genitals,  especially  the  penis.  Of  thfl 
spinal  nerves  supplying  the  genitals,  the  main  one  is  the 
pudic.  But  the  pudic  nerve  is  composed  of  nearly  all  the 
third  sacral,  and  branches  from  the  second  and  fourth  sacral. 
As  one  examines  this  nerve  he  is  forced  to  the  conclusion 
that  it  is  an  enormous  supply  for  a  small  organ. 

The  periphery  of  the  pudic  nerve  spreads  itself  like  a 
fan  over  the  genitals.  And  also  the  branches  of  this  fan- 
like nerve- apparatus  supply  —  the  genitals,  bladder,  and 
rectum — organs  which  must  act  and  work  in  harmony. 
Hence  the  great  disturbance  which  arises  in  the  pelvis 
(bladder,  rectum,  or  genitals)  when  any  one  organ  is  dam- 
aged—e.  g.,  a  rectal  fissure,  a  urethritis,  or  penile  irritation 
quickly  sets  the  whole  system  akimbo  and  Richard  is  not 
himself.  The  vast  connection  of  the  pudic  nerve  with  the 
external  genitals  (where  sensation  is  experienced)  is  remark- 
able. Not  less  remarkable  is  the  wonderfully  harmonious 
action  of  the  bladder,  rectum,  and  genitals  through  large 
branches  of  the  same  pudic. 

Another  peculiar  spinal-nerve  connection  of  the  exter- 
nal genitals  is  the  supply  of  the  pudendal  nerve  to  the 
lateral  walls  of  the  penis.  I  have  time  and  again  called  the 
attention  of  medical  men  to  the  peculiar  connection  be- 


262 


ROBINSON:  NERVOUS  RELATIONS  OF  THE  SEXUAL  ORGANS.      [N,  Y.  Med.  Joub., 


tween  the  glutacus-maximus  muscle  and  the  external  geni- 
tals by  means  of  the  pudendal  nerve  or  branch  of  the 
lesser  sciatic.  The  glutajus  maxiinus  is  the  real  muscle  that 
holds  man  upright  (physically),  but  it  is  also  the  main  mus- 
de  of  coition.  The  lesser  sciatic  nerve  supplies  only  one 
muscle,  and  that  is  the  glut;eus  maxinius,  and  then  it  sends 
off  the  large  pudendal  branch  to  the  sides  of  the  penis, 
and  hence  the  friction  of  coition  induces  active  contrac- 
tions of  the  gluticus  maximus  in  cohaoitation.  Hence  the 
spinal-nerve  supply  to  the  external  genitals  is  mainly  the 
large  pudic  and  pudendal  nerves.  In  woman  the  pudic 
nerve  is  equally  large ;  but  the  pudendal  nerve  is  much 
smaller  in  woman  than  in  man,  according  to  my  dissections. 
The  lesser  size  of  the  pudendal  nerve  in  woman  is  in  di- 
rect accord  with  the  methods  of  cohabitation.  The  vigor- 
ous and  aggressive  activity  of  man  in  coition,  and  the  quiet, 
passive  receptivity  of  woman,  explains  the  larger  pudendal 
nerve  in  man.  But  the  reverse  nerve  supply  arises  in  re- 
gard to  the  glans  clitoridis  and  the  glans  penis.  I  have 
dissected  many  a  clitoris,  and  its  nerve  supply  is  three  or 
four  times  as  large  as  that  of  the  penis  in  proportion  to  its 
size.  The  clitoris  of  woman  is  a  veritable  electrical  bell 
button,  which,  being  pressed  or  irritated,  rings  up  the 
whole  nervous  system.  And  certainly  I  have  found  for 
quite  a  while  that  adhesions  of  the  prepuce  to  the  clitoris 
have  led  to  masturbation  in  girls.  Every  gynecologist 
should  examine  the  clitoris,  and,  if  preputial  adhesions 
exist,  sivnply  break  them  up,  for  the  vast  nerve  supply  of  a 
woman's  clitoris  gives  great  chances  for  profound  irritation. 
The  poor  girl,  neglected  by  mother  and  possibly  by  doctor, 
is  soon  induced  by  the  itching  to  become  a  masturbator. 

My  attention  was  directed  to  the  study  of  the  clitoris 
three  years  ago,  and  I  find  many  a  clitoris  with  preputial 
adhesions,  and  when  I  break  them  up  the  patient  will  fre- 
quently relate  what  a  "  terrible  itching  I  have  had  for  years 
there."  "  But,"  she  would  say,  "  I  did  not  dare  to  men- 
tion it  to  the  doctor."  But  the  extensive  spinal-nerve  sup- 
ply to  the  external  genitals,  though  vast  and  intimate,  is 
but  a  small  matter  relative  to  the  supply  to  the  mternal 
genitals.  The  spinal-nerve  supply  to  the  external  genitals 
is  mainly  sensitive,  so  that  the  sexual  instinct  may  be  grati- 
fied by  the  organs,  and  that  the  functional  pleasure  may  be 
worth  the  effort.  What  I  wish  mainly  is  to  call  attention 
to  the  profound  connection  of  the  internal  genitals  with 
the  nervous  system  by  means  of  the  sympathetic  system. 
It  is  in  this  field  that  the  gynaecologist  and  the  genito- 
urinary surgeon  find  full  play  for  lucrative  operations — for 
so-called  aggressive  surgery.  In  manipulations  and  instru- 
mental examinations  of  the  genitals  is  where  and  when  one 
sees  the  nerve  storms  flash  over  the  system.  These  nerve 
storms  radiate  over  distinct  nerve  plexuses  like  electricity 
over  a  system  of  wires.  Take,  for  example,  the  uterus. 
Its  sympathetic  nerve  supply  is  enormous.  The  cervix  only, 
so  far  as  I  can  see,  has  spinal  nerves,  while  the  body  and 
fundus  is  supplied  by  the  sympathetic.  One  can  count 
some  twenty  or  thirty  strands  of  nerves  in  the  hypogastric 
plexus  which  originates  in  the  abdominal  brain  and  termi- 
nates in  the  uterus,  and  the  nerves  are  very  large.  The 
OTarian  plexus — a  very  large  plexus — goes  from  the  abdomi- 


nal brain,  and  many  of  the  nerves  of  this  plexus  terminate 
on  the  tubes  and  fundus  of  the  uterus,  so  that  the  sympa- 
thetic nerve  supply  to  the  uterus  is  enormous.  The  result 
of  a  large  nerve  supply  to  any  organ  is  its  danger  of  sad 
complications  and  stubborn  pathology.  I  have  seen  a  pa- 
tient in  the  gynaecological  chair  make  active  efforts  to  vomit 
in  less  than  fifteen  seconds  after  I  carefully  introduced  the 
sound.  In  those  ten  to  fifteen  seconds  a  complicated  nerv- 
ous phenomenon  had  occurred.  The  irritation  of  the  endo- 
metrium had  been  flashed  up  the  hypogastric  plexus  to  the 
abdominal  brain,  and  there  it  was  reorganized  and  dashed 
over  the  various  plexuses  to  other  viscera.  The  irritation, 
no  doubt,  went  to  every  viscus  similarly,  but  I  knew  it 
went  to  the  stomach,  because  it  manifested  itself  in  motion 
(vomiting).  The  heart,  lungs,  liver,  spleen,  and  digestive 
organs  no  doubt  suffered  similarly,  but  they  were  better 
able  to  resist  the  irritation.  A  study  of  the  hypogastric 
plexus  and  its  action  on  the  uterus  convinces  me  that  pres- 
sure on  the  aorta  for  post-partum  haemorrhage  is  generally 
explained  wrongly.  It  is  said  the  pressure  obstructs  the 
blood,  but  the  real  process  is  that  the  pressure  on  the  hypo- 
gastric plexus  irritates  the  peripheral  end  in  the  uterus,  and 
it  induces  the  uterus  to  contract.  This  is  more  reasonable. 
The  dominating  influence  of  uterine  disease  among  women 
is  due  to  the  vast  and  intimate  connection  of  the  uterus 
(tubes  and  ovary)  with  the  sympathetic  nervous  system. 
Besides,  a  great  and  complicated  network  of  nerves  is  easily 
deranged.  The  importance  of  the  uterus  demands  a  vast 
and  complicated  nerve  supply,  and  such  an  organ  often 
dominates  a  woman.  It  may  be  laid  down  as  a  general 
proposition  that  the  viscera  have  their  normal  function  in 
rhythm,  and  the  disturbance  of  the  rhythm  is  what  induces 
disease.  It  may  also  be  said  that  the  main  pathology  of 
the  sympathetic  is  reflex  action  from  some  distant  viscus. 

Another  idea  may  be  noted — that  the  ganglia  controlling 
the  viscera  are  entirely  out  of  the  control  of  the  will.  If 
the  visceral  movement  was  not  involuntary  or  out  of  the 
mental  sphere  of  the  mind,  men  would  speculate  and  ex- 
periment on  their  viscera.  Now,  the  viscera  being  out  of 
mental  control  no  doubt  explains  the  curious  action  of  ill 
or  neurotic  women.  The  nerve  storms  which  emanate  from 
a  pathological  uterus  flash  over  the  whole  system  by  dis- 
tinct nerve  plexuses,  and,  as  the  will  does  not  control  any  of 
such  reflexes,  the  patient  acts  on  the  induced  feelings.  The 
close  nervous  connection  of  the  uterus  with  the  nervous 
system  is  at  once  seen  in  the  great  changes  which  uterine 
disease  induces  in  both  the  mental  and  physical  life  of  a 
woman.  But  anatomical  facts,  physiological  experiment, 
and  clinical  study  all  show  that  the  genitals  and  nervous 
system  are  more  highly  and  intimately  connected  than  any 
other  system.  No  organ  influences  a  woman  mentally  or 
physically  to  such  a  degree  as  the  uterus,  even  in  its  nor- 
mal physiological  and  anatomical  condition,  while  its  patho- 
logical condition  is  still  more  manifest.  It  is  owing  to  the 
very  distinct  connection  of  the  genitals  with  the  cerebro- 
spinal and  sympathetic  system.  Let  a  woman's  genitals 
become  pathological  and  she  gets  liver  disease,  she  gets  in- 
digestion, and  she  becomes  ansEmic  and  terribly  neurotic. 
Uterine  disease  induces  eye  disease,  it  induces  heart  trou- 


March  11,  1893.] 


ROBINSON:  NERVOUS  RELATIONS  OF  THE  SEXUAL  ORGANS. 


263 


ble,  and  the  joints  and  muscles  do  not  escape.  A  woman 
■with  pelvic  disease  often  acquires  hip,  knee,  or  ankle  trou- 
ble. This  is  no  doubt  due  to  the  intimate  connection  of 
the  uterus  with  the  hip,  knee,  and  ankle  joints  through  the 
sacral  plexus;  e.  g.,  the  sacro  iliac  joint,  the  hip  joint,  and 
the  knee  joint  are  all  supplied  by  three  distinct  nerves — 
viz.,  the  great  sciatic,  the  anterior  crural,  and  the  obturator. 
Now,  these  three  nerves  are  really  the  sacral  plexus.  A 
woman  gets  cold  at  the  monthly  period  so  easily  from  wet 
feet  no  doubt  from  the  close  connection  of  the  uterus  with 
the  sacral  plexus,  but  the  lower  end  of  the  sacral  (the  sciatic 
nerve)  supplies  the  feet  which  get  wet.  The  disturbed  cir- 
culation of  women  atHicted  with  uterine  disease  is  owing  to 
the  powerful  reflexes  sent  over  the  great  hypogastric  plexus, 
and  the  normal  rhythmical  contractions  of  the  heart  and  its 
blood-vessels  are  broken  by  reflexes  due  to  uterine  disease. 

But  the  woman  alone  is  not  afflicted  with  reflexes  from 
the  genitals,  for  no  doubt  man  thinks  of  his  genitals  a  little 
more  than  woman  does  of  hers.  The  genito-uiinary  sur- 
geon who  deals  with  men  afflicted  with  urethral  disease 
full  well  knows  how  terrible  is  the  effect  of  the  mere  intro- 
duction of  a  sound  into  tlie  bladder  occasionally.  A 
healthy  man  will  frequently  faint  from  simply  the  intro- 
duction of  a  sound,  and  if  the  urethra  or  genitals  are  long 
diseased  he  will  be  profoundly  shocked.  This  means  that 
the  urethra  is  extraordinarily  supplied  with  nerves.  I  do 
not  see,  so  far,  any  better  explanation  of  so-called  urinary 
fever  after  the  introduction  of  a  catheter  than  that  it  is 
"  reflex."  The  urethral  irritation  may  travel  in  two  ways 
and  act  in  two  ways :  1.  It  may  travel  up  the  spinal  cord 
to  the  heat  center  either  by  the  sacral  plexus  through  the 
cord  or  through  the  splanchnics  through  the  cord  and  thus 
disturb  the  heat  center.  But  more  probably  the  urethral 
irritation  is  transmitted  up  the  hypogastric  plexus  to  the 
abdominal  brain  and  there  reorganized  and  sent  out  on  the 
various  plexuses.  But  it  goes  out  on  the  renal  plexus  more 
vigorously  owing  to  the  more  intimate  connection  existing 
between  the  kidney  and  the  genitals — e.  g.,  the  ureter  has 
a  plexus,  the  testicle  has  a  plexus,  and  also  a  part  of  the 
hypogastric  plexus  forms  part  of  the  renal  plexus  ;  and  also 
originally  the  kidney  and  genitals  arose  from  the  same 
body — the  Wolffian.  Now,  the  reflex  irritation  induced  by 
the  catheter  on  the  urethra  then  flashes  up  the  hypogastric 
plexus,  and  the  reorganized  forces  are  sent  to  the  kidney 
and  the  irritation  acts  on  the  kidney  to  change  its  circulation 
— it  is  congested  and  urinary  fever  follows.  The  fainting 
of  patients  on  the  introduction  of  a  catheter  is  explained  on 
the  same  principle.  The  high  nerve  supply  to  the  urethra 
being  disturbed,  the  irritation  is  transmitted  to  the  abdom- 
inal brain,  where  it  is  reorganized.  The  reorganized  forces 
are  then  radiated  out  on  the  various  sympathetic  plexuses, 
but  especially  does  it  travel  over  the  three  great  splanchnics 
up  to  the  three  cervical  sympathetic  ganglia.  The  irritation 
is  reorganized  in  the  three  cervical  ganglia  and  transmitted  by 
their  three  nerves  to  the  heart,  which  it  induces  to  move  in 
a  riotous  manner.  The  heart  is  weakened  and  the  patient 
faints.  The  irritation  of  the  genitals  being  sent  to  the  ab- 
dominal brain,  it  induces  dilatation  of  the  abdominal  vis- 
ceral circulation,  and  this  probably  explains  the  rise  of 


temperature.  Occasionally  the  introduction  of  a  catheter 
kills  a  patient,  but  that  is  due  to  the  final  weakness  of  a 
patient  after  a  long- continued  exhausting  disease.  Thus 
the  nerve  storms  arising  from  the  genitals  are  entirely  dn© 
to  the  abundant  and  extensive  nerve  supply.  The  irregular 
nerve  storms  arising  in  genitals  highly  supplied  by  nerves 
are  profound  in  their  invasion  of  the  whole  system.  They 
pervade  all  active  organs  and  disturb  rhythm  and  induce  fur- 
ther reflexes.  Reflex  action  from  the  sympathetic  explains 
much  disease — e.  g.,  when  a  man  begins  "catheter  life"  he 
begins  to  ring  his  own  death  knell,  because  by  the  use  of 
the  catheter  he  induces  reflexes  which  will  remorselessly 
follow  him  to  death.  Besides,  he  soon  introduces  infection 
into  his  urethra  and  kidneys  by  his  dirty  catheter. 

Thus  the  man  goes  through  three  stages  on  his  road  to 
the  grave  :  1.  He  has  acquired  some  form  of  obstruction 
to  the  outflow  of  urine  from  kidney  to  penis.  2.  He  in- 
troduces the  catheter,  which  calls  up  the  wide  domain  of 
reflexes.  3.  He  introduces  infection,  and  death  followa 
If  the  genitals  were  not  so  highly  supplied  by  nerves,  the 
terrible  reflexes  would  not  arise.  As  an  application  of 
the  extensive  sympathetic  nerves  to  the  genitals  and  its 
wonderful  reflexes,  let  us  examine  for  a  moment  the  result 
of  coition.  The  subject  of  fainting,  vomiting,  and  death 
has  interested  me  for  some  time,  especially  when  I  was- a 
boy  on  a  dairy  farm.  On  the  farm  I  saw  much  breeding  of 
animals,  and  the  incidents  connected  therewith  were  very 
puzzling,  as  I  did  not  see  any  explanation  of  them.  But  I 
feel  convinced  now  that  the  explanation  lies  in  the  sympa- 
thetic nerve  through  its  rhythm  and  reflex.  The  most  im- 
pressive scene  will  be  when  one  observes  the  young  stallion 
cohabit  with  the  mare  for  the  first  time,  for  the  stallion  is 
apt  to  fall  down,  at  the  end  of  a  very  short,  vigorous  coi- 
tion, in  a  dead  faint.  His  eyes  roll  upward,  and  he  looks 
as  if  he  were  dying.  After  a  few  minutes  he  recovers, 
and  slowly  seems  to  become  himself  again.  The  irritation 
due  to  the  first  evacuation  of  the  vesiculae  seminales  is 
rapidly  sent  to  the  abdominal  brain  and  then  reoi^ganized 
and  transmitted  to  the  cervical  ganglia.  Then  it  is  flashed 
to  the  heart  and  induces  irregular,  rapid,  and  hence  weak 
cardiac  action,  which  causes  the  animal  to  faint.  Besides, 
no  doubt,  the  irritation  goes  right  on  from  the  cervical 
ganglia  over  the  carotid  to  the  vascular  area  of  the  brain, 
and  there  induces  anaemia,  and  thus  faintness.  I  know  of 
a  mare  falling  dead  immediately  after  coition,  but  this  was 
probably  due  to  rupture  of  the  left  middle  cerebral  artery. 
It  is  frequent  to  observe  young  bulls  faint  away  at  the  first 
connection  with  a  cow,  and  it  is  very  common  to  observe 
the  young  bull  so  exhausted  that  he  sneaks  olf  to  a  quiet 
corner  or  slyly  lies  down  for  a  couple  of  hours.  I  never 
saw  fainting  with  dogs ;  but  the  dog's  connection  is  pro- 
longed, and  thus  limits  shock;  and  also  a  dog  has  no  se 
mcn^acs,  so  that  probably  diuiinislies  shock.  The  boar  has 
an  intensely  impressive  coition,  which  violently  affects 
his  visceral  organs  in  their  rhythm.  His  respiration  is 
disturbed,  and  the  orgasm  rises  to  such  a  pitch  that  ho 
seems  on  the  verge  of  pain.  Though  it  affects  a  young 
boar  to  have  connection  the  first  time  with  a  sow,  I  never 
saw  one  faint.    But  he  is  frequently  very  weak  and  appar- 


264 


KING:   THE  TREATMENT  OF  FRAGTTTRES. 


[N.  Y.  Mkd.  Jora., 


eatly  exliausted  for  a  couple  of  hours.  All  this  profound 
impression  in  the  coition  of  animals  is  due  to  the  irritation 
being  sent  to  the  abdominal  brain,  where  it  is  reorganized 
and  radiated  out  on  the  plexuses  of  the  various  viscera. 
The  sudden,  short  irritation  deranges  the  normal  rhythm, 
and  hence  the  pathology  of  fainting  and  vomiting.  The 
disturbance  of  rhythm  will  be  the  most  manifest  in  that 
organ  most  sensitive  or  most  essential  to  normal  life.  The 
same  rules  apply  precisely  to  man. 

Men  during  coition  occasionally  faint,  vomit,  defe- 
cate, urinate,  or  die.  The  celebrated  Skobeloff,  general  of 
the  Russian  army,  died  vi^hile  cohabiting  \?ith  an  ill- famed 
girl.  I  know  of  a  noted  judge  who  died  shortly  after  con- 
nection with  a  girl  in  a  brothel.  I  am  acquainted  with  a 
sad  affair  in  a  small  town  in  Ohio  where  a  man  of  seventy 
went  to  a  house  of  ill  fame  and  had  connection  with  a  young 
woman,  and  died  at  the  end  of  the  coition.  In  Chicago,  a 
short  time  ago,  at  one  of  the  principal  hotels,  a  man  of 
probably  forty- eight  was  found  dying  after  cohabiting  with 
an  accommodating  widow.  My  friend  Dr.  Miller  has  re- 
lated to  rae  that  he  was  acquainted  with  a  young  couple  at 
whose  first  coition  the  husband  fainted  away  and  his  bowels 
moved  involuntarily.  The  mother-in-law,  being  called, 
promptly  restored  the  young  son-in-law  to  himself.  A 
medical  man  related  to  me  a  few  months  ago  that  an  ac- 
quaintance of  his,  about  sixty  years  old,  had  connection  with 
a  strange  woman  and  fell  dead  as  he  walked  to  the  door  im- 
mediately after  the  act.  All  such  deaths  that  I  know  or  have 
read  of  have  occurred  in  elderly  men.  The  smaller  manifes- 
tations, such  as  fainting,  vomiting,  urination,  and  defecation, 
have  all  occurred  in  quite  young  men — mainly  at  the  first 
coition.  The  elderly  men  scarcely  ever  die  while  cohabiting 
with  their  wives,  as  they  are  familiar  with  them,  and  the 
excitement  of  the  orgasm  is  not  so  violent  or  intense.  It 
generally  occurs  with  an  old  man  (in  age,  if  not  years)  in  a 
first  coition  with  a  strange  woman.  Death  may  occur  with 
an  old  man  who  has  not  had  connection  with  his  wife  for 
a  long  geriod,  especially  if  the  orgasm  is  intense.  I  do  not 
include  in  such  a  subject  the  rupture  of  some  pelvic  tumor 
due  to  coition.  Stilla,  King  of  the  IIuus,  died  while  co- 
habiting with  his  young  wife.  The  explanation  of  the 
matter  lies  in  the  sympathetic  nerve  and  its  reflexes.  The 
irritation  of  the  penis  due  to  friction,  and  of  the  semen  sacs 
due  to  spasm  and  evacuation,  is  transmitted  to  the  abdomi- 
nal brain  and  there  reorganized.  The  accumulated  irrita- 
tion in  the  abdominal  brain  is  radiated  rapidly  and  on  the 
various  directions  of  least  resistance.  It  rapidly  ascends 
the  splanchnics  and  is  reorganized  in  the  cervical  ganglia 
and  sent  to  the  heart.  The  irritation  sent  so  suddenly  to 
the  heart  at  first  violently  stimulates  it  to  a  vigorous  action, 
so  that  the  blood  pressure  is  raised  to  a  high  tension  in  the 
brain,  especially  in  the  left  cerebral  artery.  Old  men  often 
have  friable  degenerated  arteries,  and  this  sudden  rise  of 
blood  pressure  induces  the  middle  (left)  cerebral  artery  to 
rupture,  and  thus  arises  the  death  from  coition.  The  pri- 
mary cause  is  the  refiexes  arising  from  the  semen  sacs  and 
genitals.  The  orgasm  is  more  intense  in  males,  and  hence 
they  die  more  frequently.  Females  rarely  suffer,  owing  to 
the  orgasm  being  slowly  induced  and  prolonged. 


The  r6le  played  by  the  vaso-motor  centers  should  not  be 
lost  sight  of.  I  have  found,  time  after  time,  that  the  gan- 
glia of  the  lateral  chain  of  the  sympathetic,  situated  at  the 
root  of  the  pudic  (third  sacral),  were  very  large,  and  this 
will  aid  in  transmission  of  irritation. 

Conclusions. — 1.  The  sexual  instinct  is  the  most  domi- 
nant instinct  of  animals. 

2.  Evolutionary  forces  have  linked  the  nervous  system 
and  the  genitals  by  numerous  and  intimate  bands  which  in- 
crease with  the  progress  of  higher  development — i.  e.,  sexual 
instincts  dominate  and  influence  the  monkey,  ape,  and  man 
far  more  than  the  lower  grades  of  animals. 

3.  By  reason  of  the  growing  and  increasing  intimate 
relation  between  the  genitals  and  the  nervous  system,  men- 
tal forces  play  a  greater  rSle  in  the  production  of  disease. 

4.  I  have  observed  that  the  monkey  is  an  inveterate 
raasturbator  in  confinement,  and  his  great  and  persistent 
attention  to  his  genitals  shows  that  the  significance  of 
sexual  instincts  keeps  pace  with  his  mental  progress. 

5.  The  severe  shock  arising  from  vaginal  hysterectomy 
shows  that  the  uterus  has  an  extensive  nervous  connection 
with  the  abdominal  brain.  In  this  operation  one  cuts  off 
the  great  hypogastric  plexus,  and  I  have  seen  an  alarming 
rise  of  temperature  (10.3°),  disturbed  respiration  and  circu- 
lation— all  from  cutting  the  hypogastric  plexus.  The  dis- 
turbance was  not  due  to  infection,  as  almost  all  of  it  arose 
a  few  hours  after  the  operations.  Occasionally  taking  out 
the  appendages  shocks,  but,  as  the  ovarian  plexus  is  small, 
the  shock  is  limited. 

6.  The  genital  and  the  urinary  organs  both  arise  from 
the  same  Wolffian  body,  so  they  are  anatomically  and  physio- 
logically connected,  and  both  have  an  enormous  nerve  supply^ 
so  that  damage  to  one  often  injures  the  other  by  reflex — e.  g., 
vaginal  hysterectomy  I  have  known  to  cause  death  by  induc- 
ing nephritis  a  few  days  succeeding  the  operation.  The  test 
tube  \vas  three  quarters  full  of  albumin  under  the  heat  test. 

7.  The  close  connection  between  genitals  and  nerve 
system  is  clearly  seen  from  the  terrible  nerve  storms  which 
flash  over  the  system  from  irritation  (manual,  instrumental, 
or  pathological)  of  the  genitals — e.  g.,  irritating  the  clitoris 
quickly  disturbs  the  woman's  whole  nerve  balance. 

8.  The  great  nerve  connection  of  genitals  and  centers 
indicates  that  all  irritation  should  be  at  once  removed.  All 
preputial  adhesions  on  the  clitoris  should  be  broken  up,  and 
the  same  with  those  of  the  prepuce.  In  short,  all  patho- 
logical conditions  of  the  genitals  should  be  at  once  righted, 
so  that  the  nerve  balance  may  be  maintained. 


A  FEW  SUGGESTIONS  UPON 
THE  TREATMENT  OF  FRACTURES.* 
By  G.  W.  KING,  M.  D., 

HELENA,  MONTANA. 

Upon  a  former  occasion  I  brought  to  your  notice  the 
subject  of  fractures,  and  in  a  general  way  demonstrated  how 
unattainable  were  perfect  cures  by  our  present  methods  of 
treatment.    It  is  my  purpose  at  this  time  to  discuss  ways 

*  Read  before  the  Montana  State  Medical  Association,  May  29,  1892. 


March  11,  1893.J 


KINO:   THE  TREATMENT  OF  FRACTURES. 


265 


and  means  whereby  we  may  lessen  tlie  probabilities  of  per- 
manent deformity  after  fractures.  That  the  outcome  of 
these  injuries  is  doubtful  is  evidenced  by  the  fact  that  no 
reputable  surgeon  can  conscientiously  promise  a  perfect  cure 
in  any  case.  When  the  orthodox  treatment  fails,  what  are 
we  to  do  ?  Follow  it  implicitly,  instead  of  attempting  to 
devise  other  and  better  means  ?  The  interests  of  our  pa- 
tients demand  progress  in  all  departments  of  surgery.  Me- 
chanical skill  is  therefore  an  essential  qualification  of  the 
practical  surgeon.  Without  it  none  can  hope  to  excel, 
much  less  avoid  many  and  serious  blunders.  The  ability 
to  sec  things  mechanically,  to  detect  ordinary  imperfections, 
to  know  when  they  are  out  of  shape  or  plumb,  is  not  given 
to  every  one  alike,  nor  can  it  be  cultivated  without  persistent 
labor.  Manual  dexterity  becomes  as  necessary  to  the  oper- 
ator as  to  the  musician.  Something  more  than  the  skill  to 
read  music  fluently  must  be  accomplished  by  the  latter;  his 
fingers  are  trained  by  constant  practice  to  touch  each  key 
with  accuracy  at  the  proper  instant,  producing  harmony  in- 
stead of  discord. 

To  know  all  the  steps  of  an  operation  is  one  thing  ;  to 
execute  them  in  a  masterly  manner  is  another.  Special 
training  for  the  work  is  absolutely  demanded  in  either  case. 
There  are  very  few  cases  strictly  surgical  that  do  not  require 
the  services  of  the  hands  as  well  as  of  the  head. 

One  of  the  early  writers,  speaking  of  the  qualifications 
of  the  surgeon,  says  :  "  He  should  have  a  firm,  steady  hand, 
not  liable  to  tremble,  and  be  no  less  dexterous  with  the  left 
than  with  the  right."  When  we  consider  how  vast  has  been 
the  field  of  research  in  medicine  and  surgery,  and  how  rapid 
has  been  the  progress  of  the  latter  in  recent  years,  it  is  ap- 
parent that  to  become  equally  skilled  in  all  departments  is 
beyond  the  scope  of  the  individual.  There  must,  therefore, 
be  in  every  physician's  practice  certain  branches  in  which 
te  becomes  proficient  at  the  expense  of  that  which  remains. 
The  hurry  and  worry  of  general  practice  leave  no  time  for 
special  work — indeed,  so  exacting  does  it  become  that  only 
those  with  extraordinary  physical  endurance  can  long  with- 
stand its  demands. 

Division  of  labor  is  therefore  an  advantage  in  that 
greater  skill  may  be  acquired  by  those  whose  work  is  lim- 
ited to  certain  lines  of  practice.  Naturally,  the  experience 
of  one  who  treats  but  a  single  fracture  in  a  year  is  not  con- 
sidered nearly  as  conclusive  as  that  of  one  whose  cases  are 
numbered  by  the  hundreds,  and  yet  much  may  be  learned 
from  a  single  fracture,  especially  if  it  is  complicated  and 
turns  out  badly. 

The  principles  laid  down  by  writers  centuries  ago  have 
not  been  changed — indeed,  the  indications  are  so  plain  that 
the  most  ignorant  can  not  mistake  them.  To  place  the 
"broken  ends  of  the  bone  in  apposition  and  retain  them,  at 
the  same  time  preserving  the  normal  relation  of  the  limb, 
is  the  sum  and  substance  of  all  treatment.  This  is  what 
the  savage,  with  his  thong  of  buckskin  and  sticks  inter- 
woven, attempts  to  do  and  often  succeeds.  This  is  what 
the  skillful  surgeon,  with  his  splints  and  dressings,  hopes  to 
accomplish,  and  often  fails,  because  he  is  bound  by  prece- 
dent, from  which  he  can  not  deviate  without  endangering 
his  reputation. 


The  reduction  or  the  so-called  setting  of  the  fracture  is 
the  most  important  part  of  the  treatment.  Whatever  dis- 
placement persists  under  the  first  dressing  is  liable  to  be- 
come permanent.  After  effusion  takes  place  and  the  mus- 
cles lose  their  elasticity,  there  is  little  hope  of  correcting 
longitudinal  deformity.  The  golden  moment  has  passed. 
Accurate  knowledge  is  necessary  to  enable  one  to  decide 
when  the  reduction  is  complete,  for  it  is  possible  for  the 
normal  contour  of  the  limb  to  be  preserved  when  the  frag- 
ments of  the  broken  bone  are  far  asunder.  If  such  a  con- 
dition remains  unrecognized  until  the  swelling  disappears, 
it  will  be  too  late  to  apply  the  remedy.  The  skillful  hand- 
ling of  fractures  is  not  so  simple  a  matter  as  many  believe 
it  to  be.  Failure  to  approximate  the  fragments  means 
months  of  suffering  to  the  patient,  a  prolonged  convales- 
cence, and  perhaps  permanent  disability.  Look  at  the  tre- 
mendous task  imposed  upon  Nature  when  a  fracture  re- 
mains unreduced.  The  fibrinous  material,  instead  of  exuding 
between  the  fractured  ends  as  it  would  do  were  they  in  ap- 
position and  kept  quiet,  must  bridge  over  the  intervening 
space  at  a  great  disadvantage.  The  only  wonder  is  that 
union  takes  place  at  all. 

Since  reduction  and  retention  is  the  treatment,  it  should 
be  made  as  absolute  as  possible.  Mobility  of  the  fragments 
is  directly  antagonistic  to  prompt  union.  The  excessive 
exudations  caused  by  it  must  be  subsequently  got  rid  of  by 
the  slow  and  unsatisfactory  process  of  absorption.  Time 
is  an  important  consideration  to  those  who  have  to  depend 
upon  their  daily  labor  for  the  support  of  themselves  and 
families.  It  is  among  this  class  that  such  accidents  most 
frequently  occur.  For  humane  reasons,  then,  as  well  as  for 
his  own  reputation,  the  surgeon  can  not  afford  to  omit  any 
of  the  details  of  treatment  that  are  likely  to  aid  in  bringing 
about  a  speedy  cure.  The  important  question  of  how  we 
shall  put  up  our  fractures  can  not  be  definitely  answered — 
the  royal  road  has  not  been  found. 

Most  of  us  have  been  familiar  since  our  student  days 
with  all  the  plans  recommended  and  in  use.  Yet,  were  we 
called  upon  at  this  moment,  what  form  of  retention  from 
among  the  multitude  would  we  choose  ?  It  might  be  urged 
with  some  reason  that  the  choice  would  be  governed  by 
time  and  place,  the  means  available,  and  so  on.  True,  cir- 
cumstances may  have  weight ;  emergencies  must  be  met 
wherever  they  occur,  whether  our  resources  are  limited  or 
otherwise.  Some  forms  of  dressing  are  difficult  to  manage 
and  require  an  expert  to  succeed  with  them.  Take,  for 
example,  the  common  board  splint.  He  who  attempts  to 
fit  it  to  the  irregularities  of  a  limb  has  my  sympathy,  for  I 
know  he  has  undertaken  an  impossible  thing.  He  may  be 
able  to  make  a  compromise — that  is  all ;  and  that  compro- 
mise may  be  fraught  with  danger,  for  even  a  little  tension 
applied  to  the  wrong  point  will  do  irreparable  injury  to  a 
broken  limb.  For  this  reason,  and  the  constant  readjust- 
ment necessary  to  make  them  of  any  use,  they  can  now  be 
profitably  superseded  by  something  better.  After  having 
tried  most  of  the  materials  recommended  for  splints,  I  have 
come  to  rely  upon  the  plaster-bf- Paris  bandage  as  the  most 
efficient  dressing  for  fractures  yet  introduced. 

Referring  to  personal  experience,  I  have  a  record  of 


266 


KINO:  TEE  TREATMENT  OF  FRACTURES. 


fN.  Y.  Med.  Jock. 


twenty-five  recent  cases  of  fracture  of  lower  extremities, 
comprising  two  intracapsular,  one  through  condyles  of  fe- 
mur, two  through  middle  third  of  femur,  eight  of  tibia 
and  fibula,  four  of  these  being  compound ;  two  of  the  lat- 
ter were  accompanied  by  fractures  of  femur  upon  opposite 
side.  There  were  twelve  cases  of  fractures  of  fibula.  Near- 
ly all  of  these  injuries  were  seen  immediately  after  they 
occurred,  and,  with  one  or  two  exceptions,  the  plaster  band- 
age was  applied  as  a  primary  dressing.  The  result  in  the 
main  was  excellent.  Two  of  the  cases  only  presented  any 
marked  degree  of  disability.  Both  were  what  is  known  as 
"  Pott's  fracture,"  one  being  complicated  with  fracture  of 
internal  malleolus  with  wedging  of  the  astragalus,  render- 
ing complete  reduction  impossible.  The  other  patient  re- 
covered, with  limited  motion  in  the  ankle  joint. 

Now,  as  to  the  technique  of  applying  the  bandage.  At 
our  last  meeting  I  exhibited  sketches  of  an  apparatus  for 
that  purpose.  I  now  take  pleasure  in  presenting  you  with 
the  latest  model  of  the  instrument  itself.  As  stated  at  that 
time,  the  principles  involved  in  its  construction  are  the  ap- 
plication of  extension  and  counter-extension,  with  the  limb 
suspended  and  fully  accessible.  Assistants  are  not  required, 
for  the  instrument  itself  is  more  reliable.  After  the  limb 
is  once  placed  in  position  and  the  tension  applied,  all  that 
remains  to  be  done  is  the  simple  application  of  the  band- 
age. The  traction  is  so  steady  and  gentle  that  no  pain  is 
experienced  during  the  process.  Muscular  action — the  prin- 
cipal obstacle  to  successful  reduction — is  easily  overcome, 
and  we  no  longer  have  to  see  our  patients  writhing  with 
pain  while  the  twisting  and  pulling  formerly  practiced  are 
going  on.  Another  important  consideration  is  that  we  are 
able  to  prevent  displacement  while  bandaging  the  limb. 
After  the  plaster  hardens,  the  instrument  is  easily  removed. 
It  is  usually  preferable  to  lay  the  limb  upon  its  outer  side 
in  the  flexed  position  until  all  tendency  to  muscular  spasm 
has  passed  away.  There  is  then  no  objection  to  extending 
it  horizontally,  if  the  comfort  of  the  patient  requires  it. 

When  the  fracture  is  compound,  and  it  becomes  neces- 
sary to  leave  an  opening  in  the  splint,  I  prefer  to  make  it 
this  way  j{  jf. 

Fractures  of  the  arm  and  forearm  can  be  reduced  by  the 
instrument  with  equal  facility  ;  and  in  emergency  cases, 
where  no  assistance  is  at  hand,  the  surgeon  can  by  its  aid 
apply  his  dressing  in  a  thorough  and  workmanlike  manner 
immediately  upon  his  arrival,  avoiding  the  delay  that  send- 
ing for  extra  help  would  occasion. 

The  plaster  bandage  may  be  used  under  nearly  all  cir- 
cumstances, but  its  value  is  perhaps  better  appreciated  in 
mining  accidents,  where  transportation  must  greatly  aggra- 
vate the  injury.  Here,  by  placing  the  patient  upon  a  litter 
and  applying  the  splint  first,  there  is  no  possibility  of  doing 
further  harm  in  hoisting  to  the  surface. 

In  regard  to  the  convenience  of  the  method,  there  is 
certainly  less  trouble  in  carrying  the  materials  than  that  of 
any  other.  A  small,  air-tight  tin  canister,  capable  of  hold- 
ing a  small  quantity  of  dry  plaster  and  a  few  bandages,  can 
hardly  be  considered  cumbersome.  Enough  for  one  or  two 
dressings  can  always  be  kept  in  readiness,  so  that  when  the 
call  is  urgent  no  time  is  lost  in  hunting  up  old  splints  and 


bandages,  with  the  hope  that  they  may  be  able  to  do  service 
until  something  better  can  be  substituted. 

I  have  but  little  faith  in  temporary  dressings — in  fact, 
do  not  believe  in  them  at  all.  If  the  immediate  reduction 
of  a  fracture  is  good  surgery,  then  permanent  retention  is 
better.  An  additional  half-hour  spent  in  getting  things 
just  right  may  save  the  surgeon  many  sleepless  nights  and 
exempt  him  from  costly  litigation  later  on.  The  only  ex- 
ceptions to  be  made  are  in  those  severer  injuries  where  no 
attempt  can  be  made  to  set  the  broken  bones  at  the  time 
of  the  injury.  Occasionally  we  have  to  deal  with  a  trouble- 
some oblique  fracture,  in  which  perfect  retention  is  next  to 
impossible. 

I  have  lately  been  conducting  a  series  of  experiments 
upon  animals  to  determine  the  advisability  of  nailing  the 
fragments  together.  I  have  succeeded  in  demonstrating 
that  a  clean  steel  nail  is  innocuous,  and  does  not  interfere 
with  prompt  union.  Successful  cases  by  this  method  have 
been  reported.  I  shall  certainly  have  no  hesitancy  in  secur- 
ing coaptation  in  that  way  should  occasion  offer. 

Position  in  the -reduction  of  fractures  ought  not  to  be 
overlooked.  Here  an  intimate  knowledge  of  anatomy  is  de- 
sirable. Take,  for  instance,  a  fracture  through  the  middle  or 
upper  third  of  the  forearm.  To  j^lace  the  hand  in  a  supine 
position  during  the  setting  of  the  fracture,  and  then  to  im- 
mediately twist  it  over  to  the  semiprone  and  retain  it  there, 
appears  to  be  a  wanton  transgression  of  mechanical  princi- 
ples, and  ofteli  results  in  loss  of  function.  Surgeons  have 
from  time  to  time  noted  the  inconsistency,  but  hitherto 
have  failed  to  profit  by  their  own  suggestions.  There  is  no 
difficulty  in  retaining  the  arm  in  the  supine  position  during 
the  treatment  if  the  plaster  bandage  is  applied  and  carried 
well  above  the  elbow,  and  finally  the  arm  swung  well  back 
against  the  side  and  resting  in  a  sling.  After  a  week  or 
ten  days,  that  portion  extending  above  elbow  may,  with 
advantage,  be  removed. 

Here  is  an  illustration  of  a  case  of  comminuted  fracture 
of  the  humerus  that  came  under  my  care  last  summer — one 
fracture  at  the  surgical  neck,  the  other  above  the  condyles. 
The  first  application  of  the  bandage  did  not  include  the 
elbow.  The  arm  was  bound  to  the  side  while  the  plaster 
was  pliable.  This,  with  weight  of  arm,  reduced  the  dis- 
placement completely ;  at  the  end  of  a  week  this  splint  was 
removed,  and  a  new  one  applied  from  the  wrist  upward  to 
the  shoulder,  holding  it  in  rectangular  position.  The  cure 
was  rapid  and  satisfactory,  and,  aside  from  the  application 
of  the  dressings,  required  no  further  care. 

With  increasing  experience  in  the  management  of  frac- 
tures, I  can  confidently  assert  that  with  the  plaster-of-Paris 
bandage  as  a  primary  dressing,  to  be  followed  in  the  con- 
valescent stage  by  the  silicate  of  sodium,  we  can  achieve  the 
best  results.  I  know  also  that  the  ever-varying  conditions 
call  for  the  exercise  of  great  judgment  as  well  as  a  practical 
knowledge  of  the  art  we  practice. 

Thorough  honest  work  is  the  need  of  the  hour.  Into 
our  hands  come  the  unfortunate  victims  of  a  thousand  acci- 
dents, stricken  and  mangled  even  unto  death.  Let  us  see 
to  it  that  neither  negligence  nor  incompetence  on  our  part 
shall  send  them  forth  crippled  and  deformed  when  it  is 


March  11,  1893.  J 


De  SGHWEINITZ:   CULTURE  MEDIA. 


267 


within  the  power  of  human  skill  to  prevent  it.  More  time 
devoted  to  study  and  experiment,  less  to  criticising  and 
slandering  our  brother  physicians,  will  ennoble  the  profes- 
sion and  make  each  member  more  worthy  to  practice  the 
"  divine  art  of  healing,"  and  more  worthy  to  receive  the 
reward  "  Well  done  ! "  when  his  labors  are  ended. 
729  Fifth  Avenue. 


CULTUEE  MEDIA 
FOR  BIOCHEMIC  INVESTIGATIONS. 

By  E.  a.  de  SGHWEINITZ,  Ph.D., 

BIOCHEMIC  LABORATORT,  BUREAU  OF  ANIMAL  INDUSTRY, 
DEPARTMENT  OP  AGRICULTURE,  WASHINGTON,  D.  C. 

While  endeavoring  recently  to  isolate  the  soluble  fer- 
ments of  the  hog-cholera  germ,*  I  have  had  occasion  to 
make  use  of  an  artificial  culture  medium  recommended  by 
Fermi  for  the  study  of  the  ferment-producing  germs  in 
general  {Archiv  fur  Hygiene,  1890,  vol.  x.  Part  I,  p.  1), 
containing  to  every  1,000  c.  c.  of  distilled  water  0-2  gramme 
magnesium  sulphate,  1  gramme  acid  potassium  phosphate, 
10  grammes  ammonium  phosphate,  and  45  grammes  glycer- 
in. In  this  solution  the  hog-cholera  germ  grows  well  and 
characteristically. 

The  idea  was  suggested  by  my  assistant,  Mr.  Emery, 
that  this  liquid  might  be  conveniently  substituted  for  beef 
broth  in  the  preparation  of  agar  or  solid  nutrient  media. 
We  accordingly  had  some  made,  by  adding  to  the  above 
solution  one  per  cent,  of  agar,  heating  and  filtering  in  the 
usual  way.  In  this  manner  a  clear,  almost  colorless  trans- 
parent medium  was  obtained,  upon  which  the  hog-cholera 
and  swine-plague  germs  grow  characteristically.  It  would 
probably  be  equally  well  adapted  for  many  other  germs. 

As  the  convenience  of  substituting  this  solution  of  salts 
for  beef  broth  was  at  once  apparent,  I  have  tried  its  adapta- 
bility for  the  cultivation  of  the  bacillus  of  tuberculosis  and 
bacillus  of  glanders,  and  have  had  in  use  in  my  laboratory 
for  some  time  media  prepared  as  follows : 

For  tuberculosis,  the  above-mentioned  solution  of  salts 
containing  seven  per  cent,  of  glycerin  and  one  per  cent,  of 
peptone,  and  for  solid  media  this  latter  liquid  without  pep- 
tone plus  one  per  cent.  agar.  Upon  these  media  the  growth 
of  the  germ  is  both  rapid  and  characteristic — more  rapid 
than  upon  an  agar  prepared  from  beef  broth. 

For  the  cultivation  of  the  glanders  bacillus,  the  medium 
was  prepared  exactly  in  the  same  way  as  that  for  tuberculo- 
sis, except  that  only  five  per  cent,  glycerin  was  used  instead 
of  seven,  the  solution  was  allowed  to  remain  slightly  acid 
instead  of  being  neutralized,  and  no  peptone  was  added. 
The  glanders  bacillus  multiplies  both  satisfactorily  and 
rapidly. 

The  solution  of  salts  used  for  these  media  when  first 
prepared  is  alkaline  in  reaction ;  by  simply  boiling,  liosv- 
ever,  it  can  be  rendered  either  neutral  or  acid,  as  in  boiling 
some  ammonia  will  be  given  otf. 

This  method  of  preparing  culture  media,  especially  for 
biochemic  work,  where  the  products  of  the  growth  of  tli(> 


*  Philadelphia  Medical  News,  October  1,  1892. 


germ  are  the  main  points  to  be  considered,  has  several  ad- 
vantages over  the  use  of  beef  broth.  It  is  always  an  easy 
matter  to  obtain  the  chemically  pure  salts,  and,  as  the 
amount  and  character  of  the  salts  entering  into  the  solution 
are  known,  it  is  less  difficult  to  obtain  and  study  the  prod- 
ucts which  are  actually  the  result  of  the  growth  of  the 
germ.  If  the  expense  is  to  be  considered,  the  medium  pre- 
pared in  this  way  is  very  much  cheaper. 

I  think  this  particular  medium,  and  media  of  this  class, 
will  prove  especially  valuable  in  the  study  of  bacterial  prod- 
ucts. 

I  hope  to  be  able  to  report  shortly  upon  the  value  and 
composition  of  a  mallein  and  tuberculin  derived  from  these 
artificial  liquids. 


A  PLEA  FOR  CLEANLINESS  IN  TIIE 
TREATMENT  OF  NASO-PHARYNGEAL  CATARRH. 
By  EDWARD  J.  BERMINGHAM,  A.M.,  M.  D., 

BURGEON  TO  THE  NEW  TORK  THROAT  AND  NOSE  INPIRMARY. 

What  would  be  thought  of  a  surgeon  who  would  treat 
a  wound  or  ulcer  by  dusting  it  with  a  powder  of  aristol  or 
iodoform  two  or  three  times  weekly  without  having  pre- 
viously cleansed  it  of  the  products  of  putrefaction  ? 

What  would  be  thought  of  the  gynaecologist  who  would 
medicate  the  uterine  cavity  or  cervix  without  liaving  pre- 
viously assured  himself  that  the  mucous  membrane  was  free 
of  tenacious  muco-pus  ? 

This  question  might  be  propounded  to  the  specialist  in 
each  and  every  department  of  medicine,  and  would  in  every 
instance  receive  the  same  reply,  which  would  be  in  effect 
that  any  such  practice  could  only  be  pursued  at  the  present 
day  by  a  practitioner  utterly  ignorant  of  the  first  principles 
of  antisepsis,  and  that  it  was  inexcusable  and  stamped  its 
advocate  as  totally  unfit  to  pursue  the  practice  of  medicine. 

In  all  departments  of  medicine  the  importance  of  anti- 
sepsis, which  is  but  another  name  for  cleanliness,  is  recog- 
nized. The  administration  of  hot  water  before  each  meal, 
or  the  more  thorough  washing  out  of  the  stomach  by  the 
siphon  ;  the  systematic  washing  out  of  the  urinary  bladder 
in  cystitis  ;  or  the  more  elaborate  and  perfected  antiseptic 
dressing  of  wounds — are  one  and  all  methods  of  cleansing, 
or  rather  of  cleansing  and  then  keeping  clean  by  the  exclu- 
sion of  germs. 

If  this  is  a  well-recognized  principle  in  snrgerv,  should 
it  not  also  be  applied  in  the  treatment  of  all  dise;ised  con- 
ditions of  the  nose  and  naso-pluirynx  ?  Is  it  not  of  the  ut- 
most importance  that  tlie  mucous  membrane  lining  these 
cavities  should  be  thoroughly  cleansed  of  all  tlio  miico-pus 
and  inspissated  mucus  which  is  constantly  accumulating  in 
an  existent  pathological  condition  ?  Astringent,  alterative, 
or  stimulating  applications  made  by  an  atomizer  or  insuf- 
fiator  without  having  previously  cleansed  ihe  membrane  of 
the  secretions,  are  applied  to  tlie  secretion  (iinl  not  to  the  dis- 
eased membrane.  As  a  result  we  find  no  benefit  even  from 
a  prolonged  course  of  treatment,  and  hence  the  oft-ex- 
pressed belief,  even  among  prt)fessional  men,  that  catarrh 
can  not  be  cured.  In  this  connection  it  is  well  to  say  that 
catarrh  is  not  referred  to  as  a  disease,  but  as  a  conunoa 


268 


POMEROY:   OPERATIONS  FOR  DIVERGENT  STRABISMUS.  [N.  Y.  Med.  Jock,, 


symptom  of  many  varied  pathological  conditions.  When 
stenosis  in  any  marked  degree  is  found  it  is  absolutely  ne- 
cessary that  it  be  first  remedied.  In  other  words,  the  nasal 
passages  must  be  restored  to  a  condition  that  will  permit 
their  respiratory  function  to  l)e  freely  performed.  Having 
done  this,  we  are  confronted  with  a  condition  of  the  mucous 
membrane  which  calls  for  a  more  or  less  prolonged  course 
of  treatment.  Tliis  treatment  will  vary,  of  course,  accord- 
ing to  the  condition  of  the  membrane  and  to  the  views  of 
the  surgeon.  But,  in  order  to  insure  a  successful  result,  the 
cavities  should  be  thoroughly  cleansed  once  or  twice  daily 
with  a  non-irritating  solution.  The  surgeon,  before  medi- 
cating the  parts,  should  satisfy  himself,  by  a  careful  exami- 
nation of  both  the  anterior  and  posterior  nares,  that  his  ap- 
plication will  come  in  contact  with  the  mucous  membrane 
lining  the  cavities,  and  not  with  the  secretion  covering  the 
membrane.  This  matter  is  of  so  great  importance  that  it 
should  be  regarded  as  of  more  consequence  than  the  topical 
applications  made  by  the  surgeon.  My  experience  has 
shown  that  the  proper  and  systematic  use  by  the  patient  of 
an  antiseptic  cleansing  fluid  will  do  more  to  restore  the  mem- 
brane to  its  normal  condition  than  the  frequent  application 
of  medicated  solutions  and  powders  usually  made  by  the 
specialist.  Properly  used,  tifty  per  cent,  of  cases  of  simple 
hypertrophic  catarrh  without  stenosis  will  be  cured  by  this 
means  alone,  and  atrophic  cases  will  be  much  benefited.  If 
cleansing  be  not  resorted  to  at  all,  or  if  it  be  improperly 
done,  the  accessory  treatment  deludes  both  physician  and 
patient,  and  fails  in  almost  every  instance. 

What  cleansing  solution  should  be  used  ?  One  that  is 
alkaline,  non-irritating,  antiseptic,  and  deodorizing.  The 
indications  are  met  in  the  employment  of  either  Dobell's  so- 
lution. Seller's  tablets,  listerine,  or  glyco-thymoline.  To  the 
last  mentioned  preference  should  be  given,  as  it  meets  the 
indications  more  fully  than  any  other  agent  now  before  the 
profession.  Diluted  with  three  times  the  quantity  of  water 
so  as  to  make  a  twenty-five-per-cent.  solution,  it  should  be 
used  by  the  patient  from  one  to  three  times  daily,  as  may 
be  advised  by  the  physician,  the  latter  bearing  in  mind  that 
it  should  be  employed  only  sufficiently  often  to  keep  the 
cavities  cleansed.  At  every  visit  the  physician  should  sat- 
isfy himself  that  the  patient  is  following  his  advice  care- 
fully and  intelligently,  and  before  making  a  topical  applica- 
tion he  should  make  a  careful  rhinoscopic  examination  to 
assure  himself  that  the  cavities  are  free  from  all  secretion. 
If  they  are  not,  he  should  first  wash  away  the  secretion  with 
a  post-nasal  spray  of  glyco-thymoline. 

The  method  of  applying  the  cleansing  solution  is  of  the 
greatest  importance.  The  old  Thudicum  douche  is  to  be 
unqualifiedly  condemned,  as  is  any  form  of  douche  or  spray 
where  a  large  quantity  of  liquid  is  introduced  with  any  force 
into  the  nasal  cavities.  Sniffing  the  fluid  into  the  nostrils 
from  the  palm  of  the  hand  is  also  fraught  with  danger. 
Every  practitioner  of  experience  in  diseases  of  the  ear  has 
frecjuently  seen  cases  where  serious  trouble  was  produced 
in  the  middle  ear  by  drawing  the  fluid  and  muco-pus  into 
the  Eustachian  tube.  Syringes  of  all  kinds — and,  in  fact, 
any  apparatus  where  the  force  of  the  stream  is  under  the 
control  of  the  patient — should  be  avoided.    Whitall,  Tatum, 


&  Co.'s  nasal  douche  tube,  although  ])ermitting  the  employ- 
ment of  but  a  small  quantity  of  fluid,  is  yet  a  safe  instru- 
ment. Dr.  Dessar's  douche  cup  meets  the  indications  well, 
but  preference  should  be  given  to  a  douche  which  lias  been 
made  by  Mr.  Oscar  Kress  at  the  suggestion  of  the  writer, 
and  wliicli  is  here  figured. 


It  is  to  be  used  in  the  following  manner :  Having 
warmed  the  cleansing  solution  by  placing  an  ounce  phial  con- 
taining it  standing  in  a  tumblerful  of  hot  water  for  a  few 
minutes,  fill  the  douche,  which  has  a  capacity  of  about  seven 
drachms,  generally  enough  for  a  thorough  cleansing.  The 
funnel  should  now  be  closed  with  the  tip  of  the  index  finger 
and  the  nozzle  inserted  into  the  nostril  so  that  it  closes  the 
latter  completely.  Throw  the  head  slightly  backward,  raise 
the  finger  closing  the  funnel,  and  allow  the  solution  to  enter 
the  nostril  and  flow  through  it  to  the  throat.  When  the 
solution  is  felt  in  the  throat  the  flow  may  be  checked  by 
simply  closing  the  fuimel  with  the  finger  tip.  The  solution 
should  be  kept  in  contact  with  the  parts  for  two  minutes  be- 
fore clearing  nose  and  throat,  and  it  should  be  used  in  each 
nostril. 

The  method  of  cleansing  herein  advocated  is  rigorously 
pursued,  not  only  in  my  private  practice,  but  also  in  the 
several  clinics  at  the  New  York  Throat  and  Nose  Infirmary, 
and  with  the  most  satisfactory  results.  In  fact,  this  is  re- 
garded as  the  most  essential  part  of  the  treatment,  and  it  is 
carried  out  as  of  the  first  importance. 

7  West  Forty-fifth  Street. 


ON  OPERATIONS  FOR 
DIVERGENT  STRABISMUS, 

ILLUbTBATED  BY  TWENTY-FIVE  CASES* 
By  OKEN  I).  POMEPwOY,  M.  D. 

Case  I. — Dr.  Z.,  aged  tliirty-two,  liad  a  decided  converging 
strabismus,  the  right  being  the  fixing  eye. 

The  vision  was  xx+  in  the  right  and  ^c''  in  the  left.  There 
was  slight  hypermetropia.  Some  years  since,  the  left  internus 
was  divided  by  an  ophthalmic  surgeon  and  resulted  in  an  absolute 
loss  of  power  in  tlie  muscle,  and  the  eye  deviated  four  lines  to 
the  left.  I  advanced  the  internus  of  the  left  hy  tlie  old  method, 
although  very  little  tendon  could  be  found,  together  with  the 
conjunctiva.  The  externus  was  freely  divided  with  extensive 
conjunctival  dissection.  The  right  externus  was  also  divided, 
and  the  position  of  the  left  was  at  about  two  lines  of  conver- 
gence.   Tiie  operation  was  done  under  cocaine. 

There  was  very  little  reaction,  and  the  status  prwsena  is  one 

*  Read  before  the  Medical  Society  of  the  State  of  New  York  at  its 
eighty-seventh  annual  meeting. 


March  11,  1893.J 


POMEROY:  OPERATIONS  FOR  DIVERGENT  STRABISMUS. 


269 


of  nearly  central  position  of  the  left  eye,  but  without  mobility, 
except  in  a  vertical  direction.  The  divergence  is  perhaps  one 
line. 

It  will  be  seen  that  the  operation  on  the  left  externus  pro- 
dnccd  a  complete  loss  of  power,  which  seemed  the  only  way  of 
restoring  the  normal  position  of  the  eye. 

Case  II. — Miss  R.,  aged  twenty-four,  has  a  divergent  strabis- 
mus of  about  two  lines.  She  fixes  with  either  eye,  but  more 
frequently  with  the  right.  Tije  vis<ion  is  xl  in  each  eye;  no 
improvement  with  glasses  and  she  seems  to  be  emmetropic. 
There  is  no  binocular  vision.  Tiie  left  internus  was  advanced 
by  the  modified  Prince  operation,  and  the  right  externus  was 
freely  divided.  Fifteen  days  afterward  there  was  binocular  sin- 
gle vision,  although  there  was  exoiihoria  of  8°  to  10°  at  distance. 
The  left  converges  the  better  of  the  two. 

Points  of  interest:  Restoration  of  binocular  single  vision, 
when  binocular  vision  was  absent  before  the  operation,  and  a 
state  of  emmetropia.  With  the  vision  so  nearly  perfect  in  each 
eye,  the  restoration  of  binocular  single  vision  was  to  be  hoped 
for. 

Case  III. — Alice  T.,  aged  twenty-five,  has  divergent  strabis- 
mus, with  vision  in  the  left  xx  and  right  <x;;  emmetropic;  fixes 
with  the  left,  and  the  right  diverges  three  lines.  The  right  in- 
ternus was  advanced  and  some  convergence  resulted  for  a  few 
weeks.  Four  months  subsequently  there  was  a  line  and  a  half 
of  divergence  and  the  externus  of  the  right  was  divided,  which 
resulted  in  correct  position.  No  binocular  vision.  This  case 
shows  that  it  would  have  been  better  to  follow  the  rule  and 
divide  the  externus  of  the  deviating  eye. 

Case  IV. — David  E.  E.,  aged  twenty-one,  has  a  divergent 
strabismus  of  about  two  lines  and  a  half.    The  right  eye  ac- 
cepts a  -h'40  D.  axis  90°  and  has  xx—  vision.    The  left  eye  is 
not  improved  by  correction,  and  has  less  than  \p  vision.  No 
binocular  vision.  lie  has  had  headaches,  nausea,  and  vertigo,  and 
some  conjunctivitis.    The  wearing  of  the  cylindrical  correction 
over  the  right  eye  seems  to  relieve  his  symptoms ;  naturally  he 
■fixes  with  the  right  eye.    There  is  no  apparent  weakness  of  the 
internus  of  the  fixing  eye.   He  has  been  wearing  a  spherico-cylin- 
drical  glass  for  reading,  but  found  it  fatiguing.    Three  nionths 
after  these  observations  the  externus  of  the  left  was  divided  at 
itsinsertion  with  free  conjunctival  dissection,  without  quite  cor- 
recting the  strabismus ;  a  suture  was  applied  deeply  in  the  con- 
junctiva near  the  inner  margin  of  the  cornea  and  attached  to 
the  inner  canthus,  tightened  sufficiently  to  cause  two  or  more 
lines  of  convergence.    This  remained  in  for  two  days,  when  it 
cut  itself  out  from  the  conjunctival  side.    After  the  tenotomy 
there  was  homonymous  diplopia  for  a  few  days,  with  a  con- 
vergence of  from  2°  to  3°.    In  spite  of  this,  the  eye  seems  to 
turn  outward  slightly.    After  about  ten  days  the  eye  was  ap- 
parently in  correct  position.     When  looking  sharply  to  the 
left  he  still  sees  double.    There  was  no  restoration  of  binocular 
single  vision.    I  did  not  attach  the  suture  to  the  fellow  eye 
across  the  nose,  because  it  seemed  to  me  that  only  the  internus 
of  the  left  was  weakened.    He  thinks  the  strabismus  com- 
menced some  years  since  after  an  inflammation  of  the  eye  fol- 
lowing vaccination,  but  no  lesion  was  visible  by  ophthalmoscoiiic 
inspection. 

Case  V. — Mary  R.,  aged  twenty-one,  has  a  divergence  of 
three  lines.  The  right  usually  fixes;  vision — right  eye,  xxi  no 
correction;  left,  '^^  with  —6-50  D.  With  this  eye  there  seems 
to  be  astigmatism  by  .laval's  test.  The  patient  was  etherized 
and  both  externi  freely  divided.  A  suture  attached  in  the  con- 
junctiva near  the  inner  margin  of  each  cornea  and  tied  across 
tlio  nose  caused  a  convergence  of  nearly  three  lines.  Two  days 
afterward  there  was  some  oedema  of  the  lids.  After  six  days 
the  eyes  were  in  correct  position,  except  that  llie  left  eye  in- 


clined to  turn  out  and  the  right  eye  slightly  to  converge* 
Would  it  have  been  better  to  have  placed  the  stitch  only  in  the 
left,  fastening  it  to  the  inner  canthus,  or  to  have  placed  a  stitch 
in  each  eye,  but  tightening  the  left  more  than  the  right? 

Case  VI. — Kate  S.,  aged  nineteen,  has  divergence  of  the 
right  eye  of  two  lines  and  a  half,  dating  back  to  an  injury  five 
years  since,  when  a  cataract  was  produced.  Subsequent  nee- 
dling removed  the  lens,  and  the>ision  became  eg.  The  field  is 
concentrically  limited  to  an  area  of  10°.  The  left  eye  has  vis- 
ion XX +  ;  and  a  hypermetropia  of  about  -j-  1  D.  No  binocular 
vision.  Both  externi  were  freely  divided  and  the  eyes  made 
to  converge  two  lines  and  a  half  by  means  of  a  suture  tied 
across  the  nose.  In  one  week  the  eyes  were  in  correct  posi- 
tion, although  the  right  internus  seemed  somewhat  insufficient. 
Would  it  have  been  better  to  have  guyed  each  eye  separately 
to  the  inner  canthus,  applying  more  convergence  to  the  more 
squinting  eye  ? 

Case  VII. — Solomon  P.,  aged  seventeen,  has  divergent  stra- 
bismus. The  right  eye  fixes  and  the  left  deviates  about  three 
lines. 

Both  externi  were  freely  divided,  and  the  right  was  made  to 
converge  about  two  lines  by  means  of  a  suture  attached  to  the 
inner  canthus. 

After  five  days  the  eyes  were  in  correct  position.  Subject 
myopic.  I  am  uncertain  as  to  the  indications  for  attaching  the 
correcting  suture  to  both  eyes  and  tying  them  across  the  nose. 
I  think  I  was  impressed  with  the  idea  that  the  right  internus 
was  much  the  weaker  of  the  two;  no  binocular  vision. 

Case  VIII. — Mary  M.,  aged  twenty,  has  a  divergence  of  the 
right  eye  of  from  three  to  four  lines.  She  counts  fingers  with 
this  eye  at  two  feet,  and  with  the  left  has  xx  vision.  No  cor- 
rection in  either  eye.  The  right  externus  was  divided  and  the 
internus  was  advanced  by  tiie  modified  Prince  method,  leaving 
the  eye  convergent  about  two  lines.  There  was  some  swelling 
of  the  lid,  and  iced  cloths  were  used  for  two  days.  The  eye 
was  slightly  convergent  for  ten  days,  when  the  position  became 
correct. 

Case  IX. — William  T.,  aged  forty-nine,  has  had  divergence 
of  the  left  eye  for  thirty-one  years,  dependent,  ajiparently,  on  a 
vascular  tumor  in  the  superior  maxillary  region,  which  also 
caused  an  entropion  of  the  lower  lid.  The  divergence  was  from 
three  to  four  lines.  After  various  methods  of  treatment,  in- 
cluding ligation  of  the  internal  carotid  artery,  the  tumor  disap- 
peared. The  vision  of  the  left  eye  was  -co,  with  an  atrophic- 
looking  nerve,  but  a  perfect  field.  The  eye  protrudes  some- 
what. The  vision  of  the  right  is  xxx-  Both  are  emmetropic. 
The  left  externus  was  divided  and  the  right  was  advanced  by 
the  modified  Prince  method,  leaving  it  convergent  about  two 
lines.  The  eye  was  convergent  for  six  days.  On  the  seventh 
day  the  stitch  was  removed  and  the  eye  became  straight.  A 
subsequent  operation  was  successfully  done  for  the  entropion. 

Case  X. — Ella  O.  B.,  aged  twenty-seven,  has  myopia  and  a 
divergence  of  the  right  eye  of  four  lines.  Under  cocaine  an- 
resthesia  the  right  internus  was  advanced  by  the  modified 
Prince  method,  and  the  eye  was  left  convergent  about  two 
lines. 

Tills  convergence  partly  remained  after  a  week.  No  fur- 
ther record. 

Case  XI. — Lizzie  E.,  aged  seventeen,  has  a  divergence  of 
the  right  eye  of  three  lines  for  the  past  seven  years.  The  vis- 
ion of  the  right  eye  is  *<?  with  —14  I).,  and  the  lelt  S"!  —  with 
—  8  D.  The  right  internus  was  advanced  without  further 
operations.  In  a  few  days  the  correcting  glasses  were  worn 
and  the  position  of  the  eyes  was  satisfactory,  although  if  the 
glasses  were  removed  tliere  was  divergence.  It  might  have 
been  better  to  have  divided  the  right  externus.    I  think  this  is 


270 


POMEROY:   OPERATIONS  FOR  DIVERGENT  STRABISMUS.  [N.  Y.  Med.  Jodr., 


the  only  case  where  myojric  correction  lias  sensibly  influenced 
the  position  of  the  eyes. 

Oase  XII. — Mr.  H.  O.,  aged  twenty-five,  has  divergence  of 
the  right  eye  of  three  lines  and  a  half.  Refraction  of  the  right 
is — 8  D  ,  and  tlie  left  is  emmetropic  or  has  slight  hy|)ernie- 
tropic  astigmatism.  The  vision  of  the  right  is  ^fj*,  and  the  left 
x'xx— •    No  binocular  vision  before  or  after  the  operation. 

Both  externi  were  divided,  and  the  right  internus  was  ad- 
vanced by  the  modified  Prince  method.  At  first  there  was  an 
over-effect,  but  after  a  week  this  disappeared. 

Case  XIII. — Mr.  H.  O.,  aged  twenty-five,  has  a  divergence 
of  the  right  eye  of  three  lines  and  a  half;  both  eyes  myo{)ic. 

The  externi  were  divided,  and  tlie  right  internus  was  ad- 
vanced by  the  modified  Prince  method,  leaving  the  eye  some- 
what convergent. 

In  one  week  the  position  was  correct,  although  there  was 
some  apparent  insuflnciency  of  the  right  internus. 

Case  XIV. — Mary  M.,  aged  twenty,  has  a  divergence  of  the 
right  eye  of  three  lines.  The  right  counts  fingers  at  one  foot, 
and  the  left  has  a  vision  of  ^x-  A  modified  Prince  advance- 
ment of  the  right  internus  was  done,  and  the  externus  was  di- 
vided, leaving  the  eye  somewhat  convergent.  In  a  week  the 
position  was  correct. 

Case  XV. — George  F.,  aged  fifteen,  had  divergence  of  the 
left  eye.  The  internus  was  advanced  by  the  modified  Prince 
operation,  and  the  externus  was  divided. 

Parallelism  was  the  result  for  a  few  days,  hut  after  three 
weeks  there  was  decided  divergence.  Evidently  the  right  ex- 
ternus should  have  been  divided. 

No  further  note. 

Case  XVI. — Lizzie  N.,  aged  fifteen,  has  divergence  of  the 
right  eye.  The  vision  of  the  right  was  M  with  -(-  2  D.  C  4- 
•75  C,  axis  75° ;  and  the  left  was  H  with  -f  -75  D.,  axis  90°. 
The  right  internus  was  advanced  by  the  modified  Prince  opera- 
tion, and  the  externus  was  divided. 

A  sufficient  eft'ect  only  was  at  first  obtained,  but  it  remained 
permanent.  It  was  done  under  ether,  and  the  eft'ect  could  not 
as  well  be  estimated  as  though  cocaine  had  been  used. 

Case  XVII. — James  R.,  aged  twenty-eight,  has  a  divergence 
of  the  right  eye  of  not  less  than  four  lines,  the  result  of  a  tenot- 
omy of  the  internus.  The  externus  was  divided,  and  the  inter- 
nus was  advanced  after  the  old  method,  as  it  was  feared  that, 
on  account  of  some  atrophy  of  the  conjunctiva,  there  would 
have  been  an  insufficient  amount  to  properly  sustain  the  pulley 
suture.  The  operation  was  done  under  ether.  The  eye  con- 
verged about  two  lines  for  three  or  four  days,  when  it  became 
parallel.  Directly  after  the  operation  the  cornea  was  nearly 
covered  by  the  ocular  conjunctiva,  the  result  of  the  dragging 
of  the  sutures.  The  patient  made  a  good  recovery,  but  with 
the  somewhat  prolonged  lumpy  elevntion  at  the  site  of  the  ad- 
vancement. There  is  almost  normal  motility  of  the  eyeball, 
with  some  insufficiency  of  the  internus.  Contrast  this  case  with 
Case  I,  which  presented  identical  conditions  apparently,  but 
where  there  was  an  absence  of  horizontal  motility  of  the  eyeball. 

Case  XVIII. — William  A.  W.  has  divergent  squint  of  three 
lines.  Right  eye  emmetropic;  left,  myopic  —  1-25  D.  Ad- 
vanced the  left  internus  by  the  modified  Prince  operation,  and 
divided  the  externus.  As  a  result  there  was  three  lines  of  con- 
vergence, which  ultimately  disappeared. 

Case  XIX. — William  T.,  aged  forty-nine,  has  divergent  squint 
in  left  eye  of  three  lines.  Vision,  -(^^;,  and  in  the  right  \ 
both  emmetropic.  Left  lundus  looks  atrophic,  but  the  field  is 
perfect. 

The  left  externus  was  divided,  and  the  internus  was  ad- 
vanced by  the  modified  Prince  o|)erati()n.  The  eye  was  left 
-slightly  (convergent. 


No  further  note. 

Case  XX. — George  F.,  aged  fifteen,  has  divergence  of  left 
eye,  I  conclude,  of  no  great  degree,  as  it  was  corrected  by  di- 
vision of  the  left  externus,  the  eye  at  first  being  slightly  conver- 
gent.   No  suture. 

Case  XXI. — Alice  F.,  aged  twenty-five,  has  two  lines  of  di- 
vergence of  the  right  eye.  Both  eyes  emmetropic.  Vision  of 
the  right  eye  is  -^q,  and  of  the  left  Jv- 

The  tendon  of  the  right  externus  was  divided,  and  on  the 
next  day  there  was  parallelism.  No  suture  used.  This  seems 
somewhat  unusual. 

Case  XXfl. — One  case,  the  notes  of  which  I  have  lost,  hav- 
ing a  three-line  strabismus,  was  operated  on  by  the  old  method, 
and  the  convergence  of  two  lines  after  the  operation  continued 
for  a  year  afterward.  Since  that  time  it  has  grown  so  much 
less  as  not  to  be  a  disfigurement.  This  is  tlie  only  case  of 
permanent  convergence  I  have  seen  as  a  result  of  operation. 
Some  of  the  cases  herein  reported  have  been  noticed  after  a 
year  or  two  to  show  .slight  divergence,  following  the  well- 
known  tendency  to  revert  to  the  original  condition. 

Case  XXI II. — Another  case,  in  which  advancement  was 
done  by  the  old  method,  resulted  in  considerable  reaction  and 
the  cornea  became  involved.  For  a  time  tlie  symptoms  were 
serious;  the  eye,  however,  recovered  with  a  small  iieripheral 
opacity  of  the  cornea,  but  without  harm  to  the  vision.  At  the 
time,  another  case  at  the  hospital  behaved  in  a  similar  manner, 
and  the  late  Dr.  Agnew  suggested  that  there  might  be  some 
septic  influence  at  work  in  the  lios()ital. 

Mode  of  Operating. — The  earlier  cases  were  operated 
on  by  the  old  method — that  is,  the  muscle,  including  the 
overlying  conjunctiva,  was  advanced  and  attached  to  the 
eyeball  by  two  sutures,  passed  into  the  conjunctiva,  reach- 
ing respectively  to  the  center  of  the  cornea  above  and  be- 
low. The  end  of  the  tendon  was  cut  off  so  as  not  to  en- 
croach on  the  cornea.  The  objections  to  this  operation 
were  the  somewhat  excessive  traumatism  inflicted  on  the 
eye,  the  danger  of  producing  a  twist  to  the  eyeball  by  un- 
equal tightening  of  the  sutures,  and  a  lumpy  elevation  on  the 
eyeball,  the  result  of  the  advanced  conjunctiva  and  muscle. 

Latterly  I  have  used  what  has  been  here  denominated  the 
modified  Prince  operation.  The  pulley  used  by  Prince  and 
his  method  of  applying  the  sutures  have  been  retained  and 
nothing  more.  For  some  years  I  have  discarded  any  spe- 
cial method  for  catching  the  tendon,  finding  it  amply  suffi- 
cient to  go  in  with  fixation  forceps  and  grasp  the  tendon. 
If  two  forceps  are  used,  tlie  tendon  may  be  more  accurately 
caught.  At  an  earlier  date,  fearing  that  the  tendon  might 
not  easily  be  found,  I  was  in  the  habit  of  attaching  the  fixa- 
tion forceps  to  it  before  division  ;  but  this  is  not  necessary. 
In  one  case  the  pulley  was  torn  out  of  the  conjunctiva  and 
the  old  operation  was  substituted,  but  I  suspect  tlie  fault 
was  in  not  passing  the  suture  so  as  to  include  a  sufficient 
amount  of  conjunctiva.  If  the  suture  somewhat  encroaches 
on  the  sclera  it  does  no  harm.  In  my  later  operations  I 
am  inclined  to  the  practice  of  not  advancing  the  muscle  at 
all,  but  dividing  one  or  both  of  the  externi  and  using  a 
suture  to  draw  the  eye  inward. 

In  one  of  the  cases  here  reported,  where  the  suture  was 
attached  to  both  eyes  and  tied  across  the  nose,  the  effect 
was  greater  on  the  less  squinting  eye,  which  seemed  to  me 
an  objection  to  the  operation. 


March  11,  1893.J 


BOOTH:  FOUR  CASES  TREATED  BY  HYPNOTISM. 


271 


It  would  jjerhaps  have  been  better  to  attach  each  eye 
separately  to  the  inner  canthus,  and  converge  the  non-fix- 
ing eye  more  than  its  fellow.  I  lay  great  stress  on  produc- 
ing considerable  convergence  by  the  sutures  ;  in  some  cases 
as  much  as  three  lines  or  more,  for  the  most  thorough  di- 
vision of  the  externi  alone  may  have  little  influence  on  the 
position  of  the  eyes. 

I  never  have  removed  a  piece  of  the  tendon  in  this  op- 
eration, or  divided  it  any  distance  from  its  insertion,  not 
having  found  it  necessary.  The  operations  have  latterly 
been  done  with  antiseptic  precautions,  although  before  tlie 
day  of  antiseptics  little  reaction  usually  resulted.  In  a  few 
instances  iced  cloths  and  atropine  have  been  necessary. 

Recapitulation  and  Remarks. — Only  two  cases  were  op- 
erated on  where  the  squint  depended  on  faulty  operation 
for  convergence.  In  Case  I  both  externi  were  divided  and 
one  internus  was  advanced  by  the  old  method,  the  result 
being  nearly  correct  position,  but  with  absolute  lateral  im- 
mobility. In  Case  XVII  advancement  was  done  with  di- 
vision of  the  externus  of  the  same  eye,  and  the  position  of 
the  eye  was  perfect  and  the  mobility  was  nearly  normal. 

It  is  not  easy  to  explain  the  absence  of  motility  in  one 
case  and  nearly  perfect  motility  in  the  other.  In  Case  II 
there  was  divergence  of  two  lines,  emmetropia,  vision  It  in 
each ;  fixes  with  either  eye,  and  no  binocular  vision.  One 
internus  was  advanced  and  the  externus  of  the  fellow-eye 
divided,  with  the  result  of  binocular  single  vision  and  exo- 
phoria  of  8°  to  10°. 

In  Case  VIII  there  was  sufficient  reaction  to  require 
iced  cloths  to  the  eye ;  eye  convergent  for  ten  days. 

Case  X  had  divergence  of  four  lines  and  was  corrected 
by  advancement  only. 

In  Case  XI  one  internus  was  advanced  with  correction 
of  the  squint,  but  in  a  few  days  there  was  relapse  and  the 
eyes  were  kept  in  position  by  correcting  the  myopia  of 
— 14  D.  in  one  and  — 8  D.  in  the  other. 

In  Case  XII  Prince's  advancement  and  both  externi 
divided ;  one  eye  emmetropic  and  the  other  myopic. 

I;i  Case  XIII  Prince's  advancement ;  division  of  both 
externi ;  both  myopic ;  eyes  straight,  but  some  insufficiency 
of  internus  of  deviating  eye. 

In  Case  XIV,  emmetropia,  squinting  eye  amblyopic  ; 
Prince's  advancement,  and  division  of  tlie  opponent ;  at  first 
over-offect,  then  correct  position. 

In  Case  XV  the  internus  was  advanced  by  the  Prince 
method  and  its  opponent  was  divided ;  after  a  few  days 
some  divergence ;  the  only  case  of  decidedly  insufficient 
effect  in  this  list. 

In  Case  XVI,  hypermetropic  astigmatism  in  one  and 
compound  hypermetropic  astigmatism  in  the  other ;  had  the 
internus  advanced,  its  opponent  divided,  and  a  correct  posi- 
tion obtained,  although  there  was  no  over-effect  at  first. 

In  Case  XIX,  both  emmetropic;  Prince's  advancement; 
tenotomy  of  externus ;  convergence  at  first,  subsequently 
slight  convergence. 

Case  XX,  slight  divergence  ;  emuuitropic  ;  corrected  by 
division  of  externus  ;  no  suture. 

Case  XXI  same  as  Case  XX,  except  one  eye  was  am- 
blyopic. 


At  the  present  time  I  am  inclined  to  the  belief  that 
nearly  all  the  cases  of  divergence  may  be  corrected  with- 
out advancement.  Especial  stress  should  be  laid  on  draw- 
ing the  eye  sharply  inward  when  the  squint  is  excessive,  in 
some  cases  as  much  as  three  or  four  lines. 

In  divergence  from  tenotomy  of  the  internus,  advance- 
ment will,  of  course,  generally  be  necessary. 

Two  additional  cases  are  here  appended — one  where  the 
squint  depended  on  a  previous  tenotomy  and  which  was 
corrected  without  advancement. 

Case  XXIV. — Rose  R.,  aged  twenty-two,  lias  a  divergence 
of  the  left  eye  of  three  lines,  dependent  on  an  operation  for 
convergent  squint  some  years  since;  left  eye  very  amblyopic; 
right,  perfect  vision  with  moderate  hyperraetropia.  Division  of 
left  externus,  with  the  use  of  an  adducting  suture,  which  caused 
nearly  three  lines  of  convergence,  although  after  the  division  of 
the  externus  the  eye  apparently  became  straight.  This  suture 
cut  its  way  out  in  from  two  to  four  days  and  the  eyes  are  in 
correct  position.  It  will  be  seen  that  this  is  the  only  case  of 
divergence  dependent  on  a  previous  tenotomy  of  the  internus 
where  advancement  was  not  done,  yet  the  operation  was  entire- 
ly adequate. 

Case  XXV. — Thomas  B.,  aged  forty-nine.  Divergence  two 
lines  and  a  half;  fixes  with  left.  Vision — right,  lxX  w'itli  — 6 
D. ;  left,  xv,  emmetropic.  Division  of  externus  of  the  riglit  and 
an  adducting  suture  attached  to  the  inner  canthus,  which  pro- 
duced two  lines  of  convergence.  In  two  days  the  suture  cut 
its  way  out  of  the  conjunctiva  and  it  was  removed.  The  eyes 
became  parallel. 


REPORT  OF 

FOUR  CASES  TREATED  BY  HYPNOTISM. 
By  J.  ARTHUR  BOOTH,  M.  D., 

ASSISTANT  PUYSICtAN,  NERVOUS  DEPARTMENT. 
MANHATTAN  EYE  AND  EAR  HOSPITAL. 

There  is  no  longer  any  doubt  that  the  treatment  of 
certain  nervous  disorders  by  hypnotism  now  holds  an  im- 
portant place,  and  the  majority  of  those  who  have  fairly  tried 
hypnotic  suggestion  are  convinced  of  its  usefulness.  AVith 
the  view  of  adding  to  the  evidence  already  publislied  in  its 
favor,  the  histories  of  the  following  cases  are  reported  : 

Case  I.  Hysteria  ;  Epileptoid  Attacks  ;  Hysterogenic  Zones  ; 
Hemianfpsthe.sia  ;  Cure  in  Twelve  Seances. — June  6,  1888. — Mary 
B.,  nineteen  years  old,  single.  From  infancy  up  to  her  eleventh 
year  she  wasperfectlv  healthy;  at  this  time  she  had  scarlet  fever 
and  was  quite  ill.  Three  years  ago  a  chair  was  pulled  from 
under  her,  and,  according  to  her  own  statement,  substantiated 
by  that  of  her  mother,  she  was  unconscious  for  an  hour  after 
the  accident. 

For  the  last  two  years  she  has  been  having  convulsive  seiz- 
ures, which  are  ushered  in  by  a  sudden  darting  ]>ain  in  the  back 
of  the  head  ;  unconsciousness  follows,  and  then  tonic  and  clonic 
movements  of  the  upper  and  lower  extremities  tiike  place.  No 
biting  of  the  tongue  or  frothing  at  the  nioutli.  These  attacks 
only  occurred  at  long  intervals  at  first,  but  within  the  last  two 
weeks  they  have  come  on  every  day,  varying  from  five  to  twelve 
in  number. 

Examination. — There  isacomideto  loss  of  sensation  to  touch 
and  pain  on  the  left  side.  While  testing  reflexes  at  the  knee,  the 
tapping  on  the  tendon  caused  atypical  hysterical  paroxysm.  Be- 
tween the  shoulder  blades  at  the  height  of  the  fifth  and  sixth 


272 


BOOTH:  FOUR  GASES  TREATED  BY  HYPNOTISM. 


(N.  Y.  Med.  Jodb., 


dorsal  vertebrso  the  patient  presents  a  surface  as  big  as  a  silver 
dollar  which  is  insensible  to  touch  and  to  the  prick  of  a  pin. 
Pressure  on  this  surface  immediately  brings  on  an  attack.  For 
five  months  internal  medication,  counter-irritation,  and  elec- 
tricity did  not  cause  any  change  in  the  condition  of  the  left  side, 
or  influence  the  character  and  frequency  of  the  spasms.  On  No- 
vember 14th  hypnotism  v/as  tried  for  the  first  time,  and  without 
any  difficulty  she  passed  into  a  deep  sleep — so  profound,  indeed, 
that  it  was  hard  to  arouse  her.  Suggestions  proper  to  the  con- 
ditions present  were  offered — viz.,  the  rest  would  do  her  good  ; 
she  would  have  no  more  attacks ;  pain  would  disappear,  etc. 

She  was  hypnotized  three  times  a  week,  and  on  December 
5th  the  pain  and  numbness  had  disappeared  and  there  had 
been  no  attack  for  ten  days.  Treatment  by  suggestion  was 
continued  regularly  for  two  weeks  longer  with  no  return  of  the 
attacks. 

June  5,  1889. — The  mother  calls  and  rei)orts  that  her  daugh- 
ter has  remained  free  from  any  convulsive  seizures. 

Case  II.  Hysteria;  Epileptoid  Attacl-a ;  Insomnia;  Cure 
in  Fifteen  Seances. — Mary  A.,  eighteen  years  of  age,  was  seen 
for  the  first  time  on  the  12th  of  June,  1889,  and  the  following 
history  obtained:  She  had  always  been  nervous,  but  otherwise 
had  had  no  trouble  until  the  appearance  of  the  menses,  two 
years  ago;  then  during  the  first  year  she  suffered  much  pain 
every  month.  For  the  past  year  menstruation  has  appeared  at 
irregular  intervals,  but  without  pain.  During  the  last  six  months 
she  has  become  very  depressed,  cries  easily,  and  is  now  having 
every  day  frecjuent  convulsive  seizures,  numbering  from  three 
to  five  a  day.  The  patient  complains  of  a  lump  frequently 
rising  in  her  throat  (globus),  and  this  is  always  a  marked  symp- 
tom just  preceding  an  attack.  She  now  begins  to  cry,  and, 
sliding  from  the  chair  on  which  she  is  sitting  to  the  floor,  a 
typical  hysterical  convulsion  follows. 

During  the  past  month  she  has  been  greatly  troubled  by 
sleeplessness,  and  now  obtains  but  a  few  hours' sleep  each  night. 
She  is  hypnotized  easily,  and,  falling  into  a  deep  stupor,  it  is  only 
possible  to  awaken  her  by  repeated  suggestion. 

June  nth. — Has  rested  better;  insomnia  less  marked;  no 
change  in  the  attacks.  Again  hypnotized  and  the  proper  sug- 
gestions made. 

July  2(1. — The  above-described  treatment  has  been  continued 
three  times  a  week.  The  patient  is  now  sleeping  well  and  is 
having  only  one  seizure  a  week. 

August  l^th. — No  attack  in  two  weeks.  Treatment  stopped ; 
to  report  in  a  month. 

September  IJ^th. — Has  been  entirely  free  from  any  return  of 
the  former  trouble. 

Case  III.  Choreic  Movements  and  Ancesthesia  of  the  left 
Arm  ;  Cure  in  Seven  Seances. — Rosa  W.,  seventeen  years  of  age ; 
works  as  a  waitress  in  a  restaurant.  She  consulted  me  at  the 
Manhattan  Eye  and  Ear  Hospital  on  December  20,  1889,  when 
the  following  history  was  obtained  : 

General  health  good  until  last  June;  then  had  scarlet  fever 
followed  by  diphtheria.  The  present  trouble  commenced  three 
weeks  ago.  At  first  there  was  only  a  slight  tremor  of  the  fingers 
of  the  left  hand  ;  this  rapidly  grew  worse  and  now  involves  the 
whole  arm,  compelling  her  to  give  up  her  position  on  account 
of  this  constant  shaking  of  the  entire  arm.  Sometimes  the 
movements  cease  for  an  hour,  but  then  return.  She  sleeps  well 
at  night,  during  which  time  the  arm  is  quiet.  The  patient  has 
never  had  any  convulsive  seizures  or  crying  spells.  Menstrua- 
tion has  not  yet  appeared.  There  is  a  coarse  rhythmical  tremor 
of  the  left  upper  extremity.  It  is  continuous  and  not  jerky. 
There  is  also  marked  loss  of  sensation  of  the  entire  hand  and  the 
anterior  surface  of  the  forearm,  shading  off  gradually  to  the  mid- 
dle of  the  arm. 


I  hypnotize  her  without  trouble  and  the  movements  cease  in 
consequence  of  suggestion.    Upon  awakening  they  reappear. 

December  21st. — Reports  a  slight  improvement;  the  arm 
shakes  less,  and  was  quiet  for  two  hours  this  morning.  Again 
hypnotized  and  suitable  suggestions  made.  Upon  waking,  the 
arm  is  without  tremor  and  sensation  has  returned  to  the  surface 
of  the  arm  which  was  aniesthetic. 

28th. — Has  been  liyj)notized  every  day  since  the  last  note. 
There  have  been  no  movements  of  any  kind  for  two  days,  and 
careful  observation  and  testing  fail  to  reveal  the  slightest  trace 
of  tremor  or  shaking. 

February  2,  1800. — Still  remains  well ;  no  return  of  the 
trouble.    She  is  now  at  work  again. 

The  cases  above  recorded  are  (juite  common  forms  of 
liysteria  with  whicli  most  of  us  arc  familiar. 

Tlie  following  case,  liowever,  is  unique,  presenting  a  type 
of  trouble  rarely  met  with  and  one  of  much  interest.  The 
patient  was  referred  to  me  about  three  weeks  ago  by  Dr. 
David  Webster  for  entire  loss  of  vision  of  the  left  eye.  The 
history  is  as  follows  : 

Case  IV. — Fannie  T.,  thirty-eight  years  old,  married.  No- 
vember 23,  1892.  Perfectly  well  until  a  week  ago;  then  no- 
ticed a  slight  dimness  of  vision  in  left  eye.  About  the  same 
time  she  was  troubled  by  pain  in  the  eye.  Three  days  ago  she 
found  that  she  could  not  see  at  all  with  this  eye.  No  vomiting, 
diplopia,  or  vertigo.  Never  had  rlieumatism,  malaria,  or  any 
serious  illness,  having  always  enjoyed  good  health  up  to  the 
time  of  the  present  trouble.  Lately  she  has  been  somewhat 
depressed  and  has  cried  several  times  without  cause.  Has  three 
healthy  children ;  no  miscarriages.  Careful  inquiry  does  not 
reveal  any  history  of  syphilitic  infection.  Bowels  and  menses 
regular. 

Examination. — There  is  complete  loss  of  vision  in  the  left 
eye ;  she  fails  to  recognize  any  article  when  held  before  it,  the 
I'ight  eye  being  closed.  Vision  of  right  eye  normal.  Pupils  active 
and  normal  in  size  ;  no  ocular  paresis  ;  fundus  normal.  Knee- 
jerks  exaggerated.  Equilibrium  good.  There  being  no  signs  of 
any  changes  in  the  o\>t\c  nerve  or  symptoms  of  organic  change 
anywhere,  the  loss  of  vision  is  probably  due  to  hysteria.  The 
patient  was  easily  hypnotized,  and,  the  necessary  suggestions 
having  been  made,  she  was  awakened  after  sleeping  five  min- 
utes. The  right  eye  was  then  covered  and  the  other  one  again 
tested.  Vision  was  about  the  same,  but  she  volunteere(f  the 
statement  that[there  was  less  blur,  and  the  pain  had  disappeared 

November  25th. — No  change ;  condition  about  the  same. 
Vision  again  tested  as  before,  and  with  the  same  results.  Has 
now  a  good  deal  of  pain  in  the  eye  and  face.  I  hypnotize  her 
and  suggest  that  she  will  have  no  more  paiii,  that  the  rest  will 
do  her  good,  and  that  she  will  now  see.  In  fifteen  minutes  she 
got  up  and,  placing  one  hand  over  the  right  eye,  recognized  a 
clock  on  the  wall  about  twelve  feet  distant,  although  she  could 
not  distinguish  the  hands  or  tell  tiie  time.  A  bunch  of  keys  was 
named  correctly  at  four  feet.    The  pain  is  entirely  gone. 

December  7th  — Has  been  able  to  see  much  better  ;  absence 
of  pain  since  last  seance.  Sees  well  at  ten  feet,  but  beyond  this 
everything  looks  blurred.  Hypnotized. 

9th. — Has  been  perfectly  well;  no  pain.  Vision  entirely  re- 
stored. 

February  3d. — Patient  has  remained  well.  Has  had  no 
trouble  with  her  vision  since  her  last  visit  to  the  hospital. 


The  French  Academy  of  Medicine. — The  Lancefs  Paris  correspond- 
ent states  that  Sii-  WiUiani  MacCoruiac,  of  London,  and  Dr.  Tilanus, 
of  Amsterdam,  have  been  elected  foreign  corresponding  members. 


-1 


Miircli  11,  1893.] 


KIMBALL:   MAGGOTS  IN  THE  NOSE. 


273 


MAGGOTS  IN  THE  NOSE 

SUCCESSFULLY  TREATED  BY  INJECTIONS  OF  CHLOROFORM  * 
By  Major  JAMES  P.  KIMBALL,  Sukgeon,  U.  S.  A., 

FORT  CLARK,  TEXAS. 

The  following  case  is  reported  as  a  contribution  to  the 
knowledge  of  a  comparatively  rare  and  little- known  dis- 
ease, but  one  which  has  repeatedly  proved  fatal  in  this  part 
of  the  country  : 

On  the  morning  of  September  18, 1892,  Private  J.J.  G.,  Com- 
pany 0,  Eighteenth  Infantry,  appeared  at  ,>-ick  call  complaining 
of  pain  in  the  forehead  and  the  orbits,  anorexia,  and  fever. 
These  symptoms  had  been  coming  on  during  tlie  preceding 
twenty-four  hours.  His  temi)erature  taken  under  the  tongue 
was  102'4°.  Remittent  fever  was  prevalent  at  the  time  and  it 
was  believed  that  he  was  coiinng  down  with  this  disease.  He 
was  admitted  to  the  hospital  and  given  the  usual  treatment  for 
fever  patients.  On  the  following  morning  he  was  much  worse. 
During  the  night  lie  had  been  delirious  at  times,  sleei)less,  con- 
stantly tossing  about  and  trying  to  get  out  of  bed.  He  com- 
plained of  intense  throbbing  pain  at  the  root  of  the  nose  and  over 
the  frontal  region.  The  nose  and  lower  eyelids  were  red  and 
swollen.  There  was  a  discharge  of  bloody  serum  from  the  left 
nostril  with  an  offensive  odor.  The  nostrils  were  washed  out 
with  Dobell's  solution,  after  which,  in  the  act  of  sneezing,  sev- 
eral maggots  were  ejected  from  the  left  nostril.  Chloroform 
by  inhalation  was  then  given,  and  all  the  larvie  that  could  be 
seen — some  fifteen  or  twenty  in  number — were  removed  with 
long,  slender  forceps,  after  which  a  drachm  of  carbolized  oil 
was  injected  into  the  nostril.  The  patient  expressed  great  re- 
lief; hut  during  the  ensuing  night  his  sufferings  returned  witli 
even  increased  intensity.  From  time  to  time  maggots  were 
ejected  in  the  act  of  sneezing  or  blowing  the  nose.  On  the 
morning  of  the  20th  the  whole  face  was  swollen,  as  was  also 
the  soft  palate.  Temperature,  104°.  Well  up  in  the  left  nostril 
was  visible  a  writhing  mass  of  maggots,  undiminished  in  number 
from  the  colony  present  there  the  day  before.  All  the  larvie 
that  could  be  seen  were  again  removed  with  forceps  and  the 
nostrils  thoroughly  washed  out  with  a  ten-per  cent,  solution  of 
carbolic  acid,  and  morphine  given  for  the  relief  of  pain.  This 
procedure  was  repeated  in  the  evening,  at  which  time  the  tem- 
perature of  the  patient  was  105°. 

On  September  21st  the  condition  of  the  patient  was  worse 
than  ever.  Both  eyes  were  closed  by  the  swelling.  The  un- 
remitting pain  and  sleeplessness  were  most  distressing;  con- 
stant watch  was  necessary  to  keep  him  from  throwing  him- 
self out  of  bed.  Maggots  escaped  not  only  from  the  nose 
but  from  the  mouth  in  the  act  of  coughing.  The  fostor  of 
the  breath  was  extremely  offensive.  The  velum  palati  was 
swollen  to  such  an  extent  as  to  prevent  deglutition.  It  was 
apparent  that  the  treatment  hitherto  employed  was  useless,  and 
an  injection  into  the  nostril  of  equal  parts  of  chloroform  and 
water  was  given,  after  which  the  nostrils  were  washed  out  and 
about  a  score  of  maggots  removed.  Food  and  drink  were  given 
through  a  stomach  tube.  Some  five  or  six  hours  after  the  in- 
jection of  chloroform  and  water  there  was  little  or  no  ameliora- 
tion in  the  man's  condition,  and  an  injection  was  given  of  two 
drachms  of  pure  chloroform.  The  pain  produced  by  the  injec- 
tion was  allayed  by  injecting  carbolized  oil,  and  the  nostrils 
were  washed  out  by  means  of  a  post-pharyngeal  syringe  with  a 
ten-volume  solution  of  j)eroxide  of  hydrogen.  The  effect  was 
immediate  and  encouraging.    Not  less  than  a  hundred  dead 


Published  by  authority  of  the  Surgeon-Genera). 


larvfB  were  expelled,  partly  by  syringing  and  partly  by  sneezing 
and  forcibly  blowing  the  nose,  and  by  coughing  out  those 
which  came  down  through  the  posterior  nares  into  the  pharynx. 

On  the  following  day,  September  22d,  there  was  some  im- 
provement in  the  patient's  condition,  but  the  trouble  was  not 
yet  overcome.  Live  maggots  were  expelled  in  the  act  of  sneez- 
ing, and  others  could  be  seen  well  back  in  the  nostril.  The 
pure  chloroform  injection  was  repeated,  resulting  in  the  expul- 
sion of  some  fifty  more  dead  maggots. 

Septemher  23d. — Live  maggots  were  again  to  be  seen  on 
looking  into  the  left  nostril,  and  the  injection  of  chloroform  was 
repeated  for  the  third  and  last  time.  A  score  or  more  of  dead 
maggots  were  got  rid  of  on  this  occasion,  and  for  several  suc- 
ceeding days  dead  ones  came  away  singly  or  in  knots  of  from 
two  to  six  when  the  nasal  passages  were  syringed.  In  all,  not 
less  than  three  hundred  maggots  were  ejected. 

Recovery  was  slow.  It  was  September  28th  before  the  pa- 
tient was  able  to  swallow  and  the  use  of  the  stomach-tube  could 
be  discontinued.  Portions  of  the  mucous  membrane  of  the  nasal 
fossae  and  naso  pharynx  in  a  gangrenous  condition  were  de- 
tached and  washed  out  from  time  to  time  up  to  October  3d, 
and  it  was  not  until  October  7th  that  the  temperature  became 
normal  and  the  patient  fairly  convalescent. 

Solution  of  peroxide  of  hydrogen,  first  used  as  an  antiseptic 
for  syringing  the  nares,  was  found  grateful  to  the  patient,  cor- 
rective of  the  ffEtor,  and  exercising  a  stimulant,  alterative  effect 
on  the  diseased  mucous  membrane,  and  its  use  was  continued 
at  intervals  of  from  five  to  six  hours  for  several  days  subsequent 
to  the  last  injection  of  chloroform. 

The  patient  is  now  under  treatment  for  dry  catarrh  of  the 
naso-pharynx  with  ozfena.  He  says  he  has  had  catarrh  since 
last  winter,  and  for  several  months  past  the  discharge  has  been 
ofl'ensive.  The  history  he  gives  of  his  recent  illness  is  that  on 
the  afternoon  of  September  16th,  about  thirty-six  hours  before 
he  applied  for  medical  aid,  while  asleep  on  a  (tench  in  the 
barrack,  he  was  awakened  by  a  tickling  sensation  in  the  nose, 
which  he  thought  had  been  produced  by  a  comrade  with  a 
straw.  This  in  all  probability  was  the  time  when  the  larvffl 
were  deposited  l>y  a  fly  in  his  nostril. 

This  fly  is  the  Sarcophaga  georgina  (Wiedemann),  an 
ovo-viviparons  insect,  the  larvte  being  hatched  within  the 
oviduct.  It  is  twelve  millimetres  in  lengtli,  with  rather  a 
small  head  and  plumose  antennal  bristles.  The  face  is 
silvery  white  with  S^black  spot  between  the  copper-colored 
eyes ;  the  thorax  light  gray  with  seven  longitudinal  black 
stripes ;  the  satiny  silver-gray  abdomen  checkered  with 
black  lines ;  black  feet  and  gray  translucent  wings.  The 
larva  is  eighteen  millimetres  long,  acephalous,  white,  cylin- 
drical, tapering  to  a  point  at  the  mouth,  and  surrounded 
with  a  spiral  ridge  like  a  screw — whence  its  popular  name 
of  "  screw  worm."  The  posterior  three  fourths  of  the 
body,  up  to  the  point  at  which  it  begins  to  taper,  is  three 
millimetres  in  diameter.  The  mouth  is  formed  hj  a  sort 
of  lip  on  which  arc  two  small  protuberances,  from  the  cen- 
ter of  the  base  of  which  protrude  two  black,  very  sharp, 
corneous  mandibles  or  booklets,  united  at  their  origin  in 
the  lip  but  separating  outside.  On  the  upper  side  of  the 
body,  back  of  the  mouth  and  underneath  the  transparent 
skin,  is  a  brown  patch.  To  ascertain  the  time  occupied  in 
their  development,  the  larvae  were  expressed  from  a  tly  upon 
a  piece  of  tainted  meat,  and  inclosed  in  a  wide-mouthed  bot- 
tle and  placed  in  the  sun.  In  twelve  hours  it  was  estimated 
that  the  mass  had  increased  in  bulk  forty  fold  ;  at  the  end 


274 


KIMBALL:  MAGGOTS  IN  THE  NOSE. 


[N.  Y.  Med.  Joob., 


of  twenty-four  hours  the  maggots  were  half-grown,  and  in 
forty-eiglit  liours  they  were  fully  developed.  The  Sar- 
cophujja  or  flesh  fly  is  found  very  commonly  here  around 
the  butcher  shops  from  about  the  first  of  March  to  the  last 
of  October.  The  habit  of  tliis  Hy  is  to  deposit  its  larv:e  on 
putrid  flesh. 

I  have  obtained  reliable  infoiination  of  seven  cases  of 
maggots  in  tlie  nose  (in  addition  to  the  one  above  reported) 
occurring  at  Fort  Clark  and  its  vicinity  during  the  last  ten 
years,  all  of  which,  except  one,  proved  fatal.  Ozffina  ex- 
isted in  all  in  which  I  have  been  able  to  ascertain  the  con- 
dition of  the  patient  at  the  time  of  contracting  the  disease. 
A4,tracted  by  the  strong  odor,  the  fly  enters  the  nostril 
when  the  victim  is  asleep  to  drop  its  living  larvfe. 

The  history  of  these  cases  I  will  give  briefly,  not  at- 
tempting to  arrange  them  in  chronological  order,  but  giving 
first  that  of  which  I  have  most  complete  details. 

Case  I.  —  Private  0.  D.  R.,  Company  C,  Eighteenth  Infantry, 
stationed  at  Fort  Clark,  Texas,  was  taken  sick  July  2,  1890, 
witli  pain  in  tlie  head  and  face,  whicii  continued  to  grow  worse 
during  this  and  the  following  day.  On  July  4th  bleeding  from 
the  nose  commonced,  and  maggots  were  discovered  in  the  right 
nostril.  Treatment  by  removal  of  the  larvaj  with  forceps  and 
syringing  with  solutions  of  carbolic  and  cressylic  acids  and 
spraying  with  carbolized  vaseline  was  vigorously  but  unavail- 
ingly  employed,  and  the  man  died  on  July  9th.  At  the  autopsy 
a  great  nutnber  of  maggots  were  found  in  the  posterior  nares 
and  nasopharynx,  some  being  free  in  these  cavities  and  moving 
ai-tively  about,  and  others  imbedded  in  the  tissues.  The  bony 
wall  of  the  nasal  cavities  was  denuded  of  mucous  membrane  in 
some  places,  in  other  places  the  membrane  was  swollen,  and 
in  still  others  broken  down  and  gangrenous.  This  man  at  the 
time  of  contracting  his  last  illness  was  suffering  from  an  ex- 
ceedingly offensive  ozsena,  whicli,  in  tlie  words  of  the  record  of 
his  case,  made  liim  "a  nuisance  in  the  company." 

Case  II.— Private  J.  B.,  Troop  I),  Eighth  Cavalry,  admitted 
to  hospital  at  Fort  Clark,  Texas,  April  27,  1884,  with  neuralgia 
of  left  side  of  face  and  epistaxis.  Conmiitted  suicide  at  8.45 
p.  M.  of  the  same  day.  "Screw  worms"  were  found  in  the 
left  nostril  and  left  antrum. 

It  is  perhaps  worthy  of  remark  that  there  is  a  tradition  in 
the  garrison  that  any  one  becoming  the  subject  of  this  disease 
would  better  kill  himself  at  once. 

Case  III. — Mr.  R.  P.  P.,  a  civilian,  who  was  suffering  from 
catarrh  and  had  come  to  Texas  for  his  health,  became  the  sub- 
ject of  maggots  in  the  nose  while  living  on  a  ranch  some  miles 
from  Fort  ('lark.  He  was  brought  to  the  post  and  admitted  to 
hospital  May  27,  1884,  and  discharged  June  14th.  I  have  been 
unable  to  find  any  details  of  treatment. 

Of  the  four  other  cases  I  have  been  able  to  gather  but 
meager  details.  All  proved  fatal.  One  was  a  solder  of  the 
Fourth  (Javalry,  who  contracted  the  disease  while  on  a 
scout,  and  died  at  Sabinal  Station,  Texas. 

Another  was  a  Mexican,  who  died  in  1882.  Tlie  re- 
maining two  were:  one  a  shoemaker,  who  died  in  1882, 
and  the  other  a  barber,  who  died  in  1884  ;  these  last  three 
were  citizens  of  the  village  of  Brackettville,  Texas. 

The  barber,  I  am  told,  had  lost  most  of  his  customers, 
driven  away  by  his  ofl^ensive  breath,  from  which  I  infer 
that  he  was  a  sufferer  from  ozicna. 

Two  cases  of  maggots  in  the  nose  are  reported  in  the 


Medical  Record,  vol.  xxviii,  p.  399,  by  T>r.  C.  M.  Harrison, 
of  Del  Jiio,  Texas,  a  town  thirty  miles  distant  from  Fort 
Clark.  The  first  was  that  of  a  Mexican  with  nasal  catarrh. 
The  treatment  consisted  in  injections  of  carbolic-acid  solu- 
tion, corrosive-sublimate  solution,  turpentine,  tannin,  and 
morpliine — "  first  one  solution  and  tlien  another,  through 
the  anterior  and  the  posterior  nares."  "  The  patient  died 
in  agony  at  the  end  of  three  days."  The  second  case  was 
that  of  a  Mexican  woman  who  was  cured  by  injecting  into 
the  anterior  nares  half  an  ounce  of  pure  chloroform  mixed 
with  an  equal  quantity  of  an  antiseptic  solution  after  vari- 
ous other  measures,  including  the  inhalation  of  chloroform, 
had  been  tried  in  vain. 

It  appears  to  be  satisfactorily  established  that  this  fly 
deposits  its  larvse  only  on  the  unsound  mucous  membrane. 
The  following  case  shows  that  when  the  conditions  are 
favorable  it  may  do  this  in  other  situations  tiian  the  nasal 
fossae  :  A  soldier  who  was  suffering  from  remittent  fever 
and  was  in  hospital  under  my  charge  at  the  same  time  as 
Private  G.,  was  also  the  subject  of  constitutional  syphilis, 
which  was  manifested  at  this  time  by  ulceration  of  the 
gums  with  a  very  offensive  odor.  For  several  days  he  was 
in  a  semi- conscious  state  of  low  delirium,  and  while  in  this 
condition  a  fly  deposited  its  larvae  in  an  ulcer  above  the 
upper  incisors.  The  nurse  discovered  them  probably  with- 
in a  very  short  time,  as  they  were  still  very  small,  although 
large  enough  to  be  moving  actively  about.  They  were  re- 
moved— between  forty  and  fifty  in  number — by  a  brush 
and  forceps.  Two  were  found  beneath  the  gum  fully  half 
an  inch  from  its  margin. 

The  injection  of  chloioform  in  tlie  treatment  of  maggots 
in  the  nose  is  recommended  by  Sir  Morell  Mackenzie  in  his 
Manual  of  Diseases  of  the  Throat  and  Nose,  1884.  It  was 
first  used,  he  states,  by  Morel,  a  French  army  surgeon, 
during  the  military  occupation  of  Mexico  by  the  French — 
1862-67 — the  remedy  having  been  originally  recommended 
by  Assistant  Apothecary  Dauzats.  He  advised  that  chloro- 
form diluted  with  one  half  its  volume  of  water  should  be 
shaken  up  and  injected  before  the  two  liquids  have  time  to 
separate.  Subsequent  to  Morel's  paper  was  one  by  Jacob, 
also  a  surgeon  in  the  French  army  in  Mexico,  who  reports 
a  severe  case  of  maggots  in  the  nose  cured  by  chloroform 
injections  and  inhalations.  He  says  pure  chloroform  was 
injected  several  times." 

The  treatment  recommended  in  the  other  standard  medi- 
cal works  of  my  library  which  make  any  mention  of  this 
disease — viz.,  von  Ziemssen's  Cyclopaedia  of  tlie  Practice  of 
Medicine,  Ashhurst's  International  Encyclopwdia  of  Suryery, 
and  Agnew's  Suryery — consists  of  inhalations  of  alcohol, 
ether,  turpentine,  and  chloroform ;  syringing  with  carbol- 
ized solutions  or  solutions  of  corrosive  sublimate,  or  decoc- 
tions of  bitter  herbs  or  tobacco  ;  injections  of  turpentine  or 
of  oil ;  insufflations  of  calomel ;  and  pencilings  with  balsam 
of  Peru.  Any  or  all  of  these  measures  in  a  fully  developed 
case  of  the  larvae  of  the  Sarcophaya  yeoryina  in  the  nasal 
passages,  I  believe,  are  of  scarcely  more  avail  than  Mrs. 
Partington  with  her  broom  against  the  waves  of  the  Atlantic 
Ocean.  By  "  fully  developed  "  is  meant  a  case  in  which 
forty-eight  or  more  hours  have  elapsed  from  the  time  of 


March  11,  1893.  J 


BARHAM:  PELI0SI8  BHEUMATIGA. 


275 


deposition  of  the  larva?  in  the  nostril.  The  maggots  then 
are  full  grown,  have  a  great  deal  of  vitality,  and  are  in  in- 
cessant motion — an  innumerable  devouring  horde. 

Before  resorting  to  injections  of  chloroform  in  the  fore- 
going case  I  tried  the  effects  upon  the  maggots  of  the  vari- 
ous articles  recommended,  omitting  decoctions  of  bitter 
herbs  and  tobacco.  A  number  of  the  larvitj  were  put  into 
a  saucer  containing  a  fifty- per-cent.  solution  of  carbolic  acid 
to  a  depth  just  short  of  complete  immersion,  so  that  respira- 
tion might  not  be  wholly  impeded.  They  struggled  to 
escape,  but  were  continually  pushed  back  into  the  liquid 
until,  at  the  expiration  of  five  minutes,  they  were  permitted 
to  crawl  out,  in  no  way  injured  by  the  application.  Immer- 
sion in  a  similar  manner  and  for  the  same  length  of  time 
in  a  l-to-500  solution  of  corrosive  sublimate  was  followed 
by  like  results.  Oil  of  turpentine  caused  the  movements  to 
cease  at  the  expiration  of  three  minutes,  but  the  maggots 
revived  after  removal.  Five  minutes'  immersion  caused 
death.  Olive  oil  and  balsam  of  Peru  produced  no  effect. 
Calomel  was  without  effect  unless  the  maggot  was  buried 
in  it  for  several  minutes,  causing  death  by  suffocation. 
Chloroform  when  broug-ht  in  contact  with  the  half-arrown 
larvaj  caused  almost  instantaneous  death ;  the  full-grown 
larvae  were  killed  by  it  in  from  five  to  seven  seconds.  The 
vapor  sufficed  to  stupefy  them  in  a  few  seconds,  but  recov- 
ery followed  its  withdrawal. 

It  appears  probable  that  a  single  injection  of  chloroform 
might  effect  a  cure  if  administered  within  thirty-six  hours 
from  the  deposition  of  the  larva?  in  the  nostril.  Not  only 
are  they  more  easily  killed  at  this  time,  but  the  bulk  is  so 
much  less  that  the  remedy  can  more  readily  come  in  con- 
tact with  them  all.  When  full  grown  they  fill  the  nasal 
fossa;  and  become  imbedded  in  the  swollen  tissues  to  an 
extent  that  greatly  increases  the  difficulty  of  their  destruc- 
tion. Mackenzie  recommends  that  the  patient  be  rendered 
insensible  by  the  inhalation  of  the  vapor  before  injecting 
chloroform  into  the  nares,  on  account  of  the  extreme  pain 
caused  by  this  procedure. 

In  the  case  reported  above,  syringing  with  carbolized 
oil  a  few  seconds  after  injecting  chloroform  assuaged  the 
pain ;  and  the  assistance  of  the  patient  in  forcing  the  dead 
or  stupefied  larvte  from  the  nares,  and  expelling  them  from 
the  pharynx  through  the  mouth,  was  of  great  service. 

The  study  of  this  case  seems  to  indicate  that  in  injec- 
tions of  chloroform  into  the  nasal  passages  we  have  a  reli- 
able remedy  for  a  disease  which,  under  any  other  method 
of  treatment  hitherto  recommended,  has  usually  proved 
fatal. 


A  medical  Marquis. — The  Britinh  Medical  Journal  states  tliat  Dr. 
Matias  Nieto  Senaiio,  the  editor  of  El  Sigh  Medico,  has  been  made 
Marcjuis  of  Guadalerzas,  in  recognition  of  liia  services  to  science  and  to 
his  country. 

Lemonade  as  a  Vehicle  for  Chloral. — Dr.  E.  Holland  calls  our  atten- 
tion to  the  fact  that  the  taste  of  chloral  hydrate  is  effectively  masked 
by  lemonade.  Two  or  three  drachms  of  the  syrup  should  be  placed  in 
a  tumbler  witli  about  two  ounces  of  water ;  if  to  this  is  added  about 
two  ounces  or  so  of  gaseous  (bottled)  lemonade,  the  mixture  may  be 
drunk  at  leisure,  and  the  soporific  action  of  the  druf^  is  in  no  way  im- 
paired.— rractitioncr. 


REPORT  OF 

A  CASE  OF  PELIOSIS  RHEUMATICA, 

WITH  A  SHORT  DISCUSSION  OF  ITS  vETIOLOGY. 
By  CDTHBERT  R.  BARHAM,  M.  D., 

rELLOW  OF  THE  PITTSBURGH  ACADEMY  OP  MEDICIKE. 

The  following  case  was  seen  in  consultation,  and  it  is 
through  the  courtesy  of  the  attending  physician  that  I  am 
permitted  to  report  it.  It  presents  some  features  of  inter- 
est, and  is  a  comparatively  rare  disease  in  this  country. 

The  history  is  as  follows : 

Female,  aged  twenty-two.  General  health  until  present 
sickness  good.  Born  in  Ireland :  came  to  this  country  in 
August,  1892.  Her  father  suffered  from  rheumatism.  One 
week  after  landing  she  suffered  from  an  attack  of  rheumatism 
(?)  of  the  knees  ushered  in  by  a  severe  cold,  and  accompanied 
by  high  temperature  and  tenderness  and  oedema  of  the  affected 
parts.    Recovery  after  three  week«. 

The  case  was  first  seen  by  me  with  Dr.  J.  H.  Wright,  of 
Allegheny.  At  this  time  (December  8th)  she  presented  marked 
swelling  and  tenderness  of  the  knees,  elbows,  and  wrists  and 
some  oedema  of  the  legs.  Over  the  knees  and  legs,  but  rather 
more  pronounced  over  the  extensor  surface,  were  a  number  of 
red  patches  of  various  sizes  from  that  of  a  finger  nail  to  that  of 
an  egg,  slightly  elevated  and  infiltrated.  The  color  did  not  fade 
on  pressure.  The  same  appearances  were  to  be  observed  over 
the  ulnar  surface  of  forearms.  The  afiected  joints  were  fixed 
by  reason  of  the  intense  pain  on  movement.  The  present  attack 
had  been  precipitated  by  exposure  to  cold  and  snow  one  evening 
about  a  week  before  I  saw  her.  The  next  morning  she  found 
her  knees  and  arms  "stiff,"  tender,  and  swollen.  The  appear- 
ance of  the  purpuric  spots  followed  shortly.  She  was  admitted 
to  the  hospital  two  days  after  the  attack  commenced.  The 
temperature  on  her  entrance,  103°  F.,  gradually  returned  to 
normal.  It  was  noticeable  that  the  increase  of  i)ain  and  tender- 
ness coincided  with  the  rise  in  temperature,  and  gradually  less- 
ened with  the  lowering  of  the  same,  though  the  purpuric  spots 
persisted  some  time  afterward  and  went  through  the  various 
stages  of  absorption,  which  was  completed  in  about  four  weeks. 

There  are  two  views  held  as  to  the  aetiology  of  the  dis- 
ease— one  that  it  is  a  variety  of  erythema  exsudativum  de- 
pendent on  the  same  causes  as  rheumatism  ;  the  second  that 
it  is  a  variety  of  purpura  closely  allied  to  purpura  liannor- 
rhagica  and  scurvy. 

Von  Zierassen  may  be  regarded  as  the  exponent  of  this 
latter  view.  He,  however,  admits  that  a  close  {etiological 
relation  probably  exists  between  this  form  and  articular 
rheumatism.  In  his  discussion  he  quotes  Traube,  who  tried 
to  prove  that  articular  rheumatism  was  identical  with  rheu- 
matic purpura;  and  Immerinann,  who,  while  describing  a 
rheumatoid  pur[)ura,  yet  considered  it  a  variety  of  "  pur- 
pura "  as  generally  understood.  Schwimmer  considers  it  a 
tropho-neurosis  due  to  a  variety  of  causes. 

Kopp,  in  his  monograph  on  tropho-neurotic  diseases  of 
the  skin,  discusses  purpura  in  general,  and,  referring  to 
rheumatic  purpura,  says :  "  It  is  a  question  whether  the 
ecchymoses  do  not  owe  their  existence  to  the  same  causes 
as  the  rheunuitism.  This  cause  may  be  cither  a  chemical 
alteration  of  the  blood  (rheumatic  diathesis)  or  a  specific 
infection."  He  states  that  in  fifteen  years'  practice  in  large 
hospitals  he  has  never  encountered  a  case.    All  these  au- 


276 


PARRISH:   OLEUM  TIGIJI  IN  FRACTURE  OF  THE  SKULL. 


[N.  Y.  Med.  Joum, 


thorities,  liowever,  regard  it  as  essentially  the  same  as  pur- 
pura baiinorrliagica. 

Of  the  former  view  we  may  take  as  our  exponent 
Crocker,  who  considers  it  a  variety  of  exudative  erythema, 
probably  due  to  the  same  cause  as  rheumatism.  I  am 
inclined  to  the  former  view,  inasmuch  as  it  presents  many 
points  of  similarity.  Both  are  introduced  by  rise  of  tem- 
perature and  malaise  ;  both  are  accompanied  by  a  rheuma- 
toid intlammation  of  the  joints ;  in  both  the  eruption  tends 
to  appear  on  the  extensor  surface,  and  is  more  abundant 
around  the  painful  joints.  The  pathology,  according  to 
Crocker,  is  primarily  that  of  erythema  exsudativum,  with 
supervening  haemorrhage.  Previous  attacks  of  rlieumatism 
or  of  rheumatic  purpura  predispose  to  it,  though  its  excit- 
ing causes  are  but  little  known,  excei)t  that  chill  appears  to 
be  a  factor  in  many  cases. 


OLEUM  TIGLII  IN  THE  TREATMENT  OE 
FRACTURE  OF  THE  BASE  OF  THE  SKULL, 

WITH  THE  REPOMT  OF  A  CASE. 

By  B.  F.  PARRISH,  M.  D. 

The  case  1  have  to  report  came  under  my  care  during 
my  hospital  service  : 

The  patient,  a  boy  of  sixteen  years,  was  brought  to  the  hos- 
pital on  October  22,  1890,  by  the  ambulance  in  a  state  of  de- 
lirium and  unconsciousness. 

The  right  side  of  his  face  was  paralyzed  and  the  right  pupil 
was  dilated.  There  was  free  bleeding  from  the  nose,  mouth, 
and  ears.  Later  the  discharge  from  these  organs  was  serous. 
His  symptoms  showed  cerebral  laceration  with  compression. 

The  patient  was  put  to  bed  and  ordered  to  be  kept  as  quiet  as 
possible.  His  ears  were  syringed  with  l-to-5,000  bichloride  of- 
mercury  solution  and  then  iodoform  was  dusted  into  the  auditory 
meatus,  and  the  whole  ear  was  dressed  antiseptically.  His  mouth 
and  nose  were  cleansed  with  clean  water.  The  patient  was  al- 
lowed milk,  beef  tea,  etc.  However,  it  was  with  great  difficulty 
that  he  could  be  induced  to  swallow  anything  at  all.  For  three 
days  the  patient's  symptoms  remained  unchanged.  His  ears 
were  dressed  twice  daily  as  long  as  there  was  any  discharge  from 
them,  and  then  once  a  day  for  a  week  longer.  On  the  third 
day  (October  25,  1890),  his  condition  not  having  changed,  be 
was  given  two  drops  of  oleum  tiglii  on  the  tongue.  Plis  bowels 
were  freely  moved  by  the  oil,  and  in  the  afternoon  of  the  same 
day  he  was  so  much  better  that  be  slept  quietly  for  several  hours. 
Up  to  this  time  he  had  bai-dly  s]e])t  at  all,  and.when  he  did  doze 
he  would  every  few  minutes  cry  out  at  the  top  of  his  voice  and 
throw  himself  violently  around  in  bed.  This  time  his  sleep  was 
unbroken.  Upon  waking  he  asked  for  food,  a  thing  he  had 
not  done  since  he  entered  the  hospital. 

Not  only  was  his  delirium  so  diminished,  but  !iis  facial  pa- 
ralysis was  also  much  less  marked. 

October  2Gth.  —  Patient's  condition  not  (juite  so  good  as  yes- 
terday afternoon.    However,  he  drank  some  milk  and  egg. 

27th. — Patient's  delirium  and  paralysis  increasing.  Milk. 

28th. — Patient's  condition  much  the  same  as  before  the  oil 
was  given.  Violent  delirium  and  marked  facial  paralysis.  He 
refuses  to  eat  or  drink  anything.  Two  drops  of  oleum  tiglii 
were  given  in  the  forenoon.  In  the  afternoon  his  bowels  had 
moved  freely  and  his  condition  was  much  improved.  His  de- 
lirium was  almost  gone  and  the  paralysis  was  much  diminished. 


He  slei)t  quietly  several  hours  during  the  afternoon,  and  awoke 
asking  for  something  to  eat.    He  was  given  milk  and  egg. 

29th. — Patient  slept  very  well  during  the  night  and  Keerns 
much  better  to-day.    Milk,  eggs,  and  beef  tea. 

30th. — Patient's  condition  is  hardly  so  good  as  yesterday, 
still  he  takes  nourishment.  He  did  not  sleep  very  well  last 
nigiit.    His  paralysis  and  delirium  are  returning. 

31st. — Patient  passed  a  bad  night;  his  delirium  and  i>aralysi8 
are  still  increasing.  In  the  morning  he  was  given  two  drops  of 
oleum  figlii.  In  the  afternoon,  his  bowels  having  moved  freely 
shortly  alter  the  oil  was  given,  he  had  a  long,  refreshing  sleep. 
After  waking  he  asked  for  food  and  drank  a  good  bit  of  milk 
and  egg,  also  some  beef  tea. 

Nmemhe7-  Ltt. — Patient's  condition  very  good  indeed.  He 
slept  well  la>t  night,  and  has  eaten  cpnte  freely  to-day.  His  de- 
lirium and  paralysis  are  less  than  at  any  time  since  he  was  ad- 
mitted. 

2d. — The  condition  of  the  patient  not  quite  so  good  as  yes- 
terday.   Still  he  is  fairly  comfortable. 

3d. — Patient  did  not  pass  a  very  good  night.  His  delirium 
and  paralysis  are  returning.  He  was  given  two  drops  of  oleum 
tiglii.  In  the  afternoon  his  bowels  had  moved  freely  and  he 
enjoyed  a  good  sleep.  He  again  complained  of  hunger.  He 
wiis  given  milk  and  eggs.  Just  as  after  the  other  doses,  again 
his  delirium  and  paralysis  diminished. 

Jfth. — Patient  in  very  good  condition.  He  slept  well  last 
night  and  eats  well  to-day. 

5th. — Patient's  condition  is  much  the  same  as  yesterday,  ex- 
cept that  his  pressure  symptoms  are  a  little  more  marked.  He 
slept  moderately  vvell  during  the  night  and  has  taken  a  fair 
amount  of  nourishment  to  day. 

6th. — The  patient  was  rather  irritable  to-day,  so  was  given 
another  dose  of  the  oil.  In  tiie  afternoon  he  was  decidedly  bet- 
ter. His  bowels  having  moved  freely,  he  quieted  down  and  slept 
several  hours.  He  again  complained  of  hunger  and  was  given 
milk  and  eggs  and  beef  tea.  His  pressure  symptoms  are  less 
marked  to-day  than  at  any  previous  time. 

7th. — Patient's  condition  good.  He  slept  well  last  night 
and  is  quiet  and  easy  to-day.  He  takes  food  with  seeming 
relish.    This  is  the  first  day  he  has  taken  solid  food. 

8th. — Patient's  condition  about  the  same  as  yesterday. 

Ofh. — Patient's  condition  remains  good. 

lOth. — The  pressure  symptoms  are  again  increasing.  He 
was  given  two  drops  of  oil,  which  caused  free  watery  stools. 

11th. — To-day  the  patient  is  in  fine  condition  and  will 
doubtless  recover.  His  mental  state  is  very  good  and  he  talks 
intelligently.  His  facial  paralysis  is  very  little,  there  are  slight 
dilatation  of  the  right  pupil  and  slight  convergent  squint  on  the 
right  side,  mouth  is  drawn  a  little  to  the  left,  and  the  tongue 
protrudes  slightly  to  the  right  side.    His  appetite  is  good. 

18th. — The  patient  has  had  the  oil  but  once  since  last  note. 
To-day  be  is  in  good  shape  and  bids  fair  to  be  out  in  a  few 
days. 

25th. — The  patient  was  discharged  cured  to-day  with  a  very 
satisfactory  result. 

lie  still  has  a  perceptible  squint  and  a  very  slight  tend- 
ency of  the  face  to  be  pulled  to  the  left  and  of  the  tongue 
to  protrude  to  the  right.  The  pupil  is  quite  normal.  His 
mental  condition  is  not  in  the  slightest  impaired. 

When  the  boy  was  last  seen  visiting  at  the  hospital,  he 
had  almost  completely  recovered  from  the  paralysis.  Doubt- 
less he  has  entirely  recovered  ere  this. 

During  the  whole  time  the  patient  was  in  the  hospital 
his  temperature  never  went  above  100°  F.    Most  of  the 


March  11,  1893.J 


LEADING 


ARTICLES. 


277 


time  it  was  near  normal.  The  pulse  also  was  normal  most 
of  the  time,  usually  becoming  a  little  slower  and  fuller  as 
the  facial  paralysis  indicated  pressure  upon  the  brain. 

This  is  the  only  case  of  fracture  of  the  base  of  the  skull 
that  I  have  treated  with  oleum  tiglii.  But  the  result  was  so 
satisfactory  and  its  beneficial  effects  were  so  evident  that  I 
shall  certainly  give  it  another  trial  at  my  first  ojiportunity. 

Each  and  every  time  the  oil  was  administered  the  de- 
lirium and  paralysis  diminished  and  the  patient's  condi- 
tion was  improved. 

Its  advantages  are : 

1.  It  is  easy  to  administer.  Frequently  it  is  difficult  to 
get  the  patient  to  swallow  anything  at  all.  This  is  easily 
given  on  the  tongue. 

2.  It  is  a  powerful  derivative. 

At  the  same  time  the  blood-vessels  of  the  alimentary 
tract  are  much  dilated  and  filled  with  blood.  Both  of 
these  results  so  diminish  the  blood  and  blood-pressure  in 
the  brain  that  inflammation  is  allayed  and  the  exudation 
absorbed. 

The  disadvantages  of  oleum  tiglii  are  : 

1.  It  is  very  apt  to  cause  the  bed  to  be  soiled  by  its 
precipitate  action.  This,  however,  can  generally  be  avoided 
by  giving  the  oil  in  the  morning  and  placing  the  patient  on 
a  good-sized  bed-pan  and  keeping  him  there  until  the  bow- 
els move,  which  time  will  vary  usually  from  half  an  hour  to 
two  hours.  Enough  oil  should  be  given  to  produce  free 
purgation. 

2.  Its  irritative  action  upon  the  alimentary  canal.  I 
do  not  believe  its  action  upon  this  tract  is  so  deleterious  as 
to  cause  much  trouble  when  the  oil  is  given  in  two-drop 
doses  not  oftener  than  each  second  or  third  day.  Of  course 
it  is  not  to  be  given  oftener  than  the  symptoms  demand. 
I  have  frequently  given  the  remedy  in  cases  of  delirium 
tremens  without  bad  eflEects  upon  the  digestive  organs.  In- 
deed, I  invariably  order  two  or  three  drops  of  the  oil  in  a  lit- 
tle pulverized  sugar  or  gum  acacia  in  beginning  delirium  tre- 
mens, and  also  after  the  symptoms  have  become  well  es- 
tablished, when  I  do  not  see  the  patient  before  that  time. 
I  have  always  secured  the  happiest  effect  with  but  little 
lasting  irritation.  It  is  wonderful  how  the  cerebral  con- 
gestion is  relieved,  and  how  the  nervousness  or  delirium 
disappears  under  this  treatment.  So  I  feel  that,  compared 
with  the  beneficial  results,  the  evil  effects  are  extremely  in- 
significant. I  do  not  think  any  of  the  milder  agents  are  to 
be  compared  with  the  oil. 

463  Fifth  Avenuk. 


A  Prize  in  Demography. — Mr.  .Joseph  Kiii  osi,  director  of  the  bureau 
of  statistics  of  the  eitv  of  Budapest,  has  estabUshed  a  prize  of  l,.5i)0 
francs  for  the  best  essay  on  the  object  and  progress  of  deinoj^raphy, 
whicli  may  be  written  in  (Jernian,  English,  French,  or  Italian,  and  shoidd 
be  sent,  without  anything  to  indicate  its  author's  identity,  to  Mr.  Korosi 
before  March  1,  18!i4. 

Taxes  on  Medicines  and  on  Alcoholic  Medicinal  Preparations. — 

Mr.  S.  M.  Burroughs  gave  a  dinner  at  the  Fulton  Club  on  Monday  even- 
ing, the  6th  inst.,  which  was  followed  by  a  meeting  to  set  forth  and 
discuss  the  objects  of  a  proposed  international  society  for  securing  the 
abolition  of  taxes  on  medicines  and  on  alcohol  to  be  used  in  the  prepa- 
ration of  medicines. 


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  11,  1893. 


THE  "NERVOUS  AMERICAN." 

The  American  is  nothing  if  not  good-natured.  He  pleads 
guilty  to  every  slander,  accepts  every  slight,  and  answers  surli- 
ness with  compliments.  This  he  ought  not  to  do,  and  it  is  re- 
freshing to  note  an  exceptional  act  on  his  part.  We  are  glad, 
therefore,  that  Dr.  Julius  Pohlman,  of  BuflFalo,  has  thought  it 
worth  while  to  gather  together  facts  that  go  far  to  show  that 
"the  rushing  American"  does  not  pay  the  penalty  of  incessant 
activity  by  premature  decay  and  death.  The  Medical  News  for 
March  4th  contains  a  most  interesting  article  by  Dr.  Pohlman 
on  the  Duration  of  Life  of  the  Nervous  American.  The  as- 
sumption, he  says,  that  increased  activity  and  greater  hurry 
mean  more  rapid  wearing  away  of  the  body  ignores  the  fact  that 
the  human  body  is  a  wonderful  piece  of  machinery,  not  only 
renewing  itself  constantly,  but  having  its  strength,  its  power 
of  endurance,  and  its  capacity  for  work  heightened  with  in- 
creased use  up  to  the  point  at  which  use  becomes  abuse.  The 
strength  of  an  organ,  he  adds,  is  determined  by  its  use,  whether 
the  statement  is  applied  to  the  brain  or  to  the  foot,  to  intellec- 
tual work  or  to  physical  labor. 

Excluding  general  statistics  as  being  susceptible  of  being 
"made  to  prove  opposite  problems,"  Dr.  Pohlman  has  con- 
cluded that  the  life-insurance  companies'  data  are  to  be  de- 
pended on.  "If,"  he  says,  "the  European's  lease  of  life  is 
longer  than  that  of  the  American,  then  the  insurance  com- 
pany will  insure  him  at  a  smaller  premium  than  his  American 
brother,  and,  if  the  latter  wears  out  faster,  it  would  be  a  sui- 
cidal policy  for  any  life-insurance  company  to  insure  him  at 
the  same  premium  at  which  the  risks  are  taken  in  Europe  on 
Europeans."  Accordingly,  he  has  taken  pains  to  obtain  infor- 
mation from  four  large  New  York  life-insurance  companies  do- 
ing business  in  both  Europe  and  America.  The  Equitable  says 
to  him:  "Our  rates  in  Europe  are  the  same  as  in  the  United 
States.  In  some  parts  of  Europe  we  charge  more,  but  it  is  not 
so  much  on  account  of  the  fear  of  extra  mortality  as  on  account 
of  the  onerous  conditions  under  which  wo  are  compelled  to  do 
business."  The  Mutual  says :  "  The  experiences  of  British  and 
German  companies  show  that  the  lives  which  were  insured  in 
those  companies  were  not  on  the  average  as  good  as  the  lives 
insured  in  American  companies.  The  experience  of  this  com- 
I)any  is  thus  far  quite  as  favorable  on  its  European  business  as 
on  its  business  in  this  country."  The  New  York  says:  "The 
rates  charged  in  nu)st  i)arts  of  Europe  and  Knghind  are  the 
same  as  those  charged  under  similar  conditions  in  this  coun- 
try." The  Geruiania  says:  "Our  premiums  are  liighor  in  Eu- 
rope than  in  America." 


278 


LEADING  ARTICLES.—. 


MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Jooh., 


After  giving  a  tabular  comparison  of  the  American's,  the 
Englishman's,  and  the  German's  expectation  of  life  at  different 
ages,  founded  on  data  collected  by  the  actuary  of  the  Gernia- 
nia  Life  Insurance  Company,  Dr.  Pohlinan  remarks  that  the 
figures  certainly  show,  so  far  as  life-insurance  statistics  go,  that 
the  American's  chances,  all  ages  considered,  are  a  little  better 
than  his  English  brother's  and  a  good  deal  better  than  the  Ger- 
man'ii,  in  spite  of  all  statements  about  climate  and  nervousness. 
We  Americans,  then,  have  "adapted  tlie  machinery  of  our  body 
to  a  liigh  speed  without  hurting  ourselves,  while  our  European 
brethren  dodge  along  at  a  low  pressure  without,  on  that  ac- 
count, prolonging  their  life." 

Still,  the  American  hoi/s  expectation  of  life,  up  to  the  age 
of  twenty,  is  somewhat  less  than  the  English  boy's  (the  figures 
for  Germans  under  twenty-one  years  old  are  not  given),  and 
leads  Dr.  Pohlman  to  ask  if  the  American  woman  is  a  less  capa- 
ble mother  than  her  English  sister.  "  Has  she,"  he  asks,  "in 
her  striving  for  fashionable  fads  and  foibles,  for  literary  crazes, 
women's  advance  clubs,  and  political  organizations,  ignored  or 
neglected  or  forgotten  the  first  and  most  important  function  of 
a  woman,  the  duties  of  motherhood?"  The  American  boy 
gains  on  the  English  boy  "from  year  to  year,  as  he  grows 
away  from  mother's  care  or  carelessness,  as  the  case  may  be." 
Therefore,  he  says,  let  us  not  impute  the  heavy  mortality  among 
our  children  to  the  climate,  but,  having  tried  to  find  out  how 
much,  if  anything,  that  factor  has  to  do  with  it,  set  to  work  to 
investigate  the  action  of  other  contributory  circumstances. 


THE  QUARTERING  OE  PERSONS  SUFFERING  FROM 
INFECTIOUS  DISEASE. 

An  institution  that  ought  to  be  provided  in  every  large  city 
is  a  comfortable  and  well-managed  refuge  for  persons  attacked 
with  some  infectious  disease  elsewhere  than  at  their  own 
homes.  New  York  is  thus  far  destitute  of  such  a  refuge.  To 
be  sure,  there  are  the  hospitals  in  East  Sixteenth  Street  and  on 
North  Brother  Island,  in  each  of  which  excellent  work  is  un- 
doubtedly done  in  the  care  of  persons  belonging  to  tlie  class 
from  which  the  wards  of  free  hospitals  are  for  the  most  part 
filled,  but  neither  of  them  is  a  place  to  which  a  well-to-do  per- 
son— man,  woman,  or  child — taken  ill  in  a  boarding-house  or 
hotel  would  like  to  be  taken.  It  is  not  right  for  the  community 
to  insist  that  he  shall  be  taken  to  such  a  place,  and  that  is  what 
it  [tractically  does  insist  upon  vk^hen  it  fails  to  provide  a  suitable 
resort — ong  where  there  is  comfort  as  well  as  safety.  The 
health  department  of  the  city,  clothed  as  it  is  with  very  great 
powers  to  act  in  such  cases,'doubtless  takes  this  view  of  the 
matter  when  it  refrains  froin  forcibly  conveying  a  sick  person 
to  one  of  the  hospitals  mentioned. 

It  hardly  falls  within  the  duty  of  the  municipality  to  furnish 
attractive  resorts  for  persons  sick  with  infectious  disease.  They 
should  be  provided  by  wealthy  and  benevolent  citizens  associ- 
ated for  the  purpose,  and  they  might,  we  think,  readily  be 
made  nearly  if  not  (juite  self-supporting.  An  element  of  gra- 
tuitous service  should  enter  into  their  management,  however. 


to  lift  them  above  the  level  of  mere  business  ventures,  if  for  no 
other  reason.  Instead  of  a  single  large  institution  for  the  re- 
ception of  persons  with  infectious  disease  of  whatever  sort, 
there  should  be  one  for  scarlet-fever  patients,  another  for 
typhus-fever  patients,  and  so  on;  for  it  would  be  calamitous  for 
a  person  attacked  with  measles  to  go  to  a  place  where  he 
would  be  pretty  sure  to  be  subjected  to  the  infection  of  diph- 
theria, for  example.  The  individual  buildings  need  not  be  far 
apart;  indeed,  they  might  all  be  grouped  aroimd  an  adminis- 
trative building  without  giving  ground  for  fear  of  spreading 
disease,  ])rovided  they  were  carefully  managed.  As  a  whole, 
the  institution  need  not  be  a  large  one  or  a  very  expensive  one. 
The  need  of  it  is  so  evident  that  we  hope  its  creation  will  before 
long  be  undertaken. 


MINOR  PARAGRAPHS. 

URETERECTOMY. 

At  a  recent  |meeting  of  the  Paris  Societe  de  chirurgie,  re- 
ported in  the  Union  medicale  for  February  18th,  M.  Reynier 
reported  a  case  of  nephropyosis  in  a  young  soldier.  Lumbar 
nephrectomy  was  performed  on  the  27th  of  May,  1892.  A 
portion  of  the  ureter  was  removed  with  the  kidney,  but  the  re- 
maining portion  of  that  canal  was  found  in  the  course  of  a  few 
days  to  be  the  source  of  a  purulent  discharge  that  escaped  from 
the  wound,  and  ^cystoscopy  showed  that  there  was  a  trickling 
of  pus  from  the  right  ureter  into  the  bladder.  On  the  29th  of 
June  an  attempt  was  made  to  remove  the  whole  remaining  por- 
tion of  the  ureter  by  the  lumbar  incision,  when  it  was  found 
possible  to  pull  out  from  sixteen  to  seventeen  centimetres  of  its 
length,  which  was  greatly  dilated.  Unfortunately,  the  ligature 
cut  through  its  coats,  and  a  fistula  persisted.  A  subsetjuent  at- 
tempt to  remove  what  stili  remained  of  the  ureter  by  Roux's 
ischio-rectal  (pararectal)  incision  proved  unsuccessful.  Finally, 
on  the  5th  of  November,  a  suprapubic  operation  was  under- 
taken, Petersen's  balloon  being  used  and  an  incision  made  like 
that  for  ligation  of  the  iliac  artery.  The  vas  deferens  was  taken 
as  a  guide  and,  the  junction  of  the  ureter  with  the  bladder  having 
been  reached,  a  ligature  was  applied  close  to  the  bladder  and  the 
twelve  centimetres  of  ureter  that  remained  were  removed.  The 
patient  made  a  good  recovery.  As  a  guide  to  the  situation  of  the 
ureter,  when  it  is  to  be  sought  for  by  an  incision  through  the 
anterior  abdominal  wall,  M.  Reynier  specifies  the  point  of  in- 
tersection of  a  line  drawn  between  the  two  anterior  superior 
iliac  spines  with  a  line  extending  vertically  upward  from  the 
pubic  spine. 


SUDDEN  DEATH  IN  PLEURISY. 

The  Lancet  for  February  25th  alludes  to  a  case  reported  by 
M.  Lesueur  in  the  Annee  medicale  de  Caen.  A  young  woman 
of  good  constitution  and  previous  good  health  was  attacked  with 
pleurisy  of  the  left  side,  with  an  abundant  eifusion.  On  the 
twelfth  day,  when  the  effusion  was  subsiding  satisfactorily,  she 
got  out  of  bed,  although  she  had  been  advised  not  to  do  so.  She 
soon  returned  to  bed  and  at  the  same  time  was  seized  with 
severe  pains  and  a  feeling  of  suffocation.  Her  lips  were  found 
to  be  blue  and  her  pulse  was  thready.  She  grew  less  and  less 
able  to  speak,  and  died  within  four  hours.  Various  explana- 
tions of  the  occasional  occurrence  of  sudden  death  in  pleurisy 
have  been  given.  In  this  case  no  disease  of  the  heart  or  lungs 
could  be  detected,  and  M.  Lesueur  suggested  that  the  death  was 
due  to  arrest  of  the  heart  by  reflex  irritation  of  the  cardiac 


March  11,  1893.] 


MINOR  PARAGRAPHS. 


279 


inhibitory  apparatus  by  reason  of  intercostal  neuritis,  althouirh 
he  admitted  that  it  iniglit  have  been  brought  about  by  asthenic 
syncope  consequent  on  the  premature  resumption  of  tlie  erect 
posture. 


THE  UTILITY  OF  GUM-LANCING. 

Apuopos  of  an  article  on  this  subject  in  the  December  num- 
ber of  the  University  Medical  Magazine,  Dr.  John  M.  Laiig- 
horne,  of  Uniontown,  Ala.,  writes  to  that  journal  to  the  effect 
that  in  an  experience  of  forty-seven  years  he  has  in  numerous 
instances  lanced  infants'  gums  in  cases  of  ditlicult  dentition,  and 
that  in  none  of  them  lias  it  produced  any  bad  effect,  but,  on  the 
contrary,  has  generally  been  followed  promptly  by  the  disap- 
pearance of  fever  and  fretfulness.  Dr.  Langhorne  closes  by  cit- 
ing a  curious  case  from  the  writings  of  the  late  Dr.  D.  Francis 
Gondie,  of  Philadelphia.  A  surgeon,  desirous  of  ascertaining 
the  condition  of  the  alveoli  in  a  child  that  apparently  had  died 
of  difficult  dentition,  made  a  free  incision  through  the  gums, 
"  whereupon  the  child  opened  his  eyes,  the  shroud  was  removed 
from  the  body,  and  by  careful  and  persevering  attention  tlie 
child's  life  was  saved." 


A  CASE  OF  ABSENCE  OF  THE  HUMERUS. 

At  a  recent  meeting  of  the  Imperio-Royal  Society  of  Physi- 
cians of  Vienna,  reported  in  the  Mercredi  medical^  Professor 
Billroth  showed  a  man,  thirty-four  years  old,  who,  in  spite  of 
the  entire  absence  of  the  shaft  of  the  humerus,  was  able  to  use 
his  arm  well  enough  to  perform  his  duties  as  a  coachman.  At 
the  age  of  five  years  he  had  been  thrown  down  by  a  carriage, 
which  passed  over  the  arm,  and  protracted  suppuration  fol- 
lowed. At  the  time  the  patient  was  shown,  the  humerus  was 
found  to  have  been  replaced  by  a  hard  cord,  as  large  as  the 
thumb,  probably  containing  the  blood-vessels  and  nerves  of  the 
arm  and  perhaps  some  of  its  muscles.  There  were  no  trophic 
disturbances  of  either  the  forearm  or  the  hand. 


STRYCHNINE  IN  THE  TREATMENT  OF  SNAKEBITES. 

The  Australasian  Medical  Gazette  for  January  gives  brief 
accounts  of  several  cases  of  the  successful  use  of  strychnine  in 
persons  suffering  from  the  bites  of  various  kinds  of  venomous 
snakes.  The  alkaloid  is  injected  subcutaneously  in  rather  large 
doses.  In  one  case,  that  of  a  girl  twelve  years  old,  a  fifteenth 
of  a  grain  was  injected  twice  within  the  space  of  ten  minutes. 
In  another  case,  one  of  tiger-snakebite,  of  which  the  Gazette 
hopes  to  give  a  full  account  in  its  February  issue,  ten  injections 
of  a  tenth  of  a  grain  each  were  given — a  grain  in  all.  This 
plan  of  treating  snakebites  is  credited  to  Dr.  August  Mueller, 
of  Yackandandah.  The  confidence  felt  in  it  is  shown  by  the 
fact  that  "  snakebite  antidote  pocket-cases  "  designed  specially 
for  its  emj)loyment  are  advertised  by  a  Sydney  instrument- 
maker. 


A  TRULY  VERMIFORM  APPENDIX. 

The  Boston  Medical  and  Surgical  Journal  for  MaiT.li  2d 
credits  Dr.  Parker  Syms  with  having  referred,  in  a  discussion 
at  a  meeting  of  the  New  York  Surgical  Society,  to  a  vermiform 
appendix  that,  having  come  into  view  in  the  course  of  an 
oophorectomy,  was  removed  because,  although  it  was  healthy, 
it  was  feared  that  its  great  length — over  five  inches — rendered  it 
apt  to  give  trouble  at  some  subsecjuent  time.  After  its  removal 
it  "continued  for  abotit  ten  minutes  to  squirm  and  turn  on  tlie 
plate  very  much  as  a  gruhworm  might  do,  and  finally  a  formed 
faecal  movement  took  place  from  it." 


A  NEW  METHOD  OF  INFLATING  THE  TYMPANUM. 

Dr.  T.  Pagan  Lowe  describes  m  the  British  Medical  Jour- 
nal for  February  25th  this  method  of  inflation  :  The  patient  is 
directed  to  hold  the  breath  at  the  end  of  a  deep  inspiration,  the 
lips  being  tightly  closed.  Air  is  tlien  forced  into  one  nostril 
with  a  syringe — preferably  a  four-ounce  ball  syringe  attached 
by  two  feet  of  soft-rubber  tubing  to  a  large  conical  hard-rubber 
nose  piece — the  other  nostril  being  compressed.  The  method 
is  recommended  as  an  alternative  in  case  Politzeration,  Valsal- 
va's method,  or  catheterism  is  impracticable  or  objectionable. 


CHOLERA  AT  MARSEILLES. 

In  view  of  the  fact  that  there  were  thirty-nine  deaths  from 
cholera  in  Marseilles  within  four  days  from  February  2d,  when 
the  existence  of  the  disease  there  was  officially  recognized,  Lyon 
medical  thinks  it  rather  optimistic  to  found  a  favorable  fore- 
cast on  the  comparatively  low  general  death  rate  reported.  More- 
over, it  says,  citing  the  Marseilles  correspondence  of  the  Mede- 
cine  moderne,  it  is  difficult  to  ascertain  the  number  of  cases,  for 
many  of  the  physicians  do  not  report  the  cases  of  recovery,  and 
even  in  death  certificates  do  not  give  the  disease  its  real  name, 
but  mention  it  by  such  titles  as  gastro-enterite,  diarrhee  choleric 
forme,  or  grippe  d  forme  intestinale. 


THE  CARE  OF  PUBLIC  URINALS. 

According  to  a  recent  article  in  the  Revue  d''hygiene,  sum-t 
marized  in  Lyon  medical,  a  Viennese  secret  preparation,  a  min- 
eral oil,  has  for  some  time  been  in  satisfactory  use  in  Berlin  as 
a  substitute  for  the  costly  and  inefficient  flow  of  water  to  com- 
bat incrustation  with  urinary  salts  and  their  ammoniacal  fer- 
mentation. The  urinal  is  painted  with  the  oil  every  day,  and  a 
small  amount  of  it  is  allowed  to  float  on  the  water  about  the 
outlet.  In  France  it  is  proposed  to  experiment  with  vaseline, 
paraffin,  or  some  other  fatty  petroleum  product. 


H^MOGALLOL  AND  H^MOL. 

In  the  Internationale  Minische  Rundschau,  No.  2,  1893, 
there  is  an  article  by  Dr.  Lang,  summarized  in  the  Deutsche 
Medizinal-Zeitung,  who  reports  excellent  results  from  the  use 
of  these  ferruginous  preparations.  Hajmogallol  he  has  em- 
ployed in  anjemia  following  protracted  rheumatism,  in  neuras- 
thenia dependent  on  anfemia,  in  anfemia  associated  with  corpu- 
lence, in  anajmic  subjects  of  heart  disease,  and  in  the  ansemia 
and  migraine  of  dyspeptics.  Hfemol  has  been  particularly  use- 
ful in  chlorotics. 


OCCASIONAL  UNILATERAL  EXOPHTHALMIA. 

The  Union  mhlicale  for  February  14th  gives  a  brief  account 
of  some  remarks  made  by  M.  Sergent  at  a  meeting  of  the  Paris 
Societe  de  biologic  on  the  occasion  of  presenting  a  man,  forty- 
four  years  old,  who  since  the  age  of  seven  had  had  exophthal- 
luia  on  the  left  side,  which  came  on  whenever  he  stooped  or 
made  an  efi'ort.  This  "  voluntary  "  exophthalmia,  so  to  s|)cak, 
was  venous  in  nature,  as  was  shown  by  the  efiVcts  of  compress- 
ing the  jugular  vein,  and  tliree  cases  of  the  kind  had  previously 
been  published. 

MENSTRUAL  BLOOD  AS  A  LOVE  POTION. 

The  Cincinnati  Lancet- Clinic  remarks  that  persons  of  color 
have  some  very  peculiar  ideas  on  the  subject  of  love  charms, 
but  avers  that  the  following  is  entirely  new  to  it:  The  woman 
mingles  some  of  her  menstrual  blood  with  the  ooftee  that  is  to 


280 


MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Med.  Joce., 


be  drank  by  her  lover  "  to  keep  him  true  and  excited."  "  We 
can  readily  see,"  says  the  Lancet- Clinic,  "how  the  latter  effect 
might  be  produced  were  he  cognizant  of  the  nature  of  the  ma- 
terial taken." 

NARCEINE. 

At  a  recent  meeting  of  the  Paris  Societe  de  therapeutique, 
reported  in  the  Union  medicale,  M.  Constantin  Paul  stated  that 
true  narceine  was  insoluble  and  inert.  Claude  Bernard  had 
employed  in  his  experiments  an  alkaloid  that  could  not  be  re- 
covered; it  was  more  soporific  and  less  i)oisonous  than  mor- 
phine. M.  Bardet  regarded  the  substance  used  by  Bernard  as 
complex,  and  said  that  ho  had  taken  fifteen  grains  of  the  nar- 
ceine of  the  present  day  without  noticing  any  effect. 


THE  INDIAN  MEDICO-CHIRURGICAL  REVIEW. 

The  number  of  medical  journals  recently  started  in  India 
and  Australasia  is  notable.  Not  the  least  among  those  that  have 
come  under  our  observation  is  the  Indian  Medico-chirurffiral 
Review,  a  monthly  edited  by  Dr.  N.  H.  Cboksy  and  published 
in  Bombay.  Tlie  first  number,  for  January,  1893,  contains 
sixty-sis  pages  of  reading  matter,  valu.ible  for  its  cliaracter  and 
variety. 

A  PILL  FOR  ANEMIA  WITH  CONSTIPATION. 

The  February  number  of  the  Practitioner  gives  the  follow- 
ing formula  of  a  pill  for  anicmia  with  constipation:  A  quarter 
of  a  grain  each  of  extract  of  nux  vomica  and  aloin,  half  a  grain 
each  of  powdered  myrrh  and  powdered  ipecac,  a  grain  of  dried 
iron  sulphate,  and  two  grains  of  extract  of  gentian.  One  such 
pill  is  to  be  taken  every  night. 


ITEMS,  ETC. 

Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  tlie  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  March  7,  1893  : 


DISEASES. 

Week  ending  Feb.  28. 

Week  ending  Mar.  7. 

Cases. 

Deaths. 

Cases. 

Deaths. 

11 

4 

15 

4 

11 

6 

15 

4 

180 

15 

199 

16 

Cerebro-spinal  meningitis.  . . . 

1 

3 

8 

4 

109 

5 

105 

4 

105 

33 

101 

26 

15 

2 

9 

2 

British  Precautions  against  Cholera. — The  British  Medical  Journal 
for  February  25th  f;ives  a  brief  account  of  a  conference  of  port  sani- 
tary authorities  held  in  London  on  the  \1t\i  ult.,  at  which  it  was 
resolved  : 

1.  That,  inasmuch  as  special  cholera  precautions  carried  out  by  the 
port  sanitary  authorities  are  for  the  benefit  of  the  whole  population, 
those  precautions,  as  far  as  they  are  special,  should  be  carried  out  at 
the  imperial  expense. 

2.  That  the  medical  inspection  of  all  ships  arriving  at  British  ports 
from  any  port  infected  with  cholera  should  be  kept  up  by  night  as  well 
as  day  as  far  as  practicable,  and  that  every  British  port  should  be  pro- 
vided with  staff  and  appliances  sufficient  for  this  purpose. 

3.  That  it  is  desiral)le  in  all  cases  that  power  of  detention  should  be 
obtained  of  all  vessels  coming  from  infected  ports. 

4.  Tliat  information  as  to  infected  ports  should  be  forthwith  issued 
hy  the  local  government  board  to  the  various  port  sanitary  authorities. 

5.  That  the  detention  of  the  medical  officer  of  health  on  board  a 
vessel  until  she  had  received  a  quarantine  certificate  was  objectionable 
and  should  be  abrogated. 


6.  That  statutory  power  should  be  obtained  to  penalize  false  answers 
given  by  the  masters  of  vessels  to  questions  put  by  the  authorities  as 
to  the  health  of  the  crew,  and  that  the  penalty  should  lie  increased. 

7.  That  power  should  be  obtained  to  require  all  vessels  (including 
fishing  vessels)  having  been  in  communication  with  infected  or  suspected 
ports  to  hoist  a  distinguisliing  signal  on  arrival. 

8.  That  the  quarantine  or  detention  of  vessels  having  no  sickness  on 
board,  and  so  certified  ljy  the  port  medical  officer,  is  unjustifiable. 

9.  That  there  should  be  an  alteration  of  the  cholera  regulations  en- 
abling addresses  of  destination  of  the  passengers  and  crews  of  vessels 
to  be  sent  direct  to  medical  officers  of  health. 

10.  That  the  crews  of  all  vessels,  while  in  infected  or  suspected 
ports,  should  be  prevented  from  going  ashore. 

11.  That  the  discharge  of  fresh-water  ballast  or  fresh-water  sand 
(whether  as  ballast  or  cargo)  from  an  infected  port  into  any  British 
port  should  be  prohibited. 

Columbia  College. — In  the  department  of  biology,  in  the  faculty  of 
pure  science,  Dr.  Bashford  Dean's  concluding  lectures  of  the  course  on 
The  Origin  and  Evolution  of  the  Fi.shes  will  be  given  on  Thursday,  the 
16th  (Chimaera  and  the  Lung-fishes;  the  Newbury  Collection  of  Giant 
Placoderms),  and  Thursday,  the  23d  inst.  (The  Embryology  of  Fishes). 
Mr.  Arthur  Willcy's  lectures  on  Amphioxus  and  Other  Ancestors  of  the 
Vertebrates  will  be  given  on  March  30th  and  April  6th,  13th,  20th, 
and  27th. 

A  Statue  of  the  late  Professor  Gross. — The  Alumni  Association  of 
the  Jefferson  Medical  College  has  appointed  a  committee  to  raise  funds 
for  the  erection  of  a  bronze  statue,  of  life  size,  of  the  late  Professor 
Samuel  D.  Gross,  M.  D.  About  $9,000  has  been  paid  into  the  treasury, 
and  $3,000  are  still  needed  to  complete  the  fund.  Checks  may  be 
drawn  to  the  order  of  J.  B.  Chapin,  M.  D. 

The  Jersey  City  Hospital  and  Dispensary. — An  examination  for  ap- 
pointment on  the  resident  staff  will  be  held  at  the  hospital,  comer  of 
Baldwin  Avenue  and  Montgomery  Street,  on  Wednesday,  the  29th  inst., 
at  12  M.    Candidates  must  be  graduates  in  medicine. 

The  Society  of  Medical  Jurisprudence. — At  the  next  meeting,  on 
Monday  evening,  the  13th  inst.,  S.  B.  Livingston,  Esq.,  of  the  New  York 
Bar,  will  read  a  paper  on  Suicide  and  Recent  Reactionary  Legislation. 

Change  of  Address. — Dr.  Calvin  Thayer  Adams,  to  No.  8  West 
Thirty-third  Street. 

Army  Intelligence. —  Official  List  of  Chanrjes  in  the  Stations  and 
Duties  of  Officers  servivg  in  the  Medical  Department,  United  States 
Army,  from  February  26  to  March  3,  1893 : 

MosELEY,  Edward  B.,  Major  and  Surgeon,  now  on  duty  in  Washington, 
will,  by  direction  of  the  Secretary  of  War,  report  in  person  to  the 
Surgeon- General  of  the  Army  for  duty  in  his  office  as  soon  as 
O'Reilly,  Robert  M.,  Major  and  Surgeon,  shall  report  for  duty  as 
attending  surgeon  in  this  city. 

The  suspension  of  the  order  directing  O'Reilly,  Robert  M.,  Major  and 
Surgeon,  to  report  for  duty  as  attending  surgeon  in  this  city,  is,  by 
direction  of  the  Secretary  of  War,  remo\  ed. 

O'Reilly,  Robert  M.,  Major  and  Surgeon,  having  reported  to  the  Major- 
General  Commanding  the  Army,  is  assigned  to  duty  as  attending 
surgeon  in  this  city,  to  date  from  February  28,  1893. 

Bartholf,  John  H.,  Major  and  Surgeon,  is  granted  leave  of  absence  for 
six  months,  to  take  effect  March  13,  1893,  with  permission  to  go  be- 
yond sea. 

Society  Meetings  for  the  Coming  Week : 

Monday,  J/a>-<7(  ISth:  New  York  Ophthalmological  Society  (private); 
New  York  Medico-historical  Society  (private) ;  Society  of  Medical 
Jurisprudence ;  New  York  Academy  of  Sciences  (Section  in  Chem- 
istry and  Technology) ;  Lenox  Medical  and  Surgical  Society  (private) ; 
Boston  Society  for  Medical  Improvement ;  Gyniccological  Society  of 
Boston;  Burlington,  Vt.,  Medical  and  Surgical  Club;  Norwalk, Conn., 
Medical  Society  (private);  Baltimore  Medical  Association. 

Tuesday,  March  llylh :  New  York  Academy-  of  Medicine  (Section  in 
Genito-urinary  Surgery) ;  New  York  Medical  Union  (private) ;  Kings 


March  11,  1893.J 


LETTERS  TO  THE  EDITOR.— PROCEEDTNOS  OF  SOCIETIES. 


281- 


County  Medical  Association ;  Medical  Societies  of  tlie  Couuties  of 
CheniUBg  (quartevly — Elmiia),  Rensselaer,  and  Ulster  (quartevly), 
N.  Y. ;  Newark,  N.  J.,  and  Trenton  (private),  N.  J.,  Medical  Asso- 
ciations; Northwestern  Medical  Society  of  Philadelphia;  Baltimore 
(iyniECological  and  Obstetrical  Society. 
Wednesday,  March  15th:  Northwestern  Medical  and  Surgical  Society 
of  New  York  (private) ;  Medico-legal  Society ;  Harlem  Medical  As- 
sociation of  the  City  of  New  York ;  Medical  Society  of  the  County 
of  Alleghany  (quarterly),  N.  Y. ;  New  Jersey  Academy  of  Medicine 
(Newark). 

Thursday,  March  IGth :  New  York  Academy  of  Medicine ;  Brooklyn 
Surgical  Society ;  New  Bedford,  Mass.,  Society  for  Medical  Improve- 
ment (private). 

Friday,  March  17th:  New  York  Academy  of  Medicine  (Section  in 
Orthoi)a;dic  Surgery);  Baltimore  Clinical  Society;  Chicago  Gyiia;- 
cological  Society. 

Saturday,  March  ISth :  Clinical  Society  of  the  New  York  Post-gradu- 
ate Medical  School  and  Hospital. 


fetters  t0  i\t  (gbitor. 


WOUNDS  WITHOUT  INJURY  TO  OVERLYING  CLOTHING. 

520  Olive  Street,  St.  Louis,  Mc,  February  28,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sie:  In  the  Journal  of  February  25th  mention  is  made  of  a 
case  of  a  man  sustaining  a  lacerated  wound  resembling  a  stab 
that  had  been  inflicted  without  injury  to  the  clothing  covering 
the  part,  reported  in  the  Lancet  of  recent  date.  The  remark  at 
the  end  of  the  paragraph  that  well-attested  instances  of  this 
sort  are  of  important  medico-legal  significance  has  led  me  to 
mention  my  own  experience. 

Some  ten  years  ago,  being  on  a  hunting  trip  in  a  very  thick 
country  where  it  was  often  necessary  to  cut  away  the  thick 
growth  in  our  trips  through  the  woods,  I  had  formed  the  habit 
of  carrying  a  small  hatchet  stuck  in  my  belt.  While  following 
game  down  a  rather  steep  hill  I  had  tlie  misfortune  to  trip  over 
a  vine  and  fall  forward  quite  heavily,  driving  the  blade  of  the 
hatchet  violently  against  my  thigh.  Upon  regaining  ray  feet  I 
felt  for  the  cut  in  my  hunting  trousers,  but,  not  finding  any, 
naturally  concluded  that  I  had  not  been  cut,  and  went  on  my 
way.  My  thigh  pained  me  some,  but  I  attributed  it  to  a  bruise, 
but  after  a  while  I  was  astonished  to  find  that  my  thigh  was 
quite  wet,  and  after  removal  of  my  clothing  found  that  I  had 
sustained  a  cut  about  three  quarters  of  an  inch  in  length.  I 
then  carefully  examined  my  trousers  for  a  cut,  but  could  find 
none. 

The  wound  was  a  lacerated  one,  and  I  concluded  had  been 
made  by  the  corner  of  the  hatchet-blade  driving  the  clothing 
ahead  of  it.  The  scar  covering  tlie  wound  is  nearly  as  broad  as 
it  is  long.  George  M.  Wagner,  M.  D. 

THE  "ELECTRICAL  NOVELTY." 

1)1  Storm  Avenue,  Jersey  City,  March  6,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  I  was  very  much  surprised  to  see  printed  in  the  last 
issue  of  the  New  York  Medical  Journal  a  letter  in  which  my 
name  is  mentioned,  and  which  is  signed  K.  C>.  Rutherford.  It 
surprised  me,  simply  because  I  did  not  know  you  admitted  com- 
munications exactly  of  that  type  into  your  columns. 

In  hastily  glancing  it  over,  the  only  matter  at  all  deserving 
my  attention — and  one  which  does  me  groat  injustice,  if  not  al- 
ready even  seriou.s  injury  with  the  public — is  the  insinuation,  or 


assertion  (I  don't  remember  which,  as  I  have  not  a  copy  of  the 
Journal  to  refer  to),  that  I  am  interested  in  the  manufacture  of 
some  particular  shoe.  I  beg  to  ask  space  in  your  earliest  issue 
to  say  that  I  am  not  either  directly  or  indirectly  connected  with 
or  interested  in  anything  whatever  of  the  kind;  but,  on  the  con- 
trary, am  offering  the  public  all  the  information  of  which  I  am 
capable  on  the  subject  on  which  I  write,  my  only  reward  being 
the  price  which  the  various  publishers  are  willing  to  i)ay  me  for 
my  articles. 

I  am  deeply  sensible  of  your  courtesy  in  allowing  me  space 
in  the  past  to  offer  my  views  on  the  importance  of  electrical 
earth-connection  as  a  necessary  condition  to  human  health ;  and 
am  perfectly  happy  for  the  present  in  leaving  the  matter  where 
it  stands  so  far  as  your  valuable  journal  is  concerned. 

George  Quarrie. 

We  can  not  allow  this  controversy  to  be  further  con- 
tinued in  our  columns. 


Uroteftrings  of  Societies. 

MEDICAL  SOCIETY  OF  THE  STATE  OF  NEW  YORK. 

Eighty -serenth  Annual  Meeting held  in  Albany  on  Tuesday, 
Wednesday.,  and  Thursday,  February  7,  8,  and  9,  1893. 

The  President,  Dr.  Lewis  S.  Pilcher,  of  Brooklyn,  in  the  Chair. 

{Vontimicd  from  page  S52.) 

The  Report^of  the  Committee  appointed  to  consider  the 
Recommendations  in  the  Inaugural  Address  was  as  follows 
The  recommendation  that  the  regents  reipiire  of  candidates  for 
the  degree  of  doctor  in  medicine  that  they  should  have  attend- 
ed at  least  three  cases  of  labor,  and  furnish  suitable  evidence  of 
the  same,  was  approved. 

The  committee  regarded  the  present  law  concerning  medical 
examinations  as  satisfactory,  with  the  foregoing  exception,  and 
hoped  that  the  society  would  so  record  itself. 

The  recommendation  that  the  annual  meetings  of  the  county 
societies  be  held  in  the  month  of  May  was  approved. 

The  committee  recommended  that  in  future  the  society 
should  determine  in  each  case  of  alleged  unprofessional  conduct 
whether  such  allegation  was  well  founded,  the  charges  to  be 
referred  to  a  committee  on  ethics,  and  that  the  present  by  law 
which  referred  to  a  code  of  ethics  be  dropped. 

It  was  also  resolved  that  it  would  be  unwise  to  appoint  a 
committee  of  conference  as  suggested  by  the  American  Medical 
Association,  and  it  was  hoped  tiiat  that  association  would  take 
such  steps  as  would  remove  the  technical  ditierences  which  pre- 
vented the  most  cordial  relations  between  the  two  bodies. 

The  report  was  unanimously  adopted,  the  portion  referring 
to  the  code  being  substituted  in  the  by-laws  for  that  portion 
which  had  been  dr()])pc<l. 

The  Report  of  the  Committee  on  Legislation  approved 
of  the  present  law  relating  to  medical  education.  It  was  be- 
lieved that  there  was  no  occasion  for  the  formation  of  new 
medical  colleges  in  this  State,  and  that  the  laws  on  this  subject 
should  be  very  stringent.  It  was  believed  that  i)hysicians 
should  be  the  princi])al  and  controlling  members  on  local  and 
State  boards  of  healtii,  and  that  the  statute  that  prevented  a 
physician  from  holding  tlie  presidency  of  a  local  board  of  health 
should  be  repealed.  It  was  reported  as  an  evidence  of  progress 
that  the  testimony  of  jiliy.-icians  required  in  courts  of  law  could 
now  be  taken  in  the  office  of  lawyers  or  referees,  so  that  the 


282 


FROGEEDINOS 


OF  SOCIETIES. 


|N.  Y.  Med.  Jodk., 


necessity  of  losing  time  hy  waiting  in  court  rooms  was  over- 
come. 

Tliis  report  was  adopted. 

The  Committee  appointed  to  consider  Matters  relating 
to  Public  Health  reported  favorably  concerning  tlie  re-estab- 
lishment of  a  national  board  of  health,  and  offered  a  resolution 
that  the  question  of  quarantine  be  lodged  entirely  witli  the 
national  Government.  It  was  also  recommended  that  a  com- 
mittee of  seven  members  of  the  society  be  appointed  to  confer 
with  the  committee  from  the  New  York  Academy  of  Medicine 
which  bad  the  same  subject  under  advisement,  and  that  Con- 
gress be  petitioned  to  pass  a  suitable  and  comprehensive  quar- 
antine law  during  the  present  session. 

The  Management  of  Suppuration  complicating  Tuber- 
culous Disease  of  the  Bones  and  Joints.— Dr.  V.  P.  Gibney, 
of  New  York,  observed  that  rest  and  suitable  protection  of  tu- 
berculous joints,  when  used  at  the  right  time,  were  valuable 
measures.  The  rest  which  was  to  be  obtained  by  certain  forms 
of  splints  was  very  desirable.  If  the  case  was  seen  early  in  the 
history  of  the  disease,  and  was  properly  cared  for,  recovery 
might  take  place  without  suppuration ;  on  the  other  hand,  a 
case  might  terminate  in  suppuration  no  matter  how  it  was  cared 
for.  The  surgical  rule  to  remove  pus  wherever  found  did  not 
apply  to  cold  abscesses,  but  the  latter  could  now  be  attacked 
fearlessly  since  the  era  of  antisepsis,  even  when  involving  the 
large  joints.  Aspiration  of  small  abscesses  of  the  joints  was 
favored,  three  to  six  operations  being  usually  necessary  before 
a  cure  could  be  expected.  Of  the  patients  that  were  operated 
upon  in  this  way,  fifty  per  cent,  were  cured;  the  remainder  re- 
quired some  form  of  bone  operation.  The  rule  concerning  op- 
erations should  be  non-interference  unless  one  was  equipped  for 
the  performance  of  as  complete  and  thorough  an  antiseptic  op- 
eration as  might  be  retjuired.  Excision  of  bone  was  not  indi- 
cated in  all  cases  in  which  the  bone  was  diseased.  The  most 
favorable  cases  for  operation  were  those  in  which  the  abscess 
was  in  the  gluteal  region,  for  the  opportunities  for  drainage  in 
this  location  were  good.  The  least  favorable  cases  were  those 
where  the  abscess  was  on  the  inner  side  of  the  thigh,  in  which 
the  opportunities  for  drainage  were  poor.  Only  a  small  per- 
centage of  cases  presented  favorable  opportunities  for  partial 
arthrectomies  and  gouging  of  bone.  It  was  never  necessary  to 
amputate  the  leg  in  children  for  tuberculous  disease  of  the 
ankle  joint.  In  tuberculous  disease  of  the  spine  a  suitable 
splint  would  be  found  useful  for  a  long  time.  The  following 
rules  would  be  found  serviceable:  Tuberculous  joints  should 
be  protected  in  the  early  stages  of  tLe  disease,  and  subsequently 
aspiration  or  incision  should  be  practiced.  Small  abscesses 
could  be  disregarded  or  aspirated.  Fifty  per  cent,  of  the  cases 
of  aspiration  resulted  in  recovery.  The  question  of  excision  of 
joints,  especially  the  hip  joint,  must  depend  upon  the  condition 
of  the  patient.  The  expectant  treatment  was  most  suitable  for 
cases  of  disease  of  the  knee  and  ankle. 

Dr.  RoswELL  Park,  of  Buffalo,  took  the  ground  that  patho- 
logical knowledge  was  a  safer  guide  than  clinical  experience 
witliout  it  in  the  treatment  of  tuberculous  disease  of  the  joints. 
As  to  the  comparative  value  of  orthopaedic  apparatus  and  op- 
erative interference,  the  latter  was  often  to  be  preferred,  be- 
cause it  greatly  shortened  the  duration  of  the  disease.  The 
speaker  was  not  favorable  to  the  treatment  by  injection  of  iodo- 
form and  glycerin  into  the  joints.  Those  who  were  cured  by 
this  treatment  could  be  cured  as  well  by  other  methods.  The 
pain  of  tuberculous  joints  was  often  to  be  relieved  by  ignipunc- 
ture.  The  operation  of  asi)iration  should  be  attempted  only 
when  full  preparations  had  been  made  for  the  performance  of  a 
more  extensive  operation  if  it  was  required.  In  certain  cases 
the  use  of  chloride  of  zinc,  tuberculin,  or  guaiacol  would  be 


found  efficient,  notwithstanding  the  prevalent  skepticism  upon 
that  subject.  Surgical  procedures  were,  on  the  whole,  regarded 
as  the  most  suitable  for  the  class  of  diseases  under  discus-sion, 
and  it  should  always  be  the  rule  to  remove  all  tissue  that  was 
in  the  least  suspicious.  The  general  rule  to  remove  pus  wher- 
ever found  did  not  necessarily  ap[)ly  to  cold  abscesses,  because 
the  constituents  of  such  abscesses  were  not  the  same  and  were 
not  equally  infectious  with  those  of  acute  abscesses. 

Dr.  Louis  A.  Weioel,  of  Rochester,  observed  that  the  gen- 
eral and  the  orthopiedic  surgeon  differed  particularly  as  to  their 
predilections.  There  were  two  varieties  of  orthopajdists— one 
of  them  favoring  the  use  of  mechanical  supports,  and  the  other 
a  combination  of  the  mechanic  and  the  surgeon.  The  latter 
was  the  one  who  got  the  best  results.  The  expectant  treatment 
was  advocated  for  certain  conditions  of  bone  disease;  if  it  was 
to  be  interpreted  as  doing  nothing,  it  was  an  undesirable  method. 
In  some  cases  the  most  effective  conservatism  would  consist  in 
the  use  of  the  knife.  The  element  of  time  should  not  be  disre- 
garded with  children,  as  it  too  frequently  was.  If  their  time 
was  not  as  valuable  intrinsically  as  that  of  adults,  the  longer  a 
disease  lasted  the  greater  was  the  expense  in  tissues  and  vital 
force.  The  argument  was  often  used  that  operations  were  per- 
formed upon  hospital  children  to  shorten  the  i)eriod  of  treat- 
ment. The  treatment  in  such  cases  was  very  productive  of 
good  results.  If  the  argument  was  valid  for  the  children  of  the 
poor,  why  was  it  not  equally  so  for  the  children  of  the  well-to- 
do?  Three  questions  which  were  very  important  for  the  con- 
sideration of  orthopaedists  were  r  Did  the  so-called  conservative 
treatment  of  tuberculous  disease  at  the  hip  joint  pi-oduce  short- 
ening of  the  limb  ?  Was  such  treatment  likely  to  lead  to  de- 
struction of  the  joint?  What  were  the  probabilities  of  infec- 
tion after  an  operation  had  been  performed  upon  a  tuberculous 
joint  ? 

Dr.  Henry  Lixg  Taylor,  of  New  York,  said  that  the  con- 
tents of  a  cold  abscess  were  not  pus,  but  an  emulsion  of  the  de- 
generated products  of  tubercular  granulation  ;  infection  with  the 
microbes  of  suppuration  might  complicate  the  original  condi- 
tion. He  wished  in  his  paper  to  emphasize  the  paramount  im- 
portance of  adequate  treatment  of  the  focal  tuberculosis  upon 
which  such  abscesses  primarily  depended.  Their  course  was 
benign  in  the  large  majority  of  cases,  if  the  diseased  joint  or 
spine  was  given  positive  mechanical  protection  according  to 
modern  methods.  He  cited  numerous  authorities  to  show  that 
when  this  was  thoroughly  done  such  abscesses  were  much  less 
likely  to  occur,  and  that  when  they  did  occur  they  were  much 
more  amenable  to  treatment  on  any  rational  plan. 

In  regard  to  the  local  treatment  of  the  abscess  itself,  in  cases 
of  acute  abscess — true  supi)uration — early  evacuation  and  the 
employment  of  means  proper  to  render  the  cavity  aseptic  were 
indicated.  In  addition  to  the  usual  solutions,  peroxide  of  hy- 
drogen had  pi-oved  itself  a  valuable  pus-killer.  In  cold  abscess 
the  author's  preference  was  in  most  cases  for  early  evacuation, 
using  peripheral  compression  and  drainage  if  necessary.  He  had 
a  high  opinion  of  the  value  of  iodotoi'm,  but  a  rather  poor  ojnn- 
ion  of  the  aspirator,  since  it  was  easily  clogged.  The  more  thor- 
oughly strict  mechanical  protection  to  the  diseased  joint  was 
used,  the  less  frequently  would  the  severer  operations  be  re- 
quired, the  less  would  be  the  danger  when  they  were  employed, 
and  the  more  favorable  would  be  the  result. 

The  Pathology  of  Carcinoma  was  the  title  of  a  paper  by 
Dr.  II.  C.  Cos,  of  New  York.  Much  had  been  hoped  for  from 
bacteriology  in  regard  to  the  elucidation  of  the  i)athology  of 
carcinoma  which  had  not  yet  been  realized.  A  variety  of  opin- 
ions was  (juoted  with  reference  to  the  nature  of  the  epithelium 
in  cancer.    The  real  cause  still  remained  unknown. 

Self-inoculability  in  cancer  was  the  same  kind  of  a  phenome- 


Marcli  11,  1893.] 


MISCELLANY. 


283 


non  as  metastasis.  Billroth"s  idea  was  that  cancer  was  a  para- 
sitic disease;  that  the  disease  must  develop  from  the  exposure  of 
epithelial  cells  to  external  infection.  The  metastatic  extension 
of  tlie  disease  was  to  be  distinguished  from  its  extension  direct- 
ly, and  could  be  accomplished  only  tiirougli  tiie  lymphatic  sys- 
tem. Cacliexia  in  cancer  must  be  regarded  only  as  an  evidence 
of  a  degenerate  condition  of  the  system.  Persistent  local  irri- 
tation was  powerful  as  a  causative  factor,  but  it  was  supple- 
mentary to  some  other  influence  as  yet  unknown.  In  the  hard 
form  of  cancer  there  was  an  apparent  change  from  a  malignant 
to  a  quasi-beiiign  condition.  This  ])roces3  was  a  very  interest- 
ing one  and  might  (continue  in  a  given  case  for  a  long  time.  The 
only  efficient  form  of  prophylaxis  yet  known  consisted  in  the  re- 
moval of  all  tissues  which  could  be  suspected  of  malignancy. 
Whether  a  specific  treatment  of  cancer  was  possible  could  not 
be  definitely  answered.  The  best  method  of  treatment  con- 
sisted in  the  early  and  complete  removal  of  all  diseased  tissues, 
and  it  was  difficult  to  define  in  a  given  case  the  limit  of  the  in- 
filtration of  the  germs  ot  the  disease. 

The  Parasitic  Theory  ot  the  .Sltioloev  of  Carcinoma  was 
the  title  of  a  paper  by  Ur.  Koswell  Park.    (See  page  233.) 
The  Value  of  Internal  Medication  in^the  Treatment^ot 

Carcinoma. — Dr.  Jarvis  S.  Wright,  of  Brooklyn,  read  a  paper 
on  this  subject.  Gould  medicine  be  of  any  use  in  the  preven- 
tion and  cure  of  malignant  disease?  Cancer  and  sarcoma  were 
probably  due  at  the  outset  to  local  [infection,  and  prevailed  es- 
pecially in  cases  in  which  the  cells  were  senile.  Surgical  treat- 
ment should,  theoretically,  be  effective  if  the  operation  was 
sufficiently  extensive.  The  habitat  of  the  micro-organism  of 
cancer  could  not  be  determined  until  it  was  determined  what 
the  micro-organism  was.  In  the  way  of  medical  treatment, 
some  cases  were  benefited  by  the  use  of  bichloride  of  mercury, 
iron,  arsenic,  etc.  It  was  even  possible  that  some  cases  might 
be  cured  by  such  treatment.  The  speaker  had  seen  very  good 
results  from  the  iuternal  use  of  bromide  of  arsenic  and  carbonate 
of  calcium.  Medicines  should  be  used  in  cancer  on  the  same 
general  principle  on  which  they  were  used  in  other  diseases, 
and  the  time  would  come  when  the  substance  would-be  found 
which  had  an  affinity  for  the  germs  of  the  disease. 

The  Results  Obtainable  from  the  Use  of  Aniline  Prod- 
ucts in  Carcinoma. — Dr.  Willy  Meter,  of  New  York,  in  a 
paper  thus  entitled,  said  that  patients  with  cancer  in  an  incura- 
ble form  should  not  be  turned  aside  as  requiring  no  attention 
any  more  than  those  who  had  other  incurable  diseases.  This 
thought  furnished  ground  for  the  use  of  the  aniline  dyes,  espe- 
cially fuclisi(ie  and  pyoctanin,  also  [erysipelas  inoculation,  and 
the  subcutaneous  injection  of  neurin.  Aniline  dyes  in  the 
treatment  of  cancer  had  first  been  recommended  by  von  Mosetig 
Moorhof,  and  his  work  had  suggested  the  reader's  experiments. 
Pyoctanin  was  prepared  in  various  forms,  in  two  colors — blue 
and  yellow.  It  was  not  poisonous,  and  could  be  used  internally 
in  doses  of  ten  or  twelve  grains.  Its  analgesic  effect  was  very 
marked,  and  in  some  instances  enabled  one  to  dispense  entirely 
with  mor[)hine.    Locally  it  caused  breaking  down  of  ulcerated 

1   tissues,  while  the  cachexia  attending  the  disease  was  relieved. 

I  In  unbroken  tissues  its  effect  was  to  cause  diminution  of  ffide- 
ma,  then  the  breaking  down  and  discharge  of  diseased  tissue. 

i  The  epithelial  cell-;  and  their  nuclei  were  not  affected  by  the 
substance  under  discussion.  Adamkiewicz  held  the  opinion 
that  cancer  was  a  parasitic  disease.  The  treatment  was  usually 
only  palliative;  in  ten  per  cent,  of  cases  it  had  been  curative. 

Caustics  in  the  Treatment  of  Carcinoma.— Dr.  Daniel 
Lewis,  of  New  York,  in  a  j)a[)er  with  this  title,  ap[)roved  of  the 
use  of  the  knife  in  all  operable  cases.  If  caustics  were  used  at 
all,  he  favored  only  the  potential  caustics.  Unna  and  Duliriug 
had  recommended  that  only  mild  caustics  should  be  used,  on 


the  ground  that  too  much  irritation  was  caused  by  the  more 
powerful  ones.  The  author  did  not  agree  to  this  view.  Caus- 
tics were  not  admissible  in  the  treatment  of  cancer  of  the  breast, 
and  but  seldom  in  the  treatment  of  cancer  of  the  uterus. 

The  Knife  in  the  Treatment  of  Carcinoma.— Dr.  N.  Ja- 
coBSON.  of  Syracuse,  was  in  favor  of  this  method  of  treatment, 
and  believed  tha,t  it  should  always  be  used  as  thoroughly  as 
possible.  Partial  operations,  partial  removal  of  diseased  organs, 
were  not  desirable. 

{To  be  continued.) 


The  Eleventh  International  Medical  Congress. — The  inauguration 

of  the  congress  will  take  place  on  the  '2-lth  of  8e[)tember,  180.3,  in  the 
presence  of  H.  M.  the  King  of  Italy.  The  work  of  the  congress  will 
begin  in  the  nineteen  sections  on  the  morning  of  the  2.5th  of  September. 
It  will  be  continued  in  accordance  with  the  arrangements  to  be  made 
and  published  both  for  the  general  sessions  and  for  the  sections.  Some 
of  the  general  sessions  will  be  devoted  to  scientific  addresses  delivered 
by  scientists  of  all  nations. 

List  of  the  Series. — Anatomy  ;  Phy.siology  ;  General  Pathology  and 
Pathological  Anatomy ;  Pharmacology ;  Internal  Medicine  ;  Diseases  of 
Children  ;  Psychiatry,  Neuropathology,  and  Criminal  Anthropology ; 
Surgery  and  Orthopa'dy  ;  Obstetrics  and  Gynaecology  ;  Laryngology  ;  Otol- 
ogy ;  Ophthalmology  ;  Odontology  ;  Military  Medicine  and  Surgery  ;  Hy- 
giene ;  Sanitary  Engineering;  Dermatology  and  Syphilidology  ;  Forensic 
Medicine ;  Hydrology  and  Climatology. 

Regulations. — 1.  The  Eleventh  International  Medical  Congress  will 
be  inaugurated  in  Rome,  on  the  24th  of  September,  1893,  and  will 
close  on  the  1st  of  October. 

2.  Any  physician  may  become  an  active  member  of  the  congress  by 
fulfilling  the  conditions  of  membership,  inscribing  his  name,  and  secur- 
ing his  admission  ticket. 

3.  Scientists  of  other  professions  who,  through  their  special  studies, 
are  interested  in  the  labors  of  the  congress  may  acquire  the  rights  and 
assume  the  duties  of  active  members,  and  participate  in  the  work  of 
the  congress,  both  by  communications  and  by  discussions. 

4.  The  fee  for  admission  to  the  congress  is  twenty-five  francs,  or 
five  dollars.*  It  entitles  to  a  copy  of  the  Tratisactions  of  the  congress, 
which  will  be  forwarded  to  the  members  immediately  after  publication. 

5.  The  character  of  the  congress  is  strictly  and  exclusively  scientific. 

6.  The  work  of  the  congress  will  be  divided  among  nineteen  sec- 
tions ;  every  member  is  requested  to  indicate,  on  paying  his  admission 
fee,  the  section  for  which  he  desires  to  be  inscribed. 

7.  The  provisional  committee  will  arrange  the  appointment,  in  the 
opening  session,  of  the  permanent  officers.  There  will  be  a  president, 
three  vice-presidents,  a  number  of  honorary  presidents,  and  secreta- 
ries. Each  section  will  elect  in  its  first  meeting  its  president  and  a 
certain  number  of  honorary  presidents,  who  shall  alternately  take  the 
chair  during  the  session.  Some  of  the  secretaries  will  be  chosen  from 
among  the  foreign  members,  in  order  to  facilitate  the  recording  both  of 
communications  and  of  discussion.s  in  the  dift'erent  languages. 

8.  There  will  be  daily  sessions,  either  general  or  sectional.  The 
times  and  numbers  of  the  general  sessions  and  the  business  to  be  trans- 
acted in  them  will  be  arranged  by  the  president  of  the  congress. 

9.  The  general  sessions  are  reserved  (a)  for  the  consideration  of  the 
common  work  of  the  congress  and  of  its  common  interests ;  (6)  for  ad- 
dresses and  communications  of  general  interest  and  importance. 

10.  The  addresses  in  the  general  sessions  and  in  such  extraordinary 
sessions  as  may  be  arranged,  will  be  delivered  by  members  chosen  by 
the  committee  for  the  purpose. 

11.  Papery  for  and  communications  to  the  congress  must  be  an- 

*  Money  order  or  check  to  the  treasurer.  Professor  Comm.  L.  Pa- 
gliani,  Rome,  Italy. 


284 


MISCELLANY. 


[N.  Y.  Med,  Jocb., 


nounced  on  or  before  June  30,  1893.  A  brief  abstract  of  every  paper 
and  communication,  with  their  conclusions,  must  l)e  sent  to  the  com- 
mittee on  or  before  July  31st.  All  of  them  will  be  printed  and  dis- 
tributed to  the  members  by  authority  of  the  president.  Such  as  arrive 
after  that  date  can  not  be  expected  to  find  a  place  on  the  regular  order 
of  business,  and  will  be  accepted  only  if  time  will  permit. 

1 2.  The  business  of  the  sections  will  be  arranged  by  their  presi- 
dents, who  will  also  determine  the  hours  of  meeting,  avoiding  those  re- 
served for  the  general  sessions.  Two  or  more  sections  may  hold  joint 
meetings  with  the  consent  of  their  presidents.  There  will  be  no  vote 
on  scientific  questions. 

13.  Fifteen  minutes  are  allowed  for  the  reading  of  a  paper  or  com- 
munication. In  the  discussion  every  speaker  can  have  the  floor  but 
once,  and  for  five  minutes  only.  To  close  the  discussion  the  author  of 
the  paper  is  allowed  ten  minutes.  Additional  time  may  be  given  him  by 
the  president,  by  special  resolution  of  the  section,  if  the  importance  of 
the  subject  under  discussion  appears  to  require  it. 

14.  The  manuscript  of  all  addresses,  papers,  and  communications 
read  either  before  a  general  session  or  a  section  must  be  handed  to  the 
secretary  before  the  close  of  the  meeting.  A  special  committee  on  pub- 
lication appointed  by  the  president  will  decide  which  or  what  i)art  of 
them  shall  be  i)ublished  in  the  Transactions  of  the  congress.  Such  mem- 
bers as  participated  in  the  discussions  are  re(iuired  to  hand  to  the 
secretaries  their  remarks  in  writing. 

15.  The  official  languages  of  the  sessions  are  Italian,  French,  Eng- 
lish, and  German.  The  regulations,  programmes,  and  daily  bulletins 
will  be  published  in  these  four  languages.  During  the  meetings,  how- 
ever, a  member  may  be  permitted  to  use,  for  a  brief  remark,  any  other 
language,  provided  some  member  present  expresses  his  willingness  to 
translate  such  remarks  into  any  of  the  official  languages. 

16.  The  president  directs  the  discussions  according  to  the  parlia- 
mentary rules  generally  obeyed  in  similar  assemblies. 

17.  Persons  not  classified  under  Article  3,  who  are  interested  in  the 
labors  of  a  special  section,  may  be  admitted  by  the  president  of  the 
congress.  They  will  receive  a  special  ticket  on  paying  their  admission 
fee,  will  not  be  entitled  to  a  copy  of  the  Transactions,  and  can  not  speak 
in  the  general  sessions  or  in  any  section  other  than  that  for  which  they 
were  inscribed. 

18.  The  president  may  invite  or  admit  students  of  medicine  to  at- 
tend and  to  listen.  They  will  be  given  a  special  admission  ticket,  free 
of  charge. 

Journeys  and  Reduction  of  Fares. — The  provisional  committee  has 
made  arrangements  with  the  different  Italian  and  foreign  railway  and 
navigation  companies,  in  pursuance  whereof  special  reduced  prices  have 
been  granted  on  the  steamers  and  railways  of  this  country  and  of  the 
countries  which  the  members  of  the  congress  are  to  traverse. 

In  Italy  the  members  of  the  congress  will  find  tickets  for  round  trips, 
starting  from  Rome ;  they  will  thereby  be  enabled  to  visit  the  most  im- 
portant cities  and  the  various  universities.  In  regard  to  this,  further 
notice  will  be  given. 

The  Ladies  of  the  Members  will  be  furnished  ladies'  tickets,  which 
will  entitle  them  to  the  reduced  fares  granted  to  the  members,  and  to 
participate  in  the  festivities  connected  with  the  congress. 

Festivities. — Besides  the  receptions  which  the  kind  and  hospitable 
citizens  of  Rome  will  offer  to  the  members,  the  Italian  colleagues  will 
endeavor  to  return  to  the  best  of  their  power  the  kindness  they  expe- 
rienced during  their  stay  abroad.  On  some  evening  yet  to  be  decided 
the  members  of  the  different  sections  will  join  at  a  dinner  which  will 
be  given  at  one  of  the  first  hotels  of  Rome.  The  Italian  physicians  have 
formed  special  committees  to  show  the  most  hearty  and  kindly  hospi- 
tality toward  the  foreign  colleagues. 

International  Exhibition  of  Medicine  and  Hyijiene. — On  the  occasion 
of  the  Eleventh  Intemational  Medical  Congress,  an  Exhibition  of  Medi- 
cine and  Ilygiene  will  be  inaugurated  in  Rome  which  will  gather  all  that 
may  practically  interest  physicians  and  specialists.  A  special  commit- 
tee has  already  insured  the  co-operation  of  all  the  most  important  manu- 
facturers of  the  world. 

Hotels. — All  the  first-class  and  second-class  hotels  of  the  Italian 
capital  will  afford  to  the  members,  during  their  stay,  all  desirable  com- 
forts. 


The  American  National  Committee,  consisting  of  Dr.  W.  T.  Brigga, 
Nashville,  Tenn. ;  Dr.  U.  P.  Howditch,  Boston  ;  Dr.  S.  C.  Busey,  Wash- 
ington ;  Dr.  C.  Cushing,  San  Francisco ;  Dr.  N.  S.  Davis,  Chicago ;  Nor- 
man W.  Kingsley,  D.  D.  C,  New  York ;  Dr.  W.  Osier,  Baltimore ;  Dr. 
W.  Pepper,  Philadelphia  ;  Dr.  F.  Peyre  Porcher,  Charleston,  S.  C. ;  Dr. 
Charles  A.  L.  Reed,  Cincinnati ;  Dr.  D.  B.  St.  John  Roosa,  New  York ; 
Dr.  A.  J.  C.  Skene,  Brooklyn ;  Dr.  James  Stewart,  Montreal ;  and  Dr. 

A.  Jacobi  (chairman),  110  West  Thirty-fourth  Street,  New  York,  draws 
the  attention  of  gentlemen  who  intend  to  participate  in  the  congress  to 
the  following:  It  is  the  earnest  wish  of  the  central  committee  to  re- 
ceive applications  at  an  early  date.  The  admission  fee  of  five  dollars 
may  be  sent  to  the  treasurer.  Professor  L.  Pagliani,  Rome,  Italy ;  in 
return,  the  ticket  of  membership  will  be  forwarded.  It  is  requested 
that  a  visiting  card,  containing  name  and  address,  he  sent  with  each 
application,  to  facilitate  exact  spelling.  The  chairman  offers  his  serv- 
ices to  whosoever  will  direct  him  to  forward  both  application  and  fee. 
Attention  is  also  directed  to  Article  11  of  the  Regulations,  according 
to  which  papers  must  be  announced  at  headquarters  on  or  before  June 
30th,  and  abstracts  be  received  on  or  before  the  31st  of  July. 

The  Pan-American  Medical  Congress. —  The  Section  in  Anatomy  has 
been  organized  with  the  following  officers:  Executive  president,  Dr- 
John  B.  Roberts,  1627  Walnut  Street,  Philadelphia;  secretaries.  Dr.  D. 
S.  Lamb  (English-speaking),  800  Tenth  Street,  N.  W.,  Washington  j 
Dr.  A.  M.  Fernandez  (Spanish- speaking),  194  West  Tenth  Street,  New 
York.  The  section  will  be  devoted  to  the  study  of  human  and  com- 
parative anatomy  and  of  biology  as  departments  of  natural  science  as 
well  as  in  their  relations  to  practical  medicine  and  surgery.  The  regu- 
lations applying  to  papers  and  discussions  which  have  been  adopted  by 
the  executive  committee  of  the  congress  are  as  follows:  Contributors 
are  required  to  forward  abstracts  of  their  papers,  not  to  exceed  six  hun- 
dred words  each,  to  be  in  the  hands  of  the  secretary-general  not  later 
than  the  10th  of  July,  1893.  These  abstracts  shall  be  translated  into 
English,  French,  Spanish,  and  Portuguese,  and  shall  be  published  in  ad- 
vance of  the  meeting  for  the  convenience  of  the  congress,  and  no  paper 
shall  be  placed  upon  the  programme  which  has  not  been  thus  pre- 
sented by  abstract.  Abstracts  will  be  translated  by  the  literary  bureau 
of  the  congress  at  the  request  of  contributors,  and  should  be  forwarded 
through  the  secretaries  of  sections.  Papers  to  be  presented  to  sections 
must  not  consume  more  than  twenty  minutes  each  in  reading,  and  when 
of  greater  length  must  be  read  by  abstract  not  exceeding  twenty  min- 
utes in  length.  Papers  read  by  abstract  may  be  printed  in  full  in  the 
transactions,  subject  to  approval  by  the  editorial  committee.  Papers 
and  discussions  will  be  printed  in  the  language  in  which  they  may  be 
presented.  All  papers  read  in  the  sections  shall  be  surrendered  to  the 
secretaries  of  the  sections ;  all  addresses  read  in  the  general  session 
shall  be  surrendered  to  the  secretary-general  as  soon  as  read ;  and  all 
discussions  shall  be  at  once  reduced  to  writing  by  the  participants. 

T?ie  Section  in  Phy.noloyy  has  the  following  officers :  Honorary 
presidents.  Dr.  Jose  M.  Bandera,  City  of  Mexico ;  Dr.  James  Blake, 
San  Francisco ;  Dr.  R.  H.  Chittenden,  New  Haven ;  Dr.  Austin  Flint, 
New  York;  Dr.  C.  Heinemann,  Vera  Cruz,  Mexico;  Dr.  Joseph  Jones, 
New  Orleans;  Dr.  J.  B.  De  Lacerda,  Rio  de  Janeiro;  Dr.  H.  N.  Martin, 
Baltimore ;  Dr.  Wesley  Mills,  Montreal,  Canada ;  Dr.  S.  Weir  Mitchell, 
Philadelphia ;  Dr.  E.  T.  Reichert,  Philadelphia ;  Dr.  Antonio  Perez 
Roca,  Lima,  Peru;  Dr.  Magin  Sagarra,  Santiago  de  Cuba;  Dr.  Carlos 
Schonlein,  Santiago,  Chile;  executive  president,  Dr.  Isaac  Ott,  Easton, 
Pa. ;  secretaries.  Dr.  A.  P.  Brubaker  (English-speaking),  Jefferson 
Medical  College,  Philadelphia;  Dr.  W.  A.  Thom  (Spanish-speaking), 
128  Main  Street,  Norfolk,  Va. ;  Dr.  Senorans  [Defensa  293],  Buenos 
Aires,  Argentine  Republic ;  Dr.  Enrique  Hertzog,  La  Paz,  Bolivia ;  Dr- 
J.  Paulo  de  Carvalho,  Rio  de  Janeiro,  United  States  of  Brazil;  Dr.  A. 

B.  MacAUum,  Toronto,  Canada;  Dr.  Julio  San  Martin  [Dragones  94], 
Havana,  Cuba;  Dr.  Antonio  Vargas  Vega  [Calle  10,  Num.  305],  Bo- 
gota, Colombia;  Dr.  Carlos  Duran,  San  Jose,  Costa  Rica;  Dr.  Carlos 
Padilla,  Guatemala,  Guatemala;  Dr.  F.  L.  Miner,  Honolulu,  Hawaii; 
Dr.  Esteban  Ferran,  Tegucigalpa,  Honduras;  Dr.  Manuel  Toussaint  [San 
Jose  de  Gracia  12],  Mexico,  Mexico;  Dr.  Guerra,  Rivas,  Nicaragua; 
Dr.  Juan  Morelli  (hijo)  [Arapey  192],  Montevideo,  Uruguay;  Dr.  Ramdn 
Porra  Picon,  Merida,  Venezuela  ;  advisory  council.  Dr.  W.  H.  Howell 


March  11,  1893.] 


MISCELLANY. 


285 


Bo.ston ;  Dr.  C.  F.  Hodge,  Worcester,  Mass. ;  Dr.  W.  G.  Thomson,  New 
York  ;  Dr.  F.  S.  Lee,  New  York ;  Dr.  G.  T.  Kemp,  Brooklyn ;  Dr.  John 
Marshall,  Philadelphia ;  Dr.  W.  S.  Carter,  Philadelphia  ;  Dr.  J.  W.  War- 
ren, Bryn  Mawr,  Pa. ;  Dr.  R.  M.  Smith,  Philadelphia ;  Dr.  F.  T.  Mall, 
Chicago ;  Dr.  Jacques  Loeb,  Chicago ;  Dr.  J.  J.  Abel,  Ann  Arbor,  Mich. ; 
Dr.  Henry  Sewall,  Denver,  Col. 

The  Section  in  Ophthalmoloijy  has  the  following  officers:  Executive 
president.  Dr.  Julian  J.  Chisliolin,  of  Baltimore  ;  honorary  presidents.  Dr. 
Herman  Knapp,  New  York  ;  Dr.  Eugene  Smith,  Detroit ;  Dr.  Stephen  C. 
Ayres,  Cincinnati;  Dr.  J.  L.  Thompson,  Indianapolis;  Dr.  X.  C.  Scott, 
Cleveland  ;  Dr.  Abner  Calhoun,  Atlanta  ;  Dr.  Herbert  Harlan,  Baltimore; 
Dr.  Charle.'*  W.  Kollock,  Charleston  ;  Dr.  Stephen  C.  Richey,  Washing- 
ton ;  Dr.  Jose  Ramos,  Mexico;  Dr.  G.  C.  Savage,  Nashville;  Dr.  J.  E. 
Minney,  Topeka ;  Dr.  W.  H.  Carmalt,  New  Haven ;  Dr.  B.  J.  Baldwin, 
Montgomery ;  Dr.  Aureho  Alarco,  Lima,  P^ru ;  Dr.  Charles  Finley,  Ha- 
vana, Cuba  ;  Dr.  Hasket  Derby,  Boston ;  Dr.  J.  C.  Kipp,  Newark ; 
Dr.  Dudley  S.  Reynolds,  Louisville ;  Dr.  Ma.ximo  Cienfuegos,  Santiago ; 
Dr.  F.  C.  Hotz,  Chicago ;  Dr.  Charles  E.  Michel,  St.  Louis ;  Dr.  Samuel 
D.  Risley,  Philadelphia;  Dr.  R.  H.  Lewis,  Raleigh  ;  Dr.  T.  E.  Murrcll, 
Little  Rock;  Dr.  E.  C.  Rivers,  Denver;  Dr.  CM.  Shields,  Richmond; 
Dr.  J.  F.  Fulton,  St.  Paul ;  secretaries,  Dr.  George  M.  Gould,  Philadel- 
phia (English-speaking),  Dr.  J.  Harris  Pierpont,  Pensacola  (Spani.<h- 
speaking) ;  advisory  council.  Dr.  Adolph  Alt,  St.  Louis ;  Dr.  L.  Webster 
Fox,  Philadelphia;  Dr.  George  T.  Stevens,  New  York;  Dr.  Edward 
Jackson,  Philadelphia;  Dr.  B.  A.  Randall,  Philadelphia;  Dr.  H.  V. 
Wurdeman,  Milwaukee  ;  Dr.  R.  Sattler,  Cincinnati ;  Dr.  L.  Connor,  De- 
troit ;  Dr.  Hiram  Woods,  Baltimore ;  Dr.  R.  L.  Randolph,  Baltimore  ; 
Dr.  J.  A.  White,  Richmond  ;  Dr.  S.  M.  Burnett,  Washington  ;  Dr.  A.  R. 
Baxter,  Cleveland ;  Dr.  J.  P.  Parker,  Kansas  City ;  Dr.  J.  H.  Thomp- 
son, Kansas  City. 

The  Section  in  Military  Medicine  and  Surgery  has  the  following  mem- 
bers of  the  advisory  council :  Colonel  Louis  Read,  M.  D.,  surgeon-gen- 
eral, N.  G.,  Pa. ;  Newton  L.  Bates,  M.  D.,  medical  director,  U.  S.  navy ; 
J.  R.  Tryon,  M.  D.,  medical  inspector,  U.  S.  navy ;  Lieutenant-Colo- 
nel Eustathius  Chancellor,  M.  D.,  medical  director,  N.  G.,  Mo. ;  Brevet 
Lieutenant  Colonel  A.  A.  WoodhuU,  M.  D.,  surgeon,  U.  S.  army  ;  Major 
Joseph  H.  Corson,  M.  D.,  surgeon,  U.  S.  army;  Major  George  Hender- 
son, M.  D.,  medical  director,  N.  G.,  D.  C. ;  C.  N.  Hoagland,  M.  D.,  ex- 
surgeon,  Ohio  Vols.  ;  Bedford  Brown,  M.  D.,  ex-surgeon,  C.  S.  army ; 
H.  C.  Goodman,  M.  D.,  ex-surgeon,  U.  S.  Vols. ;  Melancthon  Storrs, 
M.  D.,  ex  surgeon.  Conn.  Vols. ;  0.  D.  Ball,  M.  D.,  pension  ex-surgeon, 
Albany ;  Captain  H.  0.  Perley,  M.  D.,  assistant  surgeon,  U.  S.  army. 
•George  M.  Sternberg,  deputy  surgeon-general,  U.  S.  army  (president). 

National  Quarantine  Eegulations. — The  late  Secretary  of  the  Treas- 
■ury  is  reported  to  have  issued  the  following  regulations  on  the  3d  inst. : 

Every  vessel,  passenger  or  freight,  bound  for  the  United  States  must 
carry  a  prescribed  bill  of  health,  given  either  by  the  United  States  Con- 
sul or  medical  officer  detailed  by  the  President  at  the  port  of  departure. 
In  case  the  vessel  sails  from  an  infected  port  an  inspection  must  precede 
the  granting  of  the  bill  of  health,  and  an  inspection  is  required  in  the 
case  of  every  passenger  vessel  sailing  from  any  port  in  Europe,  Asia, 
Africa,  Central  or  South  America,  Mexico,  and  the  West  Indies,  whether 
said  port  is  infected  or  not.  The  inspection  must  be  made  within  .six 
hours  immediately  preceding  the  departure  of  the  vessel,  according  to 
methods  prescribed.  Should  disinfection  be  declared  to  be  necessary, 
it  is  made  compulsory  upon  the  vessel  owners  to  have  it  done  under  di- 
rection of  the  inspector. 

With  regard  to  cargo  of  vessels,  the  consul  at  port  of  departure  is 
required  to  have  knowledge  of  its  origin  and  to  have  it  disinfected  if 
necessary.  During  the  prevalence  of  an  ei)idemic  rags  and  similar  arti- 
cles arc  not  to  be  shipped  at  all,  nor  within  thirty  days  after  the  port 
has  been  officially  declared  to  be  free  from  the  epidemic.  Crews  of  ves- 
sels while  at  anchor  in  an  infected  port  are  required  to  remain  on  board. 
New  members,  before  being  allowed  on  board,  must  be  examined  by  the 
inspector,  and  prove  to  his  satisfaction  that  they  have  not  within  ten 
days  previous  been  exposed  to  any  quarantinable  disease. 

Passengers  are  divided  into  two  classes — cabin  and  steerage.  Each 
cabin  passenger  must  produce  satisfactory  evidence  as  to  his  place  of 
abode  for  four  days  previous  to  embarkation,  and  if  he  has  been  ex- 


posed to  contagion  will  be  detained  for  a  term  to  be  fixed  by  the  in- 
spector and  his  baggage  disinfected.  Steerage  passengers  shipping 
from  an  infected  port  are  to  be  detained  five  days  under  medical  obser- 
vation in  specially  provided  quarters. 

They  are  to  be  bathed  at  the  beginning  of  the  five  days'  term  and 
provided  with  disinfected  clothing.  If  cholera  should  break  out  among 
them  while  under  observation,  none  of  them  will  be  allowed  to  embark 
for  the  United  States  until  at  least  seven  days  have  elapsed  since  the 
conclusion  of  the  last  case. 

The  same  provisions  which  are  made  for  passengers  and  crews  in 
cholera-infected  ports  apply  to  ports  in  which  plague,  yellow  fever,  ty- 
phus, or  small-pox  prevail  in  an  epidemic  form. 

Passengers,  crews,  cargoes,  baggage  at  non-infected  ports,  but  com- 
ing from  infected  localities,  are  made  subject  to  the  same  restrictions  as 
are  enforced  at  an  infected  port. 

A  vessel  arriving  at  any  United  States  port  with  cases  of  contagion 
on  board  shall  be  detained  for  a  period  ranging  from  five  days  to  twenty 
days,  the  latter  only  where  typhus  fever  prevails. 

Codes  of  EtMcs.— Under  the  heading  of  Questions  of  the  Code  ;  Ad- 
vertising, the  January  number  of  the  Alienist  and  Neurologist  says 
editorially : 

"  While  it  is  undoubtedly,  as  the  code  enjoins,  derogatory  to  profes- 
sional dignity  to  resort  to  private  cards  or  public  handbills,  inviting 
public  attention  to  special  skill  in  the  treatment  of  particular  diseases, 
it  is  certainly  an  unwise  policy,  and  at  variance  with  the  dictates  of 
common  sense,  to  so  construe  the  code,  or  to  amend  it  so  as  to  debar 
regular  physicians  from  decently,  delicately,  and  properly  advertising 
their  calling  to  the  public. 

"  When  the  code  is  revised  it  should  be  explicit  on  this  subject,  and 
prescribe  what  form  of  public  announcement  should  be  deemed  proper, 
and  denounce  in  plain  terms  what  should  be  considered  indelicate  and 
unprofessional  advertising,  but  it  should  not  commit  the  folly  of  saying 
doctors  may  go  into  business,  but  must  not  make  themselves  known. 

"  While  the  method  of  the  quacks  should  not  be  countenanced  in 
the  code,  there  is  no  good  reason  why  the  qualifications  of  physicians 
should  not  be  made  public  in  a  decent,  delicate  way.  On  the  contrary, 
there  is  the  best  of  reasons,  based  on  the  demand  of  humanity  and  per- 
sonal and  professional  interest — individual  and  collective — why  a  decent 
form  of  advertising  should  be  coimtenaneed  and  encouraged.  The 
best  qualified  physicians  owe  to  humanity  a  debt  to  make  themselves 
and  their  qualifications  to  alleviate  sutfering  known.  Humanity  de- 
mands this. 

"  Why  should  charlatanry  be  allowed  to  have  the  ear  of  the  public 
and  not  scientific  medicine  ?  Can  not  regular  medicine  set  an  example 
of  decent,  delicate,  modest  advertising,  consistent  with  professional 
dignity  and  honor,  which  would  enable  a  discriminating  public  to  see  the 
true  from  the  false,  and  thus  discountenance  the  shameful  quackery 
that  now  afflicts  the  people  ? 

"  Why  should  a  reputable  young  physician  spend  years  of  study,  and 
through  toil  receive  professional  honors,  and  then  be  enjoined  to  con- 
ceal his  special  fitness  from  a  suffering  public  in  need  of  his  skill  ?  Of 
what  use  are  honors  and  exi)erience  if  they  may  not  be  made  known  ? 
What  is  there  indelicate  or  unprofessional  in  a  young  man  publicly  an- 
nouncing his  alma  mater,  more  than  there  is  in  liis  alma  mater  making 
public  announcement  of  his  graduation  ?  What  harm  is  there  in  his 
telling  where  and  under  what  masters  he  studied,  or  in  what  hospital 
he  has  served,  or  what  his  preferences  in  practice  are  ? 

"  Common  sense  and  the  general  public  judgment  would  approve  of 
a  policy  that  permitted  the  public  to  know  more  of  its  physicians  be- 
fore being  compelled  to  first  try  them  to  find  them  out. 

"  A  wise  and  generous  policy  in  the  amended  code  toward  the 
young  physician,  allowing  him  to  make  known,  in  a  delicate  and  legiti- 
mate way,  his  fitness  to  practice — such  as  his  hospital  experience,  place 
of  gi  aduation,  location,  and  special  line  of  preferred  practice — would  en- 
lighten the  public,  encourage  ambition  in  students  to  seek  medical  col- 
lege and  hospital  distinction  before  beginning  to  practice,  and  shamo 
(juackery  and  its  votaries  by  the  real  sensible  modesty  of  true  merit ; 
at  the  same  time  the  public  would  know  where  to  find  its  best  young 
doctors. 


286 


MISCELLANY. 


[N.  Y,  Med.  Jour., 


"  A  legitimate  and  delicate  form  of  public  advertising  approved  by 
the  revised  code  would  diminish  the  uumbeiless  disreputable  devices  to 
which  doctors  now  resort  for  success.  The  painfully  ))ious  doctor,  the 
church  doctor,  the  club  doctor,  the  insurance-society  doctor,  the  cheap 
insurance  company  and  railroad  doctor,  the  hotel  doctor,  the  free  dis- 
pensary and  free  clinic  doctor  with  college  attachment,  the  free  hospital 
doctor,  the  proprietary  and  mineral  water  certificate  doctor,  the  news- 
paper doctor,  the  charity  and  semi-charity  doctor  of  every  kind,  and 
the  small  college  professor,  would  be  less  numerous  than  now.  The 
little  meilical  editor  with  his  pop-gun  boom,  and  the  small  specialist 
would  become  scarcer  than  now  under  honest,  decent,  legitimate,  square 
code-tolerated  advertising.  M\ich  of  the  shameful  trickery  of  the  trade 
to  secure  practice  would  then  disappear  from  oiu-  ranks. 

"  But,  best  of  all,  the  jealous  and  unseemly  rivalries  now  existing  in 
our  profession  would  be  reduced  to  almost  nothing. 

"  Let  the  new  provision  in  this  subject  be  something  like  this : 
While  it  is  derogatory  to  professional  dignity  to  resort  to  the  ordinary 
fulsome  methods  of  the  quacks,  it  shall  not  be  considered  unprofes- 
sional for  a  regular  physician  to  publicly  announce,  in  a  modest  way, 
his  calling,  the  place  of  his  graduation,  his  preceptor,  his  hospital  e.\- 
perience,  or  his  special  line  of  pi  actice,  on  his  card  or  through  the  press, 
but  it  shall  be  deemed  highly  unprofessional,  as  it  is  in  the  highest  de- 
gree indelicate,  to  proclaim  extraordinary  skill  through  public  handbills, 
private  cards,  or  the  public  press,  or  to  resort  to  the  ordinary  news- 
paper devices  of  quacks,  such  as  '  advice  free,  no  cure  no  pay,  charge 
for  medicine  only,'  or  to  make  any  promises  that  are  not  of  probable 
fulfillment,  or  to  resort  to  any  of  the  common  trade  methods  of  suc- 
cess, such  as  '  runners '  and  commissions  on  patients  procured,  etc. 

"  What  we  should  encourage  is  honesty  in  the  dealing  of  doctors 
with  the  public.  Squ.are,  truthful,  common-sense,  delicate,  decent 
method  of  making  our  meritorious  young  doctors,  so  that  the  true  dig- 
nity of  the  profession  is  not  degraded,  the  public  may  know  who  are  the 
really  best  physicians,  what  they  can  really  do,  and  where  they  may  be 
found,  and  they  should  be  enabled  to  get  all  proper  knowledge  of  good 
physicians,  and  learn  through  the  public  press  to  seek  the  true  physi- 
cian rather  than  the  quack.  Scientific  medicine  gives  ({uackery  too 
great  advantage  by  failing  to  provide  a  proper  means  by  which  it  may 
reach  where  even  quackery  does — through  the  public  pres.-;. 

"  The  press  is  too  great  a  lever  to  be  given  over  entirely  to  the 
empirics.  There  is  no  wisdom  in  the  professional  policy  that  enjoins 
this,  and,  as  a  matter  of  fact,  the  code  does  not  enjoin  this.  It  only 
says  it  is  derogatory  to  professional  dignity  to  publish  cards  or  hand- 
bills calling  attention  to  special  skill  in  particular  diseases.  It  justly 
condemns  such  methods  as  the  ordinary  devices  of  quacks. 

"  It  would  be  wiser,  even  if  the  code  enjoined  for  all  competent  phy- 
sicians to  properly  make  themselves  known  to  the  public  by  writing, 
by  delicately  worded  cards,  etc.,  than  to  give  this  field  over  to  the 
quacks.  The  disintegration  of  practice  into  special  work,  the  reliance 
of  the  people  on  the  public  press,  and  the  demands  of  the  present  age 
differ  essentially  from  those  of  the  past  wheai  the  code  was  framed. 

"  We  stand  for  and  by  the  code,  but  we  ask  an  enlightened  and 
timely  revision,  and  that  no  dead-letter  provisions  be  allowed  to  remain 
in  it." 

The  Medical  News  for  February  25th,  commenting  on  the  recent  ab- 
rogation of  the  Medical  Society  of  the  State  of  New  York's  code,  says: 

"  Whether  or  not  this  action  be  politic  and  judicious  and  ethical 
remains  to  be  tested  by  the  logic  of  events.  It  is  a  sort  of  fy  sids,  fi/ 
reste  argument,  about  which  the  logic  of  controversy  is  of  little  use. 
There  has  certainly  been  too  much  controversy  already.  Let  us  quit 
arguing  and  try  to  unite  in  harmony.  It  is  certainly  a  fact  of  pro- 
found significance  for  the  American  medical  profession,  and  one  that 
it  behooves  us  all  to  consider  most  carefully  and  seriously." 

The  Position  of  Hypnotism  in  Therapeutics. — This  is  the  title  of 
the  sixtli  of  Mr.  Ernest  Hart's  articles  on  The  New  Mesmerism,  pub- 
lished in  the  Brilish  Medical  Journal.    Mr.  Hart  says  : 

"  The  final  question  of  the  clinical  physician  and  the  medical  prac- 
titioner is  the  practical  demand  for  the  definition  of  the  position  of 
hypnotism  in  its  relation  to  therapeutics.  I  may,  I  think,  take  it  as 
proved  beyond  all  reasonable  doubt  that  the  hypnotic  condition  is  a 


real  and  admitted  clinical  fact.  Setting  aside  all  the  inipo.stures,  fol- 
lies, and  errors  which  have  gathered  around  it — brushing  away  the  fan- 
tastic halo  of  clairvoyance,  telepathic  visional  communication,  transfer- 
ence of  thought  or  sensation  across  space,  or  by  contact  and  extemali- 
zation  of  sensation,  as  pure  fallacies,  fancies,  or  frauds — we  have  still 
beneath  them  the  solid  basis  of  the  subjective  condition  of  artificially 
induced  sleep  and  heightened  suggestibility.  What  use,  if  any,  can  be 
made  of  the  power  of  suggestion  under  these  circumstince.s  as  a  cura- 
tive agent?  In  reply  to  this  question  I  will  adduce  chiefly  the  evidence 
of  Dr.  Luys,  Dr.  Charcot,  Dr.  Babinski,  and  M.  Ballet,  analyzing  the 
results  of  long  years  of  clinical  experiment  on  a  vast  number  of  sub- 
jects in  Paris  and  in  Nancy.  M.  Babinski  discus.^es  the  subject  very 
cift-efully  in  a  lecture  which  he  gave  at  the  Salpetriere  on  June  23, 
1891.*  He  opens  his  lecture  very  frankly  with  the  statement  follow- 
ing: 'At  the  SalpStricre,  without  at  all  objecting  to  hypnotism  as  a 
weapon  of  the  therapeutic  arsenal,  it  is  considered  that  its  indications 
are  limited,  and  that  this  mode  of  cure  can  hardly  be  applied  with  suc- 
cess except  in  hysteria.'  'In  any  case  it  may,' he  considers,  ' be  af- 
firmed' (page  23)  'that  the  greater  part  of  the  effects  which  have 
been  cured  by  this  method  arise  from  and  belong  to  that  neurosi.s.' 
'  Hypnotism,'  he  further  says,  '  may,  it  must  be  admitted,  serve  in  the 
treatment  of  hysterical  manifestations,  but  it  must  be  acknowledged 
also  that  even  in  affections  of  this  class  hypnotic  practice  does  not  give 
brilliant  results.' 

"  He  groups  hysterics  from  the  therapeutic  point  of  view  into  two 
distinct  classe.s.  To  the  first  belong  the  great  number  of  hysterical 
persons  who  are  not  capable  of  being  hypnotized,  however  much  trouble 
is  taken  with  them.  Some  of  these  patients  are  no  doubt  subject  to 
the  very  old-fashioned  influence  of  suggestion  in  the  waking  state. 
Such  people  have  always  been  susceptible  to  cure  by  bread  pills  and 
distilled  water,  and  by  the  '  rapid  '  influence  of  electrotherapy,  hydro- 
therapy, etc.  In  the  second  class  are  the  hysterics — persons  who  can 
be  hypnotized — and  these  present  numerous  varieties.  Some  of  them, 
especially  those  subject  to  hysterical  neuralgia  and  cutaneous  hyperaes- 
thesia,  are  very  rebellious  to  suggestion,  and  in  others  only  a  partial 
and  very  inadequate  result  is  obtained.  In  some  cases  of  hysterical  con- 
traction of  the  limbs  suggestion  gives  relief,  but  it  has  to  be  renewed 
from  day  to  day,  sometimes  five  or  six  times  a  day,  and  is  very  liable 
to  relapse.  In  a  very  few  cases  a  gradual  and  definite  amelioration 
is  obtained,  as  in  a  case  of  hysterical  muscular  contraction  and  coxalgia 
of  which  Dr.  Babinski  is  able  to  quote  one  case.  '  Finally,'  he  asks 
himself  after  many  years  of  study  and  experience  as  chef  de  clinique  des 
maladies  nerveuses  and  as  hospital  physician,  who  has  constantly  ob- 
served the  cases  at  the  Salpetriere,  '  does  the  field  of  action  of  hypno- 
tism pass  beyond  the  domain  of  hysteria  ? '  His  final  conclusion, 
which  he  italicizes  at  the  close  of  his  address,  is  that  it  is  justifiable  to 
say,  and  he  is  authorized  to  conclude,  that  outside  of  hysteria  there 
does  not  exist  a  single  affection  capable  of  being  notably  modified  by 
hypnotism,  or  at  least  that  the  contrary  is  not  proved,  for  the  observa- 
tions published  with  that  object  are  far  from  being  demonstrative.  Of 
course,  the  opposite  thesis  is  maintained  by  M.  Bernheim,  but  after  the 
close  analysis  to  which  Dr.  Babinski  subjects  the  cases  published  by 
Dr.  Bernheim  in  his  two  books  on  psychotherapy  and  suggestion,  there 
remains  very  little  which  can  be  accepted  as  substantial. 

"  Besides  bodily  diseases,  some  alienist  physicians  have  alleged  that 
mental  maladies  may  be  cured  by  hypnotism.  Here,  again,  we  may 
take  the  results  of  competent  French  alienists  who  have  given  a  prac- 
tical trial  to  this  method.  M.  Magnau  authorizes  the  statement  that 
experiments  made  on  the  treatment  of  insanity  by  hypnotism  at  the 
Bureau  de  1' Admission  for  three  years  have  given  no  appreciable  re- 
sult, while  M.  Bernheim  himself  recognizes  that  the  domain  of  mental 
alienation  is  the  most  rebellious  to  suggestion.  Dr.  Forel,  of  Zurich,  is 
not  less  positive  in  his  conclusions.    He  says :  -j-  '  Insane  ideas  have 

*  Hypnotisme  et  hysterie,  du  role  de  Vhypnotisme  en  therapeutique 
Le9on  faite  k  la  Salpetriere  le  23  Juin,  1891,  par  J.  Babinski,  medecin 
des  hopitaux,  ancien  chef  de  clinique  des  maladies  nerveuses  k  la  Facul- 
ty.   Paris:  G.  Masson,  1891. 

\  Premier  conyrSs  international  de  Vhypnotisme,  p.  155.  Paris:  Oc 
tave  Doin,  1890. 


March  11,  1893.] 


MISCELLANY. 


287 


never  been  modified  in  any  patient.  Even  those  whom  I  succeeded  in 
hypuotizinp;,  in  rendering  auiesthesic  amnesic,  whom  I  made  realize 
post-hypnotic  suggestions,  refused  to  accept  any  suggestion  opposed  to 
•their  insane  ideas.  I  never  succeeded  in  influencing  the  course  of  true 
meliincholia  (I  do  not  speak  of  hysteric  melancholia)  by  suggestion ;  at 
most,  I  was  able  sometimes  to  produce  sleep,  and  in  one  case  to  hasten 
convalescence.'  M.  Briand,  chief  physician  of  the  Asile  of  Villejuif, 
said  on  the  same  occasion :  '  I  have  many  times  attempted  to  send 
to  sleej)  the  insane  and  delirious  who  presented  no  hysteric  taint,  but 
I  was  never  fortunate  enough  to  obtain  any  result.'  If  this  is  so  in 
France,  the  results  are  likely  to  be  at  least  as  negative  in  Great  Brit- 
ain, where  the  population  is  undoubtedly  much  less  susceptible  to  sug- 
gestion. 

'■^Hypnotic  Sarfgeslion  before  the  Law. — It  has  been  alleged  that 
suggestion  and  somnambulism  may  have  considerable  value  in  unmask- 
ing certain  crimes  to  which  the  tribunals  of  justice  have  not  hitherto 
been  able  to  attribute  their  true  character.  This  thesis  has  been  es- 
pecially maintained  by  M.  Liegeois*  and  by  M.  A.  Voisin,f  but  with  all 
his  good  will  and  with  all  his  research  M.  Li6geois  has  not  been  able  to 
bring  forward  one  single  example  in  which  suggestion  has  been  shown 
to  play  any  part  in  the  production  of  a  crime  brought  before  a  court  of 
law.  I  refer  those  who  are  interested  to  the  excellent  analysis  of  the 
work  of  M.  Liegeois  by  Gilbert  Ballet.  | 

"  There  is  only  one  case  on  record  in  which  a  distinct  declaration  has 
been  made  by  a  medical  man  of  evidence  that  crime  has  been  commit- 
ted by  a  hypnotized  person  under  the  influence  of  suggestion.  It  is  the 
case  which  M.  Voisin  records  in  the  Revue  de  riiypnothme  here  cited,  in 
which,  as  he  reports,  a  woman  accomplished  numerous  thefts  at  a  great 
shop  in  a  stats  of  automatism  and  under  suggestion  which  had  been  im- 
posed upon  her  when  hypnotized.  M.  Voisin  states  that  he  demon- 
strated the  complete  irresponsibility  of  this  woman,  who  was  left  at  lib- 
erty, while  the  three  actual  authors  of  the  crime  were  punished.  Dr. 
Voisin  referred  also  to  this  case  at  the  Bournemouth  meeting  of  the 
British  Medical  Association.  If  it  be  fully  verified  it  may  claim  to  rank 
as  a  case  in  which  the  theory  of  post-hypnotic  suggestion  has  been  of 
use  for  justice.  It  would  be  the  only  case  thus  far  noted.  But  where 
are  the  legal  documents  of  this  case,  the  magistrates'  report,  and  the 
depositions  ?  Until  we  have  them  before  us  we  can  decide  nothing  as 
to  its  authority.  They  have  been  pressingly  asked  for,  but  I  am  not 
aware  that  they  have  been  produced.  That  hypnotism  may  and  does 
lead  to  crime  iu  respect  to  the  abuse  by  hypnotic  operators  of  the  per- 
son of  the  hypnotized  subject  is  beyond  question,  and  possibly  the  cases 
may  be  more  numerous  than  published  records  can  prove,  but  to  the 
question  which  we  are  now  putting,  of  the  influence  of  suggestion  in 
producing  crime  as  the  automatic  act  of  the  subject,  or  as  the  result  of 
deferred  suggestion,  there  is  no  affirmative  answer  forthcoming  upon 
evidence  adduced.  Still  less  is  there  any  proof  that  the  doctrine  of 
hypnotic  suggestion  has  in  any  ca.se  been  of  value  for  the  purposes  of 
justice. 

"  Finally  I  pass  to  the  domain  of  surgery  and  obstetrics.  Here  we 
are  on  more  positive  ground,  and  I  shall  quote  the  words  of  Dr.  Luys  * 
— always  disposed  to  give  the  largest  interpretation  to  the  evidence  of 
the  usefulness  of  hypnotism — as  to  its  relative  inutility  in  these  positive 
departments  of  medical  and  surgical  art. 

"  Surgicnl  Application. — '  At  the  first  appearance  of  hypnotism, 
when  Braid  had  shown  that  hypnotized  subjects  are  insensitive  to  ex- 
ternal stimuli,  surgeons  conceived  the  idea  of  using  this  method  for  the 
performance  of  certain  operations  ;  in  fact,  a  certain  number  among 
them  had  the  opportunity  of  testing  it  with  a  cei'tain  amount  of 
advantage ;  but  since  the  wonderful  discovery  of  chloroform  these 

*  De  hi  svffffcsHon  cl  du  aomnambulhme  dans  leurs  rapports  avec  la 
jurisprudence  et  hi  medcci^ie  legale.  Paris,  1889.  Comptes  rendus  du 
Congres  dc  I' hypnotisme,  18S9. 

\  Revue  de  Vhijpnotiume  de  Juin,  1891. 

\  Lcs  suggestions  hgpnoliqucs  au  point  de  vue  medico-legale.  Par 
Gilbert  Ballet,  professcur  agrugc  k  la  Facult6  de  midecine,  mfidecin  de 
rh6pital,  St.  Antoine.    Paris  :  G.  Masson. 

*  Applimtions  therapeutiqucs  de  riiypnotismc.  Par  le  Dr.  J.  Luys. 
Paris:  Imprimerie  F.  Leve,  17,  Rue  Casctte,  1889. 


attempts,  so  far  as  concerns  surgical  antesthesia,  have  been  justly 
abandoned. 

"  '  At  the  present  time  the  application  of  hypnotism  to  surgical 
therapeutics  is  of  absolutely  no  account,  since  they  concern  only  the  lim- 
ited number  of  persons — namely,  the  class  of  hypnotizable  subjects.  It 
must,  however,  be  said  that  if  this  class  of  subjects  should,  by  the  em- 
ployment of  new  methods,  become  more  numerous,  it  is  possible  that  in 
certain  cases  one  might  practice  fascination,  and  thus  obtain  an  artifi- 
cial anesthesia,  the  duration  of  which  might  be  prolonged  without  any 
ill  effects.  In  the  present  state  of  things,  in  our  collection  of  hypnotic 
subjects,  when  a  small  operation  is  to  be  done  upon  them — an  abscess 
to  be  opened,  a  foreign  body  to  be  e.xtracted,  one  or  more  teeth  to  be 
drawn — I  do  not  hesitate  to  hypnotize  the  subject  and  to  hand  him  over 
to  the  surgeon.  It  happens  to  me  frequently  enough  to  have  a  certain 
number  of  subjects  with  teeth  to  be  drawn.  I  place  them  in  the  condi- 
tion of  lucid  somnambulism,  I  address  myself  to  the  dentists  of  the 
Charite,  who  examine  the  mouth  at  leisure,  and  perform  extraction  of 
the  diseased  teeth  ;  while  the  subject,  insensible  all  through,  on  waking 
has  no  recollection  of  the  operation  which  he  has  undergone,  and  is 
quite  astonished  to  find  his  extracted  teeth  in  his  hand.' 

"Application  of  Hj/imotism  in  the  Domain  of  Obstetrics. — Dr.  Luys 
writes  further  :  '  The  practice  of  hypnotism  as  applied  to  the  art  of  mid- 
wifery has  not  yet  yielded  very  satisfactory  results.  You  may  read  on 
this  subject  a  very  interesting  work  of  Dr.  Auvard,  who  sums  up  in  a 
very  conscientious  way  all  that  we  know  about  this  question.  Ijjhave 
only  had  one  sole  fact  of  this  kind  to  record,  and  it  does  not  seem  of  a 
nature  to  encourage  hypnotic  experiments  in  this  special  province.  Last 
year  I  had  in  my  wards  a  young  hypnotic  woman  whom  I  had  kept  till 
the  last  day  of  her  pregnancy  in  order  to  give  her  the  benefit  of  lethargic 
aniB.sthesia  at  the  time  of  her  confinement.  When  the  pains  came  on 
she  was  hypnotized  and  placed  in  a  condition  of  lethargy,  but  this  proved 
perfectly  useless,  for  the  intensity  of  the  labor  pains  was  such  that  they 
brought  about  the  natural  awakening  of  the  patient,  and  we  were  obliged 
to  have  recourse  to  chloroform  to  finish  the  delivery.' 

"  To  sum  up,  I  may  venture  to  quote  ray  own  conclusions  as  stated 
recently  in  the  Nineteenth  Century :  To  me  the  so-called  cures  by  hyp- 
notism seem  to  rank  in  precisely  the  same  class  as  those  of  the  faith-curer. 

"  The  hypnotic  endormeur  is  very  well  able  to  explain  the  miracles 
of  faith-cure  by  the  light  of  his  own  experience.  They  result,  as  he  ex- 
plains accurately,  from  the  reaction  of  mind  on  body,  the  effects  of  im- 
agination, of  self-suggestion,  or  of  suggestion  from  without.  Those  who 
benefit  by  them  are  especially  the  fervent  and  the  enthusiastic,  the  viv- 
idly imaginative,  the  mentally  dependent,  and,  above  all,  the  hysterical 
— male  or  female.  But  clearly  the  faith-curer  may  retort  upon  the  hyp- 
notizer  that  they  are  brothers  in  their  therapeutic  results,  if  not  in  their 
faith  and  philosophy.  The  one  can  work  about  the  same  percentage  of 
cures  as  the  other,  and  no  more ;  and  the  intervening  apparatus,  whether 
of  magnets,  mirrors,  or  of  grottoes,  only  serve  to  affect  the  imagination, 
and  to  supply  the  '  external  stimulus  '  which  is  necessary. 

"  To  this  category  belong  also  the  long  series  of  thousands  of  as- 
serted cures  of  people  who  wear  what  they  are  pleased  to  call  magnetic 
belts,  or  who  used  to  wear  magnetic  rings,  who  were  cured  by  the  Per- 
kins tractors  whether  of  wood  or  of  iron — such  are  the  prey  of  the 
quacks  of  all  ages  and  countries. 

"One  essential  fact  is,  however,  I  conceive,  that  no  new  faculty  was 
ever  yet  developed  in  any  of  these  hypnotics.  The  frauds  of  clairvoy- 
ance, of  spirit  perceptions,  of  gifts  of  language,  of  slate-writing,  of 
spirit-writing,  of  far-sight,  of  'communication  across  space,'  of  'trans- 
fer of  mental  impressions,'  of  the  development  of  any  new  sense  or 
ghost  of  a  new  sense,  remain,  now  as  ever,  for  the  most  part  demon- 
strable frauds  or  perhaps  in  a  few  cases  self-deceptions.  At  the  Sal- 
pfitiifere,  at  Nancy,  wherever  the  facts  have  been  impartially  and  critic- 
ally examined,  this  has  been  the  result.  It  results  once  more  now  from 
my  test  of  the  subjects  of  the  Charit6  and  the  iScole  Polytechnique.  It. 
will,  I  8uppo.se,  be  too  much  to  expect  that  we  shall  hear  no  more  of 
the  'New  Mesmerism,'  but  it  will  be  easy  for  any  one  thus  experiment- 
ally to  reduce  it  to  its  true  dimensions. 

"Finally,  as  to  the  practical  (piestion,  which  has  perhaps  a  greater 
interest  for  the  sociologist  anil  the  physician  than  any  which  have  sug. 
gested  themselves  up  to  this  point.    Since  the  hypnotist  faith-curer  of 


288 


MISCELLANY. 


[N.  Y.  Med.  Joub. 


the  hospital  ward  and  the  priestly  faith-curer  of  the  grotto  are  in  truth 
utilizing  the  same  human  elements  and  employing  cognate  resources, 
although  masked  by  a  different  outward  garb,  we  may  ask  ourselves 
which  can  approximate  to  the  greater  successes  and  which  does  the 
least  harm. 

"So  far  as  I  can  see,  the  balance  is  in  favor  of  the  faith-curer  of 
the  chapel  and  the  grotto.  The  results  at  least  are  proportionately  as 
numerous,  and  they  are  more  rapid.  Numerically  there  are,  I  incline 
to  think,  more  faith-cures  at  Lourdes  than  there  are  'suggestion-cures' 
in  the  Salpetri6re  or  the  Charite.  So  far  as  hypnotism  is  good  for  any- 
thing as  a  curative  agent,  its  sphere  is  as  we  have  seen  limited,  by 
Charcot,  Ferd,  Babinski,  and  all  the  most  trustworthy  medical  observ- 
ers of  Paris,  to  the  relief  of  functional  disorder  and  symptoms  in  hys- 
terical patients.  The  Nancy  school  put  their  pretensions  higher ;  but 
any  one  who  will  analyze  for  himself,  or  who  will  study  Babinski's  able 
analysis  of  the  Nancy  reputed  cases  of  cure,  will  easily  satisfy  himself 
that  such  claims  are  not  valid.  As  to  the  use  of  '  suggestion '  as  an 
anaesthetic  substitute  of  chloroform  for  operation  purposes,  that  'sug- 
gestion '  dates  back  now  beyond  the  ages  of  Esdaile  and  of  Elliotson.  It 
has  been  given  up  and  fallen  into  disuse  because  of  its  unreliability  and 
limited  application.  It  is  now  sagely  proposed  to  use  hypnotism  for 
'tooth-drawing,'  for  the  treatment  of  drunkards,  and  of  school  children. 
The  proposition  is  self- condemned.  To  enable  a  dentist  to  draw  a  tooth 
painlessly,  the  average  man  or  woman  is,  by  a  series  of  sittings,  to  be 
reduced  to  the  state  of  a  trained  automaton;  but  happily  only  a  very 
small  proportion  can  be.  The  criminal  courts  have  seen  enough  of 
hypnotic  dentists.  As  to  the  'suggestion'  cure  of  drimkards  or  the 
'suggestion'  treatment  of  backward  or  naughty  children,  systematic 
and  intelligent  suggestion  is  what  every  clergyman,  every  doctor,  and 
every  schoolmaster  tries  to  carry  out  in  such  cases  and  often  does  suc- 
cessfully— and  in  a  better  form  than  the  degrading  shape  of  hypnotism. 
Moreover,  for  drunkenness  it  is,  so  far  as  my  inquiries  go,  a  disappoint- 
ing failure. 

"  If  a  .striking  effect  is  to  be  produced  by  an  apparatus  destined 
powerfully  to  affect  the  imagination,  the  faith-curer  of  the  grotto  has 
this  advantage  over  the  endormcur  of  the  platform  or  the  hospital.  He 
does  not  intrude  his  own  personality  and  train  his  patient  to  subject  his 
mental  eyo  to  that  of  his  '  operator.'  The  '  mesmerizer'  seeks  to  domi- 
nate his  subject;  he  weakens  the  will  power,  which  it  is  desirable  to 
strengthen.  He  aims  at  becoming  the  master  of  a  slave.  I  .do  not 
need  to  emphasize  further  the  dangers  of  this  practice. 

"  The  faith  curer  of  the  grotto  strengthens  the  weaker  individuality. 
He  plays  upon  the  spring  of  self-suggestion.  The  patient  is  told  to  be- 
lieve that  he  will  be  cured,  to  wish  it  fervently,  and  he  shall  be  cured. 
So  far  as  he  is  cured,  he  returns  perhaps  a  better  and  a  stronger  man, 
and  his  cure  is  quite  as  real  and  likely  to  be  quite  as  lasting  as  if  he 
had  become  the  puppet  of  a  hypnotizer.  The  experiments  of  the  Sal- 
putriere  have  served  to  enable  us  to  analyze  more  clearly  the  nature  of 
faith  cures  generally,  and  they  have  thrown  a  ray  of  light  on  a  series  of 
phenomena  of  human  automatism  never  before  studied  so  clearly  or 
philosophically,  but  they  have  added  practically  little,  if  anything,  to 
our  curative  resources.  It  is  hardly  to  be  set  down  to  their  discredit 
that  they  have  incidentally  favored  the  reign  of  the  platform  hypnotizer 
or  the  vagaries  of  the  subjects  at  La  Charite  :  that  is  their  misfortune 
rather  than  their  fault,  but  it  is  a  grave  misfortune.  But  the  interven- 
tion of  authority  might  at  the  present,  and  I  hope  will,  cut  short  the 
absurdities  and  put  an  end  to  some  social  mischiefs  which  have  fastened 
on  to  them  and  hang  to  their  skirts.  Thus  much  as  to  the  medical 
question.  To  the  student  of  '  psychological  phenomena  '  it  is  of  great 
interest  to  note  how  successive  functions  may  be  separately  abolished 
as  the  brain  is  partially  set  to  sleep,  and  in  what  exaggerated  forms 
the  remaining  activities  may  be  brought  upon  the  stage  when  restrain- 
ing self-consciousness  is  stilled.  The  vulgar,  too,  may  find  an  ignoble 
amusement  in  the  antics  of  these  drinkers  of  petroleum  and  vinegar, 
and  of  these  seers  of  visions  and  in  the  semi-idiotic  postures  and  pro- 
ceedings of  the  hypnotized  manikin,  just  as  they  do  in  a  fanioccliini 
show  or  a  puppet  play.  But  against  such  philosophic  satisfactions  and 
vulgar  amusements  must  be  set  the  avowed  and  the  unconfcssed  mis- 
chiefs. Who  can  doubt  that  these  outbalance  any  good  result  which 
can  be  discerned  ?  " 


The  late  Dr.  William  C.  Stone. — The  Society  of  the  Alumni  of 
Bellevue  Hospital  has  passed  the  following  resolutions : 

Whereas,  it  has  pleased  Almighty  God  to  remove  from  his  earthly 
sphere  our  worthy  companion  and  professional  brother.  Dr.  William  C. 
Stone ;  therefore,  be  it 

Jiesolvcd,  that  the  members  of  the  Society  of  the  Alumni  of  Bellevue 
Hospital  express  their  sincere  sorrow  for  the  untimely  loss  of  their 
friend  and  member,  who  was  removed  in  the  fullness  of  young  man- 
hood. A  man  of  unusually  impressive  and  dignified  presence,  with  a 
manner  of  mingled  firmness  and  gentleness,  he  commanded  the  respect 
and  won  the  confidence  of  all  with  whom  he  came  in  contact. 

Resolved,  also,  that  these  expressions  of  profound  sympathy  be  ex- 
tended to  his  family. 

iWii.i.iAM  B.  Anderton, 
Matthkvv  D.  Field, 
Wii-LiAM  R.  Pryor, 

Committee. 


To  Contributors  and  Correspondents. —  T/te  aUention  of  all  viho  purpose 
fai'oriny  uh  with  eoinmnukatiom  is  respeclfull y  called  lo  the  follow- 
ing: 

Authors  of  articles  intended  for  pnhliealion  tinder  the  head  of  "  original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti- 
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THE  NEW  YORK  MEDICAL  JOURNAL,  MARCH  18,  1893. 


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THE  INTEW  YORK  MEDICAL  JOURNAL,  March  18,  1893, 


ft')n9inal  Commimtnitions. 


THE  TREATMENT  OF  NEGLECTED  CASES  OF 
KOTARY  LATERAL  CURVATURE  OF  THE  SPINE  * 
By  REGINALD  H.  SAYRE,  M.  D. 

The  correct  treatment  of  lateral  curvature  consists  in 
never  allowing  a  case  to  get  into  the  condition  of  those  I 
shall  describe  to  you  this  evening.  After  the  patient  has 
become  as  distorted  as  those  whose  pictures  I  shall  show,  it 
is  impossible  to  remove  the  deformity,  and  your  elforts  will 
simply  be  directed  toward  making  the  patient  as  free  from 
distress  as  possible,  and  in  concealing  instead  of  remedying 
the  deformity. 

These  cases  all  begin  in  a  very  gradual  way.  One  of 
the  worst  cases  that  I  ever  saw  was  that  of  a  patient  said 
by  her  ])hysician  to  have  lateral  curvature  at  a  time  when 
the  mother,  so  she  wrote  me,  could  not  believe  that  any- 
thing was  the  matter  with  this  child's  spine ;  and  yet,  in 
years  after,  when  the  case  came  under  my  treatment,  she 
was  one  of  the  most  distorted  cripples  that  I  have  ever  seen. 

When  a  mother  brings  a  little  child  to  you  and  asks  if 
there  is  anything  the  matter  with  its  spine,  don't  glance  at 
it  in  a  hurried  kind  of  way  and  say,  "  There  is  nothing 
the  matter  with  it ;  she  will  grow  out  of  all  that "  ;  but 
strip  the  child  to  the  hips  and  let  her  stand  in  her  own 
natural,  easy  attitude,  giving  her  time  to  accustom  herself 
to  her  surroundings  and  allow  her  muscles  to  relax.  In  a 
few  moments  you  will  begin  to  notice  a  dropping  of  one 
shoulder,  and  that  the  space  between  the  body  and  the  arms 
is  not  the  same  on  both  sides.  AVhen  first  in  the  presence 
of  the  physician,  these  children  very  often  hold  themselves 
quite  erect  for  a  few  moments  ;  but  after  the  first  feeling 
of  strangeness  has  worn  off  and  their  muscles  grow  a  little 
fatigued,  they  will  allow  themselves  to  drop  into  the  posi- 
tion which  they  habitually  assume  at  home,  and  then,  and 
not  until  then,  is  the  slight  deformity  apparent. 

Let  the  child  then  stand  in  front  of  you.  Hold  its  legs 
between  your  knees,  and,  while  its  knees  are  straight,  let  it 
bend  forward  and  try  to  touch  the  ground  with  its  fingers. 
In  this  position  the  scapulae  fall  forward  and  the  contour 
of  the  back  becomes  visible  (Fig.  1),  and  slight  degrees  of 
rotation  are  thus  perceptible  which  escape  observation  while 
the  child  is  in  the  upright  posture,  and  this  rotation  is  often 
more  to  be  felt  with  the  hand  than  to  be  observed  by  the 
eye.  In  a  certain  number  of  cases  you  will  find  that  the 
starting  point  of  a  lateral  curvature  is  a  deformity  of  the 
last  lumbar  and  first  sacral  vertebric,  and  that  the  spine 
i  cants  constantly  to  the  right  or  left  at  the  lumbo-sacr;d 
junction. 

At  times  the  deformity  is  more  apparent  in  front  than 
in  the  back.  You  will  notice  a  prominence  of  one  hip,  the 
flesh  at  times  sinking  in  quite  sharply  above  the  iliac  crest, 
although  the  deformity  in  the  back  is  scarcely  discernible. 

Among  the  earliest  evidences  of  rotation  you  will  find 

*  Read  before  the  New  York  State  Medical  Association,  November 
16,  1892. 


the  inequality  which  almost  always  exists  in  the  distance 
from  the  umbilicus  to  the  two  nipples.  This  is  frequently 
to  be  observed  before  any  marked  change  in  the  back  has 


Fig.  1. 


taken  place.  You  will  also  usually  find  that  the  breast  on 
the  side  of  the  convexity  is  smaller  than  that  on  the  side  of 
the  concavity. 

I  have  seen  so  many  cases  of  bad  lateral  curvature, 
where  the  mothers  tell  me  that  they  noticed  an  inequality 
in  the  two  sides  of  the  child  when  it  was  still  young,  but 
that,  on  consulting  a  physician,  they  were  told  that  the  child 
would  "  grow  out  of  it,"  that  I  feel  I  can  not  too  strongly 
impress  upon  you  the  necessity  of  observing  these  cases 
closely,  the  importance  of  taking  measures  to  straighten 
these  incipient  curves,  and  of  being  sure  that,  if  the  child 
has  a  slight  curve,  it  will  not  "grow  out  of  it"  as  it  grows 
older,  but  rather  grow  into  it,  and  when  she  comes  to  pu- 
berty have  so  decided  a  change  in  the  ribs  and  vertebne 
that  it  will  be  impossible  ever  to  wholly  rectify  the  de- 
formity. 

The  usual,  generally  received  opinion  that  lateral  curva- 
ture develops  between  the  ages  of  twelve  and  sixteen  is 
largely  due  to  the  fact  that  girls  have  their  clothes  fitted 
more  accurately  at  this  time,  and  that,  in  consequence,  a 
curve  that  has  been  present  for  a  number  of  years  first  be- 
comes recognized — very  j)ossibly  by  the  dressmaker — at  this 
period  ;  in  addition  to  which,  the  increased  bone  growth 
which  takes  place  at  this  age  causes  the  deformity  to  pro- 
gress ranch  more  rapidly  in  a  few  months  than  it  may  have 
done  in  the  same  number  of  preceding  years.  1  believe 
that  rickets  is  a  much  more  prominent  factor  in  the  produc- 
tion of  lateral  curvature  than  is  usually  believed.  We  all 
recognize  these  markeil  cases  of  rickets  where  the  bones  of 
the  entire  skeleton  aie  nwvv  or  less  deformed,  but  I  feel 


290 


SAT  RE:   CURVATURE  OF  THE  HPIIJE. 


[N.  V. 


JoOk., 


convinced  that  many  of  the  lateral  curvatures  are  due  to  a 
primary  malnutrition  which  expresses  itself  in  unequal 
growth  of  the  bodies  of  the  vertebraj,  instead  of  finding  its 
expression  in  the  lower  extremities,  as  is  usually  the  case. 
The  fact  that  these  girls  may  be  stout  and  well  nourished 
at  the  time  they  come  to  you  for  treatment  does  not  in- 
validate this  statement,  as,  after  the  active  period  of  rickets 
has  passed  by,  the  subject  may  develop  into  a  robust, 
healthy  individual,  simply  bearing  marks  of  his  earlier  dis- 
ease, and  it  is  a  frequent  occurrence  to  see  stout,  healthy 
men  with  aggravated  bowlegs  and  other  deformities  due  to 
rickets. 

In  other  cases  anterior  [)oliomj'elitis  lays  the  starting 
point  for  lateral  curvature.  I  do  not  mean  those  cases 
where  there  is  a  general  involvement  of  the  muscles  which 
passes  by,  leaving  one  side  paralyzed,  but  those  milder 
cases  in  which  the  deeper  muscles  of  the  spine  are  involved, 
possibly  to  only  a  slight  extent,  and  so  escape  our  observa- 
tion, while  yet  establishing  a  want  of  equilibrium  in  the 
muscular  supports  of  the  spine  sufficient  to  determine  a 
lateral  curvature,  and  one  which  will  be  most  resistant  to 
treatment. 

In  some  of  the  cases  I  shall  describe  this  evening  these 
conditions  have  been  present,  and  in  others  the  case  has 
been  consecutive  to  malformation  of  the  ribs,  to  pleurisy 
with  adhesions,  and  to  other  complications  which  we  do  not 
find  in  the  true  "  idiopathic  lateral  curvature,"  so  called. 

As  I  have  said  before,  the  most  effective  treatment  for 
lateral  curvature  consists  in  preventing  it,  as,  after  rotation 
with  marked  bone  change  has  taken  place,  it  is  impossible 
by  any  system  of  treatment  ever  to  restore  perfect  sym- 
metry ;  but  even  in  these  badly  distorted  cases,  although  we 
can  not  restore  symmetry,  we  can  render  the  patients  vastly 
more  comfortable  and,  to  a  certain  extent,  reduce  their  de- 
formity.* 

One  of  the  greatest  factors  in  causing  rotary  lateral 
curvature  of  the  spine  after  the  equilibrium  between  the 
muscles  of  the  trunk  has  been  destroyed — that  is,  after  the 
normal  curves  of  the  spinal  column  have  been  disturbed  by 
some  adventitious  circumstance — is  the  superincumbent 
weight  of  the  head  and  shoulders,  and  no  one  can  see  many 
cases  of  lateral  curvature  without  being  forcibly  struck  by 
the  difference  in  the  contour  of  the  body  in  the  erect  and 
prone  positions.  A  patient  that  looks  very  crooked  while 
standing  will  often  present  a  fairly  symmetrical  appearance 
while  lying  flat  upon  the  face. 

In  this  spine  which  I  now  show  you,  which  is  a  model 
devised  by  Dr.  Judson  to  illustrate  the  action  of  the 
spinal  muscles  in  causing  rotation  of  the  vertebra?,  you  will 
perceive  that  when  I  press  the  button  the  spine  takes  this 
double  curvature,  like  a  letter  S,  accompanied  by  rotation 
of  the  vertebra?,  one  upon  the  other  (Fig.  2),  and  you  will 
notice  that  as  long  as  I  keep  my  hand  pressed  upon  this 
button,  and  so  represent  the  weight  of  the  head  and 
shoulders  {)ressing  the  spine  more  and  more  out  of  the 
perpendi(-ular,  my  efforts  to  correct  the  curves  by  lateral 

.•  *  Some  years  ago  I  wrote  more  fully  on  the  subject  of  prevention  in 
the  New  York  Medical  Journal,  November  17,  1888. 

■i 


pressure  simjjly  serve  to  change  the  long  curves  into  a 
number  of  small  ones,  but  that  the  spine  is  not  made 
straight  until  I  release  tlie  l^ntton  and  allow  the  two  ends 


Fici.  2. 


of  the  iS  to  recede  from  each  other  (Fig.  .3),  or,  in  other 
words,  take  the  weight  of  the  head  and  shoulders  off  the 
spine  and  allow  it  to  become  straight.  As  soon  as  1  pull 
on  this  spine  I  straighten  it. 

In  putting  this  principle  into  practical  execution,  you 
will  find  one  of  the  greatest  helps  in  eliminating  the  curves 


■kh 


Fig.  4.  —The  arrow  a  shows  the  proper  position  for  the  application  of  force  In 
reducing  rotation  of  the  vertebrae  ;  the  arrows  b  h  are  the  improper  direction 

of  the  lateral  curvature.  The  amount  that  one  of  these 
badly  distorted  spines  will  stretch  while  the  patient  par- 
tially suspends  herself  by  means  of  a  head-swing  and  pulley 
is  surprising  to  one  who  has  not  measured  it  with  a  stand- 


March  18,  18i)3.J 


SAYRE:   CURVATURE  OF  THE  SPINE. 


291 


j  ard,  and  one  of  the  most  important  problems  that  presents 
itself  to  us  in  the  treatment  of  these  cases  is  to  find  a  suita- 
ble means  of  retaining  the  improved  position  gained  by 
this  self  suspension. 

In  my  own  experience,  nothing  has  been  so  satisfactory 
I  for  this  purpose  as  a  plaster-of  Paris  corset, 
I  and  T  find  that  cases  which  have  been  for  many 
years  wearing  numerous  dilferent  apparatus, 
applied  by  various  gentlemen  of  large  experi- 
ence, tell  me  that  they  find  the  corset  more 
comfortable  than  steel  braces ;  and  as  I  find 
that  these  cases  increase  in  health  and  vigor  as 
well  as  in  height,  as  shown  by  actual  measure- 
ment, under  treatment  by  suspension  and  plas- 
ter-of-Paris  corsets,  I  am  convinced  of  the 
I  superiority  of  this  method  of  treatment  ovei- 
other  mechanical  means,  which  simply  serve  to 
make  lateral  pressure   against  the   ribs.  In 
order  to  be  effective  in  reducing  the  rotation 
of  the  spine,  which  in  these  cases  is  the  most 
serious  element  in  the  production  of  deformity, 
vastly  exceeding  in  importance  the  lateral  de- 
viation of  the  spine,  it  is  necessary  that  the  force 
be  transmitted  to  the  ribs  in  a  direction  away 
from  the  spinal  column  and  not  toward  it,  as  you  will  see  by 
the  accompanying  diagram  (Fig.  4).    If  the  force  is  directed 
as  the  arrow  a  points  in  Fig.  4,  its  tendency  is  to  twist  the 
vertebrte  toward  the  straight  position,  whereas,  if  it  impinges 
against  the  ribs,  as  shown  by  the  arrows  b  h,  it  tends  to 
curve  the  ribs  more  and  more  and  rotate  the  vertebrae  in 
the  wrong  direction ;  this  second  result  is  what  practically 
takes  place  in  all  portable  mechanical  devices  I  have  seen, 
;  aiming  to  push  the  ribs  into  a  straight  position.    They  do 
not  practically  carry  out  the  principle  which  they  are  theo- 
retically supposed  to  embody,  and  the  force  which  is  re- 
;  quired  to  press  these  ribs  into  position  is  so  great,  if  con- 
j  centrated  at  a  single  point  as  in  these  mechanical  devices, 
jithat  pressure  of  sufficient  force  to  cause  any  practical 
change  is  more  than  can  be  endured  by  the  skin  without 
damage,  and  I  therefore  prefer  to  straighten  the  spine  as 
far  as  is  practicable  by  partial  self-suspension  and  manipu- 
lation, and  then  to  apply  a  plaster- of- Paris  corset,  while  the 
patient  is  twisted  as  far  as  possible  into  the  correct  posi- 
tion, and  thus  distribute  the  pressure  equally  over  the 
whole  trunk.    In  this  way  I  find  that  I  can  support  the 
weight  of  the  body  with  much  greater  comfort  to  the  pa- 
j  tient  and  much  more  efficiently  than  by  metallic  straps  and 
i  pads.    I  have  often  compared  this  to  pulling  out  an  accor- 
dion and  then  preventing  the  accordion  from  collapsing  by 
[means  of  plaster  of  Paris.    It  has  been  objected  to  this 
'principle  that  it  practically  does  not  keep  the  accordion 
I  from  collapsing,  and  I  have  been  very  much  interested  in 
measuring  a  number  of  extremely  bad  cases  of  lateral  curva- 
ture before  treatment  and  after  the  patients  were  supported 
ill  the  plaster- of-Paris  jacket. 

Case  I.— E.  O.,  aged  fourteen,  whose  i)ictiires  I  now  pass 
aronnd,  is  a  very  striking  example  of  iniiiroveiiiont. 
I      When  first  seen  she  was  four  feet  eight  inches  and  an  eighth 
[  high.    A  [)liitiil)  line  dropfjcd  from  tlie  chin  went  nntside  of  tlic 


right  foot  in  front,  and  behind  a  line  from  the  nape  of  the  neck 
passed  an  inch  to  the  left  of  the  inner  border  of  the  left  scapula. 
In  front  the  left  nipple  lay  to  the  right  of  the  plumb  line  dropped 
from  the  chin.  After  one  month's  exercise  she  measured  four 
feet  nine  inches  and  a  quarter  in  her  corset,  a  gain  of  an  inch  and 


Fig.  5. 


Fig.  6. 


an  eighth  in  a  month.  In  three  months'  time  she  measured 
without  the  corset  four  feet  nine  inches  and  a  quarter,  and  with 
the  corset  four  feet  ten  inches  and  an  eighth,  being  an  increase 
in  height  in  the  corset  of  two  inches,  made  by  suspension  and 
kept  by  the  corset.  I  here  show  yon  the  first  corset  made  for 
this  patient  (Fig.  5)  and  also  her  sixth  corset  (Fig.  6),  which 
illustrate  clearly  the  change  made  in  her  shape. 

Case  11. — N.  H.,  aged  fourteen,  on  October  3, 1891,  ii.eas- 
ured  four  feet  six  inclies  and  three  quarters  ;  after  suspension, 
four  feet  seven  inclies  and  three  eighths.  Tliis  gain  in  height 
from  the  first  suspension  was  never  entirely  lost,  as  on  the  5th  of 
October  she  measured,  before  stretching,  four  feet  seven  inches 
and  an  eighth  ;  after  stretching,  four  feet  seven  inches  and  a  half. 
On  October  7th  slie  measured,  after  stretching,  four  feet  seven 
inches  and  five  eighths.  On  October  12th  in  her  jacket  she 
measured  four  feet  seven  inches  and  seven  eighths.  On  October 
23d  a  new  jacket  was  applied,  and  in  that  she  measured  four 
feet  eight  inches,  being  a  gain  in  less  than  a  month  of  an  inch 
and  a  quarter.  This  patient  has  one  of  the  most  distorted  lateral 
curvatures  I  have  ever  seen.  The  deformity  was  congenital, 
and  may  possibly  have  been  produced  at  birth,  as  it  was  a  trans- 
verse presentation.  When  the  child  was  six  years  of  age  she 
had  pneumonia,  followed  by  empyema  on  the  right  side.  An 
incision  was  made  between  the  ribs  on  the  right  side  and  the 
pus  evacuated.  There  seems  to  be  an  absence  of  ribs  on  the 
right  side.  The  lower  ribs  project  down  below  the  crest  of  the 
ilium,  and  between  them  and  the  upper  ribs  is  a  V  shai)ed  gap. 
through  which  the  liver  can  be  distinctly  felt.  It  is  possible 
that  instead  of  there  being  an  absence  of  ribs  on  this  side,  they 
are  so  crowded  together  as  to  give  the  impression  that  the  full 
number  is  not  present.  The  mother  thinks  that  the.se  ribs  were 
torn  apart  at  the  birth  of  the  child. 

Case  IH.— C.  M.,  aged  fifteen,  September  24,  1891.  Height, 
five  feet  one  inch  and  an  eighth. 

October  15th. — Height,  five  feet  one  inch  and  seven  eighths. 
Gain  in  three  weeks,  three  quarters  of  an  inch. 

Case  IV.— E.  N.,  aged  fourteen,  July  7,  1891.  Height,  four 
feet  eight  inches. 

JiiJti  Mith. — Height,  four  feet  nine  inches  and  a  half.  In- 


292 


SAY  RE:   CURVATURE  OF  THE  SPINE. 


[N.  y.  Med,  Jour., 


crease  in  three  weeks,  an  inch  and  a  liiilf.  After  stretching, 
height,  four  feet  ten  inches  and  a  (juarter. 

AngiiHt  f>th. — Height  in  a  plaster-of-Paris  corset,  four  feet 
ten  inclies  and  seven  eighths,  an  increase  in  less  tlian  a  month, 
while  supported  by  his  corset,  of  two  inches  and  seven 
eighths.  [This  patient  was  shown  after  the  reading  of  tlio  pa- 
per. He  measured  without  his  corset  five  feet  one  incli.  A 
new  plaster-of-Paris  coi'set  was  tlien  put  on  liiin,  and  in  it  he 
measured  five  feet  two  inches  and  seven  eightlis,  an  increase  of 
an  inch  and  seven  eightlis.] 

Case  V. — W.  K.,  aged  fifteen. 

February  IS,  1891. — Four  feet  nine  inches  and  seven  eighths; 
after  suspension,  four  feet  ten  inches  and  five  eighths. 

14lh. — Suspended  night  and  morning;  height  this  evening 
after  suspension,  four  feet  eleven  inches  and  a  quarter,  a  gain 
in  one  day  of  an  inch  and  three  eigliths. 

20th. — Applied  plastcr-of-Paris  corset;  patient  has  been  ex- 
ercised daily  and  suspended ;  height  to-day  before  suspension, 
four  feet  ten  inches  and  acpiarter;  after  suspension  and  with 
corset,  four  feet  eleven  inclies  and  three  <iuarters. 

34fh- — Before  suspension  without  jacket,  four  feet  eleven 
inches  and  five  eighths;  after  suspension  with  jacket,  five  feet 
and  a  quarter  inch. 

March  2d. — Before  suspension  without  jacket,  five  inches 
and  an  eighth  ;  after  suspension  with  the  corset,  five  inches  and 
a  quarter,  being  an  increase  in  less  than  a  montli  of  two  inches 
and  a  quarter  in  actual  lieight  and  two  inches  and  tliree  eighths 
in  his  height  when  the  corset  was  applied. 

Case  VI.— K.  M.,  aged  thirteen  years,  April  19,  1892. 
Height  before  suspension,  four  feet  four  inches  and  three 
quarters;  after  suspension,  four  feet  five  inches  and  tliree 
eighths. 

In  October,  height  without  corset,  four  feet  six  inches  and 
three  eighths;  with  corset,  iieight  four  feet  seven  inches  and  a 
half.    (See  Figs.  A,  B,  C,  D,  E,  F,  G.) 

Case  VII. — E.  W.,  aged  seventeen. 

Septem.her  S8,  1892.—Ctime  to  me  wearing  a  metal  sup- 
port, which  was  designed  to  make  lateral  pressure  against  his 
ribs,  and  which  from  its  construction  seemed  to  me  to  be  more 
eflScient  in  compressing  than  in  elongating  his  spine.  I  re- 
quested his  father  to  take  the  boy's  height  in  his  brace  in  my 
office,  and  he  measured  four  feet  eight  inches;  on  removing  his 
brace,  he  measured  four  feet  eight  inches  and  five  eighths.  He 
was  then  suspended,  and  after  suspension  measured  four  feet 
eight  inches  and  seven  eighths.  This  is  not  the  first  case  I 
have  seen  in  which  the  patient  was  more  crooked  in  his  appa- 
ratus than  when  left  to  Nature.  This  patient  suspended  himself 
daily  until  October  ICth,  when  a  plaster-of-Paris  corset  was  ap- 
plied, and  in  it  he  measured  four  feet  nine  inches  and  an  eighth, 
being  an  increase  in  two  weeks'  time  of  an  inch  and  an  eighth 
in  his  height  in  his  plaster  corset  over  his  height  in  his  iron 
brace. 

Case  VIII. — H.  R.,  aged  nineteen,  had  spinal  meningitis  at 
the  age  of  three  which  left  him  paralyzed  in  various  muscles  of 
the  trunk  and  lower  extremities.  During  convalescence  he  was 
allowed  to  sit  in  bed  propped  up  by  pillows,  and  developed  a 
lateral  curvature.  He  was  treated  with  a  plaster-of-Paris  cor- 
set and  leg  braces  for  some  time,  when  his  mother,  becoming 
dissatisfied,  sought  other  advice,  and  for  years  he  wore  iron 
spinal  braces  of  various  kinds.  After  a  length  of  time  he  came 
under  observation  once  more,  liiis  time  with  an  aggravated 
lateral  curvature,  as  you  see  in  this  jihotograph.  His  muscles 
are  incajiable  of  holding  the  trunk  upright  without  artificial 
support,  and  I  have  tried  wood,  leather,  and  silicate  jackets  on 
him,  but  he  says  he  jirefers  plaster  of  Paris.  I  thought  by  my 
eye  tliat  he  looked  much  taller  in  his  corset,  and  so  wrote,  ask- 


ing him  to  have  his  height  taken  and  send  it  to  me.  To  day  I 
received  the  following  letter: 

"  Yai.e  Univeksity,  Notemher  1^,  1892. 

"  :  Just  received  your  letter,  and  in  reply  would  saj 

that  when  I  got  my  new  jacket  on  for  the  first  time  I  knew 
from  the  feeling  there  must  be  a  large  difi'erence  in  my  height, 
for  I  no  longer  felt  a  little  man,  but  rattier  that  I  had  been 
drawn  out  by  weight  at  bottom  and  pulleys  at  top  to  an  enor- 
mous height ;  so,  being  anxious  to  know  the  exact  fact  I  meas- 
ured myself  accurately,  and  found  to  my  great  delight,  as  well 
as  surprise,  that  with  my  new  jacket  on  (also  shoes)  I  was  five 
feet  nine  inches.  How's  that  for  a  stretch?  Taking  off  my 
jacket,  my  Iieight  (with  shoes)  is  five  feet  seven  inches  and  an 
eighth,  making  a  clear  gain  of  an  inch  and  seven  eighths.  I 
now  have  hopes  of  reaching  six  feet  some  day  by  a  good  atretch. 

"  P.  8. — Since  I  received  your  letter  I  have  measured  again 
with  the  same  results." 

Case  IX. -L.  B.,  twelve  years  old,  July  18,  1889.  Iieight, 
four  feet  one  inch  and  three  eighths. 

July  27th. — Height  after  self-suspension  and  with  corset 
applied,  four  feet  four  inches  and  a  half,  a  gain  of  three  inclies 
and  an  eighth. 

Case  X. — Emma  D.,  aged  twenty.  March  23,  1886,  four 
feet  six  inches. 

March  30th. — Patient  has  been  suspended  twice  daily  for  a 
week.  To  day  a  plaster  of-Paris  corset  was  ai)plied.  Height  in 
corset,  four  feet  eight  inches  and  an  eighth,  an  increase  iu 
height  of  two  inches  and  an  eighth,  and  decrease  around  the 
waist  of  four  inches  and  a  half. 

September  27th. — Height,  without  corsets,  four  feet  seven 
inches. 

October  Int. — New  corset  applied.  Height  in  it,  four  feet 
nine  inches  and  an  eighth,  a  gain  of  three  inches  and  an  eighth. 

This  patient  was  a  most  aggravated  case  of  lateral  curva- 
ture following  infantile  paralysis  at  the  age  of  eight,  which 
gradually  passed  off,  leaving  a  few  of  the  muscles  of  the  trunk 
impaired.  From  the  age  of  nine  she  had  always  worn  braces 
of  some  description,  and  had  grown  steadily  worse  during  this 
time. 

You  will  notice  in  this  case,  as  in  aU  the  others,  that  a 
marked  increase  in  height  takes  place  at  the  first  few  sus- 
pensions, but  that  after  tlie  initial  gain  the  subsequent  in- 
crease in  height  is  only  trifling.  Of  course,  in  the  younger 
patients  the  increase  in  height  which  is  observed  after  the 
lapse  of  several  months  is  attributable,  in  part,  to  the  natu- 
ral growth  of  the  body,  but  in  a  woman  of  twenty  the  lat- 
ter factor  does  not  enter  into  consideration,  and  hers  is  only 
one  of  a  number  of  cases  in  which  similar  increase  in  height 
has  been  noticed. 

I  was  long  ago  struck  with  the  very  great  change  made 
in  the  spines  of  these  patients  by  self-suspension,  but  it 
was  not  until  I  had  carefully  examined  the  heights  of  a 
number,  both  before  and  after  suspension,  and  with  and 
without  corsets,  that  I  realized  the  enormous  difference 
made  by  treatment,  the  increase  in  many  instances  being  so 
great  that  1  should  have  been  inclined  to  discredit  the  ob- 
servation had  I  not  personally  seen  it. 

In  one  case,  with  great  distortion,  in  which  there  was  a 
marked  presystolic  and  systolic  murmur  at  the  apex  of  the 
heart,  with  great  shortness  of  breath  on  exercise  and  pain 
in  the  right  side  on  coughing,  I  noticed  that  while  the  pa- 
tient was  suspended  in  the  swing  the  pulse  beats  dropped 


March  18,  1893.] 


SAYRE:   CURVATURE  OF  THE  SPINE. 


293 


from  140  to  122,  from  144  to  116,  from  122  to  100,  from 
100  to  86  on  various  occasions.  Every  time  when  I  noted 
the  [)ulso  it  was  from  18  to  28  beats  slower  while  suspended 
than  wlien  the  patient  was  down,  and  with  the  jacket  ap- 
plied, while  it  was  not  so  slow  as  during  suspension,  it  was, 
however,  much  less  rapid  than  when  the  jacket  was  on — 
from  6  to  20  beats  slower.  This  I  attributed  to  the  fact 
that  the  heart  was  not  so  compressed,  and  was  therefore  in 
better  condition  to  perform  its  functions.  She  noticed 
herself  that  she  was  much  less  short  of  breath  and  much 
better  able  to  take  exercise  while  supported  by  her  corset. 

I  have  noticed  a  similar  slowing  of  the  pulse  in  other 
cases,  but  never  to  so  marked  an  extent,  and  I  have  often 
had  patients  remark  the  greater  ease  of  breathing,  and  the 
relief  of  pain  in  the  side  while  supported  by  their  corsets. 

While  self-suspension,  in  the  manner  I  have  indicated, 
is  a  most  useful  means  of  diminishing  the  curvature  of  the 
spine,  it  is  not  practicable  for  a  patient  to  suspend  herself 
for  a  long  period  of  time,  and  in  many  cases  I  am  accus- 
tomed to  add  to  self-suspension  suspension  by  means  of  a 
weight  and  pulley  attached  to  a  chin  piece  which  is  fast- 
ened to  the  patient's  head  while  she  lies  on  her  back  on  an 
inclined  plane  which  is  slightly  convex. 

The  father  of  one  of  my  patients  has  devised  a  most 
beautifully  constructed  folding  couch  to  be  used  for  this 
purpose,  which  I  show  here.  It  is  capable  of  being  taken 
apart  and  carried  in  a  trunk  so  that  thi?  means  of  treatment 
can  be  employed  during  the  summer  while  the  patient  is  at 
various  watering  places  without  the  necessity  of  transport- 
ing bulky  apparatus. 

In  correcting  the  rotation,  which,  as  I  have  before  re 
marked,  is  a  vastly  more  prominent  element  in  the  produc- 
tion of  deformity  than  the  lateral  deviation  of  the  spine,  I 
find  great  benefit  from  having  the  patient  lie  upon  the  face 
upon  the  floor  or  a  firm  table  covered  with  a  thick  rug, 
while  I  make  strong  pressure  upon  the  projecting  scapula, 
pushing  in  a  direction  forward  and  away  from  the  central 
line  of  the  body  so  as  to  rotate  the  vertebra}  toward  the 
median  line  (Fig.  4,  a).  In  some  cases  I  allow  the  patient 
to  lie  for  half  an  hour  in  this  position  with  a  shot  bag  of 
twenty  or  thirty  pounds'  weight  resting  upon  the  shoulder, 
if  it  can  be  placed  so  that  the  weight  falls  in  the  proper  di- 
rection. • 

To  correct  rotation.  Dr.  Beely,  of  Berlin,  has  devised 
a  frame  in  which  the  patient  leans  forward,  with  the  el- 
bows resting  upon  a  couch,  while  the  back  is  parallel  with 
the  floor — very  much  in  the  position  of  a  boy  playing  leap- 
frog— while  a  strap  passes  across  the  bajk,  sustaining  a 
heavy  weight  at  its  end.  The  objection  to  it  is  that  the 
weight,  instead  of  twisting  the  spine  around  in  the  proper 
direction,  acts  to  compress  the  ribs  laterally,  which  objec- 
tion Schede,  of  Hamburg,  has  recently  tried  to  overcome, 
in  an  apparatus  of  his  devising,  by  attaching  the  weight  to 
broad  bands  of  adhesive  plaster,  which  are  secured  to  the 
walls  of  the  chest.  By  these  he  endeavors  to  twist  the  spine 
around  a  perpendicular  axis,  while  the  hips  and  shoulders 
are  held  immovably  fixed  by  means  of  iron  props  extending 
from  a  circular  frame  which  passes  around  the  patient,  who 
is  also  stretched  by  a  pulley-wheel  and  head-swing. 


I  have  had  no  personal  experience  with  Schede's  appa- 
ratus nor  with  that  of  Bradford,  of  Boston,  which  is  de- 
signed to  accomplish  very  much  the  same  purpose,  but  have 
been  able  to  perform  the  twisting  of  the  spine  by  means  of 
my  hands.  In  Bradford's  apparatus  the  patient  is  partially 
suspended  by  the  hands  and  arms,  the  pelvis  being  firmly 
fixed  on  a  chair  by  means  of  a  large  screw,  while  pressure 
is  made  against  the  chest  walls  at  different  points  by  means 
of  padded  screws,  which  pass  from  a  circular  band  of  iron 
which  encircles  the  thorax  at  some  distance  from  it,  and  is 
firmly  fastened  to  two  uprights  passing  from  the  chair. 

In  correcting  the  rotation  of  the  spine,  any  apparatus 
of  this  sort  must  pass  to  the  floor  for  a  base  of  support, 
and  all  the  machines  which  have  been  designed  to  rotate 
the  upper  part  of  the  thorax,  while  the  machine  takes  its 
point  of  origin  from  the  pelvis  or  thighs,  are  futile,  and  are 
lacking  in  the  mechanical  power  to  perform  the  work  they 
are  called  upon  to  do.  All  that  any  machine  fastened  to 
the  body  can  do  is  to  retain  the  improved  position  which  is 
gained  by  manipulation  or  force  applied  from  some  fixed 
point  outside  the  body,  and  to  retain  this  improved  posi- 
tion I  am  fully  convinced  that  apparatus  in  the  form  of  a 
corset  which  completely  encircles  the  body  is  preferable  to 
those  appliances  which  make  pressure  merely  at  certain 
points. 

The  material  of  which  this  corset  is  to  be  made  is  not 
of  such  vital  importance,  provided  it  is  light  and  strong 
and  not  impervious  to  the  air.  I  personally  prefer  the 
plaster-of-Paris  corset,  as  being  perfectly  efficient  and 
vastly  easier  of  construction  than  anything  else.  The 
wood  corset  of  Waltuch,  if  properly  made,  is  equally  as 
firm  as  the  plaster  jacket  and  a  little  lighter,  but,  as  usu- 
ally constructed,  does  not  retain  its  shape,  but  warps,  and 
when  exposed  to  the  heat  of  the  body  is  very  apt  to  sepa- 
rate into  the  component  layers  of  which  it  is  made.  The 
leather  jackets,  in  my  experience,  are  also  apt  to  curl  up 
along  the  edges,  and  in  summer  time  frequently  acquire  a 
disagreeable  odor ;  the  same  is  true  of  rawhide.  The  sili- 
cate of-soda  jackets  are  lighter  than  the  plaster  of  Paris, 
but  have  the  objection  that  they  retain  the  perspiration  on 
the  body  and  act  more  or  less  as  a  poultice.  The  wire  cor- 
set is  very  much  cooler  than  anything  else,  and  in  certain 
cases  is  probably  more  comfortable  as  a  retentive  appliance 
than  anything  else,  but  in  some  cases  does  not  retain  the 
increase  in  height  so  well  as  a  more  solid  material.  In  one 
of  the  cases  I  report  this  evening,  who  is  now  wearing  a 
wire  corset,  the  height  is  seven  eighths  of  an  inch  less  than 
while  she  wore  one  of  plaster  of  Paris. 

The  great  objection,  however,  which  I  would  urge 
against  all  these  forms  of  appliance  is  the  difficulty  with 
which  they  are  constructed.  A  plaster-of-Paris  corset  has, 
first  of  all,  to  be  made  in  which  a  cast  is  made,  and  over 
the  latter  the  leather,  felt,  wood,  paper,  celluloid,  water- 
glass,  or  wire  corset  is  constructed,  which  requires  either 
the  services  of  an  instrument- maker  or  the  expenditure  of 
a  great  deal  of  time  by  the  physician  himself,  and  to  those 
who  are  not  living  in  the  large  business  centers  all  of  these 
appliances  are  much  more  difficult  to  manufacture  than  the 
ordinary  plaster-of-Paris  corset.    In  cases  of  marked  dis- 


294 


SAYRE:   CURVATURE  OF  THE  SPINE. 


fN.  Y.  Mbd.  Jona.. 


tortion,  and  with  small  children,  these  second  casts  are  not 
so  accurate  in  their  lit  as  those  made  directly  on  the  body. 
Properly  made,  the  latter,  for  a  girl  of  sixteen,  should 
weigh  from  two  pounds  and  a  half  to  two  pounds  and 
three  quarters,  or,  if  very  heavy,  three  pounds,  and  yet  I 
have  frequently  seen  plaster  corsets  which  weigh  from  ten 
to  twelve  pounds.  If  the  best  dental  plaster  is  used  and 
well  rubbed  by  hand  into  the  meshes  of  crinoline  from 
which  the  sizing  has  been  removed  by  washing  before  the 
bandages  are  made,  care  being  taken  not  to  roll  the  band- 
age too  tightly  or  to  put  in  too  much  plaster  of  Paris,  a 
corset  ought  never  to  weigh  more  than  four  pounds  for  the 
largest  person,  and  those  who  comj)lain  of  want  of  success 
and  produce  corsets  like  this  one  that  I  here  show  you, 
should  only  blame  themselves  for  inability  to  learn  the 
proper  manner  of  making  a  plaster  of-l'aris  corset. 

You  see  that  this  one  is  like  a  section  of  the  wall  of  a 
house.  It  is  almost  solid  plaster  throughout  and  incapable 
of  being  bent,  and  is  not  shaped  to  the  patient's  figure,  and 
therefore  slipped  up  and  down.  On  the  other  hand,  I  occa- 
sionally meet  with  corsets  which  seem  to  consist  almost 
wholly  of  crinoline,  contain  no  plaster  of  Paris  in  the 
meshes,  and  are  as  useless  as  a  handkerchief  tied  around 
the  body.  As  a  usual  thing,  it  is  the  failure  to  use  plaster 
of  Paris  properly  which  makes  physicians  resort  to  felt  and 
leather. 

In  putting  the  jacket  on  it  is  important  in  these  greatly 
distorted  cases  that  the  patient  should  be  suspended  some 
little  time  before  the  corset  is  made,  in  order  to  gain  as 
good  a  position  as  possible.  Just  before  beginning  the 
application  of  the  bandages  the  patient  may  come  down  and 
rest  for  a  few  moments,  if  the  neck  is  tired,  and  then 
stretch  up  to  the  fullest  extent  possible.  The  physician 
sits  behind  the  patient  and  grasps  her  legs  tightly  between 
his  knees  so  as  to  steady  the  pelvis  and  applies  the  band- 
ages, beginning  at  the  waist,  passing  from  left  to  right  in 
the  ordinary  cases  of  lateral  curvature  in  which  the  right 
shoulder  is  prominent,  as  putting  the  bandages  around  the 
body  in  this  direction  tends  to  remove  the  rotation.  It  is 
often  desirable  to  have  an  assistant  push  the  prominent 
shoulder  forward  and  hold  it  in  this  position,  untwisting 
the  rotation,  as  it  were,  while  the  jacket  is  applied.  It  is 
always  best  to  have  an  assistant  in  front  of  the  patient  to 
keep  the  bandages  smooth  as  they  are  applied  and  rub  the 
layers  together  very  thoroughly.  The  bandages  should  be 
put,  one  at  a  time,  in  water  of  about  blood  heat,  end  up, 
the  length  of  time  required  to  put  on  one  bandage  being 
about  the  proper  time  during  which  the  next  one  should 
soak.  The  hips  should  be  padded  outside  the  shirt  before 
applying  the  bandages,  and  for  this  purpose  I  use  piano 
felt,  made  by  Alfred  Dolge  &  Son,  120  East  Thirteenth 
Street,  which  costs  §1.50  a  pound  ;  that  which  I  buy  is  too 
thick  to  be  used  for  padding  unless  split  in  two. 

The  knitted  shirts  which  are  put  on  next  to  the  skin, 
on  which  the  best  jackets  are  made,  are  knitted  for  me 
by  the  Lawson  Company,  No.  783  Broadway,  and  come 
down  to  the  knees,  the  end  of  the  shirt  being  reversed  after 
the  jacket  has  been  trimmed  out  and  stitched  along  the 
upper  edge,  completely  covering  in  the  plaster  of  Paris 


The  ordinary  jersey-fitting  underwear  can  be  used  for  this 
purpose  in  case  of  necessity.  Between  the  jacket  and  the 
skin  I  slide  a  thin  piece  of  tin,  two  inches  wide  and  twenty- 
four  inches  long,  covered  with  adhesive  plaster  with  the 
sticky  side  toward  the  tin,  or  a  piece  of  kid,  as  I  can  cut 
the  jackets  down  much  easier  and  quicker  with  this  pro- 
tection, and  it  also  adds  greatly  to  the  patient's  feeling  of 
security.  In  growing  girls  and  adult  females  it  is  neces- 
sary to  put  pads  over  the  breasts ;  except  in  the  case  of 
very  thin  people  or  little  children,  the  dinner  pad  is  usually 
not  necessary.  It  takes  from  twelve  to  fifteen  minutes  to 
complete  a  plaster  jacket.  As  soon  as  the  jacket  is  made, 
it  is  cut  down  the  center,  in  front,  on  the  piece  of  tin  which 
passes  down  the  median  line  of  the  body,  and  removed.  A 
thin  slice  is  taken  off  each  edge  in  almost  all  cases,  more 
being  removed  at  the  waist  than  elsewhere,  as,  except  in 
very  thin  persons,  it  is  impossible  to  draw  the  bandages 
quite  tight  enough  in  the  waist  without  making  wrinkles, 
and  the  addition  of  the  kid  which  covers  the  edge  of  the 
jacket  also  makes  it  a  little  too  large  unless  this  slice  is  re- 
moved. The  edges  of  the  jacket  are  then  brought  together 
and  retained  in  position  by  an  ordinary  roller  bandage.  If 
the  weather  is  very  damp,  the  jacket  may  be  laid  near  the 
fire  to  dry ;  in  ordinary  weather  this  is  not  necessary. 

The  next  day  the  patient  suspends  herself  again,  and 
the  corset  is  put  on  and  fastened  with  a  roller  bandage.  It 
is  then  trimmed  out  under  the  arms  and  over  the  front  of 
the  thighs  until  the  patient  can  move  her  arms  and  legs 
with  comfort.  The  corset  is  then  removed.  After  the 
corset  has  been  trimmed  out,  the  end  of  the  shirt  is  re- 
versed over  the  plaster  of  Paris  and  stitched  to  itself  along 
the  free  border  of  the  corset.  The  front  edges  are  bound 
with  kid  pasted  over  the  stitching,  and  a  piece  of  leather 
containing  hooks,  such  as  are  used  upon  shoes,  is  sewed 
with  an  awl  and  waxed  thread  along 
each  edge  of  the  corset,  the  stitch- 
ing passing  through  and  through 
the  plaster  of  Paris  (Fig.  7).  Ad- 
ditional strength  is  given  to  the 
jacket  if  this  leather  is  wide  enough 
to  cover  a  thin  strip  of  corset  steel, 
half  an  inch  wide  and  as  long  as  the 
corset,  which  is  placed  under  it. 
In  exceptional  cases  of  great  de- 
formity it  is  sometimes  necessary 
to  fasten  a  strip  of  thin  steel  on  the 
outside  of  the  corset  at  the  point 

where  most  strain  is  thrown  to  prevent  the  corset  from 
breaking.  If  the  patient  is  very  badly  deformed,  it  is  ex- 
pedient to  put  paddiug  inside  of  the  shirt  when  it  is  re- 
versed, in  order  to  make  the  jacket  as  symmetrical  as  possi- 
ble, and  thus  avoid  the  necessity  of  padding  the  clothes. 

The  corset  having  been  made  while  the  patient  is 
stretched  out,  it  should  always  be  applied  to  him  in  this 
position.  For  this  purpose  there  should  be  a  pulley- wheel 
and  head-swing  at  home  by  which  the  patients  can  suspend 
themselves  in  the  morning.  The  tripod  is  only  useful  for 
traveling.  At  home  a  hook  should  be  screwed  into  a  beam 
to  support  the  pulley-wheel.    While  thus  suspended,  the 


Fig.  7. 


March  18,  1893.] 


SAYRE:   CURVATURE  OF  THE  SPINE. 


295 


corset  is  applied  to  tlie  patient  by  some  member  of  tlie 
family,  and  retained  in  position  by  lacings  joining  the  hooks 
on  the  front  of  the  jacket.  The  lacing  should  pass  around 
the  two  central  hooks  at  the  waist  first,  and  then  run  down 
to  the  bottom,  be  reversed,  and  passed  up  again  to  the  top. 
Applied  in  this  manner,  the  corset  fits  better  than  if  the 
lacing  is  begun  at  either  end.  It  is  a  mistake  to  cut  the 
corsets  down  in  two  places,  as  I  have  frequently  seen  done, 
and  the  corset  should  not  be  made  so  stiH  as  to  render  it 
impossible  to  remove  it  unless  it  is  cut  in  two  places. 

I  show  you  here  two  little  plaster-of- Paris  jackets  which 
have  been  made  over  a  tumbler ;  the  tumbler  then  being  re- 
moved, the  open  end  of  the  box  has  been  covered  with  more 
plaster-of-Paris  bandages.  In  the  end  of  each  box  is  a 
hole  which  admits  the  stem  of  a  tobacco  pipe.  One  of 
these  boxes  is  varnished  and  the  other  has  been  left  plain, 
as  all  plaster-of-Paris  jackets  should  be. 

You  will  notice  that  when  I  blow  smoke  through  the 
pipe  into  the  unvarnished  box,  the  smoke  passes  through 
the  plaster  of  Paris  on  all  sides,  while  when  I  blow  smoke 
in  a  similar  manner  inside  the  varnished  box  it  remains  in- 
side, showing  the  box  is  impervious  to  air. 

I  have  seen  in  medical  journals  articles  advising  the 
shellacking  of  plaster  corsets,  in  order  to  render  them  more 
durable,  and  wish  to  draw  your  attention  to  the  folly  of 
adopting  this  procedure,  because  a  corset  in  this  way  be- 
comes a  poultice,  as  it  is  rendered  impervious  to  air.  In  one 
instance,  which  came  under  my  father's  observation,  the 
whole  epidermis  peeled  oS.  on  the  removal  of  a  solid  plaster 
jacket  coated  in  this  manner.  This  same  objection — the 
impermeability  to  air — applies  to  the  silicate-of-sodium  and 
leather  jackets,  unless  they  are  punched  full  of  holes. 

Some  of  these  patients  with  great  distortion,  especially 
if  it  is  dependent  on  paralysis,  require  artificial  support  as 
long  as  they  live  ;  but  others  may  have  their  muscles  devel- 
oped to  such  an  extent  that  they  can  dispense  with  arti- 
ficial aid. 

Among  the  exercises  I  have  found  most  useful  in  these 
cases  are  the  following :  The  patient  stands  on  the  foot  of 
the  concave  side  and  stretches  the  corresponding  arm  as 
high  above  the  head  as  possible,  holding  a  slight  weight  in 
the  hand.  This  can  be  repeated  a  number  of  times,  vary- 
ing with  the  patient's  strength,  as  can  also  the  other  exer- 
cises. 

Standing  with  the  convex  side  toward  a  pulley- weight, 
the  patient  lifts  the  weight  by  pulling  the  rope  with  the 
hand  of  the  concave  side,  which  is  passed  in  front  of  the 
body,  and  draws  the  rope  across  the  body  and  upward,  at 
the  same  time  leaning  the  body  toward  the  concave  side 
and  trying  to  expand  the  sunken  side  of  the  chest. 

Standing  with  the  feet  together  and  the  knees  stiff,  the 
patient  bends  forward  and  tries  to  touch  the  ground  with 
the  fingers,  and  rises  again,  lifting  the  hands  before  raising 
the  trunk. 

Standing  with  the  convex  side  toward  a  padded  sup- 
port, like  a  fence,  the  patient  bends  laterally  and  posterior- 
ly over  this,  stretching  out  the  hollow  side. 

Lying  on  the  floor,  face  upward,  both  arms  by  the  sides, 
palms  down,  the  arms  are  raised  vertically  till  the  backs  of 


the  hands  touch  the  floor  above  the  patient's  head,  the 
elbows  being  kept  stiff.  The  arms  are  then  brought  back 
laterally  to  the  position  of  starting,  while  the  fingers  just 
clear  the  floor. 

There  are  a  number  of  other  exercises  which  I  could 
dwell  on  if  time  permitted,  but  I  will  simply  draw  atten- 
tion to  these  few  as  I  have  entered  more  fully  into  this  sub- 
ject in  the  paper  quoted  above,  and  wish  this  evening  to 
speak  especially  of  the  means  of  retaining  the  improved 
position  secured  by  treatment. 

In  keeping  a  record  of  cases  I  find  that  photography  is 
a  great  help,  and  I  also  make  use  of  tracings  of  the  thorax, 
taken  while  the  patient  is  bending  forward  with  the  arms 
drooped  toward  the  floor.  These  tracings  can  be  taken  either 
with  a  piece  of  flexible  lead  tape  or  with  this  machine,  in- 
vented by  Dr.  Beely,  of  Berlin,  which  consists  of  a  number 
of  steel  rods  sliding  loosely  upon  each  other,  whose  points 
conform  to  the  outlines  of  the  trunk  when  the  apparatus  is 
pressed  upon  the  back  at  right  angles  to  the  long  axis  of 
the  body  and  held  perpendicular  to  the  floor,  after  the 
manner  of  machines  with  which  the  hatter  takes  the  out- 
line of  your  head.  By  means  of  a  lever  the  steel  rods  are 
then  locked  in  position,  and  the  machine  is  laid  upon  a 
piece  of  paper  placed  on  a  thin  sheet  of  felt ;  then,  with  a 
little  roller,  the  teeth  on  the  lower  surface  of  the  steel  rods 
are  pressed  into  the  piece  of  paper,  forming  a  line  which 
gives  the  outline  of  the  back  at  the  level  where  the  instru- 
ment was  applied.  By  taking  the  outline  of  the  trunk  at 
each  vertebra,  in  this  manner,  the  difference  in  outline  of 
the  trunk  at  different  portions  and  at  different  times  can 
be  recorded,  and  such  tracings,  taken  at  intervals  of  several 
months,  serve  as  excellent  reports  of  the  progress  of  the 
case. 

This  method  is,  however,  very  much  more  tedious  than 
photography,  and  I  employ  the  latter  very  much  more 
frequently. 

The  following  method  of  taking  an  outline  of  the  entire 
circumference  of  the  thorax,  according  to  the  manner  of 
Dr.  Mary  Putnam  Jacobi,  is  also  interesting,  and  gives  a 
cross-section  of  the  body  at  any  given  point : 

A  piece  of  flexible  metal  tape,  provided  with  a  hinge  in 
the  center,  is  passed  around  the  body  at  any  desired  point, 
and  made  to  closely  conform  to  the  contour  of  the  thorax. 
It  is  then  removed  by  opening  the  hinge,  laid  upon  a  smooth 
table,  the  ends  of  the  tape  being  brought  into  the  same  po- 
sition they  occupied  when  on  the  body,  and  plaster  of 
Paris,  mixed  with  water  to  the  consistence  of  cream,  is 
poured  into  the  center  of  the  tape  until  it  is  completely 
filled  to  the  upper  edge  of  the  latter.  When  the  plaster 
of  Paris  has  set,  the  tape  is  removed,  leaving  a  thin  slice  of 
plaster  of  Paris,  which  represents  accurately  a  transverse 
section  of  the  body  at  the  point  at  which  the  tape  was 
applied. 

In  these  sections  that  I  show  you,  which  were  made 
in  this  manner,  the  rotation  of  the  spine  is  very  conspicu- 
ous and  the  sharp  angle  of  the  ribs  clearly  brought  out.  I 
have  marked  on  these  sections  the  line  corresponding  to 
the  antero-posterior  and  lateral  diameters  of  the  body,  and 
the  sections  through  the  mid-dorsal  region  show  excellently 


296 


ROOSEVELT:  ACQUIRED  IMMUNITY  FROM  INFECTIOUS  DISEASES.    [N.  Y.  Mbd.  Jock., 


the  great  increase  of  one  oblique  diameter  and  diminution 
of  the  other,  with  prominence  of  the  right  scapula,  while 
this  section  through  the  lumbar  region  shows  the  exact  re- 
verse of  this  condition. 

These  sections  show  very  clearly  the  very  adverse  cir- 
cumstances under  which  the  heart  and  lungs  labor  in  per- 
forming their  functions  in  advanced  lateral  curvature,  and 
no  one  can  percuss  or  auscult  one  of  these  chests  without 
being  struck  with  the  unusual  number  of  abnormal  sounds 
he  meets.  Disorders  of  digestion  are  also  of  very  fre- 
quent occurrence,  and  many  of  the  cases  suffer  from  severe 
neuralgias,  due  to  pressure  on  the  intercostal  nerves  as  they 
emerge  from  the  foramina  of  exit  between  the  vertebras. 
This  preparation  shows  very  clearly  the  great  compression 
which  sometimes  takes  place  between  the  ribs,  and  shows 

how  the  bodies  of  the 
vertebrae  may  be  rotated 
around  the  perpendicu- 
lar axis  of  the  body — 
almost  to  a  right  angle 
(Fig.  8).  You  will  ob- 
serve that  the  lumbar 
vertebrae  and  the  cervi- 
cal vertebrae  in  this  prep- 
aration are  in  the  same 
plane,  while  those  in  the 
dorsal  region  are  rotated 
at  an  angle  of  eighty  five 
degrees,  and  the  ribs  are 
so  compressed  against 
the  bodies  of  the  verte- 
brae that  one  wonders 
how  the  lungs  manage 
to  expand  at  all.  The 
rotation  in  this  case  was  so  sharp  that  during  life  the  pro- 
jection was  mistaken  by  a  number  of  gentlemen  who  ex- 
amined the  patient  for  the  antero-posterior  curvature  of 
Pott's  disease,  the  angles  of  the  ribs  being  mistaken  for 
the  spinous  processes  of  the  vertebrae. 

In  exceptional  instances,  where  the  ribs  are  so  twisted 
as  to  press  against  each  other  or  against  the  crest  of  the 
ilium,  it  may  be  necessary  to  resect  one  or  more  ribs  in 
order  to  give  relief  from  pain  in  some  cases,  and  in  others 
to  avoid  caries  from  pressure. 

While  I  formerly  thought  that  many  of  these  patients 
were  so  distorted  that  it  was  useless  to  attempt  to  treat 
them,  I  have  in  a  number  of  instances  yielded  to  their 
solicitations  and  applied  plaster- of-Paris  jackets  and  com- 
menced a  system  of  exercise,  with  so  much  benefit  to  them 
that  I  have  changed  my  mind  and  concluded  that  I  have 
yet  to  see  a  case  of  lateral  curvature  so  bad  that  I  think  it 
can  not  be  rendered  more  comfortable  by  treatment ;  and 
if  we  can  make  these  miserable  cripples  less  unsightly,  can 
help  them  to  conceal  their  deformity,  or  can  relieve  it> 
even  in  a  moderate  degree,  the  result  is  well  worth  the 
time  and  trouble  spent  upon  them. 


Fig.  8. 


Change  of  Address. — Dr.  C.  Teubner,  to  No.  2.38  East  One-hundi  ed- 
and-fit'tli  Street. 


ACQUIRED  IMMUNITY 
FROM  CERTAIN  INFECTIOUS  DISEASES 

A  RESULT  OF  HEREDITY  AND  NATURAL  SELECTION. 
By  J.  WEST  ROOSEVELT,  M.  D., 

VISITING  PHVRICIAN  TO  BEIXEVUE  HOSPITAL, 
ATTENDING  PHYSICIAN  TO  THE  ItOOSEVELT  HOSPITAL,  NEW  YORK. 

The  various  theories  which  have  been  advanced  in  ex- 
planation of  the  protection  afforded  by  one  attack  of  cer- 
tain infectious  diseases  from  subsequent  attacks  may  be 
summarized  as  follows : 

1.  The  pathogenic  micro-organism  is  assumed  to  ex- 
haust the  supply  of  some  substance  present  in  the  bodies 
of  unprotected  people,  which  substance  is  necessary  for  the 
nourishment  of  the  parasite,  and  which,  once  removed  by  it, 
is  not  reproduced  by  the  body.  This  is  called  "  the  ex- 
haustion theory." 

2.  The  micro-organism  is  thought  to  produce  within 
the  body  some  substance  inimical  to  its  own  existence,  and 
this  antidotal  substance,  once  formed,  is  not  destroyed  or 
excreted  by  the  body.  This  is  called  "  the  antidote  theory." 

3.  It  is  assumed  that  in  a  successful  struggle  with  the 
invading  bacteria  the  body  cells  acquire  an  increased 
strength — become  educated,  one  might  say — and  thus  are 
able  to  destroy  the  enemy.  This  new  strength  they  trans- 
mit to  their  descendants,  so  that  the  body  is  better  able 
than  before  to  repel  subsequent  invaders.  Thus  is  estab- 
lished "tolerance"  to  the  poison,  as  it  is  maintained. 

The  first  theory  may  be  regarded  as  untenable  for  sev- 
eral reasons,  among  which  are  the  following,  which  seems 
to  me  to  be  fatal :  If  we  accept  it  we  must  believe  that 
Nature  has  provided  man  with  a  number  of  different  sub- 
stances which  can  have  no  conceivable  use  other  than  that 
of  providing  food  and  accommodation  for  pathogenic 
micro-organisms.  These  hypothetical  substances  are  evi- 
dently not  needed  by  the  human  body,  since,  ex  hypothesi, 
bacteria  remove  them  and  they  are  not  reproduced ;  yet 
the  patient  recovers  entirely,  and  is  not  at  all  the  worse  for 
his  illness.  It  would  be  hard  to  believe  that  this  could  be 
the  case  if  provision  were  only  made  for  the  growth  and 
nutrition  of  some  one  species  of  germ  ;  but  when  we  are 
called  upon  to  believe  that  the  majority  of  mankind  come 
into  the  world  with  a  separate  and  distinct  "  substance " 
suited  to  the  needs  of  the  micro-organisms  of  small-pox, 
measles,  scarlatina,  chicken-pox,  vaccinia,  yellow  fever,  and 
a  number  of  other  diseases,  the  imagination  is  staggered 
and  the  reason  revolts  against  such  a  preposterous  idea. 
In  a  sense  which  will  be  indicated  in  another  part  of  this 
paper,  and  which  was  not  in  the  minds  of  its  inventors,  it 
may  be  said  that  there  is  some  truth  in  the  theory. 

A  certain  degree  of  plausibility  is  lent  to  the  antidotal 
hypothesis  by  the  fact  that,  like  all  living  things,  bacteria 
produce  by  their  own  vital  processes  substances  which,  if 
sufficiently  concentrated,  are  fatal  to  the  producers.  The 
great  objection  to  it  is  that  we  know  of  no  organic  com- 
pound which  is  not  excreted  or  destroyed  by  the  body 
within  a  short  time  after  its  introduction  into  the  system. 
This  makes  it  hard  to  conceive  that  any  permanent  protec- 
tion can  be  afforded  by  bacterial  action. 


Mnrcli  18,  1893.J      ROOSEVELT:  ACQUIRED  IMMUNITY  FROM  INFECTIOUS  DISEASES. 


297 


Of  the  three  explanations  sns^gested — the  tliird,  that  of 
acquired  tolerance — is  nearer  to  the  truth  than  the  others, 
yet  it  does  not  altogether  satisfy  the  mind.  While  it  is  free 
from  the  objections  which  apply  to  the  others,  it  seems  to 
me  weak  in  one  important  respect.  It  is  perfectly  logical  to 
assume  that  the  power  of  resistance  existing  in  a  body-cell 
ehould  be  transmitted  to  its  descendants,  in  accordance  with 
the  laws  of  heredity  ;  but  it  is  an  assumption  hardly  warranted 
by  experience  or  observation  of  other  biological  phenomena 
which  abscribes  to  cells  the  power  of  acquiring  and  trans- 
mitting peculiar  resisting  powers  during  a  period  of  stress 
such  as  must  exist  under  conditions  which  obtain  in  the  in- 
fections diseases.  It  seems  to  be  improbable  that  such 
should  be  the  result  of  their  fight. 

To  me  it  seems  that  the  objections  to  the  theory  vanish 
if  we  apply  the  law  of  the  survival  of  the  fittest  to  the 
problem  as  well  as  the  law  of  heredity.  Let  it  be  supposed 
that  the  feebler  cells  concerned  in  the  struggle  are  for  the 
most  part  killed.  When  recovery  takes  place  the  body 
will  resume  its  original  functional  activity,  but  it  will  con- 
tain descendants  of  the  cells  originally  strong  enough  to 
destroy  the  poison  of  the  particular  disease  through  which 
it  has  passed.  Naturally  the  qualities  of  the  parent  cells 
are  transmitted  to  their  offspring.  It  is  not  so  much  by 
reason  of  new  powers  acquired  by  the  stronger  as  by  rea- 
son of  the  destruction  of  the  weaker  cells  that  immunity 
is  afforded.  This  is  much  more  in  accord  with  Nature's 
methods  as  actually  observed  in  the  whole  domain  of  biol- 
ogy. She  seems  to  prefer  to  slay  the  weak  rather  than  to 
leave  them  to  transmit  their  weakness  to  others.  The 
strong  survive  because  of  their  strength,  and  in  the  end 
this  is  a  benefit,  for  it  tends  to  perpetuate  and  improve  the 
species  and  elevate  the  type  which  composes  the  majority 
of  such  species.  In  the  long  run  it  is  far  better  that,  rela- 
tively speaking,  a  few  individuals  should  suffer  and  perish 
than  that  the  whole  number  should  do  so  at  a  later  day. 
The  survival  of  the  fittest  cells  in  the  human  body  pre- 
serves the  whole  body  from  danger,  if  the  theory  of  im- 
munity set  forth  in  this  paper  be  true.  Living  cells  then 
form  the  "substance"  assumed  in  the  "exhaustion  theory" 
to  be  destroyed  and  never  reproduced. 

The  evidence  of  its  truth  is  largely  derived  from  a  con- 
sideration of  the  action  of  certain  laws  of  Nature  upon  liv- 
ing organisms  of  complex  structure — viz.,  animals  and 
plants.  It  is  therefore  not  to  be  regarded  as  entirely 
trustworthy.  Reasoning  by  analogy  is  not  true  inductive 
reasoning  ;  it  is  not  based  upon  observed  facts.  Analogi- 
cal evidence  should  be  regarded  by  the  scientist  very  nearly 
as  circumstantial  evidence  is  regarded  by  the  lawyer.  The 
latter  can  not  be  considered  as  approaching  in  value  the 
testimony  of  trustworthy  eye-witnesses,  but  its  importance 
increases  with  each  additional  demonstrated  fact  which 
tends  to  show  that  a  certain  allegation  is  probably  correct. 
When  a  sufficient  number  of  facts  have  been  presented  in 
court,  which,  although  they  do  not  directly  prove  a  case, 
make  it  extremely  probable  that  certain  events  have  oc- 
curred (as  the  lawyers  express  it,  "  show  its  probability  be- 
yond reasonable  doubt "),  circumstantial  evidence  amounts 
almost  to  proof,  and  has  been  regarded  by  the  courts  as  actu- 


ally proof.  This  should  be  the  position  of  the  scientist  in 
respect  to  any  theory  which  does  not  rest  upon  indisputa- 
ble demonstration.  The  theory  must  explain  all  the  known 
phenomena,  and  it  must  conflict  with  none  of  them.  If 
based  upon  analogy,  the  closer  and  more  evident  the  anal- 
ogy, the  more  probable  the  theory.  As  time  goes  on  and 
new  observations  are  made  in  the  light  of  more  extended 
knowledge,  each  one  which  accords  with  the  theory  in- 
creases the  probability  of  its  truth.  When  all  known  phe- 
nomena confirm  it  and  no  single  one  fails  to  agree  with  it,  it 
may  be  considered  as  proved.  It  matters  not  whether  the 
hypothesis  was  based  upon  fact  or  fancy. 

It  seems  to  me  that  this  hypothesis  is  a  rational  expla- 
nation of  the  immunity  conferred  by  attacks  of  the  diseases 
under  discussion.  The  fact  that  attacks  of  some  acute  in- 
fectious disorders  do  not  diminish  the  susceptibility  to  in- 
fection does  not,  as  I  think,  conflict  with  it.  The  reasons 
which  justify  the  last  statement  will  be  given  in  another 
paper.  For  the  present  it  is  desired  only  to  give  very 
briefly  an  outline  of  this  theory  in  its  relation  to  certain 
others. 

If  the  doctrine  of  phagocytosis  is  correct — if  the  disease 
process  is  a  direct  conflict  between  the  phagocytes  and  the 
invading  germs — then  surely  the  weaker  cells  must  perish, 
and,  when  the  struggle  is  over,  the  body  must  find  in  the 
descendants  of  the  stronger  a  safeguard  against  subsequent 
invasions.  If  it  is  by  chemical  substances  produced  within 
the  body  that  the  bacteria  are  overcome,  the  theory  is 
perfectly  reasonable.  The  bactericide  necessarily  is  a 
product  of  cell  activity ;  it  is  the  direct  or  indirect  ac- 
tion of  the  living  tissue  elements  which  determines  the 
constitution  of  all  the  secretions  and  excretions.  The 
blood  plasma  is  no  exception.  If  the  latter  contains  as  one 
of  its  normal  constituents  something  toxic  to  certain  forma 
of  bacteria  when  present  in  sufficient  amount,  it  is  because 
some  living  cells  produce  it,  as  part  of  their  life  work.  If 
the  presence  of  the  germ  determines  the  production  of  such 
a  substance,  not  previously  existing  in  the  plasma,  it  is 
still  by  cell  activity  that  it  is  made.  If  recovery  depends 
upon  speedy  elimination  of  the  bacteria  or  some  product  of 
their  growth,  or  something  necessary  for  their  nourishment, 
again  it  must  be  accomplished  by  body  cells.  It  might  be 
that  the  micro-organisms  of  some  diseases  can  only  flour- 
ish by  killing  certain  cells,  directly  or  indirectly.  What- 
ever be  the  method  of  attack  or  defense,  the  struggle  ia 
between  germ  and  cell.  The  living  tissue  elements  which 
are  least  able  to  withstand  the  stress  of  the  conflict  must 
succumb  sooner  than  their  stronger  fellows  ;  it  matters  not 
whether  the  weakness  results  from  lack  of  sufficient  de- 
structive power  as  a  phagocyte,  or  of  sufiicicnt  power  to 
produce  an  unusual  quantity  of  some  bactericide,  or  of 
adaptability  to  changed  environment  sufiicicnt  to  manu- 
facture some  offensive  or  defensive  substance  different 
from  that  previously  produced,  or  to  withstand  the  delete- 
rious effects  of  some  product  of  bacterial  life,  or  to  remove 
some  substance  necessary  for  bacterial  nourishment,  or  to 
do  any  work  in  the  fight  of  any  sort. 

It  may  be  objected  that  there  is  no  proof  that  cells  in- 
herit qualities  possessed  by  their  ancestors.    There  ia  no 


298 


WELT:  MENTAL  DLSTURBANCES  AND  ACUTE  DISEASES  IN  vniLDHOOD.    [N.  Y.  Med.  Jo0r., 


direct  proof ;  but  to  deny  the  fact  would  be  equivalent  to 
asserting  that  the  whole  is  not  equal  to  the  sum  of  all  its 
parts,  for  the  hereditary  peculiarities  of  animals  are  admit- 
ted, and  animals  are  composed  of  multitudes  of  cells.  If 
the  latter  do  not  inherit  and  transmit  certain  peculiarities, 
how  can  the  former  ?  If  spermatozoon  and  ovum  are  able 
(as  they  unquestionably  are)  to  influence  so  powerfully  the 
development  of  the  entire  body  as  to  cause  physical  or 
mental  characteristics  to  recur  generation  after  generation, 
it  is  impossible  to  conceive  that  this  result  can  be  produced 
unless  every  generation  of  their  descendants  (the  body  cells) 
receives  and  transmits  hereditary  traits. 

It  seems  equally  inconceivable  that  the  law  of  the  sur- 
vival of  the  fittest,  which  is  of  universal  application 
throughout  the  whole  animal  and  vegetable  world  to  each 
individual  animal  or  vegetable  of  every  species,  should  fail 
to  apply  to  every  cell  forming  part  of  these  individuals. 
No  reasonable  explanation  can  be  (or,  at  all  events,  has 
been)  adduced  of  the  existence  of  such  an  anomaly  in 
Nature. 

It  is  a  much  more  plausible  supposition  that  qualities 
already  possessed  congeuitally  by  the  cells  should  be 
transmitted  to  descendants  than  that  those  acquired  in  a 
short,  fierce  struggle  should  be  transmitted.  Indeed,  the 
possibility  of  the  transmission  of  acquired  traits  is  denied 
by  some  biologists.  Of  the  congenital  traits  there  is  no 
doubt. 

Of  this  theory  it  may  be  said,  at  least,  that  it  is  very 
fascinating.  Is  it  not  also  suggestive  and  plausible  ?  Is 
it  not  worthy  of  consideration  as  a  working  hypothesis,  if 
nothing  more  ?  In  another  paper  I  shall  discuss  in  detail 
the  application  of  it  to  a  number  of  diseases,  and  also  to 
the  protective  effects  of  inoculations  with  attenuated  virus 
and  with  vaccine. 


A  CONTRIBUTION  ON 
THE  OCCURRENCE  OF  MENTAL  DISTURBANCES 
FOLLOWING  ACUTE  DISEASES  IN  CHILDHOOD.* 
By  SARA  WELT,  M.  D., 

ATTENDANT  IN  OUTDOOR  DEPARTMENT  FOR  CUILDBBN'S  DISEASES, 
MOUNT  SINAI  HOSPITAL. 

The  occurrence  of  mental  derangements  in  childhood 
has  been  known  for  a  long  time.  In  the  records  of  the 
Braunschweig  Insane  Asylum  of  the  year  iVoO  a  case  is 
mentioned  of  a  girl,  eleven  years  of  age,  who  had  been  sent 
there  for  the  treatment  of  melancholy.  Greding's  book, 
published  in  the  year  1790,  contains  a  communication  about 
a  nine- months-old  baby,  the  son  of  an  idiotic  mother,  which 
suffered  with  maniacal  attacks,  and  died  of  marasmus  and 
suffocation  at  the  cutting  of  its  first  teeth.  Indeed,  more 
than  fourteen  hundred  years  ago,  Cselius  Aurelianus,  in  his 
work  De  morhis  acutis  et  chronicis,  remarks  on  the  rare  oc- 
currence of  mania  among  children  in  the  following :  "  Gen- 
eratur  autem  mania  frequentius  in  juvenibus  ac  mediis 
aetatibus,  difficile  in  senibus  atque  difficilius  in  pueris,  vel 
mulicribus."    But  it  was  only  during  the  second  half  of 

*  Read  liefore  the  German  Medical  Society,  New  York,  December  7, 
1891. 


the  present  century  that  attention  was  called  to  and  a  thor- 
ough study  of  the  psychoses  among  children  made. 

The  first  noteworthy  treatise  originated  from  an  English 
author,  Ch.  West,  which  was  followed  in  Germany  by  a 
monograph  on  this  subject  written  by  Berkhan  in  the  year 
1865.  Somewhat  earlier  there  appeared  the  first  essay  on 
psychoses  in  connection  with  acute  diseases  by  Boileau. 
Besides  some  few  less  important  articles,  there  appeared  in 
the  year  1865  some  very  valuable  contributions  on  this  sub- 
ject by  H.  Weber  and  Muguier.  As  some  few  communi- 
cations from  Thore  and  Griesinger  prove,  the  occasional 
occurrence  of  mental  disturbances  in  connection  with  somat- 
ic diseases  was  not  unknown  to  the  older  physicians  ;  even 
Sydenham,  in  the  year  1676,  mentions  that  intermittents 
may  be  followed  by  alienations. 

The  statistics  on  the  frequency  of  mental  derangements 
in  children  vary  very  greatly  among  the  different  authors 
on  account  of  their  different  ideas  as  to  the  limits  of  child- 
hood. However  this  may  be,  it  seems  to  be  certain  that 
alienations  in  the  first  ten  years  of  life,  aside  from  idiotism, 
are  very  rare.  Out  of  ten  thousand  inhabitants,  Emming- 
haus  found  in  Germany,  between  the  first  and  fifth  years, 
0"1 8  per  cent,  insane  ;  be:ween  the  sixth  and  tenth  years, 
0'69  per  cent. ;  and  between  the  eleventh  and  fifteenth 
years,  1'46  insane;  while  Deboutteville,  in  France,  found 
among  the  insane  admitted  to  the  asylum  in  Saint- You  from 
1827  to  1834,  0'9  per  cent,  between  the  fifth  and  ninth 
years,  3"5  per  cent,  between  the  tenth  and  fourteenth  years, 
and  20  per  cent,  between  the  fifteenth  and  twentieth  years. 
Turnham  found  but  eight  children  less  than  ten  years  of 
age  among  twenty-one  thousand  three  hundred  and  thirty- 
three  insane ;  idiots,  who  are  far  more  frequent  in  num- 
ber, not  being  included.  The  most  common  mental  de- 
rangement in  childhood  is  idiocy,  be  it  congenital,  depend- 
ing upon  insufficient  development  of  the  brain,  or  acquired 
as  the  result  of  some  other  previous  cerebral  trouble.  Next 
in  frequency  is  the  maniacal  exaltation  and  mania,  while 
melancholic  depression  is  but  rarely  met  with  and  only  in 
late  childhood. 

But  I  think  we  may  assume,  with  all  probability,  that 
insanity  in  childhood  occurs  more  frequently  than  is  evi- 
dent from  the  statistics  given.  As  no  psychosis  in  child- 
hood shows  the  entire  complex  of  symptoms  as  in  adults, 
it  is  readily  understood  that  the  symptoms  of  a  mentally 
deranged  child  may  often  be  taken  to  be  bad  behavior,  and 
only  the  result — the  idiotism — will  be  recognized. 

Besides  heredity,  especially  from  the  maternal  side,  the 
setiological  factors  in  the  production  of  mental  disturbances 
in  children  are  injuries  of  the  head,  either  during  parturi- 
tion or  later  ;  acute  cerebral  trouble  and  abnormal  devel- 
opment of  the  brain  ;  insolation  ;  fright ;  masturbation  ;  and 
infectious  diseases.  Of  the  latter,  I  mention,  according  to 
their  frequency,  typhoid,  pneumonia,  acute  articular  rheu- 
matism, measles,  scarlatina,  and  angina  faucium.  During 
the  last  three  years  I  have  had  the  opportunity  of  observ- 
ing mental  derangements  following  infectious  diseases  in 
three  children.  On  account  of  their  infrequent  occurrence, 
I  take  the  liberty  of  reporting  the  mso  far  as  my  memo- 
randa permit.    In  all  three  cases  the  alienation  manifested 


March  18,  1893.]     WELT:   MENTAL  DISTURBANCES  AND  ACUTE  DISEASES  IN  CHILDHOOD. 


299 


itself  after  tlie  total  disappearance  of  the  fever — in  one 
child  in  the  defervescent  stage  of  scarlatina,  in  the  other 
during  convalescence  after  typhoid  and  diphtheria.  In  the 
literature  at  iny  disposal  I  was  able  to  find  but  one  case 
following  an  inilanimatory  affection  of  the  throat.  This  is 
described  in  II.  \N'eber's  classical  essay,  and  published  in 
the  Medico-chirurgical  Transactions  of  1865.  On  account 
of  the  similarity  in  the  aetiological  factors,  permit  me  to 
report  briefly  Weber's  case. 

A  man,  twenty-five  years  of  age,  suddenly  exhibited,  after  a 
severe  inflammatory  affection  of  the  throat,  symptoms  of  men- 
tal derangement.  Laboriug  under  the  delusion  that  his  business 
was  being  ruined,  he  tried  to  kill  his  wife,  cliild,  and  himself  in 
order  to  be  saved  from  coming  disaster ;  but,  being  prevented 
from  carrying  out  his  intentions,  he  got  well  in  less  than  two 
days  after  the  administration  of  large  doses  of  morphine  and 
a  moderate  quantity  of  wine.  He  remained  very  low-spirited 
during  the  next  fortnight,  and  only  then  did  his  previous  cheer- 
ful disposition  return.  The  delirium  was  accompanied  by  symp- 
toms of  collapse. 

The  first  case  I  observed  was  that  of  Franz  Z.,  a  boy  ten  years 
of  age,  of  healthy  parents;  a  half-brother  of  his  father  died 
of  consumption  ;  several  of  his  mother's  brothers  and  sisters 
(eight)  died  of  infantile  diseases;  one  living  sister  has  epilepsy. 
The  mother  of  the  boy  had  seven  children.  The  first  was  a 
still-birth,  the  second  died  with  pneumonia,  and  a  third  during 
dentition.  Of  the  four  remaining  living  children,  a  younger 
brother,  suffering  with  frequent  attacks  of  bronchitis,  and  a 
baby,  ten  months  old,  with  otitis  media  and  retropharyngeal 
abscess,  have  been  under  my  care  for  treatment.  Franz  was 
born  at  full  term  during  a  normal  labor,  and  early  developed 
symptoms  of  rhachitis,  the  first  teeth  appearing  at  the  end  of 
his  first  year,  and  at  the  termination  of  the  second  was  hardly 
able  to  walk.  Off  and  on  he  suffered  with  convulsions;  he  had 
measles,  scarlatina,  aud  frequently  bronchitis;  also  swelling  of 
the  glands  of  the  neck.  From  his  fifth  year  he  always  was 
healthy,  went  to  school,  and  was  an  industrious  and  intelligent 
pupil. 

In  the  latter  part  of  February,  1889,  he  fell  sick  with  high 
fever.  The  temperature  rose  to  104°  F.,  with  a  rapid  pulse. 
He  complained  of  severe  headache  and  difficulty  in  deglutition. 
On  inspection,  the  tongue  appeared  covered  with  a  thick,  yel- 
lowish-white coating.  There  was  intense  hyperremia  and 
swelling  of  the  velum  and  the  posterior  wall  of  the  pharynx, 
while  on  both  enlarged  tonsils  were  small  circumscribed  diph- 
theritic patches.  There  was  also  considerable  swelling  of  the 
submaxillary  glands.  The  viscera  of  the  thorax  and  abdomen 
were  found  to  be  normal,  and  the  constitutional  symptoms  in 
accordance  with  the  local  affection. 

To  reduce  the  temperature  I  ordered  antipyrine  in  doses  of 
0'3,  and  for  the  throat  affection  hourly  cold  compresses;  every 
two  hours  0'3  tincture  of  the  chloride  of  iron  dissolved  in 
glycerin  and  water,  besides  frequent  administration  of  milk, 
whisky,  and  beef  tea. 

The  fever  kept  on  for  the  next  three  days,  but  the  symp- 
toms decreased  in  severity,  and  on  the  sixth  day  after  the  onset 
the  local  affection  had  disappeared  with  the  exception  of  a 
slight  redness  of  the  fauces.  The  patient  felt  considerably  bet- 
ter; his  appetite  returned;  he  passed  large  quantities  of  urine, 
which  contained  neitlier  albumin  nor  susrar,  but,  although  the 
temperature  was  normal,  the  pulse  was  weak  and  fre(]uent; 
bed  rest  and  light  roborant  diet  was  therefore  ordered,  in  the 
course  of  a  few  days  the  patient  became  unusually  restless;  he 
could  not  sleep  at  night,  and  lost  his  appetite.    Contrary  to 


his  habit,  he  was  very  talkative,  and  often  gave  impudent  an- 
swers. After  the  administration  of  one  gramme  of  bromide  of 
potassium  in  the  evening  he  slept  somewhat  better;  l)ut  gradu- 
ally the  restlessness  in  the  Tnotor  as  well  as  in  the  psychic 
sphere  increased  considerably.  Being  now  in  very  good  humor 
and  in  an  incessant  talkative  and  playing  mood,  he  quickly, 
after  a  slight  cause,  became  excited  to  excessive  anger,  with 
hostile  intentions  toward  bis  family.  Sometimes,  without  any 
reason  at  all,  he  was  furious,  full  of  mischief  and  brutality.  In 
one  of  his  violent  tits,  in  an  unguarded  moment,  he  tried,  after 
having  broken  the  window  glass,  to  throw  his  little  favorite 
sister  into  the  street.  At  another  time  he  beat,  bit,  and  choked 
his  mother,  and  tore  her  dresses  off  her  body  until  he  fell  back 
exhausted.  At  times  these  raving  attacks  were  preceded  by 
stupor  with  staring  glance  and  rigid  position  of  the  body,  his 
face  as  well  as  his  hands  and  feet  being  covered  with  perspira- 
tion, while  the  pulse  was  very  frequent  and  irregular.  He  had 
lost  his  appetite  entirely,  and  only  with  a  great  deal  of  trouble 
could  he  be  induced  to  partake  of  some  food.  He  rested  very 
badly  in  spite  of  administration  of  sulphate  of  morphine.  My 
proposition  to  send  the  boy  to  an  asylum  was  not  accepted  by 
the  parents,  especially  when  I  told  them  that  the  cessation  of 
tiie  mania  in  a  few  weeks  was  to  be  expected.  In  his  madness 
he  tore  and  broke  everything  he  could  lay  hands  on,  with  the 
exception  of  the  many  portraits  of  saints  with  which  he  was 
surrounded  by  his  bigoted  mother;  with  the  fragments  and  re- 
mains he  played  for  hours.  In  the  presence  of  strangers  he 
often  would  control  himself,  and  was  then  vivacious  and  ani- 
mated, sometimes  using  rude  and  indecent  language.  Often  he 
mistook  persons  whom  he  knew  before  very  well.  Very  rarely 
he  had  hallucinations — oftener  of  sight  than  of  hearing;  they 
were  mostly  of  a  fretful  nature,  contrary  to  his  usual  gay  state 
of  mind.  This  condition  remained  nearly  unchanged  until 
the  end  of  April,  1889.  From  this  time  his  motor  and  psy- 
chical restlessness  decreased  and  slow  but  steady  improvement 
set  in ;  his  raving  attacks  occurred  less  frequently ;  he  be- 
came quieter  and  in  his  behavior  more  modest.  His  appe- 
tite increased,  and  he  passed  comfortable  nights,  yet  he  was 
unable  to  recollect  many  words.  He  also  had  totally  forgotten 
to  read  and  to  write.  At  the  end  of  May  he  was  sufficiently 
improved  to  leave  for  the  country,  accompanied  by  his  mother, 
and  returned  perfectly  restored  from  there  in  the  beginning  of 
July.  He  remembered  the  past  very  well  and  felt  ashamed  if 
anybody  referred  to  it.  He  was  able  to  read  and  write  again. 
Since  then  he  always  has  been  well,  with  the  exception  of  an 
attack  of  angina  faucium,  from  which  he  recovered  in  a  few 
days  without  exi)eriencing  any  disagreeable  consequences. 

The  second  observation  was  made  in  Lizzie  S.,  a  girl  twelve 
years  and  a  half  old,  yet  of  infantile  habitus.  She  comes  from' 
a  healthy  family  and  sufiered  from  but  few  diseases  of  child- 
hood. She  was,  however,  according  to  the  report  of  her 
mother,  always  a  pale  and  puny  child.  In  August,  1889,  she 
was  taken  ill  with  typhus  abdominalis;  fever,  roseola,  enlarge- 
ment of  the  spleen,  and  disturbance  of  the  alimentary  canal 
were  present,  but  the  course  of  the  disease  was  rather  a  mild 
one.  There  were  no  hasmorrhages  of  the  intestines  and  no  de- 
lirium febrile.  About  two  weeks  after  the  beginning  of  conva- 
lescence the  usually  vivacious  girl  became  depressed,  she  lost 
her  appetite,  and  slept  badly.  The  urine,  which  was  passed  in 
copious  quantities,  contained  neither  albumin  nor  sugar.  She 
would  often  cry  for  a  long  time  without  any  cause  whatsoever, 
and  finally  explained  that  she  was  annoyed  by  terrible  thoughts 
which  she  could  not  abandon.  She  felt  impelled  to  kill  her 
mother,  but  did  not  like  to  do  so.  The  separation  of  the  girl 
from  her  mother,  who  was  afraid  for  her  own  life,  was  impos- 
sible on  account  of  various  reasons.    Iron  and  roborant  diet 


800 


WELT:  MENTAL  DISTURBANCES  AND  ACUTE  DISEASES  IN  CHILDHOOD.    ^N.  Y.  Med.  Jodk., 


were  ordered,  and  in  the  evening  small  doses  of  opium  to  pro- 
mote sleep.  Ja  the  course  of  the  next  few  days  she  was  still 
repeatedly  troubled  with  imperative  conceptions  and  melan- 
cholic depression,  and  only  after  a  lapse  of  a  few  weeks  fully 
regained  her  normal  state  of  mind. 

The  third  case  observed  was  a  boy,  five  years  old,  very  well 
developed  for  liis  age.  He  came  from  very  healthy  parents  and 
was  liimself  never  ill  until  one  year  ago;  in  the  last  year  he  suf- 
fered from  measles  and  fre(]uent  attack.s  of  angina  tonsillaris, 
which  left  him  anajnuc  and  badly  nourished.  Last  January  he 
had  scarlatina  of  a  very  niild  type;  the  diignosis,  however, 
Could  be  made  with  certainty,  especially  as  in  the  same  house 
omly  a  few  days  before  a  child  died  of  the  same  disease,  the 
parents  of  which  frequently  communicated  with  the  family  of 
my  patient.  Fever  and  exanthema  disappeared  in  due  time; 
the  urine  was  perfectly  normal  and  there  was  no  symptom  of 
meningeal  trouble;  suddenly,  after  having  been  fretful  and 
peevish  some  time  before,  his  restlessness  increased  consider- 
ably ;  lie  did  not  recognize  and  repulsed  his  mother,  to  whom 
he  had  always  been  exceedingly  attached.  Laboring  under  the 
delusion  that  the  house  was  on  fire,  he  made  efiforts  in  his  great- 
est terror  to  leave  his  bed  and  run  into  the  street;  he  was  very 
pale  and  his  face  was  covered  with  profuse  perspiration:  his  eyes 
were  staring,  the  pulse  very  frequent  and  irregular;  whisky  and 
pulvis  Doveri  were  ordered,  but,  notwithstanding,  he  passed 
a  restless  night;  next  day  the  little  patient  had  a  similar  but 
rather  milder  attack  of  excitement  with  hallucinations;  the 
treatment  was  the  some  as  on  the  previous  occasion.  Regard- 
ing the  character  of  the  hallucinations,  it  is  of  interest  to  note 
that  there  was  really  fire  in  the  house  a  few  months  before. 
At  the  time  the  boy  was  said  to  have  been  in  great  fear.  The 
duration  of  the  mental  disturbance  in  this  case  was  forty-eight 
hours. 

The  alienations  described  have,  in  spite  of  their  differ- 
ent character,  that  in  common,  that  they  occurred  in  chil- 
dren descended  from  healthy  parents ;  that  they  followed 
closely  various  infectious  diseases,  and  appeared  some  time 
after  the  complete  decline  of  the  fever.  Especially  impor- 
tant is  the  absence  of  meningeal  symptoms  and  kidney  af- 
fection. The  character  of  the  mental  disturbance  varies  con- 
siderably: in  the  third  case  manifesting  itself  by  rapidly 
vanishing  delirium  with  hallucinations  of  sight ;  in  the  two 
first  cases  approaching  in  character  psychoses  of  spontane- 
Qtis  origin ;  in  the  second  case  the  melancholic  depression, 
BO  rarely  observed  in  childhood  ;  while  in  the  first  case  a 
slight  diphtheritic  attack  was  followed  by  an  acute  mania 
of  three  months'  duration.  In  all  patients  the  onset  of  the 
trouble  was  accompanied  by  symptoms  of  great  debility, 
even  of  collapse. 

The  described  mental  derangements  belong  to  the  cate- 
gory of  psychoses  which  H.  Weber  classifies  as  "  acute  in- 
eanity  during  the  decline  of  acute  diseases  "  ;  Kraepelin  as 
asthenic  psychoses ;  while  Traube  calls  them  "  Inanition- 
delirien." 

Already  early  the  attention  was  called  by  Thore  and 
other  authors  to  the  fact  that  psychoses  following  acute 
diseases  are  of  two  classes  :  the  first  is  met  with  during  the 
development  and  the  duration  of  the  acute  process  itself, 
while  the  second  class  is  found  only  during  convalescence,  or 
at  least  during  an  afebrile  intermission  of  the  disease.  The 
ajtiology,  as  well  as  the  course  and  the  issue  in  these  two 
groups — the  febrile  and  asthenic  deliria — differ  considerably. 


Kraepelin  points  out  that  in  the  pathogeny  of  the 
febrile  deliria  the  producing  cause  of  the  disease  prevails 
considerably  over  the  predisposition  of  the  individual ;  the 
causes  of  the  disease,  though,  are  dependent  upon  somatic 
disturbances  (high  temperature,  increased  metabolism,  etc.). 
Hence  the  monotony  of  the  febrile  deliria,  the  short  course, 
and  the  nearly  always  favorable  issue  with  the  disappear- 
ance of  the  aitiological  cause ;  on  the  other  hand,  the  pre- 
disposition of  the  individual  forms,  the  most  important 
factor  in  the  development  of  the  asthenic  form.  The  low- 
ered state  of  the  system,  depressed  by  the  preceding  fever 
and  infection,  exhibits  itself  more  when  the  circulation  ia 
retarded  during  the  decline  of  the  fever ;  and  the  brain, 
which  may  have  suffered  in  its  vitality  by  the  preceding 
rise  of  temperature,  is  the  first  organ  that  reacts  on  the  in- 
adequate supply  of  blood ;  besides,  there  may  be  an  influ- 
ence of  the  infectious  elements  (in  the  first  case  of  the 
diphtheritic  bacilli)  upon  the  central  nervous  system  itself, 
either  directly  by  affecting  the  ganglionic  cells,  or  indirectly 
through  a  change  of  the  blood  by  the  micro-organisms.  In 
this  deranged  state  of  equilibrium  of  the  system  even  slight 
irritating  influences,  such  as  are  afforded  by  the  events  of 
daily  life  and  which  are  frequently  overlooked,  may  lead  to 
the  development  of  mental  disturbances.  In  their  course 
the  asthenic  psychoses  resemble  the  mental  derangements 
of  spontaneous  origin,  and  they  usually  terminate  in  full  re- 
covery ;  with  the  progressing  convalescence  and  better  nu- 
trition of  the  brain  its  morbid  changes  disappear.  H. 
Weber  thus  thinks  the  prognosis  favorable  :  "  Die  Storung 
verschwand  in  seinen  Fallen  nach  einigen  Tagen,  ohne  an- 
dere  Spuren  zu  hinterlassen,  als  die  cines  sehr  lebhaften 
Traumes  "  ;  but  he  admits  that  in  some  cases  the  trouble 
may  become  a  permanent  one. 

Kraepelin,  whose  explanation  of  the  pathogenesis  of  the 
asthenic  psychoses  I  have  accepted,  found,  in  four  hundred 
cases  of  febrile  deliria  collected  from  the  literature,  eighty- 
seven  per  cent,  of  all  cases  cured  in  four  weeks ;  while  of 
three  hundred  cases  of  asthenic  psychoses,  only  fifty-nine 
per  cent,  recovered  in  the  same  time.  The  termination  of 
the  disease  was  in  the  first  group  sixty-three  per  cent,  re- 
coverj'  and  thirty-seven  per  cent,  fatal,  while  in  the  sec- 
ond group  eighty-two  per  cent,  recovered,  6-9  per  cent, 
died,  and  in  10'6  per  cent,  the  mental  disturbance  continued 
chronic. 

Delasiauve  tells,  from  his  great  experience,  that  a  num- 
ber of  individuals  who  have  suffered  and  recovered  from 
mania  in  their  childhood  were,  as  adults,  again  admitted  to 
the  asylum — a  fact  which  has,  quoad  prognosin,  to  be  taken 
in  consideration.  Occasionally  the  disease  may  terminate  in 
idiocy. 

As  a  matter  of  prophylaxis,  children  after  acute  dis- 
eases, especially  when  in  an  anaemic  and  poor  condition, 
ought  not  to  be  allowed  to  leave  the  bed  too  early,  and  the 
action  of  the  heart  should  be  carefully  controlled.  Threat- 
ening spells  of  weakness  ought  to  be  prevented  by  adminis- 
tration of  good  nourishment  and  stimulants.  In  occurrence 
of  deliria  strict  control  of  the  patient  becomes  necessary  ; 
bed  rest  and  a  generous  administration  of  alcoholics  and 
heart  stimulants.    Against  the  irritable  state  of  the  brain, 


March  18,  1893.] 


EI  VERS :   OA  TA  RA  GT  EXTRA  CTION. 


301 


frequent  dosing  of  sedatives  in  often  repeated  and,  if  neces- 
sary, larger  doses. 

Literature. 

1.  Claiule-Steplien  Le  Paiilmier.  Des  affections  mentales 
ehez  les  enfants  et  en  partieulier  de  la  manie.    Paris,  185G. 

2.  Berkhan.    Irresein  bei  Kindern.    Brunswick,  1863. 

3.  H.  Weber.    Medieo-cMrurg.  Transactions,  vol.  xlviii. 

4.  Kraepclin.    Archid  fur  Psycliiatrie.  Bd.  xi,  xii. 

5.  Einmingliaus.  Die  psyohischen  Storungen  des  Eindes- 
alters,  1887. 

CATARACT  EXTRACTION.* 
By  E.  C.  rivers,  A.  M.,  M.  D., 

DEJTVBR,  COL. 

The  operation  for  extraction  of  cataract  is  the  most 
important  the  oculist  has  to  perform.  It  may  not  require 
more  skill  or  judgment  on  his  part  than  other  eye  opera- 
tions, but  the  results  to  the  patient  of  having  sight  restored 
to  a  blind  eye  are  so  great  that  the  subject  must  always  be 
one  particularly  fascinating  to  both  patient  and  doctor.  In 
a  matter  of  such  moment  it  is  not  surprising  to  find  wide 
divergence  of  opinion  as  to  the  values  to  be  placed  on  dif- 
ferent methods  of  operating,  or  different  instruments  or 
manipulations  to  be  used  in  certain  steps  of  the  operation, 
and  conflicting  opinions  by  operators  of  apparently  equal 
ability  in  regard  to  the  best  dressings  and  after-treatment 
to  be  employed. 

I  do  not  propose,  however,  either  to  present  here  an 
epitome  of  the  history  of  the  operation  for  extraction,  or 
to  pose  as  a  critic  of  other  more  able  and  experienced  oper- 
ators, even  if  time  was  sufficient  and  my  ability  to  do  so 
unquestioned. 

My  object  is  simply  to  give  an  account  of  my  own  ex- 
perience in  this  line,  hoping  it  will  prove  of  some  interest, 
if  not  on  account  of  methods  and  means  that  have  proved 
of  value  in  my  hands,  at  least  that  any  failure  or  mistake 
on  my  part  might  be  instructive. 

In  order  that  any  value  can  be  attached  to  a  paper  of 
this  kind,  it  is  necessary  that  all  the  extractions  done  by 
one  person,  whether  followed  by  good  or  bad  results,  should 
be  given.  For  this  reason  I  have  not  neglected  to  give 
every  case  recorded  in  my  record  books,  or  that  I  could  re- 
member with  suflScient  accuracy,  of  operation  done  long 
enough  ago  to  have  the  result  determined.  This  is  my 
apology  for  bringing  to  your  attention  some  cases  which, 
possibly,  some  of  you  will  think  had  better  been  left  buried 
in  the  past. 

The  cases  have  not  been  selected  in  any  way,  but  have 
been  all  those  in  which  an  extraction  of  a  cataract,  whether 
complicated  by  other  disease  of  the  eye  or  not,  seemed  to 
your  reporter  to  the  best  interest  of  the  patient.  In  this 
number,  however,  I  have  not  included  cases  of  dislocated 
lenses  removed. 

The  whole  niimber  of  eyes  operated  on  is  flfty-one,  in 
thirty-eight  individuals,  the  youngest  about  twenty-three 
years  old,  the  oldest  eighty-four  years  and  six  months. 

In  enumerating  the  results,  all  in  which  vision  amounted 
to  -^"(j  or  more  have  been  called  successful ;  of  these  we 

*  Read  before  the  Colorado  State  Medical  Association,  June,  1892, 


have  forty-four.  In  only  one  of  these  was  vision  as  low  as 
the  minimum.  All  cases  not  followed  by  such  improve- 
ment will  be  related  more  at  length. 

Of  the  successful  cases,  one  was  a  Morgagnian  cataract, 
with  adhesions  to  the  iris.  One  had  a  very  peculiar  dark 
streak,  extending  from  the  center  to  the  periphery  (below) 
of  the  capsule,  easily  seen  with  the  naked  eye  on  examina- 
tion, and  at  tirst  thought  to  be  a  foreign  body,  but  proved 
not  to  be. 

One  patient,  aged  thirty-two,  had  punctate  opacities  in  the 
lower  portion  of  Descemet's  memhrace.  No  history  of  pain 
or  injury  to  eye.  Operation,  with  iridectomy,  smooth  and  suc- 
cessful. One  patient  broke  out,  two  or  three  days  after  the 
operation,  with  a  severe  facial  erysipelas.  The  eye  was  not 
affected,  and  wherever  the  skin  was  covered  on  the  cheeks  and 
forehead  by  the  bandage,  the  inflammation  did  not  extend. 
One  other  case  needs  to  be  spoken  of  on  account  of  its  being 
caused  by  a  small  piece  of  iron  in  a  man  about  twenty-three 
years  old.  The  lens  was  extracted;  no  foreign  body  found;  re- 
sults good.  Only  one  patient  got  vision  =  1.  This  was  the  only 
eye  the  patient  had.  The  opacity  was  confined  to  tbe  central 
part,  and  apparently  not  increasing,  tbe  vision  remaining  the 
same  for  over  a  year.  He  had  no  difficulty  in  getting  around, 
but  his  sight  was  not  good  enough  for  him  to  work.  Iridectomy 
was  performed,  the  lens  was  ex[)elled  without  difficulty,  and, 
much  to  my  sur[)rise,  it  came  away  altogether  and  was  perfectly 
liard.  In  two  other  cases  vision  was  nearly  equal  to  1.  One 
had  had  a  slight  corneal  cloud  since  childhood.  As  stated  above, 
only  one  case  was  as  low  as  and  that  could  be  improved  by 
further  operation  on  the  capsule,  but  the  patient  is  unwilling  to 
risk  any  loss  of  what  sight  he  has. 

Discission  of  the  capsule  was  performed  in  thirteen  cases. 
Several  other  patients  could  have  increase  of  vision  by  the  same 
means.  Tlie  secondary  operation  caused  great  damage  by  sup- 
puration of  the  vitreous  in  one  eye  operated  on  successfully  three 
years  before.  The  patient  was  operated  on  with  the  knife  made 
for  this  purpose,  and  bandaged  with  antiseptic  precautions. 
Thirty-one  hours  afterward  severe  pain  began  in  the  eye,  with 
loss  of  vision.  Examination  showed  suppuration  in  the  anterior 
portion  of  the  vitreous  and  slight  cloudiness  at  the  point  of  punc- 
ture in  the  cornea.  He  was  a  hospital  patient,  and  had  freely 
bathed  his  eye  after  I  had  left  him  with  the  holy  water  in  the 
hospital  chapel,  undoubtedly  producing  tiie  infection. 

Of  those  not  classified  as  successful,  one  patient,  who 
did  not  have  perception  of  light,  was  operated  on  at  his 
own  request  for  cosmetic  effect  alone.  Examination  after- 
ward showed  extensive  vitreous  opacities.  One  patient 
was  operated  on  at  his  request,  although  great  doubt  ex- 
isted whether  all  the  opacities  visible  were  in  the  lens. 
Here  also  extensive  vitreous  opacities  were  found.  In  both 
these  cases  the  corneal  wound  healed  perfectly  and  the 
pupil  remained  open  and  black.  Vision  of  course  was  not 
improved. 

During  the  past  few  years  a  return  has  been  made  in 
great  measure  to  the  old  method  of  "  simple  extraction  " — 
that  is  to  say,  without  an  iridectomy.  Among  my  fifty- 
one  cases  eight  have  been  done  by  this  method  and  forty- 
three  with  an  iridectomy.  I  have  found  in  this  small 
number  no  difference  in  the  average  of  vison  obtained. 

When  the  lens  is  hard  and  I  have  reason  to  think  there 
is  not  much  cortical  substance,  I  perform  the  simple  opera- 
tion, provided  no  unlooked-for  occurrences  necessitate  ex- 


302 


RIVERS: 


CATARACT  EXTRACTION: 


[N.  Y.  Mkd.  Jodb., 


cision  of  a  piece  of  iris.  In  expelling  the  lens  through 
the  natural  pupil  I  go  slowly,  giving  the  pupil  time  to  di- 
late under  the  pressure  as  it  passes  through.  In  one  case, 
where  a  simple  o{)eration  was  intended,  T  was  obliged  to 
iridectomize  on  account  of  the  rigidity  of  the  sphincter 
pupillae ;  in  another,  on  account  of  the  iris  falling  over  the 
edge  of  the  knife  and  being  wounded.  In  all  cases  of  sim- 
ple extraction  I  place  my  incision  in  the  clear  cornea,  after 
the  manner  of  Dr.  Bull,  and  have  the  apex  of  the  flap  one 
or  two  millimetres  above  the  opaque  portion  of  the  cornea. 
This  always  makes  the  iridectomy  more  difficult  to  perform 
if  it  becomes  necessary,  but  prevents  prolapse  of  the  iris. 
It  makes  more  difficult  the  making  of  a  smooth  incision, 
the  edge  of  the  flap  often  being  irregular,  and  consequently 
increasing  the  astigmatism.  Where  iridectomy  is  to  be 
done,  I  place  my  incision  as  near  the  corneal  edge  as  possi- 
ble, but  do  not  make  a  conjunctival  flap. 

In  opening  the  capsule,  I  usually,  in  both  methods,  use 
a  Knapp's  knife  and  open  it  freely  on  the  anterior  surface. 
In  simple  extraction  I  pay  no  attention  to  the  prolapse  of 
the  iris,  which  usually  takes  place  on  completing  the  cor- 
neal incision,  except  not  to  injure  it  in  any  way.  In  the 
majority  of  cases  it  returns  to  its  proper  position  spontane- 
ously after  the  lens  is  removed,  or  can  easily  be  replaced 
with  a  spatula.  * 

In  expelling  the  lens  I  always  use  the  spatula,  and  in 
some  cases,  when  the  patient  is  under  good  control,  make 
counter-pressure  with  the  fixation  forceps  over  the  posterior 
flap  of  the  wound.  To  remove  cortical  substance,  if  neces- 
sary, I  irrigate  the  anterior  chamber  with  water  that  has 
been  boiled  and  is  still  warm,  or  boric-acid  solution,  by 
means  of  an  ordinary  pipette  that  has  been  disinfected. 
The  point  is  only  inserted  at  one  corner  of  the  wound 
sufficiently  to  allow  the  fluid  to  enter  the  eye. 

The  two  most  serious  objections  I  have  found  to  the 
simple  extraction  are  the  difficulty  of  removing  the  cortical 
substance  and  the  almost  invariable  iritis  followed  by  pos- 
terior synechiae,  only  two  of  my  eight  cases  being  free  of 
the  latter.  In  several  they  were  only  slight.  The  small 
size  of  the  pupil  after  this  method  prevents  any  free  lacera- 
tion of  the  capsule  afterward  if  it  should  become  desirable. 
Fortunately,  I  have  had  no  case  of  prolapse  of  the  iris. 

Every  patient  I  operate  on  by  either  method  is  treated 
for  several  days  previously  by  a  solution  of  bichloride  (1  to 
5,000)  three  times  a  day,  and  any  conjunctival  or  lacrymal 
trouble  is  first  removed  as  far  as  possible.  Atropine  is 
employed  to  determine  the  condition  of  the  lens  and  iris  in 
all  cases.  Just  before  operating  I  disinfect  the  eye  and 
surrounding  parts  with  either  the  bichloride  or  a  saturated 
solution  of  boric  acid.  My  instruments  are  cleansed  with 
hot  water  and  usually  placed  in  alcohol,  from  which  they 
are  taken  as  needed.  My  hands  are  cleansed  with  soap  and 
hot  water.  I  always  use  a  speculum  and  remove  it  only  at 
the  completion  of  the  operation,  when  the  eye  is  thorough- 
ly washed  with  a  solution  (saturated)  of  boric  acid,  and 
cotton  wet  with  the  same  is  placed  over  both  eyes  and  held 
in  place  by  a  roller  bandage.  When  ready  to  remove  the 
speculum  I  always  caution  the  patients  not  to  close  the  lids 
tightly,  as  they  feel  like  doing  after  the  stretching  of  the 


instrument,  but  let  them  come  together  very  lightly.  I  do 
not  now  use  eserine,  even  in  weak  solutions,  after  the  simple 
extraction,  to  contract  the  pupil,  as  I  do  not  think  it  neces- 
sary or  scientific.  With  the  high  incision,  if  a  prolapse 
of  iris  should  occur,  it  would  be  much  larger  with  a  con- 
tracted pupil  than  if  the  eserine  had  not  been  used.  In 
one  or  two  of  my  eight  cases  I  filled  the  eye,  before  apply- 
ing the  compress  and  bandage,  with  a  solution  of  atropine, 
eight  grains  to  the  ounce.  I  not  only  got  no  prolapse,  but 
I  noticed  little  if  any  dilference  in  the  posterior  synechia; 
following  in  these  cases  and  in  those  in  which  I  had  used 
eserine.  I  do  not  consider  that  I  increase  the  danger  by 
using  atro[)ine,  as  it  will  not  dilate  the  pupil  as  long  as  the 
anterior  chamber  is  open  ;  and  as  soon  as  the  anterior 
chamber  is  sealed,  by  the  corneal  wound  uniting,  the  danger 
of  prolapse  is  removed. 

My  after-treatment  is  regulated  by  the  amount  of  pain 
experienced.  The  bandage  is  usually  removed,  the  outside 
of  the  lids  cleansed  with  the  boric-acid  solution,  and  the 
cotton  changed  at  the  end  of  twenty-four  or  forty-eight 
hours.  On  the  third  day  usually  I  begin  using  atropine 
drops  twice  daily.  If  the  patient  has  had  no  pain  I  do  not 
examine  the  eye  until  the  fourth  or  fifth  day.  On  the  fifth 
I  leave  the  unoperated  eye  open  if  it  has  any  vision. 

Most  of  my  patients  are  operated  on  at  their  homes,  but 
not  necessarily  on  their  beds.  I  operate  usually  at  three 
o'clock  in  the  afternoon.  I  require  my  patients  to  remain 
where  operated  on  until  bed-time,  when  they  are  allowed 
to  walk  to  the  bed  and  are  made  to  remain  there  according 
to  what  I  think  best  for  each  individual  case — usually  until 
the  fifth  day.  I  never  operate  on  both  eyes  at  one  time, 
preferring  to  give  the  patient  every  chance  to  get  at  least 
one  eye  with  useful  vision. 

The  accident  of  least  moment  happening  to  me  during 
the  operation  has  been  that  twice,  by  a  sudden  movement 
of  the  eye  during  the  passage  of  the  knife  through  the  an- 
terior chamber,  the  aqueous  has  been  evacuated.  In  both 
cases  I  cautiously  withdrew  the  knife  and  waited,  with  the 
eye  covered  by  a  compress,  until  the  chamber  refilled,  and 
then  completed  the  operation.  No  trouble  followed  in 
either  instance.  The  more  serious  accident  I  have  had  was 
once  when  I  made  the  counter-puncture. 

The  patient  became  frif^htened  and  suddenly  pulled  away 
from  me  violently  and  sat  up  before  I  could  release  my  hold 
upon  the  knife,  completing  not  only  the  corneal  inci.*i(>n,  but 
also  expelling  the  lens  in  the  capsule,  together  with  consider- 
able vitreous  adhering  to  it,  on  to  the  sleeve  of  my  coat.  I  in- 
stilled atropine  sohition  and  applied  a  bandage  and  cotton.  The 
patient  recovered  with  V.  =  which,  as  above  stated,  could 
be  improved  by  needling  the  pupillary  membrane  present,  but 
the  patient  jjrefers  to  stay  as  he  is.  The  patient  was  unnerved 
by  my  pointing  out  the  stei)8  of  the  operation  to  the  students 
near  by.    Now  I  operate  with  ray  mouih  shut. 

In  three  eyes  I  have  had  dislocation  of  the  lens,  two  of 
these  in  the  same  individual,  an  old  man  of  seventy-five 
years,  with  trembling  irides,  due  to  a  fluid  condition  of  the 
vitieous.  As  soon  as  the  lenses  were  touched  they  sank 
out  of  sight.  I  fished  up  one,  and  removed  it  from  the 
fundus  of  the  eye ;  but  neither  eye  had  any  vision,  except 


March  18,  1893.] 


PARKE:  A  UNIQUE  FRACTURE  OF  THE  PATELLA. 


303 


perception  of  light,  even  after  the  lens  had  disappeared 
from  the  pupil. 

Tlie  other  was  in  a  man  nearly  as  old— seventy- four  years — 
who  was  non  compos  mentis^  and  would  not  keep  his  eye  still 
(luring  the  delivery  of  the  lens.  About  half  the  lens  was  ex- 
pelled, when  there  was  loss  of  vitreous,  and  the  remaining  por- 
tion of  the  lens  was  dislocated  upward  out  of  sight.  Several 
attempts  to  recover  it  only  produced  more  loss  of  vitreous. 
The  eye  was  closed  with  the  usual  dressing.  The  patient  at 
first  had  good  vision,  but  after  about  six  months  the  eye  was 
lost  by  iridocyclitis. 

It  would  have  been  better  to  continue  my  attempts  until 
I  recovered  the  dislocated  lens,  but  I  did  not  then  know 
enough  to  do  so. 

One  ca«e  was  lost  by  using  a  general  ansBsthetic  badly  ad- 
ministered. The  eye  had  previously  been  iridectomized  for 
glaucoma — in  a  very  nervous  old  lady,  who  insisted  upon  having 
ether  given  her  by  her  family  plnsician.  The  administrator  al- 
lowed the  patient  to  come  from  under  itjust  as  the  operation  was 
completed.  The  vomiting  and  uncontrollable  actions  of  the  pa- 
tient cansed  extensive  loss  of  vitreous  in  spite  of  the  compress  of 
cotton  held  over  the  eye  to  prevent  it.  Inflammation  followed 
with  closure  of  the  pupil,  vision  being  ecjual  to  perception  of 
light.  Only  one  other  patient  had  any  loss  of  vitreous,  occur- 
ring as  the  speculum  was  removed ;  this  one  recovered  with 
good  vision.  One  case,  intended  to  be  a  simple  extraction,  was 
iridectomized  on  account  of  the  iris  falling  before  the  knife  and 
being  wounded  in  making  the  incision.    Vision  —  f  J. 

During  the  after-treatment  several  slight  accidents,  such 
as  injuring  the  eye  by  the  hand  or  striking  it  against  ob- 
jects, have  happened,  but  none  have  been  followed  by 
serious  results. 

In  two  cases  there  has  been  suppuration,  besides  the  one 
above  stated,  following  discission.  One  was  one  of  my  first  cases. 
No  antiseptic  precautions  were  employed.  Suppuration  began 
on  the  fifth  day.  The  pupil  was  finally  blocked  by  thick  inflam- 
matory membrane.  It  was  afterward  incised  with  De  Wecker's 
iris  scissors,  but  the  vision  thus  gained  was  soon  lost  by  closing 
of  the  pupil  made.  The  other  was  in  a  case  of  simple  extraction, 
and  began  twenty-one  days  after  the  operation — after  the  pa- 
tient was  allowed  out  of  the  house.  All  sight  for  a  time  was 
lost,  but  the  vitreous,  to  which  the  suppuration  was  confined, 
under  atropine  and  constant  hot,  moist  applications,  cleared  up. 
Vision  =  |i  at  the  last  examination  without  further  operative 
procedures.  After  the  suppurative  process  had  ceased,  a  point 
of  iris  was  observed  adherent  to  one  corner  of  the  corneal 
wound.  Whether  a  small  portion  of  the  wound  failed  to  unite 
thoroughly,  giving  entrance  later  to  some  pyogenic  micrococci 
or  not,  can  not  be  stated  positively,  but  such  was  my  opinion. 

To  recapitulate,  I  have  operated  in  all  fifty-one  times. 

Forty-four  of  these  have  been  successful  in  restoring  use- 
ful vision.  Seven  patients  have  not  recovered  vision.  Of 
these  seven,  two,  although  the  operation  was  successfully 
(lone,  were  not  expected  to  regain  any  vision,  on  account  of 
other  eye  troubles.  Two  others  had  eyes  with  fluid  vitreous, 
and  it  was  very  doubtful  if  the  blindness  was  due  to  the  cata- 
racts alone.  However,  these  operations  as  performed  would 
not  have  been  successful  if  there  had  been  vision  in  the  eyes. 
Three  cases  were  lost  through  causes  directly  connected 
with  the  operation  and  treatment,  and  which  possibly  might 
have  been  prevented — viz.,  one  of  dislocation  of  the  lens, 


one  of  suppuration,  and  one  due  to  the  effects  of  the  ether 
passing  away  too  quickly.  Of  the  fifty-one,  eight  were  done 
without  iridectomy,  of  which  none  were  unsuccessful,  and 
forty-three  with  iridectomy,  including  all  the  complicated 
cases  and  all  the  losses.  Four  per  cent,  of  cocaine  in  a  satu- 
rated solution  of  boric  acid  was  used  in  nearly  all  cases. 


A  UNIQUE  FRACTURE  OF  TDE  PATELLA. 

By  C.  R.  PARKE,  M.  D., 

SORANTON,  PA. 

The  case  that  I  wish  to  speak  of  is  of  interest  to  me 
in  that  I  had  never  seen  anything  of  the  kind  before,  and, 
after  seeing  it,  I  was  unable  to  find  a  similar  fracture  spoken 
of  in  any  of  the  works  I  was  able  to  consult. 

On  February  16,  1893,  I  was  called  to  see  M.  S.,  Hungarian 
miner,  aged  twenty-two,  single.  On  December  13,  1892,  while 
at  work  in  the  mines  loading  coal  into  a  little  mine  car,  a  car 
from  another  breast  came  down  the  track,  and  his  right  leg  was 
caught  between  the  two  cars  as  they  came  together.  The  im- 
mediate result  of  the  accident  was  severe  pain  and  inability  to 
walk.  There  was  a  severe  contusion  about  the  knee  joint, 
though  the  skin  was  not  broken. 

Extensive  swelling  immediately  followed,  and,  upon  the  ar- 
rival of  a  local  surgeon,  a  diagnosis  of  "contusion  and  sprain 
of  right  knee"  was  made.  The  treatment  consisted  of  lini- 
ments and  lotions.  -  The  man  improved  so  that  he  went  about 
the  house,  but  was  very  lame  and  had  but  slight  control  over 
the  right  leg. 

Upon  making  my  examination  on  February  16th,  I  found 
the  general  appearance  of  the  right  knee  similar  to  the  left, 
the  only  diflerence  being  that  the  riglit  patella  was  not  as 
prominent  as  the  left  and  seemed  slightly  lower  on  the  leg.  Pa- 
tient was  able  to  extend  leg  (by  muscular  force)  very  imperfectly. 
Upon  placing  my  hands  upon  the  knee,  I  found  the  ligamentum 
patellffi  lax.  The  patella  seemed  complete  in  its  entire  circum- 
ference, but  three  fourths  of  an  inch  above  the  superior  border 
I  found  the  inferior  border  of  another  patella,  which  also 
seemed  entire  in  its  circumference,  with  the  exception  of  the 
inferior  border,  which  was  nearly  straight  across.  The  surface 
of  this  second  patella  was  flat,  however,  not  convex,  as  was  the 
lower  one. 

These  two  patellaj  seemed  bound  together  by  some  kind  of 
ligamentous  union.  Upon  grasping  either  of  them  firmly,  I  was 
able  to  get  my  fingers  under  sufficiently  to  make  out  that  they 
were  but  about  half  the  thickness  of  the  normal  patella.  I 
then  realized  the  nature  of  the  trouble.  The  patella  had  been 
caught  by  its  external  and  internal  edges  between  the  little 
mine  cars,  and  had  been  cracked  throughout  nearly  its  entire 
circumference  (the  exception  being  just  at  the  attachment  of 
the  ligamentum  patellse)  just  as  one  would  crack  open  a  peanut. 
The  anterior  half  retained  its  attachment  to  the  ligamentum  pa- 
tellaa,  and  the  posterior  half  was  drawn  upward  by  the  quadri- 
ceps extensor  muscle. 

With  the  foot  placed  upon  a  chair  and  the  muscles  relaxed, 
by  extreme  extension  of  the  leg  I  was  able  to  draw  down  the 
posterior  fragment  so  that  its  lower  edge  readily  slipped  under 
the  upper  edge  of  the  anterior  one. 

Operation  in  this  case  seems  to  me  to  hold  out  a  very 
bright  promise  of  success,  for  the  fragments  could  be  wired 
easily,  and,  if  once  wired,  there  would  be  practically  no 
chance  of  them  separating.  Whether  or  no  an  operation 
will  be  allowed  I  can  not  at  present  say. 


304 


LEADING  ARTICLES. 


[N.  Y.  Med.  JoaH., 


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,  MARCH  18,  1893. 


THE  NEW  YORK  PHYSICIANS'  MUTUAL  AID  ASSOCIATION. 

The  Twenty-fourth  Annual  Report,  for  the  year  1892, 
shows  that  the  number  of  members  in  good  standing  at  the 
close  of  the  year  was  1,143,  a  net  increase  of  nearly  thirteen  per 
cent,  during  the  year.  Since  the  recent  extension  of  the  asso- 
ciation's field  heyond  the  limits  of  the  metropolitan  district,  the 
profession  tlironghoiit  the  State  has  shown  commendable 
promptness  in  availing  itself  of  the  benefits  consequent  thereon. 
Thus,  we  find  that  there  are  filteen  members  in  Albany  County, 
two  in  Broome  County,  five  in  Cayuga  County,  five  in  Chemung 
County,  one  in  Chenango  County,  one  in  Clinton  County,  two 
in'Corllandt  County,  four  in  Dutchess  County,  thirty-one  in 
Erie  County,  one  in  Essex  County,  two  in  Fulton  County,  one 
in  Greene  County,  two  in  Herkimer  County,  one  in  Jefferson 
County,  twenty  in  Monroe  County,  four  in  Montgomery  Coun- 
ty, two  in  Niiigara  County,  three  in  Oneida  County,  seventeen 
in  Onondaga  County,  one  in  Ontario  County,  five  in  Orange 
County,  eleven  in  Queens  County,  two  in  Rensselaer  County, 
four  iu  Richmond  County,  one  in  Saratoga  County,  four  in 
Schenectady  County,  one  in  Schuyler  County,  two  in  Steuben 
County,  four  in  Suffolk  County,  three  in  Sullivan  County,  one 
in  Tioga  County,  one  in  Ulster  County,  and  eighteen  in  West- 
chester County.  Besides  these,  thei-e  are  twenty- three  mem- 
bers who  are  no  longer  residents  of  the  State.  Tlie  interest  in 
Erie  County  is  so  great  that  Bufi^alo  has  an  auxiliary  commit- 
tee, consisting  of  Dr.  "W.  W.  Potter  (chairman),  Dr.  G.  L. 
Brown,  Dr.  W.  S.  Renner,  Dr.  B.  H.  Daggett,  Dr.  J.  J.  Walsh, 
Dr.  E.  II.  Long,  Dr.  E.  Wende,  and  Dr.  W.  G.  Gregory  (secre- 
tary and  treasurer). 

The  association's  hi.story,  as  the  president.  Dr.  Daniel  Lewis, 
well  says,  is  one  of  uninterrupted  growth.  The  amount  now 
paid  on  each  death  is  a  thousand  dollars,  the  highest  amount 
allowed  by  the  by-laws,  and  it  has  been  decided  that  for  the 
present  it  would  not  he  wise  to  increase  this  amount.  The 
permanent  fund  benefits  by  its  not  being  increased;  neverthe- 
less, by  a  plan  under  consideration,  part  of  the  surplus  may  be 
used  occasionally  to  make  a  payment  on  a  death,  and  thus  re- 
duce the  number  of  assessments.  As  it  is  now,  however,  the 
assessments  in  1892  were  only  fourteen,  and,  taking  this  as  a 
fair  annual  average,  each  of  the  members  is  insured  for  $1,000 
at  a  cost  (if  $14  a  year — a  very  low  rate  for  life  insurance. 

Concluding  his  report,  Dr.  Lewis  says:  "As  we  enter  upon 
the  twenty  fifth  year  of  our  existence,  it  is  with  a  keen  appre- 
ciation of  the  wisdom  and  foresight  of  the  founders  of  the  as- 
sociation, who  laid  the  corner-stone  of  this  charity  and  through 
a  long  i>eriod  of  arduous  endeavor  finally  succeeded  in  estab- 
lishing an  organization  that  will  be  enduring  and  just  as  broad 


and  comprehensive  in  its  usefulness  as  your  united  zeal  and 
energy  shall  elect  to  make  it."  These  reflections  should  com- 
mend themselves  to  every  physician  eligible  to  membership — 
i.  e.,  every  physician  living  in  the  State  of  New  York ;  further- 
more, we  think  they  should  lead  to  the  formation  of  like  asso- 
ciations in  other  States. 


MEDICAL  FADS. 
The  March  number  of  the  North  American  Review  contains 
an  article  by  a  medical  officer  of  the  city  health  department 
that  we  think  may  properly  be  termed  a  caricature  of  the  medi- 
cal profession.  It  is  very  easy  in  the  routine  of  official  work 
to  lose  touch  with  the  practical  side  of  medical  life,  and  to  as- 
sume that  it  is  a  matter  of  caprice  or  fad.  To  have  written 
currente  calamo  that  "the  practice  of  medicine  might  be  de- 
fined, not  unfairly,  as  a  succession  of  conundrums  presented  for 
solution,  with  death  to  the  jiatient  as  tiie  penalty  for  failure," 
suggests  that  persiflage,  though  some  might  call  it  flippancy, 
rather  than  sober  judgment,  served  to  guide  the  pen.  lie  who 
intimates  that  physicians  too  readily  adopt  the  new  forgets 
Hippocrates  and  his  axiomatic  advice  tliat  experiment  is  slip- 
pery and  that  the  physician  sliould  hold  fast  to  that  that  id 
good. 

The  fad  of  the  individual  or  of  the  clique  is  not  the  fad  of 
the  profession,  and  the  writer  of  tlie  article  is  unfortunate  in 
selecting  the  water-cure  as  the  first  fad  he  can  recall,  notwith- 
standing his  apology  that  he  lias  never  personally  gone  through 
or  seen  that  treatment.  While  this  may  give  him  the  feeling 
that  he  is  thus  best  fitted  to  speak  of  it  dispassionately  (like  the 
book  reviewer  who  never  reads  the  work  he  is  to  review,  be- 
cause he  might  thus  become  prejudiced),  it  prevents  his  speak- 
ing as  one  with  authority  regarding  the  wider  range  of  useful- 
ness of  hydrotherapy  than  that  of  a  tonic  to  the  nervous  sys- 
tem. 

Why  the  use  of  blue  glass  is  brought  forward  as  another 
medical  fad  is  a  mystery,  as  it  was  not  introduced  by  a  physi- 
cian, and  the  practice  never  became  even  slightly  prevalent 
with  medical  men. 

For  the  writer  to  announce  himself  as  a  believer  in  the 
faith- cure  is  a  privilege  that  must  be  willingly  accorded  him  as, 
perhaps,  a  personal  fad.  That  it  is  a  fad  of  medical  men  col- 
lectively is  a  groundless  assertion  not  justified  by  the  hoary 
saying  ex  uno  disce  omnes. 

The  grape-cure,  milk-cure,  water-cure,  and  rest-cure  are  not 
fads,  but  definite  methods  of  therapeusis  having  specified  ap- 
plicability in  certain  morbid  conditions.  The  word  cure  is  em- 
ployed in  the  German  sense,  and  not  for  the  purpose  of  imply- 
ing a  panacea. 

Medicine  is  taught  in  our  colleges  to-day  with  the  endeavor 
to  equip  the  student  with  the  capacity  for  recognizing  the  ex- 
istence and  significance  of  the  signs  and  symptoms  of  different 
diseases.  It  is  also  taught  that  remedies  have  certain  definite 
actions,  and  that  they  should  be  used  to  combat  the  causes  of 
disease  rather  than  to  overcome  its  symptoms.  A  failure  to 
recognize  these  facts  relegates  medicine  to  a  period  antedating 


March  18,  1893.J 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


305 


that  at  whicli  tlie  writer  of  the  article  referred  to  began  his 
professional  career,  making  empiricism  rather  than  science  the 
rule  and  guide  for  the  physician's  practice. 


THE  REPORT  OF  THE  STATE  COMMISSION  IN  LUNACY. 

The  recently  published  report  of  the  New  York  State  com- 
mission in  lunacy  is  a  carefully  prepared  document  that  re- 
views the  condiiion  of  each  of  the  State  hospitals  for  the  insane 
and  the  operations  of  the  State  hospital,  the  exempted  county, 
and  the  licensed  private  asylu!i)  systems.  The  commission  does 
not  think  that  the  State  hospitals  are  overcrowded,  but  recom- 
mends that  provision  be  made  for  an  increase  of  the  present 
i;  capacity  in  order  to  meet  future  demands  upon  their  space. 
I  Attention  is  again  called  to  the  inequality  in  the  salaries  paid 
to  the  officers  and  attendants  of  the  different  institutions,  and 
the  recommendation  is  made  that  the  Legislature  make  statu- 
tory provision  for  equality  of  compensation  for  all  officers  and 
employees  of  similar  grades,  particular  attention  being  directed 
to  the  fact  that  where  the  service  performed  by  women  is  the 
same  as  that  by  men,  the  compensation  should  be  equal. 

The  report  of  the  commission  on  the  cost  of  maintenance  at 
the  different  institutions  showed  such  want  of  system  that  the 
matter  is  now  undergoing  investigation. 

It  is  recommended  that  provision  be  made  for  the  erection 
of  detached  buildings  for  attendants  at  each  of  the  hospitals; 
that  there  shall  be  conferences  at  stated  intervals  between  the 
commission  and  the  managers  or  trustees  of  the  State  hospitals; 
that  the  employment  of  improper 'persons  to  convey  public  pa- 
tients to  these  hospitals  by  superintendents  of  the  poor  be  pro- 
hibited ;  that  private  patients  be  admitted  to  these  Iiospitals  at 
a  maximum  rate  of  ten  dollars  a  week;  that  a  special  patholo- 
gist to  conduct  investigations  for  all  the  hospitals  be  appointed  ; 
1  i  that  counties  shall  provide  receiving  pavilions  for  the  detention 
of  persons  to  be  examined  regarding  their  sanity,  to  be  under 
the  charge  of  a  special  officer  appointed  by  the  county  judges; 
that  agents  be  appointed  to  induce  responsible  relatives  of  in- 
sane persons  to  assume  the  expense  of  their  maintenance  in  the 
hospitals ;  that  the  State  be  redistricted  into  hospital  districts ; 
that  the  indiscriminate  vititing  of  insane  patients  be  restricted  ; 
that  the  parole  of  patients  be  regulated  by  the  commission ; 
that  special  police  powers  be  granted  to  particular  officers  of 
ho8])itals;  and  that  the  responsibility  and  power  of  the  appoint- 
ment and  removal  of  officers  and  employees  be  vested  in  the  su- 
perintendents. 

The  report  contains  the  usual  asylum  statistics,  and  also  a 
I  directory  of  all  institutions  in  the  State  that  care  for  the  insane. 
'  The  supervision  of  all  of  these  institutions  has  been  thorough, 

uud  satisfactory  evidence  is  afforded  by  the  volume  of  the  im- 

l)ortant  work  performed  by  the  commission. 


A  CHINAMAN'S  GRATITUDE  TO  A  PHYSICIAN. 

Dr.  Horace  Handle,  of  the  Tungshin  Hospital,  Ohefoo, 
North  China,  relates  in  Medical  Missiom  an  instance  of  the 


profound  gratitude  of  the  Chinese  for  successful  medical  treat- 
ment. One  of  the  magnates  of  the  place,  named  Wu,  had  been 
an  enemy  of  the  mission  for  several  years,  even  advocating  vio- 
lence in  order  to  expel  the  foreigners.  But  las^t  October  a 
change  came  over  the  man,  in  consequence  of  a  serious  and 
I)rotracted  illness.  He  was  afflicted  with  an  unusually  large 
carbuncle  upon  his  back,  and  all  the  native  treatment  he  en- 
dured simply  made  matters  worse  and  brought  him  down  al- 
most to  death's  door.  Although  he  had  repeatedly  refused  to 
consult  the  foreign  doctor,  pain  and  suffering  finally  led  him  to 
reluctantly  admit  Dr.  Handle.  That  gentleman  found  the  re- 
gion of  the  left  scapula  occupied  by  a  gangrenous  mass,  and  the 
patient's  general  conditi(m  at  a  low  ebb.  The  open  surface 
was  properly  cleansed,  then  poulticed  and  dressed  for  a  few 
days,  suitable  internal  medication  was  furnished,  and  the  pa- 
tient was  put  on  the  road  to  recovery.  Convalescence  was 
slow,  though  steady.  A  change  from  enmity  to  friendship  was 
likewise  gradually  effected.  The  patient  was  first  shamed  out 
of  his  hatred,  and  then,  seeing  the  physician's  manifest  devo- 
ti(m  and  laborious  attentions,  became  as  emphatically  grateful 
as  he  had  before  been  antagonistic.  When  he  had  fully  recov- 
ered, Mr.  Wu  caused  a  tablet  to  be  engraved,  painted  blue,  with 
gilded  and  carved  characters  expressive  of  his  unstinted  grati- 
tude. Then  a  procession  of  his  relatives  and  friends  was 
formed  at  the  patient's  house,  and  proceeded  to  that  of  the 
physician,  followed  by  two  coolies  bearing  the  tablet.  The 
townspeople  crowded  after.  When  the  destination  was  reached, 
a  speech  of  presentation  was  made,  and  the  tablet  was  nailed 
up  over  the  front  door  by  two  carpenters  who  had  been  bidden 
to  come  for  that  purpose.  Then  an  interchange  of  compliments 
took  place.  The  inscription  on  the  tablet  was  as  follows: 
"A  Heart  like  Hsi-wen's. 

"/«  early  times,  Doctor  Fan  Ilsi-wen  was  a  skillful  and 
benevolent  doctor  whose  heart  constantly  went  out  in  healing 
and  saving  the  suffering. 

"  Now  there  is  one  like  him  in  the  person  of  the  physician 
from  the  distant  West,  where  speech  and  customs  have  nothing 
in  common  with  those  of  China. 

"Last  autumn  I  fell  ill  with  a  carbuncle  and  could  not  have 
lived  to  the  winter.  Dr.  Lan  (Handle)  gave  me  healing  medi- 
cine and  cured  me  :  though  I  was  four  months  ill  he  made  me 
well. 

"  This  Dr.  Lan  has  certainly  the  power  of  life  and  death  in 
his  hands. 

"In  the  18th  year  of  Kangsu,  the  Recipient  of  Kindness, 
Wu-Shui,  Respectfully  records  this." 


MINOR  PARAGRAPHS. 

A  NEW  AND  RAPID  METHOD  OF  REMOVING  THE  UTERUa 

At  a  recent  meeting  of  the  Kansas  City  Academy  of  Medi- 
cine, as  we  learn  from  the  American  Journal  of  Snrgery  and 
Gijnaicology,  Dr.  Emory  Lanphear  presented  a  number  of  Hhroid 
tumors,  sarcomata,  etc.,  removed  by  a  new  method  of  abdomi- 
nal hysterectomy.    The  abdomen  and  vagina  having  been  care- 


306 


MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Joph., 


fully  sterilized,  he  makes  an  incision  in  the  median  line  termi- 
nating as  close  to  the  pubes  as  possible,  draws  the  uterus  with 
one  tube  and  ovary  to  one  side,  and  applies  a  clamp  to  the 
broad  ligament;  a  strong  ligature  is  passed  half  an  inch  away 
from  this,  including  tlie  blood-vessels,  and  tied  ;  the  interven- 
ing tissue  is  then  cat  with  scissors.  Upon  the  opposite  side  the 
same  procedure  is  carried  out.  When  this  has  been  done,  the 
uterus  (hitherto  held  down  by  the  broad  ligament)  can  be  lifted 
up  into  the  wound  and  separation  from  the  bladder  and  rectum 
easily  accomplished.  These  incisions,  before  and  behind,  are 
carried  into  the  vagina,  when  a  Kelly's  or  Folk's  clamp  is  in- 
troduced through  tlie  vagina  as  close  as  possible  to  the  uterus, 
its  points  reaching  the  ligature  already  tied  in  the  broad  liga- 
ment. As  soon  as  it  is  properly  applied  it  is  closed,  and  its 
fellow  clamp  inserted  upon  the  other  side,  when  the  uterus  is 
quickly  cut  away  with  curved  scissors.  The  pelvis  is  irrigated, 
the  abdominal  wound  closed,  and  drainage  made  through  the 
vagina  as  in  cases  of  vaginal  hysterectomy.  The  clamps  are 
removed  in  forty-eight  hours.  The  operation  can  be  done  in 
from  twenty-tive  to  thirty  minutes,  and  is  said  to  be  much 
easier  than  even  vaginal  hysterectomy  with  clamps.  On  ac- 
count of  this  rapidity  and  the  good  drainage  secured,  Dr.  Lan- 
phear  thinks  this  operation  can  be  done  almost  as  safely  as 
ovariotomy — certainly  as  safely  as  vaginal  hysterectomy — and 
that  it  is  much  preferable  to  any  method  that  leaves  a  pedicle 
or  stump  behind.  He  finds  it  is  not  necessary  to  unite  the 
bladder  to  the  rectum,  as  union  takes  place  just  as  quickly  with- 
out sutures  as  with  them. 


A  DEPLORABLE  SEQUEL  OF  A  SUICIDE. 

"  The  autopsy,  while  not  revealing  that  the  young  woman 
had  the  dread  of  maternity  as  an  incentive  to  suicide,  suggested 
that  she  might  have  been  driven  to  the  deed  by  remorse  for 
recent  conduct  and  had  a  reason  for  passing  herself,  in  contem- 
plation of  suicide,  as  a  married  woman." 

This  horrible  innuendo,  printed  in  a  newspaper,  is  the  con- 
solation that  the  young  woman's  afflicted  parents  receive!  It 
is  attributed  to  the  coroner  who  othciated  in  the  case,  and  up 
to  the  time  of  writing  this  paragraph  we  are  not  aware  that  he 
has  repudiated  it.  It  seems  to  be  susceptible  of  more  than  one 
interpretation,  but  the  public  has  put  upon  it  the  more  obvious 
one,  and  current  comment  on  it  takes  an  angry  tone — a  tone 
that  augurs  well,  we  hope,  for  the  movement  in  favor  of  sub- 
stituting something  like  the  Massachusetts  system  for  that 
under  which  inquisitions  as  to  causes  of  death  are  now  con- 
ducted in  this  State.  In  this  case  the  dead  girl's  parents  are 
entitled  to  the  community's  sympathy,  and  we  believe  they  have 
it;  at  all  events,  it  may  be  said  for  the  relief  of  their  feelings 
that  the  necropsy  does  not  seem  to  have  included  the  sort  of 
examination  that  would  be  indispensable  to  the  establishment 
of  facts  justifying,  if  anything  could,  a  public  statement  in- 
tended to  convey  the  meaning  that  is  commonly  understood  to 
be  the  purport  of  the  one  we  have  quoted.  The  fact  that  the 
coroner  in  this  instance  is  a  physician  makes  the  case  a  proper 
one  for  comment  in  a  medical  journal,  and  the  fact  that  this 
physician  is  a  coroner  does  not  seem  to  us  to  exempt  him  from 
the  obligation  to  confine  his  investigation  to  the  task  of  ascer- 
taining the  cause  (jf  death,  or  from  his  professional  duty  not  to 
reveal  secrets  of  this  nature. 


A  TALE  OF  A  GLASS  EYE. 

One  of  the  Rochester  newspapers  says  that  a  physician  of 
that  city  tells  the  story  of  his  once  having  been  summoned  to 
the  hospital  late  at  night  to  assist  bis  colleagues  in  the  endeavor 


to  resuscitate  a  man  profoundly  narcotized  with  opium.  One 
pet  method  after  anotlier  having  proved  ineffectual,  the  con- 
viction was  forcing  itself  on  the  medical  gentlemen  that  the  pa- 
tient was  dead.  "Finally,"  the  story  continues,  "the  eldest  of 
the  l)arty,  a  practitioner  of  thirty  years'  standing,  walked  over 
to  the  supposed  corpse  and,  lifting  the  eyelid,  looked  long  and 
searchingly  at  the  eye.  Wlien  he  let  go  he  at  once  proceeded 
to  gather  up  his  instruments  preparatory  to  leaving.  1  thought 
that  I  could  detect  a  slight  respiration,  though  very  faint,  and 
asked  him  why  he  was  leaving.  'The  man's  dead,'  he  an- 
swered, 'look  at  his  eye.'  I  turned  to  make  an  examination, 
and  sure  enougii  the  eyeball  had  a  strangely  glassy  appearance, 
noticeable  in  cases  of  death  by  opium  poisoning.  I,  too,  was 
about  to  turn  away  when,  to  the  surprise  of  all,  out  slid  the  eye 
and  down  it  fell  to  the  floor.  It  was  glass.  No  one  said  any- 
thing, but  we  continued  to  work  on  the  subject  until  nearly 
morning  and  we  brought  him  around  all  right." 


THE  PROPOSED  CROTON  WATER  COMMISSION. 

The  New  York  Academy  of  Medicine's  amendments  to  the 
Assembly  bills  authorizing  the  acquirement  of  the  Croton  wa- 
ter-shed by  the  city  provide  for  the  creation  of  a  Croton  water 
commission  consisting  of  the  commissioner  of  public  works,  the 
commissioner  of  henlth,  and  a  member  of  the  State  board  of 
health  (to  be  appointed  by  the  Governor  on  the  recommenda- 
tion of  the  said  board  of  health),  together  with  two  Croton 
water  commissioners,  one  of  whom  shall  be  a  resident  and  citi- 
zen of  the  city  and  county  of  New  York,  to  be  appointed  by 
the  Governor  on  the  recommendation  of  the  executive  commit- 
tee of  the  Chamber  of  Commerce,  and  the  other  of  whom  shall 
be  a  civil  engineer  skilled  in  sanitary  science,  to  be  appointed 
by  the  Governor  on  the  recommendation  of  the  American  So- 
ciety of  Civil  Engineers  of  the  City  of  New  York.  This  com- 
mission is  empowered  to  elfect  any  acquisition  or  extinguish- 
ment of  interest  in  the  real  estate  concerned  as  may  be  neces- 
sary for  "the  sanitary  protection  of  all  rivers  and  other  water- 
courses, lakes,  ponds,  and  reservoirs  in  the  counties  of  West- 
chester, Putnam,  and  Dutchess,  so  far  as  the  same  now  are,  or 
hereafter  may  be,  used  for  the  supply  of  water  for  the  city  of 
New  York."   

ABERRANT  CHORD.E  TEXDINE.E. 

In  the  February  number  of  the  Revue  de  medecine  there  is  a 
very  interesting  article  by  Dr.  Henri  Iluchard  on  the  subject  of 
aberrant  chordae  tendineae  {tendons  aherrants  du  cceur),  i.  e., 
chordfe  tendineaj  which,  instead  of  running  from  a  columna 
carnea  to  be  inserted  into  the  valve,  extend  from  one  point  to 
another  of  the  ventricular  wall.  M.  Iluchard  maintains  that 
when  they  are  long  and  stretch  directly  across  the  blood-current 
in  the  aortic  area  their  existence  maybe  detected  during  life  by 
means  of  certain  more  or  less  musical  murmurs,  and  he  reports 
five  cases  in  which  the  diagnosis  was  confirmed  at  the  autopsy. 
In  one  of  these  cases  the  wandering  cord  was  found  to  have 
occasioned  coagulation  about  it.  Generally  these  formations 
are  congenital ;  occasionally  they  seem  to  be  of  patliological 
origin,  chiefly  by  sclerous  atrophy  of  the  trabeculaa.  They  have 
not  been  observed  in  the  right  chambers  of  the  heart. 


THE  REVIVAL  OF  THE  THYMUS. 

At  a  recent  meeting  of  the  Societe  medicale  des  Mpitaux, 
reported  in  the  Union  medicale  for  February  21st,  M.  Marie 
mentioned  a  revival  of  the  thymus  as  an  example  of  the  com- 
pensatory hypertrophy  often  undergone  by  certain  of  the  blood- 
vascular  glands  in  consequence  of  disease  of  some  other  of  their 


March  18,  1893.] 


MINOR  PARAGRAPHS. 


307 


number.  He  had  observed  it  ia  myxoedema,  in  acromegaly, 
and  in  exoplithaiinic  goitre.  In  myxoedematoiis  idiocy  there 
might  be  simply  persistence  of  the  thymus  due  to  absence  of  the 
thyreoid  or  to  changes  in  that  organ  occurring  early  in  life ; 
but  when  myxoedeina  came  on  in  adult  life  the  thymus,  which 
must  long  before  have  undergone  involution,  might  become  re- 
vivified. In  acromegaly,  in  which  the  pituitary  gland  was  af- 
fected, and  probably  the  thyreoid  also,  the  existence  of  the 
thymus  was  generally  observed. 


ADV^\JfCEMENT  OF  THE  ROUND  LIGAMENTS. 

At  a  meeting  of  the  Association  frangaise  pour  Vavance- 
ment  des  science^  section  de  chirurgie  held  in  September,  1892 
{Revue  de  chirurgie.,  February,  1893),  M.  Chalot  described 
his  method  of  performing  this  operation,  which  he  thinks  is 
simpler  and  surer  than  the  usual  procedure.  He  opens  the  in- 
guinal canal  for  nearly  its  whole  length,  about  four  centimetres, 
80  that  the  ligament  is  easily  found,  even  in  fat  women.  lie 
dissects  each  ligament  quite  free  as  far  as  the  internal  ring, 
sometimes  opening  into  the  peritoneal  cavity.  The  uterus  is 
not  replaced  during  the  operation  until  it  is  done  by  energetic 
traction  on  both  ligaments.  Each  ligament  is  fixed  with  sutures 
through  the  whole  length  of  the  inguinal  canal.  No  pessary  is 
worn  after  the  operation.  The  author  reports  good  results  in 
six  cases,  in  one  of  them  after  the  lapse  of  fourteen  months. 


NEW  PREPARATIONS  OF  MYRRH. 

In  the  Centralblatt  fur  Minische  Medicin  for  February  25th 
there  is  an  abstract  of  an  article  by  Dr.  M.  Kohn,  published  in 
the  Milnchener  medicinische  Wochenschrift^  in  which  the  author 
reports  good  results  in  the  treatment  of  eczema  nariura  with  an 
ointment  of  myrrh,  also  in  that  of  both  simple  and  foetid  atro- 
phic rhinitis  with  tampons  imbued  with  the  ointment.  The 
use  of  myrrh  as  a  corrigent  in  the  creasote  treatment  of  pul- 
monary phthisis  is  said  to  have  proved  satisfactory.  The  prepa- 
ration employed  was  myrrholin  (a  mixture  of  one  part  of  myrrh 
and  two  parts  of  oil).  Capsules  each  containing  three  tenths 
of  a  gramme  of  creasote  and  two  tenths  of  a  gramme  of  myr- 
rholin were  very  well  borne  by  consumptives. 


MAMMARY  CANCER  AND  THE  STERNUM. 

In  the  Gazette  des  hopitaux,  1892,  No.  88,  there  is  an  article 
by  M.  Verdi6  on  the  spread  of  carcinoma  from  the  mamma  to 
the  sternum  and  its  recurrence  in  that  bone  after  ablation  of 
the  breast.  From  an  abstract  given  in  the  CentralMatt  fi'ir 
Gyndkologie  it  appears  that  M.  Verdi6  regards  implication  of 
the  sternum  as  a  concomitant  or  sequel  of  mammary  cancer  as 
of  more  frequent  occurrence  than  is  generally  supposed.  He 
thinks  that  the  bone  should  be  examined  as  carefully  as  the 
axilla,  and  that  the  presence  of  secondary  nodules  on  its  surface 
is  a  contra-indication  to  removal  of  the  breast. 


A  HINDU  METHOD  OF  "PURIFYING"  MEDICINAL  ROOTS. 

In  an  article  on  The  "Earth-sugar"  Root  of  the  Tamils  (the 
root  of  Marua  arenaria),  published  in  the  Pharmaceutical 
Journal  and  Transactions  for  January  7th  and  reprinted  in  the 
American  Journal  of  Pharmacy  for  March,  Mr.  David  Hooper 
describes  a  somewhat  peculiar  process  by  which  the  Hindus 
"purify  "  medicinal  roots.  A  clean  dnth  is  tied  over  the  mouth 
of  a  jug  filled  with  equal  parts  of  cow's  milk  and  water.  The 
bruised  root  is  laid  on  the  cloth  and  covered  with  another  ves- 
sel, inverted.    The  contents  of  the  jug  are  then  boiled,  and  the 


vapor  from  them  is  supposed  to  purify  the  root,  which  is  after- 
ward dried  and  finely  powdered. 


POST-MARITAL  AMBLYOPIA. 

In  the  last  number  of  the  Archives  of  Surgery  Mr.  Jonathan 
Hutchinson  gives  an  account  of  three  cases  of  this  affection, 
which  is  sometimes  called  Burns's  amaurosis.  The  salient  con- 
dition consists  in  a  failure  of  vision,  of  greater  or  less  degree, 
due  to  sexual  excess.  In  some  respects,  such  as  the  tendency 
to  recovery  and  freedom  from  relapse,  this  affection  conducts 
itself  like  amblyopia  from  tobacco.  The  latter,  however,  is  less 
rapid  in  its  progress  and  is  less  severe.  Although  recovery  is 
the  rule  in  regard  to  both  groups  of  cases,  it  is  possible  in  both 
that  the  affection  may  proceed  to  complete  and  irremediable 
loss  of  sight. 


A  LONDON  BANQUET  IN  HONOR  OF  VIRCHOW. 

On  Thursday  evening,  the  16th  inst.,  according  to  an  an- 
nouncement in  the  Lancet,  a  subscription  dinner  was  to  be 
given  in  London  in  honor  of  Professor  Virchow,  who  in  the 
afternoon  of  that  day  was  to  deliver  a  lecture  before  the  Royal 
Society  on  The  Position  of  Pathology  among  the  Biological 
Sciences. 


A  CONGENITAL  HERNIA  IN  A  FUNICULAR  HYDROCELE. 

At  a  recent  meeting  of  the  Paris  Societe  de  chirurgie,  re- 
ported in  the  February  number  of  the  Revue  de  chirurgie,  M. 
Phocas,  of  Lille,  mentioned  two  cases  that  he  bad  seen  of  con- 
genital funicular  hydrocele  in  which,  on  opening  tl)e  sac  of  the 
hydrocele,  a  hernial  sac  was  found  projecting  into  it.  In  one 
of  the  cases  the  tumor  had  the  appearance  of  a  two-lobed  hy- 
drocele.   Each  patient  was  about  nine  years  old. 


HICCOUGH  AND  HEREDITARY  SYPHILIS. 

AocoEDiNG  to  Carini  {Internation.  hlin.  Rundschau,  1893, 
Nos.  1,  2,  3,  4;  Union  medicate,  February  25,  1893),  hiccough 
in  the  new-born  is  to  be  regarded  as  a  symptom  of  hereditary 
syphilis.  It  is  of  rather  common  occurrence,  and  is  one  of  the 
earliest  signs  of  the  disease,  coming  on  during  the  first  few 
hours  or  days  after  birth,  sometimes  before  the  coryza.  It 
lasts  two  or  three  weeks.  The  author's  views  are  supported  by 
numerous  cases  and  by  the  effect  of  antisyphilitic  treatment  on 
the  hiccough. 


A  THIRD  ATTACK  OF  MEASLES. 

M.  Duchesne  related  at  a  recent  meeting  of  the  Paris  Society 
de  medecine  et  de  chirurgie  pratiques  the  case  of  a  man,  forty- 
two  years  old,  who  had  three  well-marked  attacks  of  measles 
within  the  space  of  two  years.  Some  authors,  he  remarked, 
according  to  the  report  in  the  Progrh  medical,  denied  the  pos- 
sil)ility  of  the  recurrence  of  the  disease.  In  the  discussion 
M.  Dignat  reported  a  case  of  two  attacks  at  an  interval  of 
eleven  months. 


CHLORALOSE. 

At  a  recent  meeting"of  the  Paris  Societe  de  JioZo(7/c,  reported 
in  the  Progrh  medical  for  February  4th,  M.  Charles  Richet 
continued  an  account  of  his  and  M.  Ilanriot's  study  of  chloral- 
ose,  a  derivative  of  glucose  and  chloral.  This  comjjound  is  said 
to  have  the  property  of  annulling  sensibility  to  pain  while  not 
aft'e(;ting  the  sense  of  touch,  also  to  cause  psychical  blindness. 
It  does  not  seem  to  have  been  used  on  the  human  subject  yet. 


308 


ITEMS. 


[N.  Y.  Med.  Joi  b., 


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  14,  1893 : 


DISEASES. 

Week  ending  Mar.  7. 

Week  ending  Mar.  14. 

Caseu. 

Deaths. 

Cases. 

Deaths. 

15 

4 

11 

4 

15 

4 

24 

n 

199 

16 

158 

21 

8 

4 

5 

7 

106 

4 

118 

9 

101 

26 

103 

41 

9 

2 

10 

2 

The  Medical  Association  of  Georgia. — The  forty-fourth  annual  ses- 
sion will  be  held  at  Araericiis  on  the  1  9th,  20th,  and  2 1st  of  April,  under 
the  presidency  of  Dr.  A.  A.  Smith,  of  Hawkinsville.  The  other  officers 
of  the  association  are  Dr.  George  J.  Grimes,  of  Columbus,  and  Dr. 
Robert  H.  Taylor,  of  Griffin,  vice-presidents ;  Dr.  D.  H.  Howell,  of  At- 
lanta, secretary;  and  Dr.  E.  C.  Goodrich,  of  Augusta,  treasurer. 

The  French  Surgical  Congress. — The  seventh  session  of  the  Con- 
grh  frani;ah  de  chiruiyic  will  be  opened  in  Paris  on  Monday,  April  3d, 
under  the  presidency  of  Professor  Lannelongue.  The  subjects  an- 
nounced for  discussion  are  Fibrous  Tumors  of  the  Uterus  and  The  Sur- 
gical Treatment  of  Tubercular  Affections  of  the  Yooi. 

The  Medical  Profession  in  Italy  is  overcrowded,  especially  in 
Naples,  where  there  is  a  physician  to  every  five  hundred  and  ten  in- 
habitants, so  that,  according  to  the  Jiiforma  medicn,  medicine  is  the 
least  remunerative  of  all  the  learned  professions. 

The  Richmond  Academy  of  Medicine  and  Surgery. — A  discussion 
on  puerperal  septicterain,  to  be  opened  by  Dr.  J.  Michaux,  was  the 
special  order  for  the  meeting  of  the  14th  inst.  The  subject  for  the 
next  meeting  is  the  management  of  abortion. 

The  Paris  Faculty  of  Medicine. — The  Revue  de  chirurgie  announces 
that  Dr.  F.  Terrier,  one  of  its  editors,  has  been  made  professor  of  opera- 
tive surgery. 

The  Death  of  Dr.  Edward  Houghton  Janes,  the  assistant  sanitary 
superintendent  of  the  city  board  of  health,  is  announced  as  having  oc- 
curred on  Sunday,  the  12th  inst.  Dr.  Janes  had  for  many  years  served 
as  a  city  sanitary  official,  and  always  most  creditably.  He  was  sev- 
enty-three years  old  at  the  time  of  his  death,  which  is  attributed  to 
disease  of  the  heart. 

The  Death  of  Professor  Benjamin  Ball,  of  the  Paris  faculty  of  medi- 
cine, a  well-known  alienist,  is  reported  as  having  taken  place  on  the  23d 
of  February. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  Statei 
Army,  from  March  5  to  March  11,  1S93 : 

Taylor,  Marcus  E.,  Captain  and  Assistant  Surgeon,  will  be  relieved 
from  duty  at  Vancouver  Barracks,  Washington,  at  the  expiration  of 
his  present  leave  of  absence,  and  will  report  in  per.son  to  the  com- 
manding officer.  Fort  Logan,  Colorado,  for  duty  at  that  post. 

Stii.es,  Henry  R.,  First  Lieutenant  and  Assistant  Surgeon,  will  be  re- 
lieved from  duty  at  Jefferson  Barracks,  Missouri,  on  receipt  of  this 
order  at  that  post,  and  will  report  in  person  to  the  commanding  offi- 
cer, Fort  Omaha,  Nebraska,  for  duty  at  that  post. 

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  3,  1893 : 

Murray,  K.  D.,  Surgeon.  When  relieved,  to  proceed  to  Key  West 
Quarantine  for  duty.    March  1,  1893. 

Bailiiache,  p.  H.,  Surgeon.  To  proceed  to  New  York  for  duty.  Feb- 
ruary 13,  1893. 

PuKViANCE,  George,  Surgeon.    Detailed  as  Chainnan  of  Board  of  Ex- 


aminers. February  13,  1893.  To  inspect  Reedy  Island,  Delaware 
River.    February  23,  1893. 

HuTTON,  W.  n.  II.,  Surgeon.  To  proceed  Ui  Solomon's  Island,  Md.,  as 
Inspector.  February  6,  1893.  When  relieved,  to  proceed  to  De- 
troit, Mich.,  for  duty.    February  13,  1893. 

Hamilton,  J.  B.,  Surgeon.  Detailed  as  Chairman  of  Board  to  prepare 
Quarantine  Regulations.  February  16,  1893.  Detailed  as  Chairman 
of  Board  to  examine  officer  of  Revenue-Marine  Service.  February 
28,  1893. 

Austin,  H.  W.,  Surgeon.  Detailed  as  member  of  Board  to  prepare 
Quarantine  Regulations.    February  1(>,  1893. 

Gassawav,  J.  M.,  Surgeon.  Detailed  as  member  of  Board  of  Examiners. 
February  13,  1893. 

Stoner,  G.  W.,  Surgeon.  To  proceed  to  Baltimore,  Md.,  for  duty. 
Febniary  13,  1893. 

Geddings,  H.  D.,  Passed  Assistant  Surgeon.  Detailed  as  Recorder  of 
Board  to  prepare  Quarantine  Regulations.    February  16,  1893. 

Wertenbaker,  C.  P  ,  Passed  Assistant  Surgeon.  Detailed  as  Recorder 
of  Board  to  examine  officer  of  Revenue-Marine  Service. 

Condict,  a.  W.,  Assistant  Surgeon.  Ordered  to  examination  for  promo- 
tion.   February  14,  1893. 

HussEY,  S.  II.,  Assistant  Surgeon.  Ordered  to  examination  for  promo- 
tion.   February  14,  1893. 

Perry,  J.  C,  Assistant  Surgeon.  Ordered  to  examination  for  promo- 
tion. February  14,  1893.  To  proceed  to  Savannah,  Ga.,  for  tempo- 
rary duty.    February  25,  1893. 

Smith,  A.  C,  Assistant  Surgeon.  Ordered  to  examination  for  promo- 
tion.   February  14,  1893. 

RosENAU,  31.  J.,  Assistant  Surgeon.  To  proceed  to  Hamburg,  Germany, 
for  temporary  duty.  February  14,  1893.  When  relieved,  to  pro- 
ceed to  Antwerp,  Belgium,  for  duty.    February  25,  1 893. 

Nydegger,  J.  A.,  Assistant  Surgeon.  To  proceed  to  Charleston,  S.  C, 
for  temporary  duty.    February  24,  1893. 

Eager,  J.  M.,  Assistant  Surgeon.  To  proceed  to  Key  West,  Fla.,  for 
duty.    March  1,  1893. 

Godfrey,  John,  Surgeon.  When  relieved,  to  proceed  to  San  Francisco, 
Cal.,  for  duty.    February  13,  1893. 

Irwin,  Fairfax,  Surgeon.  Detailed  for  duty  in  office  of  the  U.  S.  Con- 
sul, Marseilles,  Fi  ance.    February  25,  1893. 

Wheeler,  W.  A.,  Surgeon.  Detailed  as  Recorder  on  Board  of  Ex- 
aminers, February  13,  1893.  Detailed  as  member  of  Board  to  pre- 
scribe Quarantine  Regulations.    February  16,  1893. 

Wasdik,  Eugene,  Passed  Assistant  Surgeon.  To  proceed  to  Baltimore, 
Md.,  for  temporary  duty.    February  23,  1893. 

White,  J.  H.,  Passed  Assistant  Surgeon.  To  proceed  to  Hamburg, 
(Jermany,  for  duty.    February  27,  1893. 

Carrington,  p.  M.,  Passed  Assistant  Surgeon.  Granted  leave  of  ab- 
sence for  seven  days.    March  1,  1893. 

Williams,  L.  L.,  Passed  Assistant  Surgeon.  When  relieved,  to  pro- 
ceed to  Charleston,  S.  C,  for  duty.    February  14,  1893. 

Bratton,  W.  D.,  Passed  Assistant  Surgeon.  Detailed  as  member  of 
Board  to  examine  officer  of  Revenue-Marine  Service.  February  28, 
1893. 

KiNYOUN,  J.  J.,  Passed  Assistant  Surgeon.  Detailed  as  member  of 
Board  to  prepare  Quarantine  Regulations.    February  16,  1893. 

Guiteras,  G.  M.,  Passed  Assistant  Surgeon.  To  proceed  to  Gulf  Quar- 
antine Station  for  duty.    February  23, 1893. 

Society  Meetings  for  the  Coming  Week : 

Monday,  March  20th :  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  21st:  New  York  Academy  of  Medicine  (Section  in. 
General  Medicine) ;  New  York  Obstetrical  Society  (private) ;  Medical 
Society  of  the  County  of  Kings ;  Ogdensburgh  Medical  Association 
Baltimore  Academy  of  Medicine. 

Wednesday,  March  22d:  New  York  Academy  of  Medicine  (Section  in 
Laryngology  and  Otology);  New  York  Surgical  Society;  New  York 
Pathological  Society ;  American  Microscopical  Society  of  the  City 
of  New  York ;  Metropolitan  Medical  Society  (private) ;  Medical  So- 


March  18,  1893.]   LETTERS  TO  TEE  EDITOR.— REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


309 


ciety  of  the  County  of  Albany ;  Philadelphia  County  Medical  So- 
ciety. 

Thursday,  March  23d:  New  York  Academy  of  Medicine  (Section  in 
Obstetrics  and  Gyna;cology) ;  New  York  Orthopiudic  Society ; 
Brooklyn  Pathological  Society ;  Roxbury,  Mass.,  Society  for  Medi- 
cal Improvement  (private). 

Friday,  March  2Jiih :  Yorkville  Medical  Association  (private) ;  New 
York  Society  of  German  Physic'ans;  New  York  Clinical  Society 
(private) ;  Philadelphia  Clinical  Society ;  Philadelphia  Laryngologi- 
cal  Society. 

Saturday,  March  25th :  New  York  Medical  and  Surgical  Society 
(private). 


THE  UNAUTHORIZED  USE  OF  AN  AUTHOR'S  NAME. 

March  8,  1893. 
To  the  Editor  of  the  Neio  Torh  Medical  Journal : 

Sib  :  An  outrageous  use  of  my  name  and  my  contribution  to 
your  Journal  is  being  made  without  my  knowledge  or  consent 
by  the  so-called  "Mackeown's  Eye-testing  Rooms,"  of  this  city, 
in  the  form  of  an  advertisement  of  that  enterprise. 

I  have  instructed  my  attorney  to  take  the  matter  in  hand, 
and  I  desire  that  you  give  this  note  publicity  in  your  Journal. 

A.  L.  Ranney,  M.  D. 


OPHTHALMOLOGY. 

By  CHARLES  STEDMAN  BULL.  M.  D. 
[Coniinucd  from  page  258.) 

Lupus  of  the  Cheek  consequent  on  Tuberculous  Lesions 
of  the  Nasal  Mucous  Membrane,  through  the  Medium  of  a 

Lacrymal  Fistula. — Arnozan  {Arch,  d^ophthal.,  November-De- 
cember, 1891)  formulates  his  conclusions  as  follows:  1.  Certain 
cases  of  lupus  of  the  cheek  are  developed  around  an  active  or 
cicatrized  lacrymal  fistula.  2.  In  these  cases  the  fistula  facili- 
tates the  exit  of  tuberculous  products  from  within  the  nasal 
cavities,  and  is  tuerely  the  remote  consequence  of  a  tuberculous 
lesion  of  the  nasal  mucous  membrane  which  has  caused  obstruc- 
tion of  the  nasal  canal.  3.  A  rhinoscopic  examination  and  local 
treatment  should  complete  the  work  of  the  dermatologist  and 
ophthaluioiogist. 

The  Pathogeny  and  Treatment  of  Diseases  of  the  Lacry- 
mal Passages. — Gillet  de  Grandmont  {Arch,  d'ophthal.,  No- 
vember-Deoeinher,  1891)  makes  a  strong  plea  for  a  careful 
examination  and  treatment  of  the  nas;:!  fossae,  as  well  as  of  the 
eye  and  lacrymal  passages,  in  all  cases.  Bacteriology  plays  an 
important  role  here.  Affections  of  the  lacrymal  passages  are 
frequent  results  of  the  eruptive  and  infectious  fevers.  When 
diseases  of  the  lacrymal  p.issages  are  not  the  result  of  traiima- 
tism,  they  arise  from  bacteriological  causes  and  require  anli- 
sej)ti(!  treatment. 

The  Microbic  Origin  of  Keratitis.— Gillet  de  Grandtnont 
{Arch,  (rojiht/ial.,  March,  1892)  gives  the  results  of  his  investiga- 
tions as  follows  :  1.  If  the  bits  of  tissue  removed  l)y  scraping 
from  a  corneal  uh^er  are  placed  in  a  tube  on  the  inclined  surface 
of  a  peptonized  agar  solution  and  the  tube  is  placed  in  an  oven 
at  37°  O.,  at  the  end  of  from  one  to  four  days  there  appears  on 
the  surface  of  the  agar  at  the  point  touched  by  the  platinutn 


needle  a  small  opalescent  spot,  which  gradually  increases  in 
size,  forms  a  globule  like  a  grease  ^pot,  and  gradually  extends 
over  the  whole  surface  of  the  agar.  2.  If  a  particle  of  this 
whitish  mass  is  introduced  into  another  tube  of  mitrient  gela- 
tin a  similar  culture  is  obtained,  and  this  experiment  may  b© 
repealed  an  indefinite  number  of  times.  3.  If  a  particle  of  this 
culture  is  introduced  beneath  the  epithelium  of  an  animal's  cor- 
nea, there  results  more  or  less  extensive  ulceration  of  the  cornea, 
but  always  proportionate  to  the  quantity  of  material  inoculated. 
A  grayish  infiltration  surrounds  the  ulcer  and  grows  in  breadth 
and  depth.  Particles  of  tliese  experimental  ulcers  furnish  fertile 
cultures  of  organisms  similar  to  those  used  in  the  inoculation. 
4.  The  bacteriological  examination  of  the  virulent  product  shows 
a  pure  culture  of  joined  micrococci,  diplococci,  streptococci,  and 
staphylococci. 

Foreign  Bodies  in  the  Lens ;  Indications  for  their  Re- 
moval.-—Terson  {Arch,  d'ophlhal..  March,  1892)  draws  the  fol- 
lowing conclusions:  1.  The  presence  of  a  very  small  foreign 
body  in  the  lens  does  not  always  demand  immediate  interven- 
tion, but  does  demand  constant  supervision.  2.  Immediate  in- 
tervention is  demanded  when  the  foreign  body  is  voluminous, 
or  when  its  position  may  change,  or  when  the  first  sign  of  in- 
fection appears.  3.  Intervention  is  demanded  if  the  opacity  of 
the  lens  increases  so  as  to  obscure  the  position  of  the  foreign 
body.  4.  Intervention  should  consist  in  a  large  incision  in  the 
cornea  with  iridectomy,  so  as  to  adujit  of  removal  of  the  entire 
lens  with  the  foreign  body.  5.  The  incision  should  be  so  made 
that  its  center  corresponds  to  the  point  of  corneal  circumfer- 
ence nearest  the  position  of  the  foreign  body.  6.  The  mag- 
net or  electro-magnet  should  only  be  employed  when  the  for- 
eign body  is  iron  or  steel,  and  lies  in  the  superficial  laminae  of 
the  lens. 

Reid's  Pocket  Ophthalmometer.— High et  {Arch.  d''ophthal., 

March,  1892)  here  describes  the  little  instrument  devised  by 
Dr.  Reid,  of  Glasgow.  The  instrument  consists  of  an  ob- 
jective of  short  focus,  a  rectangular  prism  neutralized  in  the 
visual  axis  by  a  smaller  prism,  and  a  long  tube  with  a  Ramsden 
ocular  or  eye-piece  at  the  external  end  and  an  objective  at  the 
internal  end,  with  crossed  threads  at  its  focus.  In  front  of  this 
objective  is  a  birefracting  prism.  By  this  arrangement  the  cor- 
neal image  is  clearly  seen  only  when  the  principal  focus  of  the 
objective  coincides  with  the  corneal  surface.  The  object  is 
formed  by  a  circular  disc,  fixed  on  the  side  of  the  rectangular 
prism,  in  front  of  the  source  of  light.  The  corneal  image  of 
the  illuminated  disc  is  first  magnified  ten  times  by  the  objective, 
then  doubled  by  the  biretracting  prism,  and  the  two  images  are 
seen  so  distinctly  that  the  contact  or  the  overlapping  of  their 
adjacent  edges  may  be  distinguished  by  simply  rotating  the  long 
tube.  In  using  the  instrument,  the  disc  on  the  side  of  the  in- 
strument must  be  exactly  in  the  focus  of  the  objective.  Then 
hold  the  instrument  in  the  left  hand,  which  rests  on  the  fore- 
head of  the  patient,  and  turn  the  disc  on  the  side  of  the  in- 
strument toward  the  light  of  a  window,  or  a  gas  fiame.  on  the 
right  of  the  observer.  The  light  rellected  by  the  prism,  after 
traversing  the  objective,  is  I'efiectcd  by  the  corneal  surface. 
This  virtual  corneal  image  of  the  disc,  w^hicli  has  the  form  of  a 
white  ring,  becomes  a  real  image  at  the  principal  focus  of  the 
objective,  and,  by  means  of  the  birefracting  prism,  is  seen  by 
the  observer  as  a  double  imago  when  the  principal  focus  of  the 
objective  coincides  witii  the  corneal  surface.  The  eye  <>f  the 
patient  is  directed  toward  the  centriil  luminous  point,  and  when 
the  setting  at  the  point  of  the  instrument  is  well  made,  the  part 
of  each  circle  corresponding  to  the  adjacent  edges  should  bo 
distinctly  seen. 

Probable  Tuberculosis  of  the  Lacrymal  Gland.— De  La- 
personne  {Arch,  d^ophthal.,  April,  1892)  gives  in  detail  the  report 


310 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jour  , 


of  a  case,  occurrinj?  in  a  woman  aged  thirty-two,  who  for  three 
months  had  Imd  some  difficulty  in  moving  tlie  right  upper  lid, 
with  the  development  of  a  small  tumor  at  the  supero-external 
part  of  the  orbit.  This  tumor  was  small,  flattened  on  the  globe, 
and  extended  backward  into  the  orbit.  It  was  adherent  to  the 
orbital  margin,  was  of  firm  consistence,  and  apparently  lobulated. 
Five  years  before,  the  patient  had  been  treated  for  some  pulmo- 
nary trouble,  characterized  by  frequent  hismorrhages,  febrile 
attacks,  and  rather  rapid  emaciation — all  of  which  symptoms 
eventually  disappeared.  An  examination  of  the  chest  sliowed 
nothing  but  a  slight  roughness  of  breathing  at  the  apex  of  the  left 
lung.  The  tumor  was  removed  and  found  to  involve  the  lacry- 
mal  gland,  and  the  wound  healed  in  ten  days.  One  year  later 
the  patient  was  seen,  and  there  was  no  trace  of  any  return  of 
the  growth.  The  tumor  was  as  large  as  a  large  almond,  was 
hard,  lobulated,  and  grajish-pink  in  color.  A  diagnosis  had  been 
made  of  adeno-sarcoma  of  the  lacrymal  glaud,  and  all  the  mac- 
roscopic signs  confirmed  it.  The  microscope  showed  that  most 
of  the  substance  of  the  tumor  consisted  of  "  epithelioidal "  cells ; 
but  external  to  the  lobules  involved,  -within  the  thickness  of  the 
conjunctival  pits,  there  were  many  tuberculous  follicles,  which 
were  probably  developed  within  the  lymphatic  vessels.  The 
fibrous  envelope  of  the  gland  showed  a  diffuse  infiltration  of 
embryonic  cells.    No  tubercle  bacilli  were  found. 

The  Modern  Operation  for  Cataract.  —  Landolt  {Arcli. 
(Tojihthal.,  September,  1892)  makes  the  following  resume  of  the 
subject :  The  extraction  of  cataract  in  these  days  is  much  less 
dangerous  than  formerly.  This  progress  is  not  due  to  changes 
in  the  method  of  operating,  nor  to  a  more  complete  knowledge 
of  the  disease,  but  to  the  discovery  of  cocaine,  which,  by  its 
local  anfesthetic  effect,  has  sensibly  reduced  the  danger  arising 
from  intractability  of  the  patient,  and  still  more  to  modern  an- 
tisepsis. This  does  not  necessarily  mean  that  all  cases  of  cata- 
ract may  be  attacked  with  impunity,  with  the  same  ease,  and  by 
the  same  simple  procedure.  There  will  always  be  material  dif- 
ferences in  the  opacity  of  the  lens  in  different  cases,  and  accord- 
ing to  the  nature  of  these  differences  must  the  choice  in  the 
method  of  operating  be  decided.  The  dangers  of  the  operation 
have  been  considerably  reduced,  and  to  about  the  same  extent 
for  all  forms  of  cataract.  For  senile,  ripe,  uncomplicated  cata- 
racts the  dangers  have  been  reduced  to  almost  nothing.  In- 
complete or  unripe  and  complicated  cataracts,  however,  al- 
ways demand  special  precautions  as  to  method  of  operating 
and  subsequent  treatment.  Hence  the  method  of  operating 
should  be  modified  according  to  the  nature  and  necessities  of 
the  case. 

Lymphangeiectatic  Fibroma  of  the  Optic  Nerve.— 

Rohmer  {Arch.  (TopMlial.,  September,  1892)  reports  an  interest- 
ing case,  occurring  in  a  child  aged  three  years  and  a  half.  The 
child  had  a  strabismus  convergens  in  the  right  eye,  with  marked 
protrusion  of  the  eyeball.  There  was  a  hypermetropia  of  D.  5'50, 
and  marked  papillary  stasis.  Palpation  could  not  discover  any 
growth  back  of  the  eye.  A  month  later  both  the  squint  and 
the  exophthalmia  had  increased,  and  a  tumor  could  be  made 
out  behind  the  eye  and  along  the  external  side  of  the  orbit.  A 
long,  curved  incision  was  made  through  the  ocular  conjunctiva, 
from  above  downward,  near  the  external  margin  of  the  cornea. 
The  external  rectus  muscle  was  divided  through  its  tendinous 
attachment,  and  the  eyeball  pushed  aside.  The  finger  was  then 
introduced,  and  a  neoplasm  discovered  closely  connected  with 
the  optic  nerve.  The  optic  nerve  was  divided  close  to  the  eye- 
ball, and  by  means  of  curved  scissors  the  tumor  was  dissected 
free  from  its  attachments  and  removed.  The  cavity  was  then 
washed  out,  the  eye  restored  to  position,  the  tendon  of  the  ex- 
ternal rectus  muscle  stitched  in  place,  and  the  conjunctival  wound 
was  then  closed  by  sutures.    The  case  healed  kindly,  and  six 


months  later  there  was  no  return  of  the  growth.  The  eyeball 
was  slightly  atro[)hied  and  convergent.  The  tumor,  on  exami- 
nation, proved  to  be  a  fibroma,  with  enormous  lymphangeiectatic 
spaces  developed  between  the  fibers. 

A  Fixed  Optometric  Ophthalmoscope.— Parent  {Arch, 
dl'ophthal.^  September,  1892)  has  devised  a  modification  of  his 
former  instrument  as  follows:  The  source  of  light,  a  small  petro- 
leum lamp  surrounded  by  a  muff,  is  part  of  the  instrument,  being 
fixed  at  the  end  of  an  arm  which,  like  the  mirror,  revolves  in 
the  horizontal  plane.  A  convex  lens  of  D.  15,  colored  blue, 
mounted  in  a  standard,  runs  on  the  same  arm  and  can  be  placed 
at  any  distance,  so  as  to  send  divergent,  parallel,  or  convergent 
rays  of  light  upon  the  plane  mirror  of  the  instrument.  The 
ocular  and  objective  are  multiple  and  may  be  interchanged  so 
as  to  admit  of  examining  the  fundus  with  different  degrees  of 
magnifying  power.  All  the  movable  parts  of  the  instrument 
are  mounted  in  a  toothed  rack.  Behind  the  mirror  are  sixteen 
concave  cylindrical  lenses,  which  can  be  rotated  from  0°  to  180°. 
The  astigmatism  of  the  patient  is  determined  by  approaching 
the  eye-piece  to  the  inverted  image  until  parts  of  vessels  or 
whole  vessels  are  distinctly  visible.  Then  the  axis  of  the  con- 
cave cylinders  is  placed  perpendicularly  to  those  parts  of  the 
vessels  which  are  distinctly  seen,  and  the  disc  of  the  cylinders 
is  then  turned  until  all  the  vessels  are  seen  with  equal  dis- 
tinctness. 

The  Origin  of  Certain  Corneal  Opacities  following  Ex- 
traction of  Cataract.— Mel  linger  {Arch,  fur  Ophihal.,  xxxvii, 
4)  draws  the  following  conclusions  from  his  experiments  as  to 
the  effects  of  solutions  of  cocaine  and  mercuric  bichloride: 

1.  Sublimate  solutions  of  the  strength  of  1  to  5,000,  in  con- 
tact with  the  anterior  chamber  for  a  short  time,  cause  temporary 
parenchymatous  opacity  of  the  cornea.  If,  however,  a  portion 
of  the  solution  remains  in  the  anterior  chamber,  there  results 
an  intense  and  permanent  parenchymatous  opacity  in  the 
cornea. 

2.  Cocaine  alone  causes  no  corneal  opacity,  but  its  presence 
in  the  anterior  chamber  aids  the  fomation  of  the  opacity  due  to 
the  sublimate  solutions,  by  rendering  the  endothelium  porous 
to  fluids  and  thus  opening  the  way  for  the  effects  of  this  fluid 
upon  the  corneal  parenchyma.  Moreover,  it  lowers  the  intra- 
ocular tension,  aids  the  occurrence  of  corneal  collapse,  and  thug 
facilitates  the  entrance  of  the  sublimate  solution  into  the  an- 
terior chamber. 

Toxic  Amblyopia. — Groenouw  {Arch,  fur  Ophthal..,  xxxviii, 
1)  draws  the  following  conclusions  from  his  investigations: 

1.  If,  in  testing  the  field,  defect  for  red  only  is  found,  it  is 
probably  a  case  of  toxic  amblyopia.  It  is  possible,  however, 
that  if  the  defect  for  red  is  very  small,  the  case  might  be  re- 
garded as  an  axial  neuritis. 

2.  If  defect  for  white  is  present,  and  the  red  defect  is  a  hori- 
zontal oval  of  a  certain  size,  the  case  may  be  one  either  of  retro- 
bulbar neuritis  or  of  toxic  amblyopia.  If,  however,  the  defects 
for  both  white  and  red  are  of  the  same  size,  it  is  probably  a  case 
of  axial  neuritis. 

3.  In  toxic  amblyopia  the  scotoma  is  very  variable,  while 
in  axial  neuritis  it  is  absolute  and  unchangeable. 

4.  Peripheral  limitations  of  the  field  for  white  or  colors 
point  to  retrobulbar  neuritis.  The  optic-nerve  atrophy  met  with 
in  toxic  amblyopia  needs  no  differential  diagnosis,  as  it  occurs 
only  after  long  years  of  amblyopia. 

5.  In  toxic  amblyopia,  the  process  attacks  directly  or  indi- 
rectly the  retina  or  the  optic  nerves,  chiasm,  or  optic  tracts,  or 
it  is  located  in  the  cortex.  Of  these  three  possible  locations, 
Groenouw  thinks  that  no  sufficient  proof  has  been  offered  for 
the  location  of  the  lesion  in  either  the  retina  or  the  cortex,  and 
he  therefore  points  to  the  nerves,  chiasm,  or  tracts  as  the  loca- 


March  18,  1893.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


311 


tion  of  the  lesion,  and  tliinkn  that  the  ophthahnoscopic  evi- 
dence is  in  favor  of  this  view. 

Senile  Changes  in  the  Uveal  Tract.— Kerschhaumer 
{Arch,  fill-  Opktliul.,  xxxviii,  1)  concludes  her  investigations  as 
follows : 

1.  The  pigment  epithelium  undergoes  changes  which  are 
partially  hyperplastic  and  partially  degenerative.  2.  The  vit- 
reous lamella  of  the  chorioid  hecomes  tliickened  and  loses  its 
brilliancy.  3.  The  thickening  is  either  homogeneous  or  in  groups 
of  granules  which  form  the  beginning  of  the  so-called  chorioidal 
glands.  The  latter  changes  are  more  common  in  the  equatorial 
region  and  around  the  optic  nerve.  They  are  generally  round 
or  oval  and  tend  to  coalesce,  but  they  remain  few  and  isolated. 
4.  The  walls  of  the  vessels  become  very  rigid,  and  in  many  in- 
stances so  tliickened  that  the  lumen  is  obstructed  or  ceases  to 
exist,  and  the  vessels  are  changed  into  cords.  In  the  cliorio- 
capillaris  there  are  often  relatively  large  sj)aces  in  whicli  the 
vessels  have  been  obliterated. 

Faedchen  Keratitis.— Hess  {Arch,  far  Ophthal.,  xxxviii,  1) 
states  as  his  opinion  that  in  Fiidchen  keratitis  the  corneal  epi- 
thelium takes  an  important  part  in  tlie  formation  of  the  threads 
or  lines.  In  addition  to  the  epithelial  cells,  the  subepithelial 
tissue  also  takes  part  in  the  process.  He  thinks  it  also  possible 
that  coagulated  fibrin  or  threads  of  mucus  may  become  attached 
to  a  ciirneal  thread  or  fiber.  He  admits  that  the  whole  subject 
is  stid  decidedly  unsettled. 

Suppuration  of  the  Vitreous  due  to  Cicatricial  Prolapse 
of  the  Iris. —  Wagenmann  (.■ircli.fnr  Oihllial.^  xxxviii,  1)  draws 
the  following  conclusions  from  hi.s  observations:  The  purulent 
infiltration  of  the  vitreous  is  caused  by  recent  superficial  infec- 
tion in  the  cicatrized  prolapsed  iris,  which  has  maintained  more 
or  less  of  a  fistulous  character.  Through  this  fistulous  opening 
the  cocci  find  their  way  into  the  interior  of  the  eve,  and  not 
tlirough  the  medium  of  the  vessels.  In  some  of  the  cases  the 
streptococci  seem  to  possess  an  especially  malignant  character, 
as  evidenced  by  the  violence  of  the  inflammation.  Wagenmann 
regards  these  cases  as  entirely  ectogenous  in  character. 

Observations  on  the  Macula  Lutea.— John.son  (Arch,  of 
Ophth.,  xxi,  1)  has  arrived  at  the  following  conclusions:  ]. 
"When  observed  in  a  certain  way,  the  macular  ring  in  its  entire 
circumference  can  be  seen  in  every  person  under  thirty-five 
years  of  age,  and  frequently,  though  with  diminishing  fre- 
<iuency,  over  that  age.  If  the  source  of  illumination  be  gradu- 
ally lowered,  the  reflection  from  the  fundus  decreases  more 
rapidly  than  that  from  the  margin  of  the  macula,  so  that  a  pe- 
riod arrives  when  more  light  is  reflected  from  the  latter  than 
from  the  general  fundus,  and  at  that  moment  the  ring  appears. 
2.  The  macula  is  invariably  circular,  and  probably  corresponds 
to  the  extreme  limit  of  the  macular  region.  3.  The  ring  is 
without  doubt  due  to  the  cuii-sluqied  dip  of  the  macula.  Seeing 
the  ring  in  almost  every  [lerson,  and  being  thereby  able  to  de- 
termine the  limit  of  the  macular  region,  it  may  prove  of  prac- 
tical value  in  diagnosticating  whether  a  lesion  or  defect  is  situ- 
ated within  or  without  the  region  of  acute  vision. 

The  .etiology  of  Inflammation  of  the  Eye  after  Injury 
with  Foreign  Bodies.— Poplaw ska  (Arch,  of  Ophth.,  xxi,  1) 
sums  up  the  results  of  her  studies  as  follows:  Plight  of  the 
twelve  eyeballs  examined  showed  microbes.  These  were  with- 
out exception  bacilli,  and  each  case  showed  but  a  single  variety, 
so  that  there  was  in  no  case  a  mixed  infection.  The  bacilli 
always  lay  in  the  medium  whicih  contained  the  foreign  body  — 
viz.,  the  vitreous— and,  in  si)ite  of  careful  searching,  were  never 
found  in  the  anterior  (diamber,  iris,  retina,  or  chorioid.  In  the 
vitreous  they  were  confined  to  a  small  locality,  almost  always 
immediately  surrounding  the  foreign  body.  In  one  case  the 
lens  also  contained  bacilli,  but  here  the  lens  capsule  was  ruj)- 


tured.  and  as  the  bacilli  also  lay  near  the  posterior  surface  of 
the  lens,  it  is  ]jofsibIe  that  tliey  were  carried  into  the  lens  with 
the  pus  in  a  purely  mechanical  way,  and  there  proliferated. 
Either  these  bacilli  entered  the  eye  with  the  unclean  splinter 
and  there  developed  and  multiplied,  and  by  their  pathological 
processes  caused  panophthalmitis,  or  they  were  present  in  the 
conjunctival  cnl  de-sac,  passed  into  the  eje  by  the  canal  formed 
by  the  foreign  body,  and  there  produced  the  pano[)htlialmitis. 

A  Statistical  Review  of  the  Proportion  and  Cause  of 
Blindness  in  Thirty-two  Thousand  Eyes  consecutively 
treated  in  the  Jelferson  College  Hospital.— Hansell  and  Bell 
(Arch,  of  Opiithal.,  xxi,  1)  summarize  the  results  of  their  inves- 
tigation as  follows:  Attention  is  called  to — 1.  The  extremely 
low  proportion  of  blind  eyes  to  the  aggregate  of  eyes  examined. 
2.  The  fact  that  liability  to  blindness  in  males  is  one  hundred 
per  cent,  greater  than  in  females.  3.  The  percentage  of  males 
blinded  from  surgical  causes  is  only  slightly  higher  (three  per 
cent.)  than  from  medical  causes,  but  in  females  eyes  blinded 
from  medical  causes  are  greatly  in  excess.  4.  The  left  eye  is 
ten  per  cent,  more  frequently  the  seat  of  fatal  disease  than  the 
right  eye.  5.  The  third  decade  (twenty  to  thirty  years)  of 
human  life  far  exceeds  all  others  in  furnishing  subjects  of  dis- 
ease or  injury  fatal  to  sight.  6.  Traumatism,  including  unsuc- 
cessful cataract  operations,  gunshot  wounds,  foreign  body  in 
the  eye,  and  dislocated  lens,  was  responsible  for  nearly  thirty 
per  cent,  of  the  total  number  of  the  cases  of  blindness. 

Objective  Strabismometry.— Maddox  {Arch,  of  Ophthal., 
xxi,  ])  makes  use  of  the  following  plan  in  othce  strabismome- 
try: On  the  wall  is  a  horizontal  board  with  a  candle  in  the 
center,  and  marked  to  the  right  and  left  therefrom  in  metre 
angles  or  degrees,  or  both,  for  a  distance  of  one  metre.  The 
figures  to  the  right  are  black  and  those  to  the  left  red.  A 
string,  one  metre  long,  is  fixed  by  one  end  to  the  center  of  the 
board.  The  patient  is  placed  opposite  the  candle  at  the  distance 
of  one  metre,  the  string  being  raised  to  measure  the  distance, 
and  then  allowed  to  drop.  While  the  patient  is  told  to  look  at 
the  candl*-,  the  observer  places  his  own  head  a  little  lower  than 
the  imaginary  line  from  the  patient's  squinting  eye  to  the  candle, 
but  in  the  same  vertical  plane  with  it,  so  as  tp  look  into  the  said 
eye  from  the  distance  of  about  a  foot.  At  once  the  amount  of 
squint  is  roughly  guessed  by  the  position  the  reflected  image 
of  the  candle  occupies  on  the  cornea.  The  sound  eye  is  then 
covered  to  let  the  s(juinting  one  look  at  the  candle,  and  while  it. 
does  this  the  position  of  the  corneal  image  is  carefully  noted. 
Then  the  good  eye  is  uncovered,  and  the  patient  is  told  to  look 
at  the  number  on  the  board  which  has  been  guessed  as  the 
probable  measure  of  the  squint.  If  correct,  the  corneal  image 
will  now  occupy  the  same  position  on  the  squinting  eye  that  it 
did  when  the  best  eye  was  covered  and  the  squinting  eye  was 
fixing  the  flame.  If  the  guess  is  short  of  tlie  mark,  he  is  told 
to  look  at  the  next  figure,  or  the  next  still.  If  the  guess  is  over 
the  mark,  he  is  directed  to  figure  less.  The  figure  settled  on 
gives  at  once  the  measure  of  the  squint  in  its  primary  deviation. 
To  measure  the  secondary  deviation,  cover  the  fixed  e.ve  with 
the  hand,  so  as  to  turn  the  squinting  eye  into  the  fixing  one. 
The  psitient  is  then  told  to  look  at  the  same  number,  but  on  the 
opposite  side  of  the  candle.  On  momentarily  uncovering  the 
covered  eye,  the  corneal  image  will  be  seen  in  its  fixation  posi- 
tion if  the  secondary  squint  is  equal  to  the  primary.  In  eyes 
that  have  no  central  fixation  the  secondary  deviation  can  not  be 
measured.  To  test  for  concomitancy,  the  patient's  head  should 
be  rotated  twenty  or  thirty  degrees  to  the  right  and  then  to  the 
left,  anil  the  sfjiiint  measuix'tl  in  each  of  tlu'so  positions. 

Papilloma  of  the  Conjunctiva  encroaching  on  the  Cornea. 

— Sims  {Arch,  of  Ophthal..^  xxi,  1)  reports  the  histories  of  two 
such  cases  with  the  nHi  rosco[)ic  aiipearances.    The  two  tumors 


312 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


ftJ.  y.  Med.  Joum., 


were  identical  in  structure,  consifting  of  numerous  papillae,  each 
containing  a  loop  of  blood-vessels,  surrounded  by  layers  of  epi- 
tlielial  cells.  Little  connective  tissue  was  to  be  seen,  except  a 
tliin  sheath  rouml  the  vessels,  and  the  line  of  demarcation  be- 
tween this  tissue  and  the  internal  layer  of  cpithetiuin  was  well 
marked  throughout.  The  epithelial  layer  was  increased  three 
times  in  tiiickness. 

Optic  Neuritis  after  Measles  and  Intermittent  Fever.— 
Woods  (Arch,  of  Ophth.,  xxi,  1)  tiiinks  that  cases  of  blindness 
after  measles  seem  to  be  of  two  kinds — 1.  Those  showing  no 
eye  lesions  until  late  in  tlie  history  of  the  case.  2.  Those  with 
marked  neuritis  from  tlie  beginning.  The  former  are  probably 
due  to  some  cerebral  lesion,  probably  vascular,  with  consecu- 
tive nerve  disease;  the  latter  are  due  to  basilar  meningitis. 
The  most  natural  explanation  of  their  connection  with  measles 
seems  to  be  that  tliis  disease  lowers  the  powers  of  resistance  of 
the  tissues,  and  renders  secondary  infection  easy. 

The  Treatment  of  Trachoma.— Jaesche  (Arch,  of  Ophthal., 
xxi,  1)  thinks  that  Himl^'s  fenestrated  forceps  is  well  adapted 
for  pressing  out  the  follicles.  If  the  trachoma  be  frenh,  with 
prominent  lymph  follicles  and  moderate  swelling  of  the  con- 
junctiva, it  is  suBicient  to  seize  the  conjunctiva  in  such  man- 
ner that  one  branch  of  the  forceps  lies  in  the  retrotarsal  fold 
and  the  other  at  the  margin  of  the  lid.  The  forceps  is  then 
closed  with  some  force  and  drawn  over  the  conjunctiva  in 
such  a  way  that  not  only  tlie  follicles  are  pressed  out,  but  the 
entire  swollen  portion  of  the  conjunctiva,  with  the  hypertro- 
phied  papillsB  and  the  new-formed  vessels,  are  thoroughly 
crushed.  In  the  second  stage,  when  the  conjunctiva  is  markedly 
swollen  and  infiltrated  and  bleeds  easily,  the  papilliB  are  greatly 
hypertrophied,  the  follicles  partly  degenerated,  repeated  and 
energetic  crushing  of  the  conjunctiva  is  required.  In  the  third 
stage,  when  the  conjunctiva  shows  a  fairly  smooth,  atrophic, 
bloodless  surface,  and  the  underlying  tissue  is  infiltrated,  thick- 
ened, and  sclerosed — if  the  forceps  is  used  in  such  cases,  half- 
degenerated  follicles  escape  from  the  depth  of  the  conjunctiva 
in  unexpected  quantity.  If  all  the  roughness  of  the  conjunctiva 
is  removed,  the  worst  cases  rapidly  improve.  Cold  applications 
should  be  made  frequently,  using  either  a  sublimate  solution  or 
one  of  boric  acid.  After  the  second  day,  instillations  of  a  two- 
per-cent.  solution  of  silver  nitrate  are  to  be  used. 

The  Treatment  of  Trachoma  by  the  Expression  of  the 
Morbid  Substance  with  a  Roller  Forceps.— Knapp  (Arch,  of 

Ophth.,  xxi,  1)  describes  the  instrument  devised  by  himself  for 
the  purpose  as  follows  :  The  instrument  is  made  according  to  the 
principle  of  the  mangle.  The  branches  of  an  ordinary,  rather 
strong  forceps  divide  at  their  ends  like  a  horseshoe,  the  free 
space  of  which  is  occupied  by  a  creased  stei  l  cylinder  which 
rolls  on  pivots  in  sockets.  A  more  recent  modification  has  coni- 
cal pivots,  which  dip  into  corresponding  depressions,  and  the 
cylinders  can  be  removed  and  reinserted.  The  rolling  cylinder  is 
twenty  to  twenty-five  millimetres  long  and  one  millimetre  to  a 
millimetre  and  a  half  thick.  It  is  nsade  of  steel,  and  can  be 
taken  apart  to  be  cleansed.  The  mode  of  application  is  as  fol- 
loivs:  The  patient  is  etherized,  except  in  mild  cases  of  superfi- 
cial granular  deposit.  The  u[)per  lid  is  everted,  seized  at  the 
convex  border  of  the  tarsus  with  an  ordinary  fixation  forceps, 
and  drawn  over  the  eye,  so  as  to  ex[)ose  the  whole  palpebro- 
bulbar  conjunctiva.  The  infiltrated  part,  if  necessary,  may  then 
be  superficially  scarified  with  the  three  bladed  "  sillonneur  "  of 
Johnson.  One  blade  of  the  forceps  is  pushed  deeply  between 
the  ocular  and  ])ul|)ebral  conjunctiva,  the  other  is  applied  to 
the  everted  substance  of  the  tarsus.  The  forceps  is  com- 
pressed with  more  or  less  force,  drawn  forward,  and  the  infil- 
trated soft  substance  8()ueezed  out  as  the  cylinders  roll  over  the 
surfaces  of  the  fold  held  between  them.    This  manoeuvre  is  re- 


peated all  over  the  conjunctiva  until  the  granules  and  the  juice 
are  completely  pressed  out  of  the  tissue.  The  forceps  passes  two 
or  three  times  ovei-  the  same  i)lace,  until  the  absence  of  resist- 
ance proves  that  all  foreign  tissue  substance  is  removed.  If  the 
tarsal  conjunctiva  contains  granules,  one  blade  of  the  forceps  is 
applied  to  the  skin,  the  other  to  the  conjunctiva,  and  the  in- 
strument is  drawn  across  several  times  until  all  the  granules 
have  disappeared.  The  mucous  membrane  is  then  washed  w  ith 
a  mild  aiitise[)tic.  The  lids  and  conjunctiva  may  swell  consid- 
erably for  a  few  days,  but  in  the  great  majority  of  cases  the 
recovery  is  rajdd  and  free  fnun  ii  rilation. 

Further  Experiments  on  the  Lymph  Streams  and  Lymph 
Channels  of  the  Eye.— (iiiford  (Arch,  of  Ophth.,  xxi.  2)  sum- 
marizes the  results  of  his  experiments  as  follows:  1.  The  ferro- 
cyanide  and  fiuorescein  methods  do  not  give  trustworthy  re- 
sults in  determining  the  ph \  siological  currents  of  the  eye. 
The  lines  upon  which  most  stress  has  been  laid  can  be  obtained 
perfectly  well  in  the  dead  eye.  2.  Btilling's  view  that  there 
is  no  outlet  from  the  vitreous  forward  around  the  lens  is  incor- 
rect. The  zonula  is  freely  permeable  for  solid  paiticles,  free 
pigment  being  carried  regularly  from  the  vitreous  into  the  an- 
terior chamber.  The  failure  of  the  attempts  to  inject  the  ante- 
rior chamber  from  the  vitreous  is  probably  due  to  the  closure 
of  the  chamber  angle  from  the  increased  vitreous  tension.  It 
is  probable  that  the  Huid  secreted  by  the  ciliary  processes,  po.ste- 
rior  to  the  zonula,  divides  into  two  portions,  one  part  passing 
forward  into  the  posterior  chamber  and  thence  through  the 
pupil  into  the  anterior  chamber,  the  other  passsing  back 
through  the  vitreous  and  out  through  the  central  canal  of  the 
opticus  into  the  tissues  of  the  orbit.  3.  There  is  no  evidence  of 
any  current  passing  from  the  posterior  chamber  through  the 
root  of  the  iris.  Pigment  bearing  leucocytes  may  pass  into  the 
latter  from  either  posterior  or  anterior  chambers,  more  readily 
from  the  latter,  from  which  they  sometimes  pass  clear  through 
the  iris  into  the  posterior  chamber.  4.  There  is  no  evidence 
of  any  current  from  the  anterior  chamber  through  the  mem- 
brane of  Descemet  into  the  cornea.  Pigment  panicles  from 
the  aqnemis  are  taken  up  by  the  protoplasm  of  Descemet's  en- 
dothelial cells.  Experiments  on  both  dead  and  living  animals 
show  a  free  connection  for  non  diflfusible  substances  between 
Fontana's  spaces  and  the  circumcorneal  veins.  It  is  therefore 
]>robable  that  the  greater  part  of  the  aqueous  leaves  the  eye  in 
this  way.  Other  finer  lymph  channels  lead  from  Funtana's 
spaces  into  the  posterior  layers  of  the  cornea,  into  the  peri- 
vascular spaces  of  the  sclero  corneal  junction,  into  the  sclera, 
chorioid,  and  perichorioidal  space.  Wherever  these  channels 
communicate  with  spaces  in  which  there  is  a  lower  pressure 
than  that  within  the  anterior  chamber,  they  must  serve  to  some 
extent  as  outlets.  5.  Between  the  retinal  pigment  epithelium 
and  the  layer  of  rods  and  cones  is  a  tolerably  well  defined  space, 
from  which  pigment  passes  freely  into  the  retina,  but  hardly,  or 
not  at  all,  into  the  chorioid  proper,  except  along  occasional 
penetrating  blood-vessels  in  the  neighborhood  of  the  optic 
nerve.  6.  While  certain  facts— such  as  the  regular  passage  of 
pigment  and  bacilli  from  Fontana's  spaces  into  the  cornea,  and 
the  progress  of  subconjunctival  htemorrhages  in  the  same  direc- 
tion, together  with  the  impermeability  of  Descemet's  membrane 
from  behmd — speak  for  the  nourishment  of  the  cornea  from  its 
periphery,  the  corneal  lymph  stream,  if  any  exists,  is  too  we.'dc 
to  perceptibly  affect  the  diffusion  of  fluorescein  or  the  progress 
of  pigment  particles  through  its  tissues. 

Idiopathic  Vitreous  Haemorrhages.- Spalding  (Arch,  of 
Ojihth.,  xxi,  2)  thinks  that  in  these  cases  the  prognosis  seems  to 
be  favorable.  No  perfect  restoration  of  vision  is  possible,  but 
useful  vision  is  regained  in  a  majority  of  cases.  The  (etiology 
remains  in  doubt.    So  long  as  we  exclude  all  myopic  eyes,  it 


March  18,  1893.] 


MISCELLANY. 


313 


would  seem  as  if  some  strain,  or  the  sniipression  of  habitual 
discharges,  or  actual  overwork  of  the  eyes,  must  be  the  excit- 
ing cause.  As  regards  the  treatment,  he  recommends  the  hypo- 
dermic use  of  pilocarpine  hydrochloride,  in  doses  of  one  twelfth 
of  a  grain,  once  a  day  for  two  weeks.  Jf  any  dose  produces 
weakening  effects  on  the  heart,  the  next  dose  may  be  dimin- 
ished or  omitted  for  two  days.  If  no  visible  effect  is  produced, 
the  dose  may  be  gradually  increased  as  high  as  one  sixth  of  a 
grain.  Mercurials  may  be  used  in  some  cases  when  the  rarefac- 
tion of  tlie  vitreous  ceases  from  any  cause  Heurteloup's  artificial 
leech  is  (juite  indispensable  in  the  beginning  of  the  attack. 
The  constant  current  has  been  claimed  as  efficacious  in  some 
cases. 

A  Traumatic  Retention  Cyst  of  the  Conjunctiva.— Lopez 

(Arch,  of  Ophthal.,  xxi,  2)  reports  a  case  of  this  nature  in  a 
nmn  aged  twenty-four.  Up  to  twelve  years  of  age  the  eyes 
were  i)erfectly  healiliy.  At  that  age  he  received  an  injury  from 
the  horn  of  a  cow  in  the  left  orbital  cavity,  which  was  followed 
by  a  violent  inflammation.  lie  was  taken  to  a  hospital  and  an 
operation  was  performed,  the  nature  of  which  lie  did  not  know. 
From  that  time  a  tumor  commenced  to  form  in  this  region,  and 
has  increased  to  its  present  size  without  causing  any  symptom 
exc3i)t  deformity.  The  tumor  was  conical  anteriorly,  and  was 
covered  by  the  ankylosed  lids,  the  free  borders  of  which  could 
•only  be  separated  about  four  millimetres  from  each  other. 
The  tumor  fluctuated,  the  sensation  on  palpation  being  that  of 
a  ball  filled  with  fluid.  There  was  a  diverticulum  toward  the 
lacrymal  sac.  Near  the  inferior  and  external  orbital  margin  was 
a  sequestrum.  The  tissue  joining  the  two  lids  was  divided  on 
a  director,  and  the  palpebral  fissure  was  enlarged  at  both  ends. 
The  lids  were  then  se|)arated  from  the  cyst  wall  with  scissors. 
In  this  cutting,  the  cyst  was  opened,  giving  exit  to  a  yellowish, 
transparent  fluid,  and  at  the  bottom  of  the  cyst  cavity  the  eye- 
ball was  discovered  in  a  perfectly  healthy  condition.  A  jjortion 
of  the  anterior  cyst  wall  was  removed,  and  in  this  were  im- 
bedded three  pieces  of  dead  bone.  Sutures  were  then  intro- 
duced to  reduce  the  palpebral  fissure  to  its  normal  size.  At  the 
end  of  a  month  the  patient  could  count  fingers. 

( 7'o  be  concluded.) 


St  i  s  f  ^  n  a  It  5 . 


Myxcedema. — At  a  recent  meeting  of  the  Edinburgh  Medico-chirur- 
gical  Society,  re])()rted  in  the  Lancci  for  February  25th,  a  discussion  on 
this  subject  was  opened  by  Di.  Byrom  Hramwell,  who  had  to  deal  with 
the  clinical  aspects  of  the  disease.  He  thought  it  would  be  difficult  to 
say  anytliing  new  on  the  subject.  The  disease  was  common  in  Edin- 
burgh and  its  neighborhood  ;  so  it  was  in  other  parts  of  Scotland  and 
in  the  north  of  England.  It  was  rare  in  Germany,  where  acromegaly 
was  comparatively  common.  In  Arherica  also  it  was  rare.  He  thought 
there  must  be  some  atmospheric  or  telluric  conditions  determining  its 
prevalence.  It  was  not  described  as  a  distinct  disease  till  1873.  It  oc- 
curred most  commonly  in  women.  It  was  aLso  seen  in  the  form  of  spo- 
radic cretinism  in  the  child.  The  disease  presented  a  remarkable  c(m- 
trast  to  exophthalmic  goitre  and  acromegaly,  but  with  the  latter  it  had 
features  in  common.  Myxedema  began  slowly  and  insidiously,  the  first 
symptoms  being  increased  siisceptibility  to  cold,  inal>ility  to  perspire, 
and  lassitude.  Dr.  Bramwell  then  described  the  appearances  charac- 
terizing the  well-developed  disease.  In  exophthalmia  and  acromegaly 
there  was  a  tendency  to  excessive  perspiration.  In  myxo'dema  there 
was  increased  electrical  resistanc(>,  the  reverse  being  the  case  in  exoph- 
thalmia. There  was  no  more  striking  feature  than  the  improvement  in 
the  mental  condition  during  treatment,  and  Dr.  Brainwoll  refci  red  to  a 


sporadic  cretin  under  treatment  who  had  had  only  a  thyreoid  and  a  half 
so  far  and  yet  her  whole  nature  was  transformed,  and,  whereas  she  had 
only  grown  two  inches  in  the  preceding  two  years,  she  had  since  grown 
an  inch  within  five  weeks.  The  mental  slowness  in  myxedema  was  in 
great  contrast  to  the  excitability  in  exophthalmia.  It  was  not  uncom- 
mon for  myxoedematous  patients  to  have  to  be  sent  to  asylums.  Sight 
and  hearing  were  sometimes  impaired.  Myxoedematous  patients  and 
cretins  thrived  best  when  their  surroundings  were  warm.  The  actual 
body  heat  was  low,  and  Dr.  Bramwell  showed  charts  illustrating  this 
and  the  elevation  of  temperatuie  which  took  place  under  treatment ;  in 
this  also  the  disease  contrasted  with  exophthalmia.  In  acromegaly  a 
subnormal  temperature  was  likewise  present.  In  the  patient  he  was 
treating  with  the  thyreoid  the  breasts  became  turgid,  swollen,  and 
painful. 

Professor  Greenfield  then  took  up  the  pathology  and  morl)id  anato- 
my of  the  disease.  His  pathological  connection  with  the  subject  had 
been  of  long  standing.  When  he  was  pathologist  to  St.  Thomas's  Hos- 
pital he  had  made  the  post-mortem  examination  of  the  case  under  Dr. 
Ord  which  was  the  ground  of  his  first  report  on  the  condition,  and  on 
which  was  founded  the  name  "  myxcedema."  The  primary  and  most 
essential  fact  in  the  pathology  was  the  atrophic  change  in  the  thyreoid. 
There  was  little  accurate  knowledge  as  to  the  cause  of  the  change. 
The  functions  of  the  gland  were  obscure ;  it  was  only  certainly  known 
that  in  some  way  it  was  concerned  iu  the  metabolic  changes  of  the  nu- 
tritive fluids,  and  that  it  had  some  relation  to  the  elaboration  of  mucin. 
It  probably  secreted  a  material  of  the  nature  of  a  ferment  which  passed 
into  the  blood  and  stimulated  the  secretion  of  the  skin  glands  and  in 
some  way  acted  upon  the  heart.  In  myxredema  the  gland  was  atro- 
phied ;  in  sporadic  cretinism  it  might  be  almost  absent.  In  exophthal- 
mic goitre  there  was  an  exactly  opposite  condition — an  enormous  in- 
crease in  its  secreting  structure  and  also  of  the  colloid  material  in  its 
spaces.  In  ordinary  cystic  goitre  associated  with  cretinism  there  was 
an  enormous  increase  in  its  substance.  One  should  not  regard  the 
morbid  appearance  of  the  thyreoid  in  my.xoedema  as  of  too  great  im- 
portance or  exclude  other  considerations  in  relation  to  its  function.  In 
myxcedema  the  sweat  glands  and  sebaceous  glands  acted  defectively 
and  the  latter  atrophied  with  other  parts  of  the  skin.  The  normal 
transpiration  being  deficient,  the  lymph  seemed  to  stagnate  and  accumu- 
late. That  this  was  so  seemed  to  be  shown  by  the  improvement  seen 
after  hot  baths.  Professor  Greenfield  then  laid  stress  upon  the  altered 
reaction  of  myxnjdematous  cases  to  tuberculosis.  They  showed  a 
marked  proclivity,  while  the  manifestations  of  the  proce.ss  were  greatly 
modified.  The  patients  in  five  cases  from  which  he  showed  specimens 
died  from  phthisis,  as  also  one  in  a  case  of  sporadic  cretinism.  The 
phthisis  was  characterized  by  its  rapid  course  and  the  absence  of  the 
ordinary  syonptoms  of  tuberculosis.  He  thought  the  power  of  repair 
in  myxcedema  was  good,  but  asked  for  information.  He  had  studied 
the  material  from  seven  cases  of  myxa;dema  and  one  of  sporadic  cre- 
tinism. In  all  the  thyreoid  was  diminished  in  size  ;  there  was  either 
generally  or  in  parts  an  advanced  condition  of  atrophy  with  fibroua 
overgrowth.  In  some  all  gl.and  tissue  had  disappeared  ;  in  others  the 
filuous  tissue  was  highly  cellular;  in  one  there  was  a  lymphoid  infil- 
tration at  parts.  These  changes  and  the  changes  in  the  epithelium  were 
parallel  to  those  seen  in  all  wasting  glands.  In  the  arteries  there  were 
the  changes  found  in  all  interstitial  inflammations.  In  the  skin  there 
were  marked  changes  in  all  the  glandular  elements  and  in  the  hair  fol- 
licles ;  they  showed  various  stages  of  atrophy.  Often  there  was  exten- 
sive deposit  of  pigment  in  the  skin.  The  epidermis  became  very  thin. 
The  (edema  was  deeply  situated.  The  change  might  be  called  a  myx- 
omatous degeneration  of  the  tissue  affected  ;  but  in  the  skin,  in  the 
tongue,  and  elsewhere  there  were  sometimes  areas  of  dense  fil)rous 
overgrowth.  In  the  kidneys  there  were  occasionally  a  swelling  and 
pallor  due  to  the  presence  of  a  myxomatous  degeneration  around  the 
arteries  at  their  division,  and  an  extension  of  a  myxomatous  and  cellu- 
lar infiltration  between  the  tubules  in  that  position,  while  the  cortex 
was  normal.  He  had  found  no  change  in  the  nervous  system,  except  in 
the  peripheral  nerves,  in  which  there  were  fretpiently  indications  of  a 
chronic  neuritis.  How  far  this  was  due  to  the  disease  he  did  not 
know.  The  lymphatic  glands  and  suprarenal  capsules  were  normal. 
A  large  nuiubor  of  photographs  were  shown  l)y  lime-light  illustiatitig 


314 


MISCELLANY. 


[N.  Y.  Med.  Jocv., 


the  points  of  the  paper,  one  of  these  beinp;  a  section  of  the  thyreoid 
of  an  old  man  who  die(i  of  cirrhosi.s  of  the  liver,  which  showed  changes 
exactly  resembling  those  found  in  myxajriema.  This  cotnmiinication 
was  further  illustrated  by  about  fifty  microscopical  preparations  and 
a  number  of  naked-eye  specimens  fioni  the  cases  that  had  been  ex- 
amined. 

Dr.  Lundie,  whose  part  in  the  opening  discussion  was  the  treatment 
of  the  disease,  gave  a  clear  and  concise  resume  of  the  history  of  the 
treatment  by  thyreoid  injection  and  feeding.  He  used  the  treatment 
for  the  first  time  in  November,  1891,  and  the  patient  had  recovered. 
There  was  a  relapse  when  the  treatment  was  stopped,  but  recovery  again 
took  place  by  feeding.  He  gave  one  cighteentli  of  a  sheep's  thyreoid 
daily.  He  referred  to  the  recorded  experience  on  the  subject,  and  drew 
attention  to  the  necessity  of  warning  patients  against  unusual  exertion 
at  an  early  stage  of  the  treatment. 

Dr.  Affleck  referred  to  the  former  treatment  by  hot  baths,  rubbing, 
etc.,  and  showed  photographs  illustrating  the  appearances  before  and 
after  treatment.  He  thought  we  were  yet  only  collecting  information 
and  that  it  was  important  that  those  who  had  cases  should  record  them. 
They  should  inquire  into  the  antecedents  with  a  view  to  find  out  the 
SBtiology  of  the  disease,  for  he  thought  there  might  be  some  underlying 
nervous  condition  interfering  with  the  thyreoid  and  leading  to  its  atro- 
phy. Some  patients  became  insane.  He  thought  Addison's  disease  pre- 
sented an  interesting  analogy  to  myxedema  and  .suggested  feeding  with 
suprarenal  capsules.  The  evidence  in  favor  of  thyreoid  feeding  was 
overwhelming  and  he  welcomed  it  as  a  most  important  contribution  to 
modern  therapeutics.  He  then  showed  a  boy  with  sporadic  cretinism 
who  had  immensely  improved  under  treatment  by  ingrafting. 

Peritonitis  and  Bright's  Disease. — At  a  meeting  of  the  Johns  Hop- 
kins Hospital  Medical  Society,  held  on  November  1,  1892,  a  continued 
report  of  which  is  to  be  found  in  the  January-February  number  of  the 
John  Hopkins  Hoapilal  Bulletin,  Dr.  Flexner  presented  specimens  from 
a  case  of  peritonitis  attributed  to  Protenx  vulgaris.  In  tlie  discussion 
Dr.  Welch  said  that  the  case  was  interesting  with  reference  to  the  gen- 
eral subject  of  the  relation  between  peritonitis  and  Bright's  disease. 
The  experiments  of  Grawitz,  Halsted,  and  others  had  demonstrated  that 
the  mere  introduction  of  the  ordinary  pyogenic  cocci  into  the  healthy 
peritoneal  cavity  of  animals  did  not  suffice  to  produce  peritonitis,  but 
that  the  co-operation  of  certain  secondary  or  accessory  causes,  such  as 
the  presence  of  strangulated  tissue,  wounds,  stagnating  fluids,  etc.,  in 
the  peritonajum  was  necessary  in  order  to  enable  these  bacteria  to  cause 
peritonitis.  In  Bright's  disease,  both  acute  and  chronic,  as  well  as  in 
cirrhosis  of  the  liver  and  many  cases  of  heart  disease,  ascites,  some- 
times associated  with  fibrous  thickening  of  the  peritonsBum,  was  a  com- 
mon condition,  and  this  might  be  regarded  as  a  predisposing  or  acces- 
sory cause  of  acute  peritonitis  ;  but  in  addition  to  this  we  might  reckon 
with  a  lessening  of  the  vital  resistance  offered  by  the  tissues  and  fluids 
to  the  growth  of  pathogenic  bacteria.  Ascitic  fluid,  like  the  blood 
serum,  was  possessed  of  germicidal  power,  but  we  could  understand 
that  in  some  cases  of  Bright's  disease  or  cirrhosis  of  the  liver  this 
germicidal  power  might  be  very  much  diminished  or  abolished.  We 
had,  therefore,  as  one  factor  in  the  causation  of  acute  peritonitis  ac- 
companying Bright's  disease  an  already  damaged  peritonaeum  with  pos- 
sible reduction  of  the  resistance  of  the  fluids  and  tissues  to  bacteria. 
The  other  and  an  essential  factor  was  the  entrance  into  the  peritoneal 
cavity  of  bacteria  capable  of  causing  acute  inflammation.  Sometimes 
we  could  find  the  portal  of  entrance  of  these  bacteria  in  a  complicating 
erysipelas,  a  leg  ulcer,  etc.,  but  often  the  most  careful  search  failed  to 
reveal  the  point  of  invasion,  and  here  we  were  in  much  the  same  con- 
dition as  in  our  explanations  of  many  cases  of  acute  ulcerative  endo- 
carditis ingrafted  upon  an  old  chronic  endocarditis.  We  must  assume 
that  the  bacteria  entered  the  circulation  or  passed  from  the  alimentary 
canal  without  readily  demonstrable  lesion  at  the  point  of  invasion. 
Such  bacteria  would  probably  be  eliminated  or  destroyed  without  doing 
any  harm,  if  they  did  not  find  a  damaged  tissue  or  some  point  in  the 
body  where  the  normal  resistance  to  their  growth  was  lessened.  In 
this  way  we  might  explain  some  of  the  cases  of  acute  peritonitis  sec- 
ondary to  Bright's  disease.  He  had  seen  a  few  such  cases,  both  genu- 
ine acute  purulent  peritonitis  and  acute  sero-librinous  peritonitis,  asso- 


ciated with  acute  and  chronic  diffuse  nephritis,  and  this  group  of  cases 
of  peritonitis  was  a  recognized  one.  The  peritonitis  was  then  usually  a 
terminal  event.  That  it  was  not  a  more  connnon  condition  was  prob- 
ably due  in  large  part  to  the  germicidal  power  ordinarily  jwssessed  i)y 
ascitic  and  other  fluids  of  the  body. 

Di'.  Thayer  said  that  the  clinical  aspects  of  the  case  of  peritonitis 
caused  by  the  proteus  were  in  some  ways  rather  interesting.  The  girl 
was  brought  in  on  Friday  night.  She  was  nineteen  years  of  age,  a  pro.s- 
titute,  and  but  little  history  was  obtained.  Her  friends  said  that  her 
symptoms  dated  only  three  or  four  days  back.  The  week  before,  she 
had  not  been  feelirrg  very  well.  She  had  several  attacks  of  vomiting, 
and  the  jjhysician  who  saw  her  said  that  ther  e  was  "  nothing  the  matter 
with  her."  Withirr  twenty  four  hours  before  she  was  brought  in  she 
becanre  very  dull,  and  on  entrance  was  alnrost  unconscious.  At  that 
time  she  was  veij  well  norrrished ;  physical  examination  was  entirely 
negative,  barring  the  fact  that  she  was  dull  and  drowsy  and  could  be 
roused  with  difliculty.  The  tension  of  the  pulse  was  slightly  increased, 
and  the  second  aortic  sound  was  somewhat  accentuated.  The  irrine  was 
scanty,  of  low  specific  gravity,  and  contained  a  slight  trace  of  albumin, 
but  no  casts  could  be  found  on  repeated  car-eful  examinations.  She 
was  given  diuretics,  pilocarpine,  and  hot-air  baths,  with  vei'y  little  re- 
sult. There  was  scarcely  any  sweating,  and  the  amount  of  urine  passed 
was  small.  She  died  on  Monday  after  noon  in  a  convulsion.  It  was  an 
interesting  point  that,  although  the  urine  was  examined  several  times 
and  the  centrifugal  apparatus  used,  no  casts  were  found,  while  exami- 
nation of  frozen  sections  of  the  kidneys  showed  numerous  liyaline  casts 
in  the  tubules. 

Subphrenic  Pyo-pneumothorax. — The  Feljr-uary  number  of  the  Prac- 
tilioncr  gives  a  summar  y  of  an  article  published  in  the  Berliner  klinische 
Wochenxrhrift,  1892,  No.  46,  in  which  Professor  Leyden  records  an  un- 
usual case  of  this  affection.  The  patient,  a  girl  of  eighteen,  was  ad- 
mitted to  hospital  shortly  after  the  influenza  epidemic.  She  complained 
ver'y  little:  had  moderate  fever-,  with  a  high  pulse  frequency  and  slight 
pain  in  the  right  side ;  otherwise  she  looked  well,  had  good  appetite 
and  slept  well.  With  moderate  dullness  in  the  right  side  of  the  chest 
and  crepitating  rdkfi,  there  was  no  expectoration ;  and  the  condition 
was  looked  upon  as  an  inflammatory  affection  of  the  lower  part  of  the 
right  lung.  Everything  went  on  well  for  a  time,  there  being  little  com- 
plaint. The  fever  decreased  withorrt  a  crisis  ;  but,  what  was  very  sig- 
nificant, the  pulse  retained  its  high  rate,  and  there  was  great  distention 
of  the  abdomen.  The  account  given  by  the  patient  of  the  illness  was 
that  she  was  quite  well  until  three  days  before  admission  into  the 
Charite,  when  she  ate  some  orange  peel,  then  vomited  and  felt  pain  in 
the  right  side.  No  light  could  be  obtained  from  the  histor-y,  and  it  was 
necessary  to  await  the  issue  of  events.  Some  little  time  after,  there 
was  presented  the  appearance  of  a  right-sided  pneumothorax,  which  was 
considered  to  be  subphrenic.  Vesicular  br-eathing  was  heard  on  the 
right  side  from  the  clavicle  to  the  second  rib ;  from  that  downward  the 
breath  sound  was  absent  where  it  had  been  heard  very  well  a  few  days 
before.  The  suceussion  sound  was  ample  evidence  of  a  cavity  contain- 
ing gas.  For  the  diagnosis,  it  was  ascertaineii  that,  above  the  second 
rib,  loud  pure  vesicular  murmur  was  present,  which  coirld  be  heard  on 
deep  inspiration  as  low  as  the  third  intercostal  space,  and  there  was  no 
displacement  of  the  heart.  The  hollow  percrrssion  note  was  audible  as 
far  down  as  the  costal  margin,  the  displacement  of  the  line  downward 
could  not  be  made  out  on  account  of  the  tympanitic  note  from  the  ab- 
domen, and  probably  an  intestine  lay  over  that  organ.  Stinking  pus 
was  oljtained  by  means  of  the  hypodermic  needle,  and  it  contained  bac- 
teria and  two  bilirubin  cr-ystals ;  on  the  second  day  some  pieces  of  food 
colored  with  bile ;  and  on  the  third  day  two  ascarides  eggs.  These  ob- 
servations proved  a  perforation  of  the  gut;  and  this  was  confirmed  on 
the  third  and  four-th  day  when  there  flowed  a  large  quantity  of  fiecal- 
looking  and  feecal-smellirrg  fluid.  The  seat  of  the  communication  was 
thought  to  be  the  cajcum — but  the  diagnosis  was  founded  on  probabili- 
ties, as  no  thickening  was  to  be  felt  in  that  region.  After  operation, 
drainage-tubes  were  placed  in  the  abscess  cavity  to  give  free  exit  of 
prrs  and  allow  of  disinfection.  Good  hopes  were  entertained  of  a  suc- 
cessful result,  the  general  condition  being  good,  and  the  patient  pre- 
viously healthy.    For  a  time  thiirgs  went  well,  the  abscess  dischar'ging 


March  18,  1893.] 


MISCELLANY. 


815 


fitcal  fluid.  Then  suddenly  the  patient  bepan  to  cough,  and  a  few  days 
later  spat  up  fuecal  matter.  There  was  a  hope  that  the  perforation  in 
the  lung  would  exhaust  itself,  as  the  cavity  freely  discharged  matter. 
But  the  cough  became  worse,  sleep  failed,  and  the  patient  soon  died  ex- 
hausted. The  necropsy  confirmed  the  existence  of  subphrenic  pyo- 
pneumotliorax.  The  right  lung  was  very  small,  retracted,  and  healthy, 
and  no  perforation  was  found  in  it.  The  intestines  were  matted  ;  the 
vermiform  jtrocess  was  rudimentary  and  completely  closed.  The  origi- 
nal cause  of  the  trouble  had  therefore  healed  up;  but  above  the  ca'cum 
there  was  a  peritoneal  fiecal  abscess;  and  along  the  ascending  colon  an 
elongated  purulent  induration,  which  ran  upward,  was  continuous  with 
the  cavity  underneath  the  diaphragm.  Evidently  when  the  opening  was 
made  in  the  side,  this  enormous  abscess  cavity  collapsed  and  contracted 
considerably.  It  was  further  found  that  the  abscess  had  burrowed 
downward  toward  the  symphysis,  extending  over  to  the  left  side,  and 
thence  spreading  upward  to  the  hollow  of  the  diaphragm.  The  left- 
sided  collection  of  pus  was  not  so  large,  the  spleen  lay  imbedded  in  it, 
and  the  matter  had  burst  through  the  left  lung,  thus  explaining  the 
expectoration  of  fiecal  fluid.  This  case  is  an  example  of  how  puzzling 
and  complicated  the  relations  of  some  abscesses  are,  so  that  it  is  almo.st 
impossible  to  make  an  accurate  estimate  during  life.  Renvers  records 
a  case  of  subphrenic  abscess  on  the  left  side  which  did  well  after  draw, 
ing  off  the  pus  through  a  trocar. 

The  Imported-Eag  Question  Again. — The  New  York  Herald  for 
March  9th,  in  an  article  entitled  Bacteria  Found  in  German  Rags,  pub- 
lishes among  other  things  the  following  certificate  by  Dr.  PauJ  Gibier : 

"This  is  to  certify  that  on  January  5th  I  received  for  bacteriological 
examination  a  sealed  envelope  which  contained  some  fragments  of  rags 
as  coming  from  Bremen,  Germany,  on  the  steamship  State  of  Alabama, 
December  10,  1892. 

"  Upon  opening  the  envelope  I  found  eleven  small  pieces  of  old 
linen,  soiled  and  covered  with  spots  which  seemed  to  be  desiccated  blood 
and  pus.    The  whole  was  perfectly  dry. 

"  I  took  a  small  piece  of  one  of  the  rags,  soaked  it  in  a  small  quan- 
tity of  sterilized  water,  and  crushed  it  with  a  glass  rod.  The  micro- 
scopical examination  showed  various  organic  elements — deformed  blood- 
corpuscles,  white  and  red,  and  numerous  bacteria. 

"  In  order  to  ascertain  whether  these  bacteria  were  alive,  and,  if 
so,  in  what  proportion,  I  took  two  grammes  (half  a  drachm)  of  small 
pieces  of  the  rags  cut  from  different  ones.  Of  course  this  was  done 
with  every  possible  aseptic  precaution ;  the  rags  were  taken  with  ster- 
ilized forceps,  cut  with  scissors  heated  over  the  flame  of  a  Bunsen 
burner,  put  in  a  sterilized  glass,  and  crushed  with  a  sterilized  glass  rod 
in  twenty  cubic  centimetres  (two  thirds  of  an  ounce)  of  water  sterilized 
for  an  hour  in  the  autoclave  under  fifteen  pounds  steam  pressure. 

"  A  small  quantity  of  the  water  taken  from  the  crushed  rags  was 
prepared  on  glass  tests  in  order  to  see  whether  it  contained  bacilli  of 
tuberculosis.  The  ordinary  preparations  were  made,  but  no  bacilli  of 
tuberculosis  could  be  detected  under  the  microscope. 

"  Five  cubic  millimetres  of  the  liquid  extract  of  the  two  grammes 
of  rags  were  thoroughly  mixed  with  five  cubic  centimetres  of  sterilized 
water,  and  again  five  cubic  millimetres  of  the  latter  w^ere  mixed  in  the 
same  manner  with  ten  cubic  centimetres  of  gelatin  at  fifteen  per  cent., 
prepared  as  usual  and  spread  over  glass  plates  previously  sterilized  and 
then  refrigerated. 

"After  the  plates  had  been  exposed  sixty  hours  at  a  temperature  of 
20°  C.  (68°  F.),  one  hundred  and  ten  colonies  were  counted,  which  had 
developed  on  the  different  plates,  twelve  of  which  were  liquefying  the 
gelatin. 

"These  different  colonies,  examined  under  the  microscope,  proved 
to  be — 

"(1)  A  diplocoecus,  non-licpiefying  the  gelatin. 

"  (2)  A  staphylococcus  of  a  long  form,  liquefying  the  gelatin. 

"  (3)  A  staphylococcus,  liquefying  the  gelatin,  which  was  identified 
with  the  Staphyloroccus  alhns  of  the  pus. 

"  (4)  A  microccocus  in  zooglea,  liquefying  the  gelatin. 

"  (5)  A  large  staphylococcus,  non-li(iuefying  the  gelatin. 

"(6)  A  bacillus  under  the  form  of  long  rods,  which  seemed  to  be  the 
BarilliiK  s-iihlilix,  liquefying  the  gelatin. 


"(7)  A  Tortila  cerevisim. 

"  (8)  Another  tonila,  ]>roducing  colonies  of  a  red  color. 
"  (9)  A  staphylococcus,  which  grows  only  in  the  depth  of  the  gelatin 
(anaerobic). 

"  (10)  A  streptococcus  of  a  slow  growth,  non-liquefying  the  gelatin, 
which  resembles  the  streptococcus  of  erysipelas. 

"  (11)  A  very  fine  micrococcus,  non-liquefying  the  gelatin. 

"  Cultures  of  these  different  germs  were  made  on  gelatin  and  agar, 
also  in  peptonized  Ijrotii,  and  their  pathogenic  properties  were  tried  on 
guinea-pigs,  rats,  and  rabbits. 

"  Though  No.  1 ,  No.  3,  No.  4,  No.  5,  No.  9,  and  No.  1 1  caused  slight 
illness,  with  an  elevation  in  the  temperature  of  one  or  two  degrees  cen- 
tigrade, yet  the  animals  inocidated  with  the  cultures  of  these  germs  re- 
covered. No.  2,  staphylococcus  liquefying  the  gelatin,  seemed  to  have 
a  different  effect  upon  the  rabbits  at  least.  These  animals,  after  hav- 
ing received  in  the  veins  an  inoculation  of  this  culture,  died  at  the  end 
of  from  forty-eight  to  sixty  hours.  No.  10  also,  the  streptococcus  re- 
sembling that  of  erysipelas,  though  it  produced  but  a  slight  elevation  of 
temperature  in  guinea-pigs  and  rats,  killed  rabbits  and  was  found  in 
their  blood  after  death. 

"  The  deductions  which  may  be  made  from  these  experiments  prove 
that  the  rags  which  I  have  examined,  and  which  I  should  judge  came 
from  a  hospital  or  dispensary,  and  which  were  soiled  with  pathological 
liquids,  had  not  been  submitted  to  an  effectual  process  of  disinfection 
if  any.  They  certainly  were  not  submitted  to  a  high  temperature,  as 
the  torute  which  are  contained  among  the  germs  foimd  in  the  rags  are 
destroyed  after  a  few  minutes  by  a  temperature  of  70°  C.  (158°  F.). 

"  The  number  of  living  germs  contained  in  two  grammes  of  the  rags 
was  not  less  than  four  hundred  milUons  for  the  small  quantity  examined 
or  eight  hundred  millions  per  drachm.  I  leave  to  others  the  task  of  cal- 
culating how  many  would  be  contained  in  a  pound  or  in  a  ton.  I  can 
safely  say,  however,  that  if  germs  are  contained  in  such  quantities  in 
rags  which  seem  to  have  been  used  in  some  hospital,  there  is  no  reason 
why  germs  of  diseases  of  any  kind  can  not  be  contained  in  such  matter. 
For  instance,  the  germs  of  cholera,  the  microbes  of  typhus,  tuberculo- 
sis, typhoid  fever,  diphtheria,  small-pox,  or  any  other  contagious  disease 
may  be  found  in  rags  of  similar  origin.  They  would,  consequently  be 
dangerous  for  any  one  who  comes  in  contact  with  them  and  might  be 
the  means  of  spreading  an  epidemic." 

The  Association  of  American  Physicians. — The  preliminary  pro- 
gramme of  the  eighth  annual  meeting,  to  be  held  in  the  Army  Medical 
Museum  and  Library  Building,  Washington,  on  May  30  and  31  and 
June  1,  1893,  includes  the  following  titles:  The  president's  address,  bv 
Dr.  A.  L.  Loomis,  of  New  York ;  a  discussion  on  Myxoedema  (referee. 
Dr.  F.  P.  Kinnicutt,  of  New  York ;  co-referees.  Dr.  J.  J.  Putnam  of 
Boston,  and  Dr.  M.  Allen  Starr,  of  New  York) ;  Sporadic  Cretinism  in 
the  United  States,  and  A  Supplementary  Report  on  Amoebic  Dysentery, 
by  Dr.  William  Osier,  of  Baltimore;  Some  Problems  in  the  ^f^tiology 
and  Pathology  of  Texas  Cattle  Fever  and  their  Bearing  on  the  Com- 
parative Study  of  Protozoan  Diseases,  by  Dr.  Theobald  Smith,  of  Wash- 
ington ;  Experiments  with  the  Bacillus  diphtheria;,  by  Dr.  A.  C.  Abbott 
of  Philadelphia;  The  Parasitic  Nature  of  Cancer,  by  Dr.  Heneage 
Gibbes,  of  Ann  Arbor ;  A  New  Pathogenic  Bacillus,  by  Dr.  H.  C.  Ernst 
of  Jamaica  Plains,  Mass.  ;  Gonorrheal  Myocarditis,  by  Dr.  W.  T.  Coun- 
cilman, of  Boston ;  The  Prophylaxis  of  Cholera,  with  Special  Reference 
to  Immunization,  by  Dr.  E.  0.  Shakespeare,  of  Philadelphia  ;  Creasote 
in  the  Treatment  of  Tuberculosis,  by  Dr.  J.  T.  Whittaker,  of  Cincin- 
nati ;  On  a  Simple  Continued  Fever,  by  Dr.  G.  Baumgarten  of  St 
Louis;  The  Treatment  of  Typhoid  Fever,  by  Dr.  S.  A.  Fisk,  of  Denver- 
The  Intestinal  Treatment  of  Chlorosis,  by  Dr.  F.  Forchheimer,  of  Cin- 
cinnati ;  The  Probable  Origin  and  Early  Symptoms  of  Certain  Chronic 
Diseases  of  the  Kidneys,  by  Dr.  C.  S.  Bond,  of  Richmond,  Ind. ;  The 
Reactions  of  the  Urine  with  Ether,  by  Dr.  A.  H.  Smith,  of  New  York  • 
A  Study  of  Addison's  Disease  and  of  the  Adrenals,  by  Dr.  W.  G.  Thomp- 
son, of  New  York ;  Two  Cases  of  Cystin  Calculus,  and  Two  Cases  of 
Diaphragmatic  Hernia,  by  Dr.  James  Tyson,  of  Philadelphia;  Sub- 
phrenic Abscess,  with  Special  Reference  to  Cases  which  simulate  Pneu- 
mothorax, by  Dr.  A.  L.  Mason,  of  Boston ;  Suljphrenic  Absce.ss,  bv  Dr. 
S.  J.  Meltzer,  of  New  York ;  Sarcoma  of  the  Lung,  with  Specimen,  by 


316 


MISCELLANY. 


(N.  Y.  Med.  Joub. 


Dr.  D.  W.  Prentiss,  of  Washington  ;  Piilsatinp  Pleural  Effusions,  by 
Dr.  .1.  C.  Wilson,  of  Philadelphia;  The  Importance  of  Uteiiiie  Dis[)lace- 
ments  in  the  Production  of  Vomiting  during  the  Early  Stages  of  Preg- 
nancy, by  Dr.  G.  M.  Garland,  of  Boston  {to  be  discussed  by  Dr.  W.  T. 
Lusk  and  Dr.  W.  M.  Polk) ;  Experimental  Observations  concerning  the 
Nature  of  Chorea,  by  Dr.  H.  C.  Wood,  of  Philadelphia;  and  a  paper  by 
Dr.  W.  M.  Polk,  of  New  York.  There  will  probably  be  time  at  the 
meeting  for  the  reading  of  two  or  three  papers  more  than  those  on  this 
programme.  Members  who  desire  to  contribute  such  papers  are  re- 
quested to  send  the  titles  of  thein  to  the  secretary.  Dr.  Henry  Hun,  149 
Washington  Avenue,  Albany,  N.  Y. 

The  New  York  Academy  of  Medicine. — The  special  order  for  the 
meeting  of  Thursday  evening,  the  10th  inst.,  was  a  paper  on  The  Sur- 
gery of  Gall  stone  Obstruction,  by  Dr.  Robert  Abbe. 

For  the  next  meeting  of  the  Section  in  Ophthalmology  and  Otology, 
on  Monday  evening,  the  20th  inst.,  a  discussion  on  The  Kindergarten 
System  in  our  Public  Schools,  and  its  Possible  Effect  on  the  Eyes  of  very 
Young  Children,  is  announced. 

At  the  next  meeting  of  the  Sectiim  in  General  Medicine,  on  Tuesday 
evening,  the  21st  inst.,  the  subject  of  The  vEtiology  and  Treatment  of 
Primary  Anasmias  is  to  be  discussed,  and  Dr.  W.  H.  Porter  is  to  read  a 
paper  on  Hiemogallol  in  the  An.emia  of  Malassimilation. 

At  the  next  meeting  of  the  Section  in  Laryngology  and  Rhinology, 
on  Wednesday  evening  the  22d  inst.,  there  is  to  be  a  discussion  on  La- 
ryngeal Neoplasms. 

At  the  next  meeting  of  the  Section  in  Obstetrics  and  Gynaecology, 
on  Thursday  evening,  the  23d  inst,  there  will  be  a  discussion  on  Sym- 
physeotomy. 

Some  comparatively  New  Drugs  and  their  Scientific  Names. — The 

Progres  medical  gives  the  following  list : 


Common  Names.  Scientific  Names. 

Antipyrine  )  Pheiiyldimethylpyrazoline. 

Analgesine  ) 

Antifebrine   Acetanilide,  or  phenylacetaniide. 

Antinervine  Salieylbiomanilide. 

Antisepsine  Paramonobromophenylacetamide. 

Antiseptol  Cinchouine  sulphiodate. 

Anisol  Methyl  pheuate. 

{   lodothymol. 

Annidaline  S 

•^"'"^  {  Beta-naphthol  salicylate. 

Naphthalol  \ 

Bromol  Tribromphenol . 

Creolin  A  creso!  preparation. 

Cresalol  Paracresol  salicylate. 

Exalgine  ilethylphenyl  acetamide. 

Hypnal  A  mixture  of  chloral  and  antipyrine. 

lodol  Teti  iodopy  rrol. 

lodopyrine  lodantipyrine. 

Orexiiie  Phenyldihydroquinazoline  hydrochloride. 

Phenethol  Ethyl  phenate. 

Primuline  Sodium  thioparatoluidinesulphonate. 

Saccharin  Orthosulphamidobenzoic  anhydride. 

Salol   Phenyl  salicylate. 

Salophen  .  .   Acetylparamidosalol. 

Salipyrine  Antipyrine  salicylate. 

Sulphonal  Diethy  Isulphondimethylethaue. 


The  Prize  of  the  Medical  Society  of  the  County  of  New  York. — The 

members  of  the  society  are  invited  to  compete  for  the  annual  gold- 
medal  prize,  of  the  value  of  one  hundred  dollars,  to  be  awarded  by  the 
society  at  its  next  annual  meeting  in  October,  for  the  best  essay  pre- 
eented  on  any  medical  or  surgical  subject.  The  award  will  be  subject 
to  the  following  conditions :  1.  The  competitor  shall  be  a  member  of 
the  Medical  Society  of  the  County  of  New  York.  2.  The  competitor's 
name  shall  not  be  revealed  until  after  the  decision  of  the  committee  on 
prize  essays  has  been  rendered.  The  essay  shall  be  designated  by  a 
motto  and  shall  be  accompanied  by  a  sealed  envelope  exhibiting  the 
8ame  motto  and  inclosing  the  author's  name  and  address.    4.  If  no 


essay  presented  shall  be  adjudged  by  the  committee  worthy  of  thcpiize, 
no  award  will  be  made.  .'5.  The  essay  must  be  in  the  hands  of  the 
committee  on  or  before  the  first  day  of  October,  1893. 

[Signed]  E.  B.  Bkonson,  Chairman, 

Va  Wot  Thirty-fourth  Street. 

The  Fan-American  Medical  Congress. — The  executive  president  of 
the  Section  in  Therapeutics,  Dr.  Hol)art  Amory  Hare,  of  Philadelphia, 
asks  us  to  state  that  it  is  the  earnest  desire  of  the  officers  of  the  section 
that  both  specialists  and  general  practitioners  should  contribute  articles 
to  its  proceedings.  Gentlemen  who  desire  to  read  papers  at  the  meet- 
ing should  notify  Dr.  Hare  at  once  of  their  intention,  and  should  send 
him  by  July  10th,  at  the  latest,  an  abstract  of  their  papers  in  order  that 
they  may  be  translated  into  the  three  official  languages  of  the  congress 
and  announced  in  the  programme.  The  importance  of  this  section  and 
the  interesting  papers  which  have  already  been  promised  give  a.ssur- 
ance  of  a  very  successful  meeting. 


To  Contributors  and  Correspondents. —  The  attcniion  of  all  who  purpose 
fiii'oriwj  iiH  irith  connniinicadofiS  is  reHpectfuUy  culled  to  the  follow- 

Aiitliorx  of  articles  intended  for  publication  under  Hie  head  of  "original 
contributions  "  are  respectfully  informed  that,  in  acceplintj  such  arti- 
cles, we  always  do  so  loiih  the  understanding  that  the  following  condi- 
tiotis  are  to  be  observed  ••  (/)  when  a  manuscript  is  sent  to  this  jour- 
nal, a  similar  manuscript  or  any  abstract  thereof  must  not  he  or 
hdve  1)een  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (S)  accepted  articles 
are  sitlijcct  to  the  customary  rules  of  editorial  revision,  and  will  he 
publinhcd  as  promptly  cui  our  oilier  myagemcnts  will  admit  of — v-e 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  am/ 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
niated  in  a  communication  accoiripanijing  the  manuscript,  aiid  no 
new  conditions  can  be  considered  after  the  manuscript  lias  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  publicalvm  in  this  journal,  either  because  they  are 
loo  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  firoj'ession 
at  large.  We  can  not  enter  into  any  correspoiidnice  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer''s  name  and  addnss,  not  necessarily  for  publication.  Ko  at- 
tention will  be  paid  to  anonymous  communications.  Hereafter,  cor- 
respondents asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  he  given  in  this  journal,  will  he  answered  by 
number,  a  private  communicaiion  being  previously  sent  to  each  cor- 
respondent informing  him  under  what  number  the  atiswer  to  hit  note 
is  to  be  looked  for.  All  comjnunicaiions  not  intended  for  ptiblication 
under  the  author^s  name  are  treated  as  strictly  confidential.  We  can 
not  (jfive  advice  to  laymen  as  to  particular  cases  or  recommend  indi- 
vidiial  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 icill  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  pro  fession  who  send  us  in  formation  of  matters  of  interest 
to  our  readers  will  he  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  commimications  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  cui- 
dressed  to  the  publishers. 

Contribwors  who  wish  to  order  REPRIXTS  of  tluir  articles  .should  d) 
so  on  a  blank  prepared  for  that  purjiose,  which  wid  be  ient  to  them 
by  the  pmbltslurs  on  receipt  of  a  request  to  that  effect.  The  order 
should  he  sent  to  ilie  publishers,  and  kot  to  ilie  editor. 


THE  raw  YORK  MEDICAL 


(ii>xi  gin  a  I  Co  m  m  w  n  i  c:i  t  i  o  n  s . 


OBSERVATIONS  ON 
A  CASE  OF  RECUKRExNT  AM<EBIC  DYSENTERY, 
WITH  SUCCESSIVE  LXRV.E  HEPATIC  ABSCESSES.* 
By  JOHN  WINTERS  BRANNAN,  M.  D., 

ASSISTANT  PATHOLOGIST  TO  ST.  FRANCIS  HOSPITAI,,  NEW  YORK. 

The  following-  case,  occurring  in  the  practice  of  Dr. 
George  M.  Edebolils,  is  believed  to  possess  points  of  in- 
terest from  a  clinical,  a  surgical,  and  a  pathological  stand- 
point. During  a  period  of  time  extending  over  about  six 
years  five  different  hepatic  abscesses,  the  result  of  amoebic 
dysentery,  were  diagnosticated  and  successfully  operated 
upon,  the  patient  finally  succumbing  to  a  sixth  hepatic  ab- 
scess which  opened  spontaneously  and  led  to  death  by  ex- 
haustion. Post-mortem  pathological  investigation  deter- 
mined the  presence  of  amoebje  coli  in  both  the  large  intes- 
tine and  the  liver,  and,  in  addition,  occupied  itself  largely 
with  the  question  of  the  reproduction  of  glandular  hepatic 
tissue  to  supply  the  place  of  that  destroyed  by  suppuration. 

For  the  following  clinical  history  I  am  indebted  to  Dr. 
G.  M.  p:debohls : 

•J.  R.,  a  married  grocer,  was  tliirtj-eight  years  of  age  when 
he  tirst  came  under  the  observation  of  Dr.  Edebohls  in  August, 
1886.  He  liad  been  a  sailor  in  early  youth,  but  had  never 
visited  the  tropics  and  had  never  been  sick  a  day  until  1885, 
many  years  after  he  had  a'^andoned  tfie  sea.  He  had  an  attack 
of  dysentery  in  July,  1885,  and  again  in  May,  1880.  A  few 
weeks  after  convalescence  from  this  last  attack  he  noticed  the 
forma'ion,  with  aocoinp  iniment  of  fever,  of  a  painlul  tumor  im- 
mediately beneath  the  xiplioid  process  of  the  sternum.  Tlie 
clinical  symptoms  pointed  to  liepatio  abscess,  and  this  diagnosis 
was  confirmed  by  exploratory  puncture. 

To  avoid  unnecessary  repetition  in  the  further  history  of  the 
case,  it  may  be  stated  at  once  that  eacli  of  the  sis  hepatic  ab- 
scesses from  which  the  patient  suffered  was  preceded  by  an  at- 
tack of  acute  dysentery,  the  bowel  affection  antedating  the 
hepatic  abscess  by  intervals  varying  from  two  to  sis  weeks.  In 
each  instance  the  abscess  was  diagnosticated  and  located  by  ex- 
ploratory puncture  and  the  removed  pus  examined  microscopic- 
ally, with  negative  results,  the  beginning  of  the  case  antedat- 
ing the  introduction  of  the  aniteha  coli  into  pathology.  Tlie 
amcebio  were  first  found  post  mortem.  In  the  interval  between 
the  operative  cure  of  each  hepatic  abscess  and  the  next  attack 
of  dysentery  the  patient  was  apparently  quite  well  and  fol- 
lowed his  avocation  as  grocer.  All  the  operations,  extending 
over  a  period  of  five  years,  were  performed  by  Dr.  Edebohls. 

Abscess  No.  1,  in  right  lobe  of  liver,  was  operated  upon, 
under  cocaine  anassthciia,  August  31,  188f).  Incision  five  to  six 
centimetres  long,  parallel  to  and  two  centimetres  and  a  half 
distant  from  the  free  border  of  the  right  costal  cartilages.  Peri- 
toneal surfaces  adherent  over  abscess  which  was  situated  at  a 
depth  of  a  centimetre  and  a  half  from  tlie  surface  of  the  liver 
and  contained  ninety  grammes  of  pus.  Drainage  and  irrig.ation 
with  subliiiiiite  solution  (1  to  4,000)  for  two  weeks.  Definite 
healing  of  abscess  and  fistula  one  week  later. 

Abscess  No.  2,  right  lobe,  was  incised,  under  etlier  narcosis, 


*  The  histological  studies  recorded  in  this  paper  were  made  in  the 
Pathological  Laboratory  of  the  College  of  Physicians  and  Surgeons, 
Columbia  College,  N'cvv  York. 


JQURl^AL,  MapvCii  25,  1893 

December  5,  1886.  Incision  somewhat  lower  and  some  three 
centimetres  to  right  of  scar  of  former  incision.  Abscess  at  a 
depth  of  tliree  centimetres  from  liver  surface ;  eighty  grammes 
of  pus  evacuated.  Drainage  for  three  weeks ;  then  again  defi- 
nite closure  and  good  health  for  three  years  and  a  half. 

Abscess  No.  3.  Operation  in  two  sittings.  Cceliotomy,  Sep- 
tember 16,  1890.  The  patient  being  etlierized,  an  incision,  seven 
centimetres  in  length,  closely  hugging  the  free  border  of  the 
right  ribs,  led  into  the  free  peritoneal  cavity.  Thorough  digital 
exploration  of  stomach,  liver,  gall  bladder,  and  neighboring 
parts,  all  of  which  were  normal  except  liver.  No  adliesions 
anywhere,  not  even  behind  scars  of  two  former  incisions  into 
liver.  Abscess  situated  deep  in  right  lobe  and  well  beneath 
cover  of  ribs.  Parietal  peritonaeum  stitched  to  surface  of  liver 
in  circular  form  and  abdominal  wound  filled  with  iodoform 
gauze.  On  September  25th,  without  an  anaesthetic,  an  incision 
was  ma<le  penetrating  the  liver  substance  to  the  depth  of  five 
centimetres,  when  a  small  abscess  was  reached,  emptied,  and 
drained.  During  the  following  days  immi-nse  quantities  of  bile 
were  discharged  with  the  pus.  The  symptoms,  however,  did 
not  improve. 

Abscess  No.  4  was  discovered  in  the  posterior  portion  of 
right  lobe  of  liver,  and  opened  on  October  17,  1890,  under  ether 
narcosis,  by  an  incision  through  the  eighth  intercostal  space 
posteriorly  on  a  line  with  the  outer  border  of  the  scapula.  The 
pleura,  lung,  diaphragm,  peritonaeum,  and  liver  were  divided 
with  the  Paqueliu  cautery  until  a  large  abscess  was  reached, 
from  which  over  five  hundred  grammes  of  pus  were  evacuated. 
A  finger  was  inserted  into  the  still  open,  smaller,  anterior  ab- 
scess, a  uterine  dressing  forceps  introduced  into  the  larger 
posterior  abscess,  the  saeptum  between  the  two  (composed  of 
healthy  hepatic  substance  two  centimetres  thick)  perforated  by 
the  forceps,  and  a  double  drainage-tube  of  large  caliber  drawn 
througli  the  liver  fore  and  aft.  By  this  means  perfect  drainage 
and  irrigation  was  possible,  the  patient  sitting  up  and  catching 
in  a  basin  at  the  front  incision  the  sublimate  solution  (1  to 
5,000)  which  his  wife  allowed  to  run  in  at  the  intercostal  incis- 
ion [losteriorly.  This  drainage  was  kept  up  for  nearly  three 
months,  when  both  abscess  cavities  and  incisions  healed  defi- 
nitely. 

On  December  1,  1890,  tlie  patient,  with  drainage-tubes  in 
position,  was  shown  at  a  meeting  of  the  German  Medical  So- 
ciety of  New  York. 

Abscess  No.  5,  situated  in  the  left  lobe  of  the  liver,  one  cen- 
timetre and  a  half  from  the  surface,  was  opened  on  April  I, 
1891,  under  mild  cocaine  anjesthesia,  the  patient  being  almost 
moribund  and  too  feeble  to  bear  a  constitutional  anaesthetic. 
Adhesions  had  formed  between  the  liver  and  [larietes,  and  no 
difficulty  was  experienced  in  this  operation.  Eighty  grammes 
of  pus  were  evacuated,  and  drainage  maintained  for  a  week. 
The  abscess  cavity  closed  definitely  in  a  month. 

Abscess  No.  6,  situated  in  the  right  lobe,  was  not  operated 
upon.  Dr.  Edebohls  being  summoned  after  spontaneous  open- 
ing had  occurred  and  when  the  patient  was  already  in  extreniU. 
This  last  abscess  opened  on  March  18,  1892,  and  discharged  a 
large  quantity  of  dirty,  shreddy  material  and  pus.  Patient  died 
of  exhaustion,  due  to  the  combined  dysenteric  and  hepatic  affeC' 
tions,  on  March  23,  1892. 

The  entire  large  intestine  and  tlie  liver,  which  had  been  re- 
moved at  autopsy  a  few  hours  after  death,  were  presented  in  a 
fresh  state  by  Dr.  Edebohls  at  a  meeting  of  the  New  York 
Pathological  Society  held  the  same  evening. 

Two  features  of  the  clinical  history  deserve  special  at- 
tention.   The  first  wa.s  the  intense  and  terrible  shock  on 


318 


BR  ANN  AN:  RECURRENT  AMCEBIC  DYSENTERY. 


fN.  Y.  Med.  Jode., 


each  of  the  three  occasions  when  tlie  hepatic  tissue  was  cut 
through  without  the  employment  of  a  general  anaesthetic. 
While  the  incision  through  the  abdominal  walls  left  the 
patient  unmoved,  the  brave  man  collapsed  totally  as  soon 
as  the  liver  was  incised.  The  pulse  became  small,  on  one 
occasion  imperceptible  ;  profuse,  clammy  perspiration  sud- 
denly broke  out;  respiration  was  suspended;  and  during 
one  operation  Dr.  Edebohls  feared  his  patient  had  died  un- 
der the  knife.  In  a  fairly  large  surgical  practice  he  had 
never  seen  anything  so  profound  in  the  way  of  shock  and 
collapse. 

The  second  point  of  interest  was  the  total  disappear- 
ance, after  three  years,  of  the  firm  peritoneal  adhesions 
through  which  the  first  two  abscesses  had  been  opened  and 
drained. 

The  autopsy  was  made  twelve  hours  after  death.  The  body 
was  fairly  well  nourished.  Jn  the  right  hypochondriac  region, 
just  below  the  border  of  the  ribs,  was  a  small  opening  from 
which  pns  oozed.  Tlie  liver  wastirmly  adherent  to  the  abdomi- 
nal wall  in  front  and  to  the  diapliragm  above.  At  several 
points  on  its  anterior  surface  there  were  deep  furrows  asso- 
ciated with  an  extensive  development  of  fibrous  tissue.  This 
fibrous  tissue  extended  into  the  substance  of  the  liver  to  the 
depth  of  from  two  to  five  centimetres  in  places.  In  the  ante- 
rior middle  portion  of  the  right  lobe  of  the  liver  there  was  a 
large,  thick-walled  cavity,  lined  with  a  pyogenic  membrane  and 
containing  a  large  amount  of  neurotic  tissue  and  pus.  This 
cavity  communicated  witii  the  external  opening  al)ove  referred 
to  below  the  costal  margin. 

There  were  no  other  abscesses  in  the  liver.  There  was  no 
involvement  of  the  lung  in  the  process  in  the  liver,  nor  was 
the  lung  adherent  to  the  diaphragm.  The  intestitfes  were  in 
places  bound  together  by  old  adhesions.  There  was  no  evi 
dence  of  recent  inflammation  of  the  peritonaeum.  The  small 
intestine  was  normal.  The  large  intestine  was  the  seat  of  ex- 
tensive ulceration  of  the  mucous  membrane,  most  marked  in 
the  descending  colon  and  the  rectum.  The  ulcers  were  mostly 
irregularly  oval  in  shape  and  of  greater  or  less  depth.  Some 
of  them  extended  into  the  muscular  coat  of  the  bowel.  The 
other  organs  of  the  abdominal  and  thoracic  cavities  presented 
no  noteworthy  changes. 

The  contents  ot  the  hepatic  abscess  were  examined  for  liv- 
ing amo'biB,  but  with  negative  result.  The  autopsy  was  made 
late  in  the  day  and  the  microscopic  examination  was,  unfor- 
tunately, rather  hurried.  Cover  glasses  prepared  from  the  pus 
also  failed  to  show  amoebae.  Portions  of  the  intestinal  ulcers 
and  of  the  abscess  wall  of  the  liver  were  hardened  in  strong 
alcohol.  Sections  were  then  made  and  stained  with  various 
media.  The  methylene- blue  stain  seemed  to  ofi'er  no  advantages 
over  the  more  usual  hsematoxylin  and  eosin  stain.  By  means  of 
the  latter  stain  the  amoebae  were  recognized  both  in  the  intes- 
tine and  in  the  liver.  They  were  not  found  in  all  the  ulcers, 
though  this  may  have  been  due  to  insufficient  search.  In  some 
ulcers  they  were  present  in  large  numbers,  lying  apparently  in 
the  lymph  spaces  at  the  edge  of  the  ulcer.  No  amoebae  were 
found  in  the  blood-vessels.  The  amoebae  in  the  liver  were  much 
more  difficult  to  recognize  and  were  in  much  smaller  number. 
They  lay  always  in  the  outer  fibrous  wall  of  the  abscess;  none 
were  seen  in  the  liver  tissue  itself. 

In  s[)ite  of  the  extensive  destruction  of  hepatic  tissue,  which 
must  have  resulted  from  the  numerous  abscesses  referred  to 
aliove  by  Dr.  Edebohls,  the  liver  itself  was  of  normal  size.  It 
was  thought  at  the  time  of  the  autopsy  that  the  liver  might  be 


an  instance  of  the  new  formation  of  glandular  tissue  described 
by  Ponfick  as  occurring  in  both  man  and  animals.  With  the 
view  of  elucidating  tliis  point,  sections  were  made  in  various 
parts  of  the  organ  and  studied  with  great  care. 

Ponfick,*  in  his  animal  experiments,  removed  large 
portions  of  the  liver  in  rabbits,  and  the  animals  lived  with 
apparently  undisturbed  hepatic  functions,  (^n  killing  the 
rabbits  at  intervals  varying  from  three  to  twelve  weeks 
after  the  operation,  the  liver  was  found  to  have  regained  its 
normal  size,  and  Ponfick  was  aole  to  observe  the  successive 
phases  of  the  reproductive  process,  showing  the  division  of 
nuclei,  increase  of  cells,  growth  of  young  bile-duct  radicles, 
etc. 

His  studies  f  in  man  are  based  upon  six  cases  of 
echinococcus  of  the  liver,  in  which  one  lobe  was  entirely 
destroyed  by  the  growth,  but  the  other  was  so  much  en- 
larged tliat  the  liver  was  of  normal  size  and  weight  at  the 
time  of  death.  In  one  case,  for  instance,  the  remains  of 
the  right  lobe  weighed  only  150  grammes,  in  place  of  the 
normal  1,350  grammes,  while  the  left  lobe  had  liypertrophied 
to  such  an  extent  as  to  weigh  1,580  grammes  instead  of  its 
normal  weight  of  450  grammes. 

In  man  the  regenerative  process  had  ended  and  its 
steps  could  not  be  demonstrated  ;  but  there  was  evidence, 
in  Ponfick's  opinion,  of  its  having  taken  place.  The  ar- 
rangement of  the  he])atic  lobules  was  peculiar,  differing  from 
the  usual  radiate  grouping  of  the  glandular  elements.  The 
cells  lay  heaped  up  together,  evidently  without  plan,  and  simi- 
larly the  vessels  lying  between  them  did  not  have  the  usual 
relation  to  a  single  central  collecting  vein.  The  capillaries 
had  many  side  branches,  forming  even  net  like  meshes. 
Not  all  parts  of  the  lobules  were  equally  involved,  but  only 
certain  portions,  especially  those  in  the  periphery.  Here 
not  only  the  arrangement  of  the  cells  was  peculiar,  but 
also  their  size  and  form,  contrasting  strongly  with  the  cells 
in  the  central  and  intermediate  zones.  The  diameter  was 
less — only  one  half  or  even  less  that  of  the  normal  cells. 
Normally  the  central  and  intermediate  cells  are  said  to  be 
smaller  than  those  of  the  periphery  ;  here  the  reverse  was 
the  case.  The  form  also  was  peculiar ;  in  place  of  the 
hexagonal  type,  which  the  majority  always  have,  the  cells 
were  short  and  full,  peculiar  compressed  forms,  now  quad- 
rate, again  and  more  frequently  five-sided,  and  also  notice- 
able for  having  usually  only  one  nucleus. 

The  new  liver  tissue  is  thus  seen  to  be  more  or  less 
atypical  in  form  ;  yet  the  hepatic  functions  were  appar- 
ently preserved  in  all  the  cases  observed  by  Ponfick. 

Returning  now  to  our  own  case,  what  conditions  have 
we  to  explain  the  normal  size  of  a  liver  which  had  been  the 
seat  for  years  of  a  chronic  destructive  process  ?  We  have 
already  referred  to  the  connective-tissue  growth  extending 
at  several  points  from  the  surface  of  the  liver  deeply  into 
its  substance.    This  connective  tissue  evidently  represented 

*  E.  Ponfick.  Experimentelle  Beitriige  zur  Pathologic  der  Leber. 
Arch.  f.  path.  Anaf.,  etc.,  Berlin,  Bd.  118,  p.  209,  1889,  and  Bd.  119, 
p.  193,  1890. 

f  E.  Ponfick.  lleher  Recreation  der  Leber  beim  Menschen  ;  ein 
Beitrag  zur  Cellular- Pa thologie.  Eesischr.  Rudolf  Virchow,  Berlin, 
1891,  p.  1. 


March  25,  1893.J 


ROE:   THE  CORRECTION  OF 


DEFORMITIES  OF  THE  NOSE. 


319 


the  cicatrices  left  by  the  various  abscess  cavities.  The 
cicatricial  tissue  was  so  abundant  that  it  of  itself  would  go 
far  toward  replacing  the  liver  tissue  destroyed.  In  other 
parts  of  the  liver,  far  removed  from  the  seat  of  the  ab- 
scesses, there  was  also  an  extensive  formation  of  connective 
tissue.  This  newly  formed  tissue  not  only  followed  Giisson's 
capsule  between  the  lobules,  but  extended  into  the  lobules 
between  the  liver  cells.  In  other  words,  there  was  chronic 
interstitial  hepatitis,  both  intralobular  and  interlobular. 

The  new  tissue  was  very  irregular  in  its  distribution, 
being  more  abundant  in  some  portions  of  the  liver  than  in 
others.  It  was  nowhere  very  large  in  amount  and  was  not 
visible  to  the  naked  eye.  It  had  not  shown  any  tendency 
to  contract ;  the  inclosed  liver  tissue  was  not  compressed. 

But  this  new  formation  of  connective  tissue  was  not 
the  only  process  present  to  explain  the  size  of  the  liver. 
Throughout  the  greater  part  of  the  organ  the  capillaries 
were  large  and  rather  irregular  and  distended  with  blood, 
and  contained  cells  of  various  sizes  and  shapes.  These 
cells  were  apparently  either  normal  or  proliferated  endothe- 
lium. 

The  liver  cells  in  the  region  of  the  dilated  capillaries 
were  somewhat  distorted,  but  otherwise  not  much  changed. 
In  no  part  of  the  liver  was  there  noted  the  peculiar  arrange- 
ment of  the  lobules  described  by  Ponfick.  The  regular  dis- 
tribution of  the  capillaries  was  maintained  and  the  cells  did 
not  vary  materially  from  the  normal  type  in  either  size  or 
shape. 

While  it  is  evident,  from  the  experiments  of  Ponfick  and 
others,  that  more  or  less  extensive  losses  of  parenchymatous 
tissue  may  be  made  good  by  a  reproduction  of  specialized 
cells,  our  observations  in  this  case  would  call  attention  to 
the  fact  that  the  repair  of  such  losses  in  an  organ  restored 
to  its  original  size  can  be  largely  accounted  for  by  a  wide- 
spread dilatation  of  the  thin-walled  blood-vessels. 


THE  CORRECTION  OF 
DEFORMITIES  OF  THE  NOSE 

RESULTING  FROM  ABSCESS  OF  THE  NASAL  S.EPTUM* 
By  JOHN  0.  ROE,  M.  D., 

ROCHESTBU,  N.  Y. 

Five  years  ago  I  submitted  to  the  profession  an  opera- 
tion for  the  correction  of  the  deformity  termed  "  pug  nose  " 
by  an  intranasal  operation  without  wounding  the  skin,f  and 
again,  in  1891,  an  operation  equally  new  for  the  correction 
of  angular  deformities  of  the  nose,  also  by  a  subcutaneous 
operation. J 

At  the  present  time  I  desire  to  present  for  your  consid- 
eration a  simple  method  by  which  the  deformity  frequently 
arising  from  abscess  of  the  nasal  sicptum  may  also  be  cor- 
rected by  a  subcutaneous  and  intranasal  operation. 

*  Read  before  the  American  Laryngological  Association  at  its  four- 
teenth annual  congress. 

\  The  Deformity  termed  "  Pug  Nose  "  and  its  Correction  by  a  Sim- 
ple Operation.    Medical  Record,  New  York,  1887,  vol.  xxxi,  p.  621. 

\  The  ("orrection  of  Angular  Deformities  of  the  Nose  by  a  Subcu- 
taneous Operation.    Medical  Jx'ecord,  New  York,  1891,  vol.  xl,  p.  67. 


Deformities  of  the  nose  resulting  from  abscesses  of  the 
nasal  sajptum  are  of  comparatively  frequent  occurrence.  In' 
nearly  all  cases  they  can  be  prevented  if  the  abscess  is  early 
recognized  and  properly  treated.  It  sometimes  happens  that 
the  abscess  is  unrecognized,  and  for  this  reason  a  deformity 
of  the  nose  is  caused  which  might  have  been  prevented.  In 
some  cases,  however,  in  spite  of  the  most  active  and  efficient 
treatment,  abscesses  of  the  nasal  sa;ptum  produce  sufficient 
deformity  to  give  the  nose  a  very  unsightly  appearance. 

Abscesses  of  the  sjeptum  may  originate  from  a  variety 
of  causes :  from  simple  inflammation  resulting  from  colds ; 
from  the  purulent  affections  of  the  nostrils  often  found  in 
children  ;  from  syphilis  ;  and  from  traumatism.  A  scrofu- 
lous, strumous,  or  rhachitic  diathesis  frequently  predisposes 
to  this  affection.  Abscess  of  the  nasal  sfeptum  also  fre- 
quently results  from  disease  of  the  teeth,  particularly  in 
children,  for  it  is  during  the  first  dentition  that  abscess  of 
the  nasal  sseptum,  as  well  as  of  the  ear,  is  most  frequently 
found.  The  following  case  very  clearly  illustrates  the  influ- 
ence of  irritation  caused  by  diseased  teeth  in  the  production 
of  such  an  abscess : 

A  young  man  seventeen  years  of  age  was  referred  to  me  by 
his  family  physician  on  account  of  an  obscure  acute  afifection  of 
the  nose  causing  much  swelling  and  obstruction  of  the  nostrils. 
One  week  previous  to  the  time  when  I  saw  him  he  had  the  two 
upper  incisor  teeth  filled  with  amalgam.  For  two  or  three  days 
afterward  his  teeth  were  very  sensitive  and  painful  if  he  at- 
tempted to  bite  with  them.  The  third  day  after  the  teeth  were 
filled  he  began  to  have  a  soreness  in  his  nose,  followed  by  a 
swelling  which  completely  occluded  both  nostrils  The  day  be- 
fore I  saw  him  a  slight  purulent  discharge  from  the  left  side  was 
noticed,  with  a  corresponding  lessening  of  the  swelling  in  th«t 
side.  C>n  examining  his  nose,  I  found  tiie  sseptum  bulging  very 
much  on  both  sides  of  the  cartdaginous  portion.  On  exploring 
it  with  a  probe,  this  swelling  exhibited  the  characteristic  doughy 
condition  of  an  abscess.  I  incised  the  swelling  freely  on  both 
sides  at  the  lower  portion  of  the  steptum,  and  about  a  teaspoon- 
ful  of  pus  escaped.    The  cavity  was  tlH)roughly  evacuated,  the 


cavity  of  the  abscess  was  cluanscd  with  a  twenty-per  cent, 
solution  of  peroxide  of  hydrogen,  and  the  nostrils  were  ligiitly 
l)acked  with  an  antiseptic  wool  dressing.    Jt  was  cleansed  and 


320 


ROE:   THE  CORRECTION'  OF  DEFORMITIES  OF  THE  NOSE. 


[N.  Y.  Med.  Jodr., 


dressed  dnily,  and  every  effort,  made  to  ])reveiit  any  extension 
of  the  disease  and  destructioo  of  the  cartilage.  The  discharge 
of  pus  speedily  disappeared,  but  the  triangular  cartilage  had 
become  so  much  involved  as  to  cause  a  breaking  down  of  the 
upper  portion  and  the  destruction  of  tlie  sinail  cartilages  on  the 
dorsum  of  the  nose  that  serve  as  a  connecting  link  between  tlie 
shield  c  irtilage  and  the  nasal  hones.  Fig.  1  represents  the  nose 
after  this  had  taken  place. 

In  adults,  abscess  of  the  nasal  siuptum  causinjy  deformi- 
ty of  tlie  nose  usually  results  from  syphilis,  as  it  is  rarely 
that  sufficient  destruction  of  the  cartilages  results  from 
abscess  of  simple  inflammatory  origin  to  allow  of  a  sink- 
ing in  of  the  nose.  Deformity  of  the  nose  resuhing 
from  simj)le  abscess  of  the  sajptum  can  ordinarily  be  dis- 
tinguished from  that  caused  by  syphilis  by  the  fact  that 
in  the  former  case  there  is  simply  a  destruction  of  the 
whole  or  a  portion  of  the  triangular  cartilage,  while  the 
soft  tissues  remain  intact ;  whereas  in  syphilis  the  soft 
parts  are  also  frequently  destroyed  with  the  cartilaginous 
parts,  leaving  a  large  perforation  in  the  sasptum,  and  a  cor- 
responding depression  of  the  central  portion  of  the  nose. 
In  some  instances,  however,  syphilitic  perichondritis  may 
result  in  abscesses  of  the  sneptum  and  cause  a  destruction  of 
the  cartilaginous  portion  without  destruction  of  the  soft 
parts.  In  those  instances  in  wliich  the  abscess  is  confined 
to  the  cartilaginous  portion  of  the  saeptum  and  produces 
sufficient  destruction  of  the  small  connecting  cartilages  to 
permit  the  dorsum  of  the  nose  to  drop  in,  it  gives  the  cen- 
tral portion  of  the  nose  a  depressed  appearance  as  if  the 
person  had  been  struck  upon  the  top  of  the  nose  with  a 
small,  round  body,  like  a  poker. 

In  some  instances  the  destruction  goes  on  until  the  car- 
tilage is  almost  or  entirely  destroyed  and  the  nose  becomes 
flattened  upon  the  face.  A  most  pronounced  case  of  this 
kind  came  under  my  care  about  four  years  ago. 

A  girl,  sixteen  years  old,  had  had  from  infancy  an  extremely 
flattened  condition  of  the  nose  I  hat  was  undoubtedly  the  result 
of  an  unrecognized  abscess,  there  being  no  history  of  inherited 
specific  disease,  or  evidence  of  scrofulous  taint.  Examination 
showed  the  nasal  bones  to  be  normal,  but  the  triangular  carti- 
lage of  the  sfBptum  to  be  entirely  absent.  The  soft  parts  were 
intact  in  their  normal  proportions,  but  so  flattened  upon  the 
face  from  lack  of  central  support  as  to  give  the  girl  a  very  un- 
sightly appearance.  The  difficulty  m  this  ca-^e  was  to  find 
enough  material  to  render  the  sseptum  sufficiently  firm  and 
rigid  to  hold  up  the  end  of  the  nose.  There  was,  as  is  usual  in 
these  cases,  a  marked  widening  and  thickening  of  the  dorsum 
of  the  nose  proi)ortionate  to  the  amount  of  flattening.  This 
thickened  ridge  of  tissue  was  incised  through  to  the  under  side 
of  the  skin  on  both  sides  a  short  distance  from  the  saeptum  at  a 
point  where  it  thinned  into  the  alsB  of  the  nose.  The  skin  was 
then  raised  from  the  dorsum  of  the  nose,  and  the  flaps  were 
turned  upwar  1  and  held  in  place  by  small  ivory  splints,  having 
holes  through  which  sutures  were  passed  from  one  to  the  other 
through  the  flaps,  and  tied  so  as  to  hold  them  firmly  in  place 
without  strangulating  the  parts.  This  relieved  the  flattened  con- 
dition of  the  nose  and  also  gave  the  dorsum  a  sharper  appearance. 
The  nose  was,  however,  altogether  too  flat.  Owing  to  the  entire 
absence  of  the  triangular  cartilage,  there  was  not  sufficient  cen- 
tral sup[)ort  to  hold  the  nose  upright.  In  order  to  inci'ease  the 
solidity  of  the  sasplum,  1  first  scarified  each  side  of  the  lower 
portion  of  the  sa;[)tum  and  the  floor  of  tlio  nose,  and  divided 


the  anterior  portion  of  the  sfeptum,  leaving  the  front  portion 
of  the  skin  intact.    I  then  cut  wide,  thick  flaps  from  the  floor 


Fig. 

of  the  nostril  opposite  the  portion  of  the  Sfeptum  which  I  wished 
to  render  more  rigid.  These  were  turned  upward  and  held 
together  with  clami)s  in  a  manner  similar  to  the  upper  flaps, 


Fig.  3. 

and  their  ui)per  borders  were  also  connected  to  the  cut  por- 
tion of  the  sfpptum  with  fine  sutures.  The  result  was  most  ex- 
cellent, as  will  bo  seen  by  the  illustrations;  for  the  flni)s,  when 
united  to  the  sa'])tum,  were  found  sufficient  to  support  it,  and 


March  25,  1893.] 


ROE:   THE  CORRECTION  Ot  DEFORMITIES  OF  THE  NOSE. 


321 


give^  the  nose  a  very  presentable  appearance- -so  much  so  that 
it  would  not  be  suspected  that  the  previous  very  flattened  con- 
dition had  ever  existed.     In  order  to  maintain  the  nose  in 

position  until  the  parts 
liad  become  thoroughly 
healed,  I  placed  in  the 
nose  small, spiral s[)ring>, 
as  shown  in  Fif^.  4,  the 
upper  arm  bein;;  bent  to 
the  proper  contour,  so 
as  to  lie  along  under  the 
dorsum,  the  other  arm 
l>ing  along  the  tloor  of 
the  nose.  Tiie  tension 
was  regulated  by  bend- 
ing tlie  spring  to  the  desired  tonicity  before  introducing  it. 
These  springs  wui'e  worn  until  the  nose  became  firiiilv  fixed 
and  their  further  use  was  not  re(iuii-ed.  Fig.  2  represents  the 
condition  of  the  nose  before  the  operation.  Fig.  3  represents 
the  nose  about  three  months  after  the  operation. 

I  have  also  found  these  springs  exceedingly  serviceable 
for  holding  in  place  fractured  noses,  as  illustrated  in  an  ex- 
ceedingly interesting  case  which  I  reported  in  a  previous 
article.* 


Fig.  4. 


Figs.  5  and  6  represent  the  nose  of  a  man  thirty-five 
years  of  age,  wliei'e  the  central  portion  had  been  flattened 


Fig.  0. 


from  destruction  of  the  sseptum  by  an  abscess  so  as  to  cause 
a  fVery  pronounced  deformity.    The  soft  parts,  however, 

*  Med.  Record,  1891  ;  op.  rit.,  p.  50. 


were  not  destroyed,  but  greatly  distorted.  In  this  case  the 
skin  was  first  raised  from  the  depressed  portion  of  the  nose. 
Flaps  composed  of  the  distorted  tissue  were  cut  from  the 
inside  of  the  outer  wall  of  each  nostril  and  turned  up  so  as 
to  till  the  depressed  portion  of  the  center  of  the  nose,  and 


held  there  by  pins,  and  the  proper  shape  maintained  by 
a  mold  conformed  to  the  outside  of  the  nose.    The  result 


was  excellent,  as  shown  in  Figs.  7  and  8,  which  represent 
the  condition  of  the  nose  after  the  parts  were  firmly  healed. 

In  a  similar  manner  an  operation  was  performed  on  the 
nose  of  the  young  man  whose  case  has  already  been  de- 
scribed, and  it  is  illustrated  in  Fig.  1.  The  depressed  por- 
tion of  tlie  nose  was  completely  restored. 

This  method  of  restoring  sunken  noses  also  ol>viates 
the  necessity  of  resorting  to  the  plan  devised  by  iNlartin  * 
or  other  orthopaxlic  appliances.  Martin  su])ports  the  de- 
pressed portion  of  the  nose  by  a  mechanical  device  made 
of  platinum,  jilaced  under  the  skin  so  as  to  raise  it  suffi- 
ciently to  give  the  nose  a  symmetrical  shape. 

As  I  pointed  out  in  a  previous  paper,  f  the  nose  is  not 
unsightly  on  account  of  its  size,  l)ut  by  reason  of  its  shape. 
Therefore,  when  the  central  portion  of  the  nose  is  de- 
pressed, if  we  either  raise  the  dcjjresscd  portion  so  as  to 
bring  it  on  a  line  with  the  end  of  the  nose,  or  so  lower  the 
end  of  the  nose  as  to  bring  it  on  a  line  with  the  depressed 


*  Claude  Martin.  De  la  protlicse  iinnu'diate,  etc. 
f  .)/«/.  Record,  1887,  vol.  xxxi;  ojk  ril.,  p.  622. 


Paris,  lS8t». 


322 


BERGEN:  DIGITALIS  AND  CHLORAL  IN  PNEUMONIA. 


[N.  Y.  Mkd.  Joub., 


portion,  we  restore  the  nose  to  a  symmetrical  shape.  Tlie 
nose  will  also  appear  much  larger  than  before  the  opera- 
tion, although  in  the  latter  instance  it  will  necessarily  be 
somewhat  smaller. 


OBSERVATIONS  ON 
THE  TREATMENT  OF  PNEUMONIA 
BY  MEANS  OF  DIGITALIS  AND  CHLORAL. 
By  LLOYD  M.  BERGEN,  M.  D., 

HIGHLAND  PARK,  ILL. 

The  great  field  of  medical  and  surgical  science  to- day 
presents  such  a  myriad  of  novel  evolutions,  and  is  so  teem- 
ing with  the  brilliant  achievements  of  pathological  and 
clinical  research,  past  and  present,  that  the  physician  who 
attempts  keeping  abreast  of  the  times  naturally  enough 
frequently  becomes  disheartened  regarding  his  pansophical 
ambitions,  and  turns  from  his  literature  in  confusion.  The 
most  intricate  and  fanciful  theories  which  have  absorbed 
his  entire  interest,  and  which,  in  his  enthusiasm,  he  has 
eagerly  grasped  as  truth,  are  frequently — in  the  succeeding 
issue  of  his  journals — dissected  beneath  the  scalpel  of  cold 
criticism  and  consigned  to  well -merited  oblivion. 

The  "  Brown-Sequard  folly"  had  scarce  completed  its 
circuit  of  the  globe,  startling  the  entire  profession  with  the 
boldness  of  its  claims,  when  it  was  speedily  overtaken  by 
utter  annihilation.  The  lymph  of  Koch  plunged  hundreds 
of  the  world's  greatest  pathologists  into  intense  controversy 
before  having  its  claims  properly  adjusted  and  being  placed 
before  the  profession  in  the  light  of  its  true  value. 

The  cause  of  much  of  this  confusion  lies  in  the  error 
which  appears  to  possess  even  our  greatest  investigators — 
that  of  expressing  themselves  hurriedly.  Frequently,  rely- 
ing upon  superiority  of  position,  they  become  promulgators 
of  immature  theories  and  ideas  which  have  not  been  satis- 
factorily demonstrated,  and  can  not  endure  the  crucial  test 
of  a  general  adoption.  These  hurried  opinions,  emanating 
from  recognized  sources  of  high  authority,  are  readily 
adopted  and  propagated  by  the  great  body  of  physicians 
until  some  more  keen  and  logical — and  I  may  add  daring 
— observer  ventures  a  protest,  which  is  often  followed  by  a 
perfect  avalanche  of  statistics  and  opposing  testimony  di- 
rected against  the  reasonableness  or  advisability  of  the  meas- 
ure in  question. 

In  the  realm  of  medicinal  therapeutics  especially 
should  the  average  physician  exercise  due  care  and  con- 
servatism in  adopting  or  rejecting  new  and  novel  lines  of 
treatment  intended  to  supplant  those  older  and  more  thor- 
oughly tested.  The  science  of  medicinal  therapeutics  is 
still  so  far  in  its  infancy  that  new  suggestions  for  treatment 
by  means  of  drugs  can  scarcely  be  hoped  to  appeal  to 
us  through  a  minute  and  accurate  demonstration  of  their 
physiological  action  and  its  relation  to  certain  pathological 
conditions  encountered.  The  exact  nature  of  tissue  changes 
wrought  by  the  administration  of  medicines,  and  their  im- 
mediate and  final  influence  over  physiological  and  patho- 
logical metabolism,  are  still  enveloped  in  a  great  deal  of 
uncertainty.  Even  our  so-called  rational  therapeusis  must 
as  yet,  even  when  employed  in  conjunction  with  all  our 


chemical,  physiological,  and  pathological  knowledge,  be  re- 
garded in  the  light  of  an  applied  science — devoid,  to  a  great 
degree,  of  accuracy,  and  therefore  necessarily  unsatisfac- 
tory. With  our  present  knowledge  we  can  not  remedy  this 
condition  of  things,  and  until  that  great  future  day  of  sci- 
entific triumph,  when  therapeutic  empiricism  shall  give  way 
before  absolute  therapeutic  rationalism,  we  are  obliged  to 
content  ourselves  with  a  reliance  upon  our  notions  of  the 
relations  between  medicine  and  disease,  as  clinically  ob- 
served, noting  as  minutely  as  possible  the  results  obtained, 
and,  by  making  known  these  results,  obtain  a  general  con- 
sensus of  opinion  as  to  the  methods  most  desirable  and 
which  will  result  in  the  greatest  good. 

With  this  object  in  view,  the  author  has  been  led  to 
present  his  experience  regarding  the  treatment  of  one  of 
the  most  formidable  of  all  acute  diseases — pneumonia.  Our 
ideas  regarding  the  general  and  local  management  of  this 
disease  have  undergone  a  marked  revolution  during  recent 
years.  The  jacket  poultice  has  been  replaced  by  the  ice 
bag  and  ice  cradle.  Hyperpyrexia  is  now  met  with  a 
prompt  and  fearless  application  of  the  cool  bath,  and  an 
occasional  resort  to  the  cold  pack.  The  disease  is  fed, 
since  we  have  learned  that  abundant  nourishment  from  the 
beginning  is  an  all-important  factor  in  aiding  recovery. 

All  of  these  recent  and  radical  displacements  of  older 
ideas  have  now  been  thoroughly  tested,  and  clinical  reports 
from  all  parts  of  the  world  attest  a  gratifying  reduction  of 
mortality  as  a  result. 

While  these  recent  ideas  were  being  evolved  in  the  do- 
main of  general  and  hygienic  treatment,  the  therapeutists 
have  not  been  idle. 

Beyer  *  has  exhibited  antipyrine  in  a  number  of  cases 
with  some  degree  of  apparent  success.  Pieragnoli  f  has 
recently  made  use  of  calomel  and  opium,  for  which  he 
alleges  good  results  so  far  as  mitigating  the  general  course 
of  the  disease  is  concerned.  Green  \  strongly  advises  the 
employment  of  peroxide  of  hydrogen.  Desseau  *  has  sug- 
gested veratrum  viride,  aconite,  and  calomel  as  a  means  of 
increasing  the  flow  of  venous  blood  to  the  liver,  thus  both 
relieving  the  pulmonary  circulatory  embarrassment  and 
stimulating  the  hepatic  organ  to  a  greater  destruction  of 
toxic  substances  in  the  blood. 

To  Petresco  ||  is  probably  due  the  credit  of  having  been 
the  first  to  exhibit  digitalis  in  full  doses  at  the  beginning 
of  the  disease.  He  administers  the  drug  at  the  astonishing 
rate  of  a  tablespoonful  of  the  fresh  infusion  every  half  hour 
in  severe  cases.  He  states  that  seventy-five  to  one  hun- 
dred and  fifty  grains  of  the  drug  may  be  given  daily  aud 
continued  from  two  to  four  days,  and  that  he  has  never  ex- 
perienced a  case  of  poisoning. 

Hershey  ^  gives  the  infusion  of  digitalis  in  tablespoon- 
ful doses  every  hour,  while  Balfour  ^  has  made  use  of  the 

*  Medical  News,  June'15,  1890. 

■f-  Lo  Spen/nentale,  Florence,  June,  1890. 

I  Journal  of  the  Rcapiratory  Orgam,  August,  1890. 

*  Archives  of  Piediairics,  Philadelphia,  September,  1891.  TJiera- 
peuiic  Gazette,  Detroit,  November,  1891. 

II  Thcrapcuiische  Monatshcfte,  Berlin,  February,  1 890. 
^  Medical  News,  Philadelphia,  August,  1891. 

^  Edinliuryh  Medical  Journal,  November,  1891. 


March  25,  1893.J 


BERGEN:  DIGITALIS  AND  CHLORAL  IN  PNEUMONIA. 


323 


combined  administration  of  digitalis  and  chloral  during  the 
earlier  stages  of  pneumonia.  i 

In  order  to  a  general  understanding  of  the  almost  im- 
mediate relief  following  the  exhibition  of  digitalis  in  pneu- 
monia, and  the  subsequent  amelioration  of  the  inflamma- 
tory changes,  we  must  keep  in  view  a  general  idea  of  the 
morbid  anatomy  of  the  disease  during  the  early  stage — 
viz.,  the  stage  of  congestion.  Pneumonia  is  a  disease 
whose  every  period  is  characterized  by  the  word  acute. 
There  is  scarcely  another  disorder  marked  by  such  intense 
and  rapidly  varying  tissue  alterations  or  followed  by  so 
profound  a  degree  of  exhausted  vitality.  It  is  ushered  in 
by  an  intense  congestive  hyperannia,  with  a  rapidly  suc- 
ceeding inflammatory  exudate,  so  profuse  that  within  a  few 
hours  the  air  is  driven  from  the  alveoli  and  respiratory 
bronchioles.  A  rapid  detachment  of  epithelial  cells,  homo- 
geneous plates,  and  blood  cells  follows,  coagulation  of  the 
entire  mass  of  the  inflammatory  debris  occurring  later.  Dur- 
ing this  earlier  stage  of  hepatization,  Ziegler  informs  us,* 
"  the  lung  is  still  highly  vascular  and  filled  with  blood  "  ; 
the  capillaries  are  greatly  distended,  and,  as  a  result  of  this 
engorgement,  extravasation  of  the  liquid  elements  and  even 
solid  constituents  of  the  blood  takes  place.  The  degree  of 
hyperemia  and  the  duration  of  its  existence  determine  the 
amount  of  exudation,  and  as  directly  the  severity  and  ex- 
tent of  the  inflammatory  changes  occurring  in  the  atfected 
area  later.  It  is  at  this  early  stage,  while  the  pathological 
changes  are  still  almost  purely  vascular  in  character,  that 
we  may  reasonably  hope,  by  prompt  and  intelligent  inter- 
ference, to  modify  and  limit  the  subsequent  textural  dis- 
organizations. 

It  is  neither  necessary  nor  within  the  scope  of  this  ar- 
ticle to  inquire  into  the  morphological  elements  which  are 
now  demonstrated  to  exist  as  the  direct  {etiological  factors 
in  exciting  this  initial  hyperaemia.  Whether  the  disease 
is  considered  as  constitutional  or  local ;  whether  the  excit- 
ing principle  is  of  chemical,  thermal,  traumatic,  or  bacte- 
rial origin  ;  whether  it  finds  access  to  the  lung  tissues 
through  the  air  passages  or  general  circulation — the  fact 
remains  unmodified  and  undisputed  that  the  first  noticeable 
local  manifestations  consist  in  a  great  embarrassment  of  the 
pulmonary  circulation  due  to  hyperaemia.  It  would  conse- 
quently appear  rational  to  direct  our  first  efforts  toward 
an  attempt  to  relieve  the  overdistended  capillaries  by  in- 
ducing an  increased  circulatory  activity  throughout  the 
diseased  portions  of  the  lung.  This  object  may  be  par- 
tially accomplished  by  such  methods  as  venesection  and  by 
measures  adopted  for  the  purpose  of  diminishing  the  vol- 
ume of  blood  in  the  pulmonary  vessels  and  spaces  by  at- 
tracting it  to  other  parts  of  the  body ;  also  by  the  local 
application  of  cold  over  the  seat  of  congestion.  The  first 
of  these  measures  is  palpably  practicable  only  in  those 
cases  of  robust  and  plethoric  type.  The  second  is  followed 
by  only  very  slightly  beneficial  results.  The  last  is  of 
doubtful  utility,  whatever  of  benefit  it  furnishes  being  more 
probably  due  to  its  action  as  a  general  refrigerant  than  to 
*  any  direct  local  influence  over  the  congestion.  Increased 

*  Text-book  of  Pathological  Anatomy  and  Pathogenesis. 


circulatory  activity  in  the  hyperaimic  tissues  may  best  be 
brought  about  by  increasing  the  vis  a  tergo  of  the  blood 
current.  The  heart  is  the  organ  which  must  be  relied  upon 
to  overcome  the  obstruction. 

Digitalis  is  undoubtedly  the  drug  possessing  the  most 
desirable  influence  over  the  cardiac  organ  in  so  far  as 
powerful,  lasting,  and  safe  stimulation  is  concerned,  and  it 
is  in  just  such  a  circulatory  emergency  as  that  experienced 
in  the  first  stage  of  pneumonia  that  we  may  witness  its 
fullest  and  most  beneficial  action.  The  drug  should  be 
exhibited  in  full  doses  of  the  fresh  infusion,  the  idea  being 
to  obtain  prompt  and  decisive  action  on  the  part  of  the 
cardiac  muscles.  In  response,  we  find  the  pulsations  are 
at  once  slowed  and  strengthened,  and,  as  a  consequence, 
the  blood,  being  forced  through  the  affected  area,  overcomes 
the  dyscrasia  and  substitutes  an  active  circulation  for  one 
bordering  upon  stasis.  As  a  result,  we  may  reasonably  be- 
lieve that  we  accomplish  not  only  a  relief  of  the  vascular 
engorgement  and  diminution  in  the  amount  of  extravasa- 
tion going  on,  but  a  positive  reabsorption  of  a  part  of  the 
liquid  exudate  already  manifest.  Clinical  appearances  cer- 
tainly bear  us  out  in  our  presumption  that  these  changes 
do  occur. 

The  action  of  digitalis  is  chiefly  confined  to  the  organs 
of  circulation.  Under  the  stimulation  of  full  medicinal 
doses,  cardiac  action  is  slowed  through  stimulation  of  the 
vagus  in  the  heart  and  medulla,  while  from  a  similar  stimu- 
lation of  the  intrinsic  cardiac  ganglia  ventricular  contrac- 
tions increase  in  force.  As  a  consequence,  arterial  pres- 
sure rises.  Through  the  lengthened  diastole  the  ventricles 
are  well  filled,  and  during  systole,  through  increased  force, 
they  are  thoroughly  emptied.  In  pneumonia  the  adminis- 
tration of  digitalis  in  sulficient  doses  to  accomplish  the 
best  results  requires  care  and  watchfulness  on  the  part  of 
the  therapeutist.  It  should  be  exhibited  almost  to  the  full 
limit  of  tolerance,  and  must  not,  of  course,  be  carried  be- 
yond the  first  stage  of  its  action.  Symptoms  of  accumula- 
tion must  be  carefully  observed,  although  it  will  be  found 
that  the  dose  borne  with  comfort  and  salutorv  effect  is 
much  larger  than  that  tolerated  under  normal  circulatory 
conditions.  This  peculiar  tolerance  of  the  drug  might  be 
roughly  compared  to  giving  an  engine,  pushing  a  heavy 
load,  a  full  head  of  steam,  when  a  similar  pressure  applied 
in  the  absence  of  a  load  to  oppose  its  force  would  result  in 
the  destruction  of  the  machinery.  With  a  heavy  circula- 
tory obstruction  ahead  which  must  be  met  there  is  very 
little  danger  of  a  runaway  heart  being  caused  by  the  action 
of  digitalis. 

It  is  true  that  by  thus  increasing  the  cardiac  effort  we  cause 
an  increased  arterial  tension,  still  higher  blood  pressure,  and 
consequently  augment  the  elements  opposing  the  heart. 
But  we  must  remember  that  in  this  early  stage  we  are  deal- 
ing with  a  presumably  sound  organ  which  is  capable  of 
great  exertion,  and  not  one  overdistended,  worn  out,  and 
failing  through  prolonged  overwork.  Manifestly,  when  wo 
have  overcome  this  abnormal  peripheral  resistance,  arterial 
pressure  will  rapidly  fall,  allowing  the  heart  to  rest  and  re- 
cover. 

Again,  we  must  bear  in  mind  the  condition  of  the  pul- 


324 


BERGEN:  DIGITALIS  AND  CHLORAL  IN  PNEUMONIA. 


|N.  Y.  Mkd.  Jouk., 


monary  veins  in  this  hyperiemic  stage.  We  know  that  the 
variations  in  pulse-rate  are  regulated  entirely  by  the  dura- 
tion of  diastole,  systole  remaining  practically  unchanged  at 
all  times.  During  this  hyperiEmic  stage  we  find  frequently 
the  pulse-rate  running  up  to  140  or  150  a  minute.  This 
means  a  corresponding  shortness  of  diastole — the  period 
during  which  the  ventricles  are  resting  and  tilling  with 
blood.  Consequently  this  diminution  in  the  time  of  emp- 
tying the  veins  raises  the  pressure  within  them,  and  thus 
adds  another  factor  to  embarrass  the  onward  flow  of  blood 
through  the  engorged  capillaries.  Under  the  influence  of 
digitalis,  diastole  is  greatly  lengthened,  the  veins  are  emp- 
tied, and  the  heart  strengthened  by  the  enforced  period  of 
rest  between  contractions. 

One  observer  professes  to  have  aborted  several  attacks 
of  pneumonia  at  the  end  of  the  second  and  third  days  by 
this  treatment.  The  author  has  never  observed  this  result, 
although  such  an  accomplishment  might  not  be  considered 
beyond  the  range  of  possibility  when  we  observe  a  temper- 
ature of  106°  fall  to  normal  in  twelve  hours  from  the 
beginning  of  treatment.  The  results,  as  manifest  by  the 
selected  cases  here  reported,  point  rather  to  a  marked  dimi- 
nution in  the  severity  of  the  subsequent  inflammatory 
changes  and  products  than  to  a  shortening  of  the  duration 
of  the  disease.  This  permanent  mitigation  of  the  disorder 
is  probably  also  partially  due  to  the  fact  that  in  certain 
more  favorable  spots  in  the  diseased  areas  the  process  stops 
short  with  the  stage  of  congestion,  the  beginning  exuda- 
tion being  rapidly  reabsorbed,  the  remainder  taking  on 
more  the  character  of  an  inflammatory  a?dema,  character- 
ized by  a  conspicuous  absence  of  fibrinous  elements.  This 
we  are  reasonably  led  to  infer  from  the  rapidity  with  which 
certain  affected  regions  are  discovered  to  have  apparently 
recovered  and  contain  air,  even  as  early  as  twenty-four 
hours  from  the  beginning  of  the  treatment.  In  brief,  the 
complexus  of  symptoms,  as  observed  clinically,  which  evi- 
dence beneficent  results  may  be  summarized  as  follows  : 

1.  Prompt  and  permanent  temperature  decline. 

2.  Lessened  respiratory  embarrassment. 

3.  Almost  complete  disappearance  of  cyanosis  (often 
complete). 

4.  Marked  lessening  of  pulmonary  pain. 

5.  Amelioration  of  cough. 

6.  Slowing  and  strengthening  of  the  heart's  action. 

7.  Increased  activity  on  the  part  of  the  cutaneous  and 
urinary  systems. 

8.  Moderately  increasing  resonance  over  the  affected 
area.  (This  last  is  sometimes  so  great  as  to  lead  to  the 
hope  of  the  disease  having  been  aborted.) 

These  changes,  under  a  watchful  guidance  of  the  drug, 
are  to  a  great  degree  permanent.  The  temperature  remains 
kind,  unless  influenced  by  a  fresh  extension  or  migration  of 
the  disease  to  healthy  portions  of  the  lung. 

In  a  very  great  majority  of  the  cases  which  have  fallen 
under  the  author's  observation  there  has  appeared  a  marked 
tendency  on  the  part  of  the  disease  to  terminate  by  lysis. 
In  one  case  only  has  there  been  noted  anything  approach- 
ing a  distinct  crisis.  How  far  this  termination  of  the  dis- 
order has  been  influenced   by  the  method  of  treatment 


adopted,  or  whether  it  occurred  in  all  these  cases  as  an  in- 
teresting coinciflence,  we  are  not  at  present  prepared  to 
state.  It  certainly  could  not  be  attributed  to  constitutional 
vice  or  alcoholism,  as  but  two  of  the  cases  presented  indi- 
cations of  the  presence  of  either.  Another  prominent  fea- 
ture and  worthy  of  note  in  this  group  of  cases  has  been 
the  quantity  and  quality  of  the  sputa.  Without  exception, 
the  amount  of  expectorated  matter  was  very  small.  Tn  Case 
V  no  cough  or  expectoration  was  present  after  the  third  day. 
Slight  traces  of  blood  were  observed  during  the  first  half 
of  the  second  day.  In  Case  IV  the  cough  subsided  entirely 
on  the  fourth  day,  but  returned  slightly  on  the  eighth  in  a 
very  mild  form,  the  expectorated  matter  consisting  simply 
of  free  glairy  mucus,  and  marked  by  a  very  trivial  amount 
of  fibrin  and  epithelial  debris.  In  both  these  cases  the 
physical  signs  presented  all  the  indications  of  rapid  and  un- 
interrupted resolution  by  absorption. 

Regarding  the  action  of  chloral,  there  appears  a  diver- 
sity of  opinion  and,  it  must  be  admitted,  considerable  ob- 
scurity. During  its  exhibition  there  results  certainly  a 
diminished  reflex  excitability  and  consequent  tissue  relaxa- 
tion. Possibly  through  this  same  relaxation  of  the  general 
vascular  system  and  through  partial  paralysis  of  the  periph- 
eral vessels,  the  general  blood  pressure  falls,  allowing  an  in- 
crease in  the  systemic  blood  volume,  thus  affording  an  ad- 
ditional outlet  for  the 
overtaxed  pulmonary 
capillaries.  Aside  from 
this,  its  influence  in 
calming  the  cerebral  ex- 
citement and  anxiety 
tends  in  a  general,  but 
none  the  less  effective, 
manner  to  husband 
strength  and  promote 
recovery. 

Below  are  given  clini- 
cal charts  of  five  cases 
selected  from  a  total  of 
sixteen.  These  are  pre- 
sented, not  because  they 
furnish  more  brilliant 
results,  but  from  the 
fact  that  they  serve  as 
the  best  examples  of  dif- 
ferent type,  age,  nation- 
ality, temperament,  hab- 
its, and  occupation. 

In  none  of  the  six- 
teen cases  observed  did 
the  temperature  fail  to 
fall  to  within  one  degree 
and  a  half  of  normal 

during  the  first  eighteen  hours  of  treatment.  In  the  cases 
of  the  more  robust  patients  a  ten- grain  calomel  powder 
was  given  with  the  initial  dose  of  digitalis  and  chloral. 
The  medicinal  treatment  consisted  in  administering — be- 
ginning with  the  first  recognition  of  the  nature  of  the  dis- 
ease— half  an  ounce  of  the  fresh  infusion  of  digitalis,  re- 


Case  I.— a.  G.,  twen  y-two  years  of  age,  a 
native  of  Germany,  by  occupation  a  car- 
p.nter. 


March'"25,  1893.] 


BERGEN:  DIGITALIS  AND  CHLORAL  IN  PNEUMONIA. 


325 


peated  every  hour  until  the  temperature,  pulse,  and  respira- 
tion] had  fallen  to  nearly  normal.    When  this  point  was 

1       2        3       4       5       6       7       8  9 
M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E. 


106° 


105° 


104^ 


103 


102° 


100 


Case  II.  -Pneumonia  cf  the  right  lung  ;  apex  most  eeriouely  involved.  H.  C, 
thiity-eight  years  cf  age,  a  native  of  Sweden,  by  occupation  a  bricklayer. 
Recovery  uneventful. 

*  Taken  on  the  morning  on  which  the  patient  got  out  of  bed  and  dressed 
himself. 

approached,  the  intervals  of  the  dose  were  lengthened  to 
two,  three,  or  even  four  hours,  and  gradually  the  quantity 

1       23       4567       8       9      10  11 
M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E  M.E.  M.E.  M.E.  M  E. 


106 


105° 


lO'F 


103 


102° 


100 


Cask  in.— Pneumonia  of  the  lef liing.   J.  D.,  twenty-six  years  of  ago,  a  native 
of  America,  by  occupation  a  bookkeeper.  Recovery. 


was  reduced  until  the  disease  had  practically  subsided. 
The  amount  of  chloral  was  determined  independently  of  the 

13       3       4        56        7        89  10 
M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E  M.E. 


Case  IV. -Pneumonia  at  the  base  of  the  right  lung.   J.  G.,  twenty-eight  years 
of  age,  a  native  of  Ireland,  by  occupation  a  carpenter.  Recovery. 

digitalis,  although  the  two  drugs  were  without  exception  ad- 
ministered in  combination.    Twenty  grains  were,  in  a  major- 

12        34  56789 
M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E.  M.E. 


106° 


105 


lO-V 


103° 


102° 


101° 


100 


Cask  V.  -  Pneumonia  at  the  base  of  the  ,  ight  lung.   T.  S.,  twenty-two  years  of 
agf,  a  native  of  Scotlan  ,  byj occupation  a  lal)oicr.   Recovery  unevenlfiiJ. 

ity  of  cases,  given  at  the  initial  dose,  ten  grains  being  given 
hourly  until  the  patient  presented  a  condition  of  decided 


326 


BROWN:   THE  THERAPEUTICS  OF  ASIATIC  CHOLERA. 


[N.  Y.  Med,  Jocb., 


drowsiness,  and  thereafter  the  aim  was  to  modify  the 
amount  in  sufficient  quantity  to  maintain  a  condition  of 
perfect  quietude  during  the  first  forty-eight  hours  of  the 
disease. 

Venesection  was  not  practiced  in  any  case.  In  three 
instances  an  ice-bag  was  applied  over  the  affected  area, 
and  in  no  case  was  any  other  antipyretic  measure  adopted  with 
the  view  of  reducing  temperature.  No  effort  was  required  in 
this  direction,  since  hyperpyrexia  was  uniformly  absent 
after  the  first  few  hours. 

The  temperature  of  the  sick-room  was  maintained  as 
nearly  as  possible  at  55°  F.  Light  sponge  baths  were  ad- 
ministered night  and  morning,  and  an  abundant  absolutely 
milk  diet  enforced. 

In  one  case  only  was  there  any  threatening  cardiac  ac- 
tion ;  this  occurred  in  Case  I  on  the  fifth  day.  The  pa- 
tient, a  very  ignorant  individual,  cared  for  by  still  more 
ignorant  attendants,  insisted  upon  dre.ssing  and  walking 
down  stairs.  This  being  followed  by  extreme  exhaustion, 
those  present  became  alarmed  and  gave  the  patient  an 
ounce  of  poor  whisky,  which  was  followed  by  very  irregular 
and  rapid  heart  action,  with  severe  dyspnoea.  A  prompt 
resort  to  strychnine  and  enforced  quiet  speedily  overcame 
the  danger.  In  one  case,  owing  to  persistent  dullness  over 
the  right  base,  associated  with  a  low  febrile  condition,  aspi- 
ration was  performed  at  three  different  points.  The  results 
were  negative,  and  the  disease  passed  on  to  slow  but  un- 
eventful recovery  by  absorption. 

Perhaps  the  most  interesting  feature  of  these  cases  and 
one  which  surprised  the  author  was  the  tremendous  and 
prompt  temperature  decline  at  the  outset  of  the  disease. 
As  evidence  that  this  decline  is  due  to  a  removal  of  the 
cause,  it  might  be  stated  that  in  three  cases  the  digitalis 
and  chloral  were  withheld  after  the  first  eighteen  hours, 
with  a  view  of  noting  the  result.  The  temperature  showed 
no  tendency  to  rise  to  more  than  a  very  moderate  eleva- 
tion, the  pulse  and  respiratory  rate  keeping  in  good  pro- 
portion. In  one  case  only  were  alcoholic  stiumlants  ad- 
ministered in  more  than  mere  tonic  doses.  The  condition 
of  the  patient  in  each  of  the  other  cases  was  not  such  as  to 
furnish  an  indication  for  their  use.  Expectorant  mixtures 
were  for  a  similar  reason  discarded.  Resolution  occurred 
almost  entirely  through  absorption,  being  gradual  but 
satisfactory. 

In  conclusion,  it  may  be  observed  that  while  the  author 
is  fully  aware  there  is  nothing  original  with  him  in  this 
method  of  the  therapeutic  management  of  these  cases,  he 
believes  the  rationale  of  the  course  deserves  a  more  general 
consideration  and  practical  test ;  therefore  he  wishes  to  re- 
port the  clinical  results  and  deductions  which  he  has  drawn 
from  his  personal  experience  in  private  practice,  and  also 
desires  to  place  himself  on  record  as  an  ardent  believer  in 
this  method  of  medication,  in  the  hope  that  he  may  aid  in 
causing  a  wider  and  more  thorough  adoption  of  it.  Those 
contemplating  its  employment  should,  he  believes,  bear  in 
mind  one  cardinal  point,  which  will  to  a  certainty  modify 
the  degree  of  success  or  failure  attending  the  results.  In 
order  to  insure  a  satisfactory  issue,  the  two  drugs — but 
particularly  the  digitalis — must  be  administered  boldly. 


If  digitalis  is  exhibited  in  cautious  or  even  moderate 
doses,  the  therapeutist  will  assuredly  meet  with  disappoint- 
ment or  failure.  Those  who  have  adopted  the  treatment 
are  unanimous  in  their  declarations  that  the  drugs  are  well 
borne,  and  fears  of  accumulation  are  demonstrated  to  be 
practically  unfounded.  Crowd  the  digitalis  in  full  doses 
every  hour  until  the  temperature,  pulse,  and  respiration 
fall  to  a  point  approximating  normal,  which  usually  occurs 
within  eighteen  or  twenty  hours,  and  the  succeeding  stages 
of  the  disease  will  in  all  likelihood  remain  within  easy 
control. 


TEIE 

THERAPEUTICS  OF  ASIATIC  CHOLERA. 
By  PAUL  R.  BROWN,  M.  D., 

MAJOR  AND  S0UGEON,  U.  8.  ARMY,  PORT  SUPPLY,  INDIAU  TERRITOKT. 

As  it  is  possible,  if  not  probable,  that  Asiatic  cholera 
will  become  epidemic  in  this  country  during  the  coming 
year,  I  have  been  led  to  ask  myself  the  question,  In  case 
you  should  be  called  upon  to  treat  a  case  of  cholera,  what 
method  of  treatment  would  you  pursue,  and  what  would  be 
your  reasons  for  adopting  any  particular  method  to  the  ex- 
clusion of  all  others  ?  In  endeavoring  to  determine  this 
question  I  have  consulted  the  medical  literature  of  Asiatic 
cholera,  so  far  as  it  has  been  accessible  to  me,  and,  with 
possibly  one  or  two  exceptions,  I  have  found  no  methods 
that  are  not  purely  empirical,  and  that  practically  there  has 
no  advance  been  made  in  the  treatment  of  this  disease  for 
the  last  sixty  years. 

After  the  stage  of  premonitory  diarrhoea  has  passed, 
almost  all  the  various  methods  proposed  have  been'  equally 
unsuccessful,  the  percentage  of  deaths  varying  from  thirty 
to  seventy  per  cent.,  according  to  the  severity  of  the  epi- 
demic. Thus  far  no  rational  method  of  treatment  has  as 
yet  been  proposed  by  therapeutists  for  the  medication  of 
this  terrible  scourge,  with  possibly  one  or  two  exceptions, 
which  will  be  mentioned  later  on. 

In  answer  to  my  own  question,  so  far  as  any  informa- 
tion which  I  am  able  to  derive  from  the  various  text-books 
and  ephemeral  literature  of  the  subject  is  concerned,  I  am 
compelled  to  make  the  humiliating  confession  that  I  do  not 
know.  Any  method  of  treatment  which  I  might  adopt 
would  be  purely  theoretical,  yet  nevertheless  rational,  as  I 
should  be  unwilling  to  pursue  any  method  that  was  not,  at 
least  in  my  opinion,  based  upon  the  indications  capable  of 
being  derived  from  the  morbid  elements  of  the  disease. 
Possibly  such  a  method  would  be  fully  as  unsuccessful  as 
any  of  the  empirical  ones  now  in  vogue,  but  I  should,  like 
Dr.  Sangrado,  have  the  melancholy  satisfaction  of  -feeling 
that  my  theory  was  correct,  although  the  majority  of  my 
patients  died. 

It  is  now  unquestionably  proved  that  the  comma  bacil- 
lus discovered  by  Koch,  if  not  the  predisposing  or  proxi- 
mate cause  of  Asiatic  cholera,  is  invariably  present  in  the 
small  intestine  at  some  time  during  the  course  of  this  dis- 
ease, and,  further,  it  is  all  but  demonstrated  that  the  devel- 
opment and  multiplication  of  the  comma  bacillus  in  this 
terrain,  peculiarly  favorable  to  its  evolution,  is  the  direct 


March  25,  1893. J 


BROWN:    THE  TEERAPEUTICS  OF  ASIATIC  CHOLERA. 


327 


or  indirect  cause  of  the  series  of  patliological  phenomena 
known  as  Asiatic  cholera.  Possibly  some  peculiar  toxin 
elaborated  by  the  comma  bacilli  may  be  the  exciting  cause. 
These  bacilli  apparently  find  their  environment  in  the  small 
intestine,  so  well  adapted  to  their  development  that  they 
are  only  exceptionally  found  in  other  organs.  The  post- 
mortem lesions  found  in  the  intestines  are  comparatively 
insignificant,  consisting  essentially  in  a  stripping  off  of  the 
epithelium  of  the  intestinal  villi.  Occasionally  there  may 
be  some  ulcerations  resembling  those  of  typhoid  fever.  The 
other  organic  lesions  are  probably  due,  at  least  the  majority 
of  them,  to  the  general  dehydration  of  the  organism. 

The  essential  fact  in  the  disease  appears  to  be  a  vaso- 
motor paralysis  of  the  intestinal  vasculai-  system,  produced 
directly  by  the  bacilli  or  the  toxinc  fabricated  by  them.  This 
paralysis,  in  conjunction  with  the  removal  of  the  epithelium, 
permits  the  rapid  dehydration  of  the  circulation  and,  con- 
sequently, of  the  entire  organism. 

Nearly  all  the  various  symptoms  are  direct  resultants  of 
the  aqueous  loss  through  the  small  intestine.  The  general 
condition  of  shock,  which  is  sometimes  present  before  there 
is  any  diarrhoea  or  any  loss  of  fluids  sufficient  to  interfere 
with  the  normal  functioning  of  the  cerebrum,  is  probably 
attributable  to  the  direct  fulminating  effect  of  the  cholera 
infection  upon  the  terminal  nervous  filaments  distributed  to 
the  small  intestine. 

The  rational  indications  naturally  arising  from  the  pres- 
ence of  the  comma  bacilli  in  the  small  intestine  and  the 
vaso-motor  paralysis  produced  by  them,  directly  or  indi- 
rectly, would  be  as  follows  :  First  of  all,  to  destroy  the  in- 
truders in  situ,  or,  if  this  is  not  possible,  to  weaken  their 
development  and  prevent  their  further  multiplication  by 
rendering  their  environment  unsuitable  for  their  evolution ; 
secondly,  to  overcome  the  vaso-motor  paralysis  caused  by 
them,  and  metamorphose  it  into  a  vaso-motor  contraction ; 
thirdly,  to  repair  the  aqueous  losses  resulting  from  the  gen- 
eral dehydration  of  the  economy.  In  my  opinion,  at  least, 
these  are  the  indications  which  must  be  fulfilled  if  we  hope 
to  overcome  the  disease  proper  and  its  resulting  effects,  and 
all  methods  of  treatment  not  fulfilling  these  indications,  or 
endeavoring  so  to  do,  must  be  empirical  and  probably  faulty, 
although  not  necessarily  so. 

What  means  have  we  at  our  command  capable  of  fulfill- 
ing the  first  indication — the  destruction  of  the  microbes  in 
situ — and  by  what  channels  can  we  reach  these  intruders 
into  the  intestinal  economy  ?  The  means  of  destruction  are 
multitudinous,  but,  unfortunately,  the  greater  portion  of 
them  are  homicidal  as  well  as  microbicidal  in  amounts  capa- 
ble of  producing  the  desired  effect. 

With  the  exception  of  tannin  and  peroxide  of  hydrogen, 
there  are  probably  no  microbicides  that  can  be  administered 
by  the  mouth  in  quantities  sufficient  to  produce  any  appre- 
ciable effect  upon  the  bacilli  of  cholera  without  at  the  same 
time  endangering  life.  Salol  has  been  proposed  as  an  in- 
testinal microbicide,  and  has  been  unsuccessfully  prescribed 
in  cholera.  It  is  very  feebly  germicidal,  and  can  only  be 
administered  in  small  amounts  from  the  fact  that,  after  its 
solution  by  the  pancreatic  juice,  it  breaks  up  into  salicylic 
acid  and  phenol,  and  large  doses  of  it  produce  carbolic-acid 


poisoning.  At  the  present  time  we  are  practically  limited, 
so  far  as  administration  by  the  mouth  is  concerned,  to  tan- 
nic acid  and  peroxide  of  hydrogen. 

A  sufficiently  strong  solution  of  tannin  will  destroy  the 
comma  bacillus,  and  this  medicine  is  practically  harmless 
in  virtually  unlimited  amounts.  As  five  grammes  have  been 
given  to  a  rabbit  without  perceptible  effect,  we  need  have 
no  fears  as  to  its  use  in  very  large  doses.  The  effects  upon 
the  stomach  being  sometimes  unpleasant,  and  as  it  changes 
rapidly  into  gallic  acid  in  that  organ,  it  is  advisable  to  pre- 
scribe it  in  such  a  way  that  its  action  will  not  commence 
until  it  has  passed  into  the  small  intestine.  In  addition,  it 
will  then  be  brought  in  more  direct  contact  with  the  cholera 
microbes.  By  making  the  medicine  up  into  tablets  covered 
with  salol  or  keratin,  we  can  insure  its  passage  through 
the  stomach  undissolved.  Tablets  containing  0"33  gramme, 
or  five  grains,  are  of  convenient  size  for  administration. 
These  tablets  could  be  administered  ad  libitum.  Four  to 
five  tablets  could  be  prescribed  hourly  for  several  hours, 
according  to  circumstances.  Tannic  acid,  in  addition  to 
its  antiseptic  effect,  has  a  marked  astringent  effect  which 
would  probably  be  more  or  less  beneficial.  Solution  of 
peroxide  of  hydrogen  is  unquestionably  a  very  active  and 
powerful  germicide.  One  part  in  ten  thousand  is  sufficient 
to  sterilize  water,  but  a  stronger  solution  (1  to  1,000)  is 
necessary  to  insure  the  destruction  of  the  cholera  bacillus. 
Accordins  to  Gifford,  the  fifteen- volume  solution  will  de- 
stroy  anthrax  spores  in  three  quarters  of  a  minute,  and 
Miguet  is  of  the  opinion  that  it  is  more  active  than  corro- 
sive sublimate.  It  can  be  safely  administered  by  the  stom- 
ach in  doses  of  four  to  sixteen  cubic  centimetres  (one  to  four 
teaspoonfuls),  largely  diluted  with  water.  A  teaspoonful 
of  this  medicine  to  a  quart  of  water  will  practically  repre- 
sent a  l-to-250  solution,  or  four  times  stronger  than  is  ne- 
cessary to  destroy  the  comma  bacillus  outside  the  body. 

It  has  no  unpleasant  effects  wlien  taken  internally  unless 
the  doses  are  excessive  arid  the  use  of  the  medicine  is  pro- 
longed. The  peroxide  of  hydrogen  can  then  be  depended 
upon  to  destroy  any  bacilli  in  the  stomach,  and  perhaps 
also  those  of  the  extreme  upper  portion  of  the  small  intes- 
tine. During  an  epidemic  of  cholera  it  will  be  of  value  in 
the  sterilization  of  water,  a  teaspoonful  to  a  gallon  being 
sufficient  for  this  purpose.  Its  taste  is  not  unpleasant,  and 
in  that  amount  of  water  it  would  not  be  perceptible. 

The  hypodermic  and  rectal  methods  of  administration 
must  now  be  taken  into  consideration.  It  is  absolutely 
impracticable  to  administer  hypodermically  microbicidal 
medicines  in  quantities  sufficient  to  have  any  appreciable 
effect  upon  the  comma  bacilli  of  the  small  intestine  without 
great  risk  to  life,  and,  as  our  object  now  is  to  destroy  the 
microbes  in  situ,  I  shall  not  further  consider  them  from 
the  standpoint  of  this  indication. 

As  the  cholera  bacilli  have  their  habitat  in  the  intes- 
tines, it  is  not  a  matter  of  astonishment  that  endeavors 
should  have  been  made  to  reach  them  by  the  rectum.  But, 
unfortunately,  we  are  again  handicapped  by  our  inability 
to  use  sufficiently  lai'ge  amounts  of  such  substances  as  are 
fatal  to  their  existence  outside  the  organism  without  great- 
ly endangering  the  lives  of  our  patients.    Almost  all  the 


328 


BROWN:   TEE  THERAPEUTICS  OF  ASIATIC  CHOLERA. 


[N.  y.  Med.  Jode., 


germicides  produce  grave  local  effects  or,  by  their  absorp- 
tion, endanger  life  on  account  of  the  constitutional  symp- 
toms which  they  induce. 

On  this  account  our  choice  is  necessarily  limited.  Can 
tani,  of  Naples,  has  comparatively  recently  made  use  of 
large  quantities  of  tannic  acid  in  his  so-called  "  entero-clys- 
mic "  method,  his  idea  being  to  destroy  the  bacilli  and 
render  harmless  the  ptomaines  elaborated  by  them.  Four 
or  five  times  a  day  he  makes  use  of  the  follow,ing  enema, 
injecting  it  as  high  up  the  bowel  as  possible : 
Tannic  acid.  10  grammes,  or  about  150  grains; 

Water   1,000  grammes,  or  about  1  quart; 

Gum  arable..  30  to  50  grammes,  or  about  450  to  750  grains ; 
Laudanum. .  .  30  drops. 

Cantani  maintains  that  this  method  is  absolutely  suc- 
cessful during  the  first  stage  of  cholera.  His  results  need 
confirmation.  Hydriodic  acid  has  also  been  proposed  with 
a  view  to  its  microbicidal  effects,  but  1  am  not  aware  that 
it  has  ever  been  used.  It  may  prove  valuable  if  it  can  be 
used  in  sufficient  quantity,  as  iodine  is  an  exceedingly 
powerful  disinfectant ;  and  Hayem,  in  his  recent  work  on 
therapeutics,  gives  it  even  a  higher  rank  than  corrosive  sub- 
limate. According  to  Jalan  de  la  Croix,  a  l-to-2,000  solu- 
tion of  iodine  is  sufiiciently  strong  to  kill  adult  bacteria  in 
culture  bouillon ;  and  Davaine  states  that  smaller  amounts 
yet  (1  to  150,000)  will  destroy  the  bacillus  anthracis,  and 
(1  to  10,000)  the  virus  of  septicasmia.  If  the  cholera  bacil- 
lus is  as  susceptible  as  tlie  Bacillus  anthracis  to  the  action 
of  iodine,  it  would  be  perfectly  safe  to  use  solutions  of 
iodine  for  its  destruction  in  situ  if  the  statement  of  Davaine 
is  correct.  A  solution  of  seven  centigrammes  of  iodine  to 
two  thirds  of  a  litre  of  water,  or  one  grain  to  twenty 
ounces,  is  sufficiently  strong  to  kill  the  bacillus  of  anthrax. 
Lugol's  solution,  or  tincture  of  iodine  in  water,  could  be 
safely  used  in  two  or  three  times  the  amount  recommended 
by  Davaine.  Fresh  tincture  of  iodine  should  not  be  em- 
ployed on  account  of  the  precipitation  of  the  iodine,  and 
as  alkalies  present  in  the  intestine  will  form  compounds 
with  the  iodine,  it  should  be  prescribed  in  acid  solution, 
possibly  nitric  or  sulphuric  acid.  There  is  a  possibility 
that  the  fumes  of  iodine  might  be  tolerated  by  the  intes- 
tine for  a  short  time. 

I  would  most  strongly  suggest  the  use  of  injections  of 
solution  of  peroxide  of  hydrogen  by  the  rectum  in  cases  of 
Asiatic  cholera.  There  is  no  doubt  as  to  its  microbicidal 
properties  and  its  tolerance  by  the  system  generally.  A 
teaspoonful  of  a  ten-volume  solution  to  a  quart  of  water 
would  probably  be  suflSciently  strong,  but  ten  times  this 
strength  would  do  no  harm.  The  enemas  should  be  large 
and  injected  as  high  up  the  bowel  as  possible,  the  patients 
being  placed  in  a  posture  favorable  to  their  retention  of  the 
clysters.  Whether  they  can  be  forced  above  the  ileo-csecal 
valve  is  questionable ;  but  the  attempt  should  be  made. 
After  the  enema,  abdominal  massage  should  be  gently  prac- 
ticed to  bring  the  liquid  in  contact  with  all  parts  of  the  in- 
testinal walls.  Theoretically,  great  hopes  may  be  enter- 
tained as  to  the  favorable  results  of  this  practice,  but  actual 
trial  can  only  prove  its  worthlessness  or  usefulness.  It 
theorelicaUy  certainly  fulfills  the  first  indication — the  de- 


struction of  the  bacilli  in  situ.  Injections  of  sulphurous- 
acid  gas  in  solution  might  prove  valuable.  According  to 
the  table  of  De  la  Croix,  a  l-to-2,000  solution  kills  fullv 
developed  bacteria.  In  the  abnormal  condition  of  the  in- 
testinal surfaces  there  would  probably  be  no  dangerous 
absorption.  Possibly  the  gas  itself  could  be  forced  into 
the  intestine,  and  if  this  were  practicable  and  safe  it  would 
undoubtedly  pass  the  ileo-caecal  valve  and  act  upon  tlie 
upper  portion  of  the  small  intestine. 

I  am  not  aware  that  the  use  of  oxygen  gas  has  ever  been 
recommended  in  cholera  as  a  local  disinfectant.  I  can  see 
no  objection  to  its  use,  although,  even  if  it  should  prove 
valuable,  it  would  be  difficult  to  employ  it  outside  of  large 
cities  where  there  would  be  no  opportunity  of  obtaining 
the  charged  cylinders.  Its  utilization  would  probably  only 
be  practicable  in  hospitals.  Oxygen  gas  is  one  of  our  most 
powerful  disinfectants,  and,  in  addition,  it  has  a  markedly 
stimulant  effect  which  might  be  turned  to  advantage. 
There  would  be  no  practical  diflSculty  in  inflating  the  in- 
testine with  this  'gas,  and  probably  no  danger.  Senn  hrfs 
repeatedly  inflated  the  intestine  with  hydrogen  gas.  Other 
gases  or  fumes  arising  from  the  volatilization  of  various 
substances  might  be  utilized. 

The  fumes  of  cinnabar  would  probably  destroy  the 
comma  bacillus,  but  the  effect  upon  the  patient  might  be 
questionable.  Of  course  it  is  understood  that  these  various 
methods  of  treatment,  with  the  exception  of  that  of  Can- 
tani, are  purely  theoretical  and  hypothetical.  They  are  cer- 
tainly rational  and  fulfill  the  indications.  Still,  I  am  per- 
fectly aware  that  experiments  upon  the  living  organism  are 
entirely  different  from  those  made  upon  the  culture  bouil- 
lon. Many  of  the  previously  mentioned  methods  are  based 
upon  the  germicidal  power  manifested  by  various  medicines 
under  such  circumstances  and  are  sub  judice. 

Peroxide  of  hydrogen,  however,  has  proved  markedly 
germicidal  when  applied  to  suppurating  wounds  and  can  be 
safely  used  internally.  As  the  essential  clinical  fact  in  Asi- 
atic cholera  is  the  vaso-motor  paralysis  of  the  intestinal 
vascular  system  produced  directly  by  the  comma  bacilli  or 
indirectly  by  the  toxin  elaborated  by  them,  the  rational  in- 
dication is,  if  possible,  to  overcome  this  paralysis  and  pro- 
duce the  contrary  condition — a  vaso-motor  contraction. 
What  medicines  have  we  capable  of  producing  the  latter 
effect,  and  by  what  channels  shall  we  introduce  them  into 
the  organism  ?  As  time  is  an  exceedingly  important  factor 
in  the  treatment  of  a  case  of  cholera,  the  hypodermic 
method  of  administration  of  these  medicines  is  to  be  pre- 
ferred to  all  others.  In  addition,  the  stomach  is  frequently 
in  such  a  condition  that  it  is  impossible  to  administer  medi- 
cines by  this  channel. 

Strychnine,  morphine,  and  ergotine  all  produce  vaso- 
motor contraction  of  the  vessels.  Nux  vomica  was  used  as 
long  ago  as  1795  by  Hufeland  in  an  epidemic  of  dysentery 
occurring  at  Jena,  and  his  success  was  so  remarkable  that 
his  practice  had  a  host  of  imitators.  Strychnine  produces 
general  vaso-motor  spasm  with  rise  of  blood  pressure  and 
contraction  of  the  arterioles.  If  the  doses  given  are  exces- 
sive, the  vaso-motor  spasm  is  followed  by  paralysis.  Sul- 
phate of  morphine  is  also  a  vaso-motor  stimulant,  and  the 


Maroli  26,  1893.] 


BROWN:   THE  THERAPEUTICS  OF  ASIATIC  CHOLERA. 


329 


Buccess  which  has  followed  its  administration  in  large  doses 
hypodermically  in  cases  of  cholera  is  probably  due  to  this 
action.  Gscheidlen  asserts  that  morphine  stimulates  the 
vaso-raotor  system,  and  that  the  arterioles  of  the  mesentery 
contract  under  the  influence  of  large  doses  of  this  medicine. 
In  addition  to  its  direct  vaso-motor  effect,  it  has  a  beneficial 
action  in  checking  intestinal  peristalsis.  Ergotine  is  perhaps 
the  most  valuable  of  all  the  medicines  producing  vaso-motor 
contraction  of  the  vessels,  as  its  effect  is  the  most  lasting  in 
this  respect. 

It  is  the  verdict  of  physiology  that  ergotine  produces 
general  vaso  motor  spasm  with  resulting  contraction  of  the 
arterioles  and  marked  diminution  of  their  caliber,  and  that 
this  contraction  is  comparatively  permanent.  The  employ- 
ment of  ergot  in  dysentery  and  clironic  diarrhoea  was  rec- 
ommended by  Dr.  Fontayral,  of  Montpellier,  in  1858,  and 
the  value  of  this  recommendation  was  proved  by  the  expe- 
rience of  Massolaz  with  French  troops  in  the  Orient.  In 
1871  Dr.  Luton,  of  Rheims,  again  called  attention  to  its 
use,  he  having  prescribed  it  with  marked  benefit  in  an  epi- 
demic of  dysentery. 

Professor  Georges  Hayem,  of  Paris,  says  that  ergot  has 
frequently  been  successfully  prescribed  in  intestinal  hasmor- 
rhages.  The  beneficial  results  which  have  followed  the  use 
of  this  medicine  in  dysentery,  diarrhoea,  and  hfemorrha/e 
are  undoubtedly  due  to  its  vaso  motor  effects.  The  ergotine 
of  Yvon-Sick  is  preferable  to  that  of  Bon  jean.  It  differs 
from  that  of  the  U.  S.  P.  in  that  the  essential  oil  is  ex- 
tracted with  sulphide  of  carbon.  The  dose  is  practically  the 
same  as  that  of  the  U.  S.  P. — about  thirty-three  centi- 
grammes (five  grains).  The  ergotine  of  the  U.  S.  P.  should 
be  dissolved  in  glycerin  and  water,  the  ergotine  of  Yvon-Sick 
in  water  alone.  These  doses  may  be  prescribed  hourly  for 
an  indefinite  period  without  injury. 

Piton,  an  eminent  French  physician,  in  haemorrhage,  lays 
great  stress  upon  the  ergotine  injections  being  made  in  the 
affected  region.  Such  being  the  case,  it  is  to  be  recom- 
mended that  in  cholera  they  be  made  in  the  abdomen.  Our 
two  first  indications  having  been  fulfilled,  we  will  pass  to 
the  consideration  of  the  third  and  last — the  repairing  the 
aqueous  losses  resulting  from  the  general  dehydration  of 
the  economy.  Even  after  the  choleraic  diarrhoea  has  ceased, 
the  patient  may  die  as  the  result  of  these  losses.  Intra- 
vascular saline  injections  will  probably  repair  these  losses 
sooner  than  anything  else.  As  the  result  of  the  diarrhoea 
and  vomiting,  in  cholera,  the  blood  is  particularly  lacking 
in  saline  and  watery  constituents.  The  formula  used  by 
Hayem  in  the  cliolera  epidemic  of  1884  in  France  is  as  fol- 
lows : 

Distilled  water   1  litre,  about  a  quart ; 

Chloride  of  sodium.  .     5-00  grammes,    75  grains; 

Sulphate  of  sodium . .  10-00  "  150  " 
Other  formulae  have  been  used,  the  amounts  and  differ- 
ent constituents  varying  a  little,  but  they  are  practically  the 
same.  Transfusions  of  defibrinated  blood  may  be  of  value 
in  some  cases.  Subcutaneous  saline  injections  may  also  be 
used  for  this  purpose  as  recommended  by  Pregaldino.  The 
above  formula  can  be  used  for  these  injections.  Cantani 
employs  subcutaneous  injections  similar  to  those  of  Hayem 


except  that  they  contain  more  chloride  of  sodium.  Subcuta- 
neous injections  of  defibrinated  blood  have  been  used  by  von 
Ziemssen  in  the  treatment  of  anaemia.  They  possibly  might 
prove  useful  in  cholera.  All  these  injections  should  be  ad- 
ministered at  the  normal  temperature  of  the  body,  or  possi- 
bly a  degree  or  two  higher.  A  theoretical  method  of  treat- 
ment of  Asiatic  cholera  has  been  sketched  which  certainly 
is  rational  and  fulfills  the  principal  indications.  Whether 
it  would  be  succesful  can  only  be  proved  by  trial ;  but  it  cer- 
tainly can  not  be  more  unsuccessful  than  some  of  the  em- 
pirical ones.  Of  course  it  is  well  understood  that  the  major- 
ity of  cases  of  cholera,  if  taken  at  the  very  inception  of  the 
disease,  will  readily  yield  to  rest  and  the  ordinary  astringent 
medicines.  But  when  the  disease  has  fully  developed,  when 
there  is  vomiting  and  rice-water  discharges,  all  methods  of 
treatment  hitherto  have  been  comparatively  futile.  The 
fully  developed  disease  is  only  taken  under  consideration  in 
the  treatment  outlined  above,  although  parts  of  this  method 
are  equally  applicable  to  the  very  first  manifestations  of 
cholera. 

Taking  a  hypothetical  case  of  Asiatic  cholera  where,  for 
instance,  there  had  been  slight  diarrhoea  and  general  malaise 
for  one  or  two  days,  in  a  robust  and  healthy  adult,  followed 
in  twenty-four  to  thirty- six  hours  by  nausea  and  mor*  or 
less  vomiting,  with  rice-water  discharges  from  the  bowels  at 
frequent  intervals,  although  symptoms  of  collapse  had  not 
yet  made  their  appearance,  I  would  suggest  the  following 
method  of  treatment  based  on  the  facts  and  suggestions 
previously  mentioned.  In  the  first  place,  a  hypodermic  in- 
jection in  the  abdominal  wall  of  the  whole  of  the  following 
formula : 

Sulphate  of  strychnine.  0-004  grni.,  about  -^^  grain  ; 
Sulphate  of  morphine. .  0-02      "         "     \  " 
Ergotine  of  Yvon-Sick .  0*3.3      "        "     5  grains; 

Distilled  water   4-00      "         "      1  teaspoonful. 

This  injection  to  be  repeated  in  an  hour.  In  succeeding 
injections  the  strychnine  omitted  entirely,  and  the  morphine 
also  if  there  are  any  signs  of  narcotism.  Half-hourly  in- 
jections of  the  ergotin,  and,  if  the  diarrhoea  does  not  im- 
prove, still  larger  doses  of  the  ergotin  may  be  used. 

Solution  of  peroxide  of  hydrogen,  a  teaspoonful  to  a 
pint  of  hot  water,  should  be  administered  by  the  mouth,  in 
small  quantities,  at  once,  to  avoid  exciting  vomiting.  A 
quart  an  hour  of  this  strength  of  solution  may  be  safely 
used.  In  case  there  is  but  little  vomiting,  tannin  tablets, 
in  1-50-grarame  doses,  about  twenty  grains,  hourly.  Can- 
tani's  enemas  of  tannin,  etc.,  every  two  hours,  alternating 
with  rectal  injections  of  solution  of  peroxide  of  hydrogen, 
two  teaspoonsful  to  a  quart  of  hot  water.  All  enemas  should 
be  given  at  a  temperature  of  38°  to  40°  C,  100-4°  to  104° 
F.  Where  oxygen  gas  can  be  procured,  inflation  of  the  in- 
testine is  well  worthy  of  trial.  The  other  procedures  above 
mentioned  may  be  employed  in  case  of  failure  of  those  just 
recommended.  Complete  rest  of  body  and  mind  should  be 
enjoined  in  all  cases. 

I  am  of  the  opinion  that  the  measures  noticed  above  will 
ordinarily  prove  successful.  In  severe  and  desperate  cases 
the  einploymcnt  of  subcutaneous  injections  and  transfusions 
of  saline  solutions  is  to  be  recommended.    Transfusion  of 


330 


GIRDNER:  PROBES  AND  PROBING. 


[N.  Y.  Med.  Jouh., 


defibrinated  blood  may  be  of  some  service.  It  is  exceed- 
ingly difficult  to  formulate  a  treatment  for  every  case,  and 
much  will  depend  upon  the  judgment  of  the  practitioner. 
The  above  outlined  plan  may  prove  to  be  worthless.  Until 
such  time  I  shall  employ  it  unless  some  more  rational  one 
may  be  proposed. 


PROBES  AND  PROBING.* 

By  JOHN  HARVEY  GIRDNER,  M.  D. 

The  frequent  failure  attending  the  operation  of  probing 
for  the  bullet  in  gunshot  wounds  is,  I  think,  sufficient  ex- 
cuse for  asking  your  attention  for  a  few  minutes  to  a  pro- 
cedure ordinarily  considered  of  minor  importance. 

Whether  it  is  better  surgery  to  locate  and  remove  the 
bullet  in  gunshot  wounds  or  allow  it  to  remain  is  not  under 
discussion ;  but  I  may  say,  in  passing,  that  my  observation 
has  been  that  in  the  cases  where  it  was  thought  to  be  a 
good  thing  to  allow  the  bullet  to  remain  in  the  body, 
this  conclusion  was  not  reached  until  all  the  ordinary 
methods  to  locate  and  remove  it  had  been  tried  and  failed. 

That  eminent  American  surgeon,  Professor  Samuel  D. 
Gross,  wrote  :  "  The  probe,  from  its  great  usefulness,  may 
almost  be  considered  as  another  finger."  When  we  use 
an  ordinary  probe  in  the  examination  of  a  gunshot  wound, 
we  depend  entirely  on  the  sense  of  touch  to  inform  us  of 
tlie  exact  location  of  the  bullet.  We  can  determine  in  this 
way  with  fair  accuracy  the  consistence  of  objects  our 
probe  finds  in  the  wound,  as  soft  or  hard ;  but  the  sense  of 
touch  leaves  us  ignorant  of  what  a  given  object  w^e  feel  is 
composed  of — whether  it  is  bullet,  bone,  or  some  other  sub- 
stance of  like  consistence. 

The  porcelain-tipped  probe  was  devised  with  the  hope 
of  aiding  in  distinguishing  between  hard  masses  found  in 
gunshot  wounds,  by  the  presence  or  absence  of  lead  mark- 
ings on  the  porcelain  tip ;  but  it  is  found  that  so  much 
rubbing  against  the  bullet  is  required  to  produce  lead 
markings  sufficiently  distinct  as  not  to  be  effaced  by  the 
fluids  and  tissues  in  withdrawing  the  probe  from  the 
wound,  that,  except  in  rare  instances  where  the  bullet  is 
favorably  located,  this  instrument  is  of  no  practical  use.  I 
ought  to  say  that  this  opinion  of  the  Nelaton  probe  is  not 
based  alone  on  my  own  experience  and  experimentation  with 
it,  but  coincides  with  the  opinions  of  a  number  of  eminent 
military  surgeons  both  here  and  abroad  who  have  favored 
me  with  replies  to  inquiries  as  to  their  experience  with  it. 

There  is  another  difficulty — and  it  applies  to  all  ordinary 
probes  yet  devised — viz.,  the  tortuous  course  often  taken 
by  the  bullet  through  the  tissues  to  its  final  destination. 
When  the  track  of  the  missile  is  a  series  of  curves  and  an- 
gles, which  it  not  infrequently  is,  it  is  simply  impossible 
to  cause  a  probe  to  follow  it. 

I  recognize  the  fact  that  no  man  has  the  right  to  criti- 
cise and  play  the  part  of  an  iconoclast  unless  he  has  some- 
thing better  to  offer  than  that  he  would  set  aside,  and  in 
the  instrument  which  I  shall  presently  show  and  allow  you 


*  Read  Isefore  tlie  Section  in  General  Surgery  of  the  New  York 
Academy  of  Medicine,  November  14,  1892. 


to  test  I  think  we  have  a  probe  which  overcomes  all  the 
defects  pointed  out  in  the  old  method  of  probing  gunshot 
wounds. 

In  using  the  telephonic  bullet  probe  we  substitute  the 
accurate  sense  of  hearing  for  the  uncertain  sensations 
communicated  to  the  hand  by  the  ordinary"  probe.  No 
battery  is  used  and  the  current  which  operates  the  instru- 
ment is  supplied  from  the  body  of  the  patient  operated  on. 
Its  construction  is  simple  and  I  will  describe  it.  Take  a 
receiver  like  that  held  to  the  ear  when  conversing  over  an 
ordinary  telephone,  and  to  one  of  its  binding  posts  attach 
a  wire  three  feet  long,  and  to  the  other  end  of  this  wire  at- 
tach a  l>ulb  of  aluminum  of  such  a  size  as  to  be  con- 
veniently held  in  the  patient's  buccal  cavity  between  the 
teeth  and  cheek.  To  the  other  binding  post  attach  a  simi- 
lar wire,  and  to  the  free  end  of  this  second  wire  attach  a 
probe  also  made  of  aluminum,  and  the  instrument  is  com- 
plete. 

To  use  it,  place  the  aluminum  bulb  in  the  patient's 
buccal  cavity,  hold  the  receiver  to  your  ear  with  one  hand 
and  with  the  other  probe  the  wound,  and  you  will  hear  no 
sound  until  the  probe  touches  the  bullet,  and  you  will 
then  hear  a  distinct  clicking,  grating  sound  in  the  receiver, 
and  you  know  beyond  all  doubt  that  you  have  found 
the  lead.  If  the  track  of  the  bullet  is  tortuous  and  your 
probe  can  not  be  made  to  follow  it,  you  have  only  to  sub- 
stitute a  steel  bulb  for  the  aluminum  one  and  a  delicate 
tempered  steel  needle  for  the  aluminum  pi'obe,  and,  instead 
of  trying  to  follow  the  track  made  by  the  bullet,  you  thrust 
the  needle  into  the  tissues  in  the  area  where  you  suspect 
the  bullet  to  be,  just  as  you  would  a  hypodermic  needle, 
and  continue  to  do  'so  until  you  hear  the  noise  in  the  re- 
ceiver, and  the  needle  will  serve  as  a  guide  to  cut  down 
and  remove  the  missile. 

In  order  that  you  may  test  the  instrument,  I  will  place 
the  bulb  in  this  boy's  mouth,  and  after  moistening  one  of 
his  hands  I  will  place  a  bullet  in  it,  together  with  a  piece  of 
bone,  and  you  will  find  that  when  the  bone  is  touched  with 
the  probe  you  will  hear  no  sound  in  the  receiver,  but  the 
slightest  touch  on  the  lead  produces  a  distinct  clicking, 
rasping  sound. 

I  am  pleased  to  be  able  to  tell  you  that  after  much 
trouble  I  have  at  last  succeeded  in  having  these  instruments 
made,  and  they  are  now  for  sale  by  the  W.  F.  Ford  Manu- 
facturing Co.  and  by  Tiemann  &  Co.,  both  of  this  city. 


FOREIGN  BODY  IN  THE  TYMPANUM. 
By  H.  E.  GREENE,  M.  D., 

CKAWF0ED8VILLE,  IND. 

Although  the  practical  importance  of  peculiar  cases 
may  not  be  great,  yet  they  are  always  of  interest,  and  there 
are  few  of  us  who  do  not  take  more  pleasure  in  a  case  the 
like  of  which  we  never  expect  to  meet  again  than  in  one  of 
common  occurrence  and  consequently  of  far  more  real  value. 
It  is  in  the  hope  of  interesting  rather  than  instructing  that 
the  writer  reports  a  case  which  lays  no  claim  to  anything 
new  either  in  the  line  of  diagnosis  or  treatment : . 


March  25,  1893.J 


LEADING  ARTICLES. 


331 


Near  the  middle  of  March,  1892,  Mr.  0.  G.,  a  farmer,  called 
at  ourofiiceand  gave  the  following  history  :  Ten  days  previonsi 
while  walking  over  his  farm,  he  had  met  with  a  peculiar  acci- 
dfent.  Mr.  G.  is  a  cripple,  one  leg  being  several  inches  shorter 
than  its  fellow,  and  as  a  result  the  gentleman  walks  with  a  roll- 
ing gait  that  gives  his  body  a  lateral  to-and-fro  movement.  As 
he  was  passing  a  clump  of  alder  bushes  he  suddenly  felt  what 
seemed  to  be  a  terrible  blow  in  the  ear.  He  almost  fell  to  the 
ground,  and  it  was  several  seconds  before  he  could  overcome 
the  impression  that  some  one  had  struck  him  and  realize  that  a 
twig  from  the  alder  bushes  had  penetrated  his  ear.  The  pain 
was  intense  and  he  became  so  dizzy  that  he  staggered  on  his 
way  to  the  house.  In  the  course  of  a  few  hours  the  pain  stopped 
and  he  had  experienced  no  inconvenience  since,  but,  as  he  hap- 
pened to  be  passing  the  writer's  office,  "thought  he  would  drop 
in  and  see  if  it  was  all  right." 

Upon  examination,  the  canal  and  membrana  tympani  were 
perfectly  normal  except  for  a  faint  streak  just  posterior  to  the 
handle  of  the  malleus,  which  looked  as  though  a  paracentesis 
had  been  done  and  union  by  first  intention  obtained.  The  hear- 
ing was  almost  normal,  and,  in  the  absence  of  symptoms,  the 
opinion  was  expressed  that  he  would  have  no  further  trouble. 

About  three  weeks  later  Mr.  G.  called  again  with  the  infor- 
mation that  his  ear  had  been  paining  him  and  was  discharging. 
A  perforation  was  discovered  at  the  bottom  of  the  membi-ane 
ielow  the  original  seat  of  injuri/.  The  presence  of  a  foreign 
body  was  at  once  suspected,  but,  as  the  opening  was  very  minute 
and  the  diagnosis  uncertain,  tlioi'ougii  exploration  was  not  pos- 
sible or  justifiable. 

Jhe  routine  treatment  for  purulent  otitis  media  was  given, 
and  in  a  few  days  the  discharge  apparently  ceased  and  the  pa- 
tient was  lost  sight  of.  A  month  later  he  reappeared  and  com- 
plained that  the  discharge  had  soon  returned  and  bad  continued 
ever  since.  His  hearing  was  very  poor,  the  discharge  offensive, 
and  the  middle  ear  seemed  full  of  granulations.  The  possibility 
of  a  foreign  body  was  again  suggested,  but  the  patient  refused 
to  have  the  opening  made  larger,  and  the  next  week  was  spent 
in  snaring,  scooping,  and  scraping  away  granulations  which 
sprang  up  almost  as  fast  as  they  were  removed.  Improvement 
was  not  marked  and  Mr.  G.  went  to  a  neighboring  city  and  con- 
sulted one  of  the  most  eminent  aurists  in  the  country.  He  re- 
turned with  the  opinion  that  the  ear  contained  no  foreign  body, 
and  a  letter  advising  a  continuance  of  the  treatment  he  had  been 
receiving.  The  writer  went  to  work  with  renewed  zeal  and 
spent  another  week  or  two  fighting  granulations.  One  day, 
while  syringing  out  the  ear  after  a  particularly  thorough  scrap- 
ing, a  dark  speck  was  noticed  in  the  water  returning  from  the 
ear.  It  was  very  small  and  the  use  of  a  microscope  was  required 
to  determine  that  it  was  a  fragment  of  bark. 

When  the  patient  returned  next  day  the  perforation  in  the 
membrane  was  slightly  enlarged  and  a  fine  stream  directed  into 
the  middle  ear.  Almost  immediately  a  dark  'object  presented 
itself  at  the  opening.  It  was  easily  seized  with  the  forceps  and 
removed.  The  cause  of  all  our  trouble  proved  to  be  a  twig  of 
alder  ten  millimetres  long  and  two  millimetres  in  diameter. 

Six  months  later  I  saw  the  patient.  The  discharge  had 
stopped,  the  opening  bad  almost  entirely  closed,  and  his  hear- 
ing was  very  good. 


The  Medical  and  Surgical  Society  of  Baltimore. — The  programuie 
for  the  mcctiug  of  Thursday,  tlie  28d  Inst.,  contained  tlie  annoiuico- 
raent  of  a  paper  on  A  Case  of  Probable  Meningeal  Hiuinorrbage  with 
Symptoms  resemliling  (iencral  Paresis,  by  Dr.  George  J.  Preston,  and 
of  one  entitled  Remarks  on  an  Interesting  Case,  with  Uecovery,  by  Dr. 
Hiram  Woods. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Prank  P.  Fostbr,  M.  D. 


NEW  YORK,  SATURDAY,  MARCH  25,  1893. 


NITROGLYCERIN. 

Recent  exploits  in  the  field  of  medicine  by  secular  journals 
might  lead  some  to  conclude  that  a  new  and  wonderful  dis- 
covery had  been  made  by  the  medical  profession  in  the  thera- 
peutic use  of  this  powerful  explosive.  How  far  this  is  from 
the  truth  every  educated  physician  well  knows.  We  have  been 
aware  of  its  properties  since  1858,  when  Field,  Harley,  and 
others  published  the  results  of  their  experiments  with  it,  but 
even  with  this  long  experience  it  can  not  be  said  that  the  pro- 
fession at  large  understands  thoroughly  its  physiological  action 
and  therapeutic  indications.  We  all  know  in  a  general  way 
that  it  is  a  heart  stimulant,  but  when  to  use  it,  how  to  use  it, 
and  how  much  of  it  to  use  are  not  so  well  known.  Nitroglycerin 
is  a  transparent  liquid,  soluble  in  alcohol,  in  ether,  in  oils,  in  fats, 
and  slightly  in  water.  It  is  administered  either  in  solution  or 
in  pill.  The  dose  laid  down  in  the  books  is  from  -^^-^  to  -^^  of  a 
grain,  but  of  this  we  shall  speak  farther  on.  Its  physiological 
action  is  similar  to  that  of  nitrite  of  amyl,  but  it  is  more  pow- 
erful and  its  effect  is  less  transitory.  It  is  absorbed  undecom- 
posed,  and,  decomposition,  due  to  the  alkalies  in  the  blood, 
taking  place  within  the  vascular  system,  nitrous  acid  is  set  free 
in  a  nascent  state.  It  is  distinctly  a  muscle  poison,  acting  uj)on 
the  spinal  cord  before  the  cerebral  ganglia,  and,  applied  to  the 
exposed  heart  of  a  frog,  it  arrests  it  in  diastole  at  once.  It 
causes  in  mammals  "great  depression  with  very  rapid  pulse 
and  respiration,  paralysis  of  reflex  action  and  voluntary  motion, 
loss  of  sensation,  and  death  by  ^toppage  of  respiration " 
(Brunton).  It  reduces  the  blood  pressure  rapidly  and  effect- 
ively, and  improves  the  circulation  by  reducing  the  resistance 
that  the  heart  has  to  overcome,  and  by  stimulating  the  cardiac 
muscle  itself.  Both  the  force  and  number  of  the  beats  are  in- 
creased. It  decreases  the  oxidizing  power  of  the  blood  and  re- 
duces bodily  temperature  by  thus  limiting  oxidation.  From 
this  it  may  be  seen  that  the  drug  is  applicable  to  cases  of  car- 
diac weakness  or  failure  accompanied  by  full  veins  and  high 
arterial  pressure.  Thus,  in  cases  of  threatened  hasmorrhage,  in 
phthisis  pulmonalis,  in  typhoid  fever,  ia  apoplexy,  its  use  would 
be  strongly  indicated,  and  experience  has  shown  its  exceeding 
value  in  such  cases.  In  the  early  stages  of  pneumonia,  where 
the  arterial  tension  is  high  and  the  venous  system  congested, 
and  where  no  very  large  area  of  breathing  space  has  been  ob- 
structed, it  would  bo  indicated,  but  it  is  questionable  if  its  use 
is  advisable  in  the  later  stages,  when  the  heart's  action  is  al- 
ready too  rapid  and  the  oxidation  of  the  blood  deficient.  Digi- 
taline  or  strychnine  would  then  seem  to  meet  the  indications 
better. 


332 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jock., 


It  i8  a  powerful  but  not  an  irritating  diuretic.  Miirrell  lias 
reported  a  case  in  which  the  urinary  secretion  was  increased 
from  fourteen  drachms  and  a  half  to  fifteen  ounces  in  half  an 
Lour  by  a  dose  of  twenty  minims  of  the  one-per-cent.  solution. 
This  action  of  the  drug  will  explain  its  favorable  influence  in 
Bright's  disease,  uraemia,  uraemic  asthma,  and  allied  conditions. 
In  nervous  aiFections,  headache,  neuralgia,  epileptic  vertigo, 
and  epilepsy,  in  angina  pectoris,  gastralgia,  hepatic  and  renal 
colic,  and  puerperal  convulsions,  it  has  been  used  with  almost 
universally  good  eflfects — i.  «.,  when  scientifically  administered  ; 
but  our  imperfect  knowledge  of  the  pathology  of  these  condi- 
tions precludes  our  understanding  the  action  of  the  drug  in 
controlling  them.  In  fatty  degeneration  of  the  heart,  in  the 
feeble  heart  of  old  age,  and  in  general  failure  of  health  in  ]jer- 
sons  whose  weak,  small  pulso  and  peculiar  pallor  indicate 
habitual  fullness  of  the  venous  system,  nitroglycerin  is  one  of 
the  most  effective  therapeutic  agents  at  our  command. 

In  angina  pectoris,  however,  it  has  produced  the  greatest 
benefits,  and  some  consider  it  almost,  if  not  quite,  a  specific  in 
this  disease.  Pushed  to  its  physiological  effect,  it  not  only  re- 
lieves but  prevents  the  attacks,  and,  fortunately  for  the  suf- 
ferers, it  acts  so  raj)idly  that  it  may  be  taken  upon  the  first  in- 
dication of  an  approacliing  paroxysm,  and  thus  prevent  it. 

Recently  the  drug  has  been  shown  to  be  useful  in  asphyxia 
from  illuminating  gas.  Avery  {Med.  Age,  Feb.  25,  1891)  and 
Hoffman  (AUg.  med.  Centr.-Zeit.,  1891,  No.  13)  have  each  re- 
ported cases  of  gas  poisoning  in  which  it  was  efficient  after 
other  remedies  had  failed.  The  former  used  a  tenth  of  a  grain 
and  the  latter  a  sixty-fourth  of  a  grain  hypodermically.  Tliere 
were  no  unfavorable  effects  in  any  of  the  six  cases  reported, 
and  all  the  patients  made  good  recoveries.  So  far  it  has  proved 
successful  in  all  these  cases,  and  we  may  well  give  it  a  more 
extended  trial. 

In  Bright's  disease  it  is  said  to  reduce  the  amount  of  albu- 
min in  tlie  urine  ;  but  sufficient  observation  has  not  yet  been 
made  to  determine  whetherithe  total  excretion  is  diminished  or 
only  the  percentage  owing  to  the  increased  secretion  of  urine. 

In  connection  with  elaterium,  nitroglycerin  has  been  said  to 
be  useful  in  rayxoedema. 

As  with  all  powerful  agents,  its  best  effects  are  produced 
only  when  it  is  in  the  hands  of  an  accomplished  therapeutist. 
It  can  not  be  said  to  have  been  tried  until  it  has  been  pushed 
to  its  physiological  effects.  In  normal  conditions  these  are 
often  produced  by  exceedingly  small  doses,  but  in  pathological 
conditions  it  is  sometimes  remarkable  how  much  it  will  take  to 
produce  them.  Pushed  to  this  point,  it  produces  a  sense  of  full- 
ness in  the  head  and  at  the  base  of  the  brain,  singing  in  the 
ears,  and  a  sort  of  pulsation  about  the  neck  and  head,  especially 
at  the  root  of  the  nose,  as  if  epistaxis  were  threatened.  It  pro- 
duces its  maximum  effect,  according  to  Korzinsky  (Schmidt's 
Jahrbuch.,  cxciii,  p.  132),  in  fifteen  minutes,  and  should  there- 
fore bo  administered  frequently  until  its  action  is  apparent. 
Two  minims  and  a  half  of  the  one-per  cent,  solution  given  to  a 
lady  for  neuralgia  have  been  known  to  [)roduce  faintness,  pal- 
lor, stertorous  breathing,  and  unconsciousness  for  a  few  min- 


utes. She  soon  recovered  from  the  effects,  however,  and  the 
neuralgia  was  cured.  Hare,  in  his  text-book  on  therapeutics, 
says  that  no  more  than  a  fiftieth  of  a  grain  should  ever  be 
used,  hut  those  who  habitually  employ  the  drug  find  that  such 
a  dose  is  rarely  sufficient  to  produce  its  effects.  In  one  of 
the  hospitals  of  New  York  the  initial  dose  is  said  to  be  four 
minims  of  a  one-per-cent.  solution,  and  this  is  increased  every 
hour  until  the  physiological  effects  are  produced  or  relief  is 
obtained.  The  writer  has  frequently  given  twenty  minims 
of  the  one  per-cent.  solution,  and  in  one  case  gave  thirty 
minims  every  two  hours  for  seven  days  without  producing 
any  marked  physiological  effects,  but  witii  good  results  so  far 
as  recovery  was  concerned.  Brunton  says  the  dose  may  be 
gradually  increased  from  one  two-hundredth  to  one  tenth  of  a 
grain.  Huchard  employs  it  constantly  in  doses  of  a  thirtieth  of 
a  grain  and  upward,  and  Murrell  gives  as  high  as  a  fifth  of  a 
grain,  as  has  already  been  stated.  No  cases  of  death,  so  far  as 
we  can  find,  have  been  reported  from  the  therapeutic  use  of 
the  drug. 

It  will  thus  be  seen  that  those  who  have  obtained  the  best 
results  from  this  drug  have  used  it  in  larger  doses  than  is  gen- 
erally supposed.  A  minim  of  the  one-per-cent.  solution  is  the 
ordinary  initial  dose.  This  should  be  repeated  every  half-hour, 
and,  if  no  effects  are  produced  by  three  doses,  it  should  be  in- 
creased one  drop  every  hour  until  they  are.  The  drug  is  not 
cumulative,  and  its  toxic  effects  are  so  marked  that  there  is 
little  danger  of  their  being  overlooked.  In  all  the  cases  in 
which  these  symptoms  have  been  reported  as  alarming  the  pa- 
tients were  promptly  relieved  by  alcoholic  stimulation.  Those 
who  have  had  experience  with  the  drug  in  gas  asphyxia  advise 
beginning  with  moderately  large  doses — a  fiftieth  of  a  grain  or 
more. 

AMUSIA. 

The  term  amusia,  recently  introduced  into  medical  nomen- 
clature, may  be  said  to  denote  with  regard  to  the  musical 
faculty  about  what  the  word  aphasia,  in  its  most  comprehen- 
sive use,  imports  with  regard  to  the  faculty  of  speech.  Some 
interesting  examples  of  loss  or  impairment  of  the  ability  to  pro- 
duce or  to  comprehend  music  are  on  record,  and  a  condensed 
account  of  the  more  important  observations  bearing  on  the  sub- 
ject is  given  in  a  revue  generate,  by  Dr.  Paul  Blocq,  published  in 
the  Gazette  hebdomadaire  de  medecine  et  de  chirurgie  for  Feb- 
ruary 25th. 

Aphasia  is  not  always  accompanied  by  amusia,  as  was  men- 
tioned by  Bouillaud  so  long  ago  as  in  1865.  There  is  a  weD- 
known  story  of  a  certain  apheraic  who  sang  the  Marseillaise 
with  the  only  articular  sound  that  he  could  make,  and  Bernard 
speaks  of  an  aphasic  who  sang  that  melody  and  the  Parisienne 
with  the  substitution  of  tan,  tan,  tan  for  their  proper  words. 
Proust  had  a  patient  who  could  write  music,  although  incapa- 
ble of  reading  it.  A  still  more  curious  case  was  recorded  by 
Grasset  in  1878,  that  of  an  officer  who,  while  he  could  articulate 
only  pardi  and  1)  in  his  attempts  to  speak,  could  sing  the  wordf 
of  the  first  verse  of  the  Marseillaise  with  the  utmost  correct- 


March  25,  1893.] 


MINOR  PARAGRAPHS. 


333 


nes9.  Charcot's  authority  is  given  to  the  story  of  a  trom- 
bone-player wlio  lost  his  capability  of  performing  on  the  in- 
strument, although  lie  had  ])reservec]  all  bis  other  faculties. 

Blocq  credits  Knoblauch  with  having  established  the  au- 
tonomy of  such  a  pathological  state  as  arausia  in  1888.  In  1891 
Wallaschek  made  an  important  classification  of  the  varieties  of 
amusia,  distinguishing  motor  amusia,  in  which  the  patient 
comprehends  music,  but  has  lost  the  power  of  singing;  sensory 
amusia,  in  which  the  subject  can  no  longer  distinguish  sounds; 
paramusia,  in  which  the  subject  sings,  but  with  mistakes  in 
time  and  note;  musical  agraphia,  or  loss  of  the  power  to  write 
notes;  musical  alexia,  loss  of  the  ability  to  read  music;  and 
musical  amiraia,  loss  of  the  power  of  playing  on  an  instrument. 
Blocq,  like  Onanoff,  adopts  an  analogous  classification,  distin- 
guishing a  receptive,  or  sensory,  amusia  and  a  motor,  or  expres- 
sional,  amusia,  the  former  including  auditory  amusia  and  mu- 
sical alexia,  and  the  latter  comprising  true  amusia  (loss  of  the 
power  of  singing),  musical  amimia,  and  musical  agraphia.  True 
sensory  amusia  may  be  termed  musical  deafness,  and  musical 
alexia  may  be  called  musical  blindness. 

Concerning  the  pathological  significance  of  amusia  almost 
everything  is  yet  to  be  learned,  but  it  is  certain  that  Blocq  has, 
by  his  analysis  of  the  data  now  in  our  possession,  done  much 
to  facilitate  the  necessary  investigation. 


MINOR  PARAGRAPHS. 

THE  TREATMENT  OF  CHOLERA. 

The  Gazette  des  hopitaux  for  Februarj'  25th  contains  a  cyclo- 
paedic article  on  this  subject  by  one  of  the  hospital  physicians 
of  Paris,  Dr.  L.  Galliard.  Summarizing,  in  conclusion,  he  says 
that  ill  slight  cases,  cases  of  cholera  leger,  rest  in  bed  and  absti- 
nence from  so.id  food  are  almost  all  that  is  required.  In  grave 
cases,  however,  the  precursory  diarrhoea  should  be  treated  ener- 
getically. If  this  diarrhoea  can  not  be  cut  short,  no  time  should 
be  wasted  in  trying  opium  or  such  feeble  antiseptics  as  the  salts 
of  bismuth,  for  example,  but  recourse  sbould  be  had  at  once  to 
one  of  the  two  remedies  which  commend  themselves  to  our  con- 
fidence. These  are  calomel  and  lactic  acid.  They  should  not 
both  be  used,  but  one  or  the  other  be  chosen.  If  it  is  calomel, 
acid  drinks  are  to  be  avoided.  If  there  is  a  tendency  to  collapse 
and  cyanosis,  hot  baths  are  to  be  employed,  together  with  fric- 
tions, subcutaneous  injections  of  ether  and  caiFeine,  and  inhala- 
tions of  oxygen.  If  there  is  algid  collapse,  with  the  radial  pulse 
imperceptible,  transfusion  should  be  used.  The  proper  drinks 
are  iced  aerated  waters,  champagne  diluted  with  water  and  iced, 
and  very  weak  iced  coffee.  Neither  milk,  nor  soup,  nor  alcohol 
should  be  given  before  the  stage  of  reaction.  Tea  often  causes 
vomiting.  If  the  use  of  milk  and  other  alimentary  substances 
is  allowed  too  soon,  the  danger  of  relapse  is  incurred.  The  use 
of  ass's  milk  is  of  service  in  the  gastric  irritability  of  convales- 
cents ;  so  is  that  of  pe[)tonized  enemata.  In  spite  of  their  im- 
patience, convalescents  must  be  kept  in  bed  for  a  long  time. 


THE  TEUCRINE  TREATMENT  FOR  LOCAL  TUBERCULOSIS. 

AoooEDiNG  to  the  Medical  Week,  at  a  recent  meeting  of  the 
Vienna  Medical  Club  Professor  von  Mosetig-Moorhof  described 
a  new  treatment  for  local  tuberculosis  by  injections  of  an  ex- 
tract of  Teucrium  soordium  (water-germander),  to  which  ho  has 


given  the  name  of  teucrine.  The  extract  is  prepared  from  the 
dried  plant  by  lixiviation  with  hot  distilled  water,  the  liquid  be- 
ing evaporated  to  the  consistence  of  honey,  then  repeatedly 
washed  with  alcohol,  and  concentrated  until  its  specific  gravity 
reaches  ri50.  Teucrine  is  a  brownish-black  liquid  having  an 
acid  taste  and  a  cabbage-like  odor.  It  has  an  acid  reaction  and 
is  soluble  in  water.  It  contains  certain  sulphates,  especially  cal- 
cium sul[)hate.  Administered  internally  in  doses  of  eight  grains, 
it  excites  the  appetite  and  acts  as  a  stomachic  tonic.  The  reac- 
tion produced  by  the  subcutaneous  injection  of  this  extract  is 
both  general  and  local,  the  former  being  manifested  by  a  rise  of 
temperature  that  may  reach  101"3°  to  104°  F.  and  is  often  pre- 
ceded by  a  rigor.  The  site  of  the  injection  becomes  red,  pain- 
ful, and  oedematous.  The  therapeutical  effects  vary  according 
to  the  presence  or  absence  of  caseous  degeneration  in  the  tuber- 
cular manifestation.  "With  the  first  condition  the  injection  gives 
rise  to  an  acute  inflammation  followed  by  i-apid  breaking  down 
and  destruction  of  the  affected  tissues ;  with  the  second,  the 
tuberculous  material  becomes  absorbed.  A  cold  abscess  is  trans- 
formed into  an  acute  abscess  iu  forty-eight  hours,  and  may  be 
cured  in  from  eight  to  ten  days  provided  it  is  not  connected  with 
diseased  bone.  In  the  latter  case  a  fistula  forms  that  is  healed 
more  .slowly.  These  results  are  usually  obtainable  by  a  single 
injection  of  forty-five  minims  of  teucrine,  and  the  cure  is  perma- 
nent in  von  Mosetig-Moorhof's  experience.  The  same  effect  is 
produced  in  acute  or  chronic  adenitis  by  a  single  injection,  the 
inflammation  gradually  subsiding  if  the  glands  are  not  caseous. 
Favorable  results  have  also  been  obtained  in  lupus  and  in  ac- 
tinomycosis. 


POTASSIUM  IODIDE  IN  THE  TREATMENT  OF 
ACTINOMYCOSIS. 

In  a  government  report  prepared  by  Dr.  D.  E.  Salmon,  of 
the  Bureau  of  Animal  Industrj',  there  are  recorded  very  favor- 
able results  of  the  use  of  potassium  iodide  in  the  "lumpy-jaw  " 
of  cattle.  Ordinarily,  where  there  is  a  hard  tumor  as  large  as 
a  hen's  egg,  it  will  subside  within  two  or  three  weeks  under  the 
action  of  about  150  grains  of  the  iodide  daily.  The  employ- 
ment of  the  remedy  need  not  be  continued  until  the  disease  has 
wholly  disa])peared ;  when  the  tumor  has  shrunk  to  about  a 
third  of  its  original  volume  the  work  of  cui'e  will  go  on  without 
the  further  administration  of  the  drug.  The  treatment  is  the 
most  efficacious  when  decided  iodism  is  produced. 


STUDENTS'  EXPENSES  AT  HARVARD. 

The  secretary  of  Harvard  University,  Mr.  Frank  Bolles,  has 
issued  a  pamphlet  consisting  of  a  collection  of  letters  from 
undergraduates,  graduates,  and  professional-school  students, 
"  describing  in  detail  their  necessary  expenses  at  Harvard  Uni- 
versity," together  with  an  introduction  in  which  many  of  the 
statements  made  in  an  address  by  Professor  George  H.  Palmer 
in  1887  are  so  supplemented  as  to  make  them  apply  to  the 
present  time.  Only  one  of  the  letters  seems  to  have  been  writ- 
ten by  a  medical  student.  That  gentleman's  entire  expenses 
for  the  year  1891-'92  were  $337.60.  He  adds  that  he  would 
not  advise  any  other  person  to  make  the  attempt  at  quite  so  low 
a  figure,  but  that  from  $300  to  $350  should  make  one  quite 
comfortable. 


ADDISON'S  DISEASE  WITHOUT  LESION  OF  TUK 
SUPRARENAL  CAPSULES. 

At  a  recent  meeting  of  the  Societe  des  sciences  medicales  de 
Lyon,  repoi  ted  iu  Lyon  medical  for  February  26th,  M.  Koux,  a 
hospital  interne,  presented  some  specimens  from  the  body  of  n 


334 


MINOR  PARAORAPHS. 


[N.  Y.  Med.  Joub., 


man  who  had  died  of  tuberculosis  after  having  shown  abundant 
sifrns  that  he  was  the  subject  of  Addison's  disease.  The  tuber- 
culosis was  found  to  affect  tlie  cervical  lyini)hatic  glands,  the 
larynx,  and  the  peritontoum,  but  not  the  lungs.  The  suprarenal 
capsules  appeared  absolutely  healthy,  although,  on  section, 
some  diminution  of  their  medullary  substance  was  observed. 
Tlie  left  semilunar  ganglion  was  so  imbedded  in  adhesions  that 
it  was  impossible  to  extricate  it,  and  the  case  was  thought  to 
favor  the  theory  of  the  nervous  origin  of  Addison's  disease. 


PRURIGO  SECANDI. 

This  affection,  ihefarie  operatoire  of  the  French,  is  said  to 
be  more  prevalent  in  France  than  elsewhere  at  present.  Sev- 
eral well-known  surgeons  of  that  country  have  deplored  it  in 
the  New  York  Herald,  presumably  the  Paris  edition,  according 
to  the  British  Medical  Journal's  Paris  correspondent.  Pro- 
fessor Le  Fort  says  that  the  young  French  surgeons  arc  accus- 
tomed to  seek  out  some  operation  unknown  in  France,  and 
then  search  for  a  victim  on  whom  to  perform  it,  in  order  that 
they  may  report  the  case  before  a  medical  society  and  perhaps 
show  the  patient.  Thereupon  they  take  up  the  operation  as  a 
specialty,  perform  it  on  a  hundred  or  two  hundred  pati"ents, 
and  thus  gain  a  reputation.  Professor  Verneuil  thinks  this 
practice  is  j>articularly  prevalent  among  callow  gynaecologists. 


BENZOSOL  AS  A  REMEDY  FOR  DIABETES. 

The  Lancefs  Vienna  correspondent  says  that  benzosol,  or 
benzoylguaiacol,  has  lately  been  recommended  by  a  Cracow 
physician  as  a  very  useful  remedy  in  diabetes  mellitus.  From 
fifteen  to  forty-five  grains  are  to  be  given  daily.  Professor  von 
Jaksch  is  cited  as  reporting  a  case  in  which  the  use  of  the  drug 
was  followed  by  the  cessation  of  glycosuria,  but  caution  in  its 
employment  is  evidently  necessary,  for  the  patient  spoken  of 
by  von  Jaksch  is  reported  to  have  died  in  consequence  of  a  toxic 
enteritis  attributed  to  its  action.  Moreover,  a  Vienna  chemist 
is  said  to  have  stated  that  it  renders  diabetic  urine  laevorotary, 
and  thus  tends  to  vitiate  polariscopic  examinations  of  such  urine. 


THE  COMMUNICATION  OF  MORBID  MENTAL  CONDITIONS  TO 
ANIMALS. 

At  a  recent  meeting  of  the  Paris  Soci6t6  de  biologic,  report- 
ed in  the  Progrh  medical  for  March  4th,  M.  Fer6  spoke  of  some 
curious  cases  of  folic  communiquee  in  dogs  of  degenerate  races 
which,  living  with  mistresses  affected  with  certain  forms  of  in- 
sanity, had  adopted  their  morbid  emotional  conditions.  For  ex- 
ample, they  had  become  agoraphobic,  and  no  longer  dared  to 
cross  a  street,  and  they  could  not  endure  certain  odors.  This 
communicated  mental  state  had  been  quite  similar  to  that  ob- 
served in  man,  and  had  been  cured  by  the  same  treatment — 
isolation. 


EPIDERMIN. 

AoooKDiNG  to  the  American  Therapist,  this  is  the  name  of 
a  bland  liquid,  of  unknown  composition,  the  watery  part  of 
which  evaporates  when  it  is  applied  to  a  part,  leaving  a  pro- 
tective film.  A  very  satisfactory  substitute  may,  it  is  said,  be 
made  with  equal  parts  of  white  wax,  powdered  acacia,  glycerin, 
and  distilled  water.  The  wax  is  melted,  and  the  acacia  is  tritu- 
rated with  it  in  a  warm  mortar;  then  the  glycerin  and  water 
are  mixed  and  heated  to  the  boiling  point,  the  mixture  is  added 
to  the  wax  and  acacia,  and  the  whole  is  stirred  until  it  has 
<ooled. 


THE  ITSE  OF  PURGATIVES  IN  NURSING  WOMEN. 

In  the  March  number  of  the  Practitioner  Dr.  William  J.  Gow 
alludes  to  a  popular  impression  that  purgatives  administered  to 
a  nursing  woman  often  lead  to  disturbance  of  the  suckling's 
bowels,  gives  a  condensed  account  of  his  own  ex[)eriment8  with 
several  of  the  ordinary  j)urgatives,  and  expresses  his  conclusion 
that  magnesium  sulphate  administered  to  a  nursing  woman  fre- 
quently causes  looseness  in  the  child,  while  senna,  cascara  sa- 
grada,  and  aloes  rarely  have  that  effect. 


OOPHORECTOMY  AS  A  REMEDY  FOR  OSTEOMALACIA. 

The  Gazette  hehdomadaire  de  medecine  et  de  chirurgie  for 
March  11  th  makes  brief  mention  of  a  report  of  two  cases,  pub- 
lished by  Dr.  Stern  in  the  Munchenermedicinische  Wochenschrift, 
1893,  No.  6,  of  puerperal  osteomalacia  in  women,  aged  respect- 
ively twenty-seven  and  thirty -one  years,  in  which  a  radical  cure 
was  effected  by  means  of  oophorectomy.  The  ovaries  showed 
no  abnormity,  but  the  vascularity  of  the  annexa  was  extreme 
and  the  vessels  were  as  mucli  developed  as  in  women  at  the 
close  of  pregnancy. 

THIONAL  AS  A  HYPNOTIC. 

In  the  March  number  of  the  Journal  of  Nervous  and  Men- 
tal Disease  there  is  a  summary  of  an  account  given  by  Dr.  Brie, 
of  Bonn,  in  the  Neurologisches  Centralblatt,  1892,  No.  2.5,  of 
his  experience  with  trional.  In  forty-two  cases  of  insanity  he 
has  given  360  doses  ranging  from  fifteen  to  forty-five  grains. 
He  believes  it  to  be  the  best  of  hypnotics,  being  almost  taste- 
less, easily  administered,  acting  rapidly,  and  rarely  giving  rise 
to  unpleasant  after-effects.  Its  use  is  indicated  in  simple  in- 
somnia and  in  that  of  insanity  with  restlessness  and  excite- 
ment. 

ELECTRICAL  ILLUMINATION  OF  THE  MOUTH. 

According  to  the  Medical  Press  and  Circular  for  February 
22d,  Mr.  N.  Stevenson  has  found  that  when  an  incandescent 
light  is  introduced  into  the  mouth,  for  the  purpose  of  ascertain- 
ing by  translumination  the  condition  of  the  maxillary  antra, 
this  introduction  of  light  "  by  a  back  door,  as  it  were,"  has  not 
the  effect  of  causing  the  pupils  to  contract,  although  to  the  ob- 
server the  pupillary  orifices  appear  as  blood-red  apertures.  The 
author  suggests  that  this  observation  Tuay  come  to  have  some 
ophthalmological  significance. 


METHYLENE  BLUE  IN  MALARIAL  DISEASE. 

AcooEDiNG  to  the  Medical  Weelc  for  February  10th,  Dr. 
Guttmann  stated  at  a  recent  meeting  of  the  Berlin  Medical  So- 
ciety that  the  failures  that  bad  been  reported  of  any  therapeutic 
action  of  methylene  blue  in  malarial  disease  had  possibly  been 
due  to  the  use  of  an  impure  preparation  of  that  drug.  He  said 
that  in  doses  of  a  grain  and  a  half,  administered  in  capsules 
every  two  hours  and  continued  for  at  least  four  weeks,  there 
would  be  a  reduction  in  the  size  of  the  spleen  and  relief  of  the 
malarial  symptoms. 

PROLAPSE  OF  THE  PLACENTA. 

The  Mercredi  medical  for  March  8th  gives  a  summary  of  an 
account  by  Dr.  Feinberg,  published  in  the  Centralblatt  fur 
Gyniikologie,  1893,  No.  5,  of  a  case  of  prolapse  of  a  normally 
imi)lanted  placenta.  The  prolapse  occurred  immediately  on  the 
rupture  of  the  membranes,  but  the  author  was  not  called  to  the 
case  until  an  hour  later,  when  the  child  was  dead.  The  pla- 
centa was  normal,  and  the  mother  had  always  been  healthy. 


March  25,  1893.] 


ITEMS.— LETTERS 


TO  THE  EDITOR. 


335 


ITEMS,  ETC. 

Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Uealth  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  Marcli  21,  1893  : 


DISEASES. 

Week  ending  Mar.  14. 

Week  ending  Mar.  21. 

Cases. 

Deaths. 

Cases. 

Deaths. 

11 

4 

10 

5 

24 

21 

8 

158 

21 

161 

12 

0 

12 

5 

118 

<» 

111 

V 

103 

41 

97 

50 

10 

2 

6 

2 

Meetings  of  State  Medical  Societies  for  the  Month  of  April. — Flori- 
da Medical  A.ssociation,  Jacksonville,  4th ;  Medical  A.ssociation  of  the 
State  of  Alabama,  Tuscaloosa,  8th ;  Medical  Society  of  the  State  of 
Tennessee,  Nashville,  11th  ;  Medical  Society  of  the  State  of  California, 
San  Francisco,  18th;  Medical  Association  of  Georgia,  Americus,  19th  ; 
Mississippi  State  Medical  Association,  Jackson,  19th;  Medical  Assoeia. 
tion  of  Montana,  Great  Falls,  19th  ;  Medical  and  Chirurgical  Faculty  of 
Maryland,  Baltimore,  25th  ;  South  Carolina  Medical  Association,  George- 
town, 28th. 

Salts  and  Senna  mitigated. — Lyon  medical  gives  the  following 
formula:  Infuse  10  parts  of  senna  and  15  parts  each  of  magnesium 
sulphate  and  roasted  coffee  in  120  parts  of  boiling  water,  strain,  and 
sweeten. 

The  Richmond,  Va.,  Academy  of  Medicine  and  Surgery. — At  the 

next  meeting,  on  Tuesday  evening,  the  28th  inst.,  Dr.  William  J.  Gor- 
don is  to  read  a  paper  on  Transfusion,  and  Dr.  Landon  B.  Edwards  is 
to  open  a  discussion  on  The  Management  of  Abortion. 

Cook  County  Hospital,  Chicago. — At  the  recent  annual  competitive 
examination  for  the  positions  of  interne  at  this  institution  eight  posi- 
tions were  secured  by  E.  H.  Tinen,  F.  A.  McGrew,  R.  B.  Oleson,  J.  .1. 
Claussen,  G.  W.  Skinner,  T.  J.  Williams,  T.  P.  Findley,  and  T.  A.  Olney, 
in  the  order  named. 

The  Long  Island  College  Hospital. — The  annual  commencement 
exercises  were  held  in  the  Brooklyn  Academy  of  Music  on  Wednesday 
evening,  the  22d  inst.  The  programme  announced  an  address  by  Dr. 
Alexander  Hutchins. 

The  Death  of  Dr.  Laurence  Johnson  took  place  on  Saturday,  the 
18th  inst.,  as  the  result  of  pneumonia.  The  deceased,  who  was  in  the 
forty-eighth  year  of  his  age,  was  iin  esteemed  practitioner  and  known 
as  an  accomplished  botanist. 

The  Death  of  Dr.  Frank  Harold  Ingram  took  place  on  Friday,  the 
17th  inst.,  from  angina  pectoris.  The  deceased  was  a  promising  prac- 
titioner.   At  the  time  of  his  death  he  was  only  thirty-three  years  old. 

Society  Meetings  for  the  Coming  Week : 

Monday,  March  27ih :  Medical  Society  of  the  County  of  New  York ; 
Boston  Society  for  Medical  Improvement;  Lawrence,  Mass.,  Medical 
Club  (private) ;  Cambridge,  Mass.,  Society  for  Medical  Improve- 
ment ;  Baltimore  Medical  Association. 

Tuesday,  March  28th:  New  York  Academy  of  Medicine  (Section  in 
Laryngology  and  Rhiuology) ;  New  Yoi  k  Dermatological  Society 
(private) ;  New  York  Otological  Society  (private) ;  BulTalo  Obstetri- 
cal Society  ;  Medical  Society  of  the  County  of  Lewis  (([uarterly), 
N.  Y. ;  Boston  Society  of  Medical  Sciences  (private) ;  Richmond,  \'a., 
Academy  of  Medicine  and  Surgery. 

Wednesday,  March  29th :  Auburn,  N.  Y.,  City  Medical  Association  ; 
Berkshire,  Mass.,  District  Medical  Society  (Pittsfield). 

Saturday,  April  Id :  (Jlinical  Society  of  the  New  York  Post-graduate 
Medical  School  and  Ilospital ;  Manhattan  Medical  and  Surgical  So- 
ciety (private) ;  Miller's  River,  Mass.,  Medical  Society. 


Answers  to  Correspondents : 

No.  398. — Any  wholesale  grocer  ought  to  be  able  to  furnish  you 
with  both  articles. 

iVo.  399. — The  president  of  the  association  is  Dr.  Daniel  Lewis,  No. 
249  Madison  Avenue. 


THE  QUESTION  OF  INFECTED  RAGS. 

New  York,  March  21,  189S. 
To  the  Editor  of  the  New  Yorh  Medical  Journal  : 

Sir:  I  have  read  with  much  interest  the  report  of  Dr.  Paul 
Gibier,  reprinted  in  your  issue  of  Marcli  18th  from  the  New 
York  Herald  of  March  9th,  giving  the  result  of  his  bacteriologi- 
cal examination  of  certain  rags.  Dr.  Gibier's  report  is  inter- 
esting to  the  non-professional  man  because  it  states  in  logical 
order,  with  admirable  conciseness  and  in  language  of  pre- 
cision, the  various  steps  and  noted  results  of  a  scientific  process. 

In  conclusion,  Dr.  Gibier  appends  his  deductions :  1.  That 
the  rags  probably  came  from  a  hospital  or  dispensary,  that  they 
were  soiled  with  pathological  liquids,  and  that  they  had  not  been 
subjected  to  effective  disinfection.  2.  That  the  number  of  liv- 
ing germs  in  the  two  grammes  examined  was  not  less  than  four 
hundred  million. 

I  should  like  to  call  attention  to  the  admirable  scientific 
caution  of  Dr.  Gibier.  The  Herald  put  above  his  report  the 
headline  Bacteria  Found  in  German  Rags.  Dr.  Gibier,  it  will 
be  observed,  declines  to  assume  any  responsibility  as  to  the 
origin  of  the  rags.  In  his  report  he  certifies  merely  that  "  on 
January  5th  I  received  for  bacteriological  examiuation  a  sealed 
envelope  which  contained  some  fragments  of  rags  as  coming  from 
Bremen,  Germany,  on  the  steamship  State  of  Alabama,  Decem- 
ber 10,  1892."  That  is,  the  rags  were  alleged  to  be  of  German 
origin. 

I  beg  leave  to  point  out,  in  the  absence  of  any  evidence  that 
the  rags  in  question  ever  came  from  Germany  or  were  a  part  of 
the  Alabama  cargo,  that  the  result  of  Dr.  Gibier's  examination 
has  no  bearing  in  determining  questions  of  sanitary  policy  with 
regard  to  the  importation  of  rags  or  in  respect  to  the  efficiency 
of  disinfecting  processes  now  in  use.  As  there  is  no  testimony 
concerning  the  history  of  the  rags,  the  question  of  their  origin 
opens  up  a  wide  field  for  curious  conjecture. 

Permit  me  to  append  the  following  comment  upon  this  ex- 
amination by  Deputy  Surgeon-General  Sternberg,  of  the  United 
States  Army : 

"  I  have  carefully  read  Dr.  Gibier's  report,  and  iiave  no 
doubt  that  he  found  the  various  bacteria  desci'ibed  by  him  in 
the  sample  of  rags  submitted  to  him  for  examination,  but  he  does 
not  claim  to  have  found  any  specific  disease  germ.  The  kind  of 
bacteria  he  describes  are  constantly  found  on  the  surface  of  the 
bodies  of  healthy  persons.  Millions  of  similar  bacteria  are  at- 
tached to  the  soiled  underclothing  sent  to  the  wash  by  the  must 
cleanly  persons.  It  is  safe  to  assert  that  Dr.  Gibier  would  have 
obtained  the  same  results  from  rags  picked  up  anywhere  in  this 
city."  Augustine  Smhii. 


THE  SKILLED  WITNESS  IS  ENTITLED  TO  A  FEE. 

Meadvim.h,  Pa.,  March  1,  1893. 
To  the  Editor  of  the  New  Yorh  Medical  Journal: 

Sir  :  In  the  trial  of  Dr.  E.  0.  Quimby  yesterday  for  malprac- 
tice in  treating  a  fracture  of  the  olecranon  and  of  the  neck  of 
the  radius,  in  the  Crawford  County  Court,  in  which  Dr.  Quitnby 


/ 


336  PROGEEDINOS 

was  acquitted,  Dr.  Theodore  J.  Young,  of  Titusville,  Pa.,  was 
called  by  tlie  prosecution  as  an  expert  witness. 

After  the  doctor  had  answered  the  preliminary  questions  as 
to  his  graduation,  length  of  time  in  practice,  etc.,  the  plaintiff's 
attorney  requested  him  to  examine  the  young  man's  arm  and 
state  to  the  Court  and  jury  his  opinion  of  the  case.  Dr.  Young 
promptly  answered  :  "I  decline  to  examine  the  arm." 

As  he  was  leaving  the  witness  stand  the  plaintiff's  attorney 
asked  him  to  give  the  Court  his  reasons  for  refusing  to  examine 
the  case.  He  said :  "  Mr.  Richmond,  I  am  an  expert.  I  have  given 
years  of  hard  study  to  acquire  my  medical  knowledge  and  have 
spent  much  money,  and  I  decline  to  be  brought  here  to  give 
testimony  without  an  expert's  fee."  The  doctor  then  left  the 
court  room. 

The  doctor's  refusal  to  testify  in  this  case  should  meet  with 
the  approval  of  all  fair-minded  men,  and  I  have  written  out  an 
account  of  this  case  to  let  it  be  still  more  widely  known  among 
medical  men  that  they  can  refuse  to  testify  in  Court  in  cases 
where  they  have  not  received  a  fee  before  they  go  on  the  wit- 
ness stand  which  shiiU  compensate  them  for  the  time  they  shall 
spend  in  giving  expert  testimony. 

W.  D.  IJamakee,  M.  D. 


Jrocccbings  of  Sonctics. 

NEW  YORK  NEUROLOGICAL  SOCIETY. 

Meeting  of  March  7,  1803. 

The  President,  Dr.  M.  Allen  Stark,  in  the  Chair. 

Clonic  Spasm  of  the  Muscles  of  Mastication.— Dr.  Frkd- 
EKiOK  Peterson  presented  a  woman,  aged  fifty-seven,  who  six 
years  before  liad  had  all  her  upper  teeth  removed  and  artificial 
ones  put  in.  The  first  set  did  not  fit  well,  and  a  new  one  was 
substituted.  The  work  about  the  moutli,  and  the  necessity  for 
keeping  her  mouth  open  for  long  periods  of  time  while  she  was 
in  the  dentist's  chair,  resulted  in  the  development  of  this  spasm. 
"When  she  was  sitting  quietly,  not  using  the  jaw  muscles,  there 
was  a  continuous  clonic  spasm  of  the  masseters.  temporals,  and 
pterygoids.  Tlie  jaw  opened  and  shut  slightly  and  moved 
from  side  to  side.  She  was  tired  and  worn  out  with  trying  to 
keep  her  teeth  together.  The  chief  difficulty,  however,  was 
when  she  attempted  to  speak;  then  the  mouth  opened  wide 
and  there  was  a  subluxation  of  the  jaw  downward  and  forward 
from  the  glenoid  cavity.  During  the  first  six  months  the 
mouth  would  not  close  at  all,  except  at  night,  when  the  spasm 
relaxed. 

Dr.  Peterson  said  that  while  tonic  spasm  of  the  masticatory 
muscles  or  trismus  was  quite  a  common  symptom,  the  condi- 
tion presented  in  this  case  was  very  rare.  As  regarded  treat- 
ment, atropine,  hyosoine,  conium,  and  electricity  had  been  used 
perseveringly  without  any  s[)ecial  effect.  Latterly  sulphate  of 
duboisine,  in  doses  of  one  two-hundredth  of  a  grain,  three  times 
daily,  had  afforded  mucli  relief  by  quieting  the  spasmodic  move- 
ments almost  wholly  at  times.  In  addition  she  wore  an  ap- 
paratus made  especially  for  her,  which  kept  her  jaw  closed 
and  allowed  her  to  talk  between  her  teeth  without  the  uncom- 
fortable tonic  spasm  of  the  depressors  of  the  jaw,  although  the 
clonic  movements  of  tiio  masseters  and  pterygoids  might  keep 
on  as  before.  The  movements  ceased  at  night.  The  affection 
had  lasted  nearly  seven  years. 

Dr.  William  M.  Leszynsky  had  soon  a  case  of  clonic  spasm 
of  both  platysmata  following  prolonged  work  upon  the  patient's 


OF  SOCIETIES.  [N.  Y.  Med.  Joub., 

lower  jaw  by  a  dentist.  The  spasm  in  that  cmso  lasted  only  three 
or  four  days.  Slight  spasm  of  the  jaw  muscles  after  dental  op- 
erations was  not  uncommon. 

Rhytlimical  Spasm  of  the  Limbs. — Dr.  Edward  D.  Fishbe 
presented  a  woman,  aged  forty-three,  who,  having  always  be- 
fore enjoyed  good  health,  had  begun  about  a  year  before  to 
have  attacks  of  rhythmical  spasm  of  the  limbs.  The  spasm  was 
sometimes  confined  to  one  or  hoi\  arms  or  to  the  lower  ex- 
tremities, but  the  motion  sometimes  involved  all  the  limbs  at 
the  same  time.  Tlie  attacks  came  on  spontaneously  and  lasted 
about  five  minutes.  A  number  of  such  attacks  might  occur 
during  the  day,  or  she  might  remain  free  from  them  for  a  day 
or  two.  The  muscles  were  becotuing  more  rigid  and  it  was 
very  difficult  to  bend  the  elbow  or  move  the  arm.  Tlie  woman 
had  no  general  symptoms,  but  complained  of  fatigue.  The 
muscles  of  the  arm  were  becoming  decidedly  developed.  Va- 
rious methods  of  treatment,  hypnotism  included,  had  been  em- 
ployed without  apparent  effect.  Under  hyy)notism  she  had  had 
all  four  extremities  moving  violently.  Her  sight  was  appar- 
ently normal.  It  seemed  to  be  impossible  for  her  to  control 
the  spasm.  There  was  no  analgesia.  The  speaker  considered 
hysteria  to  be  the  basis  of  the  attacks. 

Dr.  Peterson,  in  reply  to  a  question,  said  he  did  not  think 
that  duboisine  would  prove  of  much  value  in  this  case,  which 
was  probably  hysterical. 

Dr.  Mary  Potnam  -Tacobi  referred  to  cases  of  head-jerking 
in  children.  The  rhythmical  movements  sometimes  seen  in 
such  cases  she  considered  rather  analogous  to  those  in  the  case 
presented. 

Innervation  and  the  Functions  of  the  Sympathetic 
Nerves. — Dr.  J.  E.  Culver  read  a  paper  with  this  title.  He 
reviewed  at  length  the  distribution  and  functions  of  the  sympa- 
thetic nervous  system,  and  traced  the  relationship  between  its 
disturbed  action  and  interference  with  respiration,  oxidation  of 
the  blood,  and  other  physiological  processes. 

Basedow's  Disease. — Dr.  William  H.  Thomson  read  a  paper 
on  this  subject.  He  began  by  stating  that  the  progress  of  pa- 
thology often  illustrated  the  disadvantage  of  the  premature 
naming  of  diseases  after  some  of  their  common  or  prominent 
symptoms,  for  further  knowledge  might  show  a  disease  to  have 
much  wider  relationships  than  had  at  first  been  suspected,  and 
in  some  cases  to  exist  without  these  symptoms  being  present. 
If  such  was  the  case,  the  symptomatic  name  might  then  operate 
to  prevent  a  correct  diagnosis.  The  name  exophthalmic  goitre 
had  had  much  influence  in  preventingthe  i-ecogniiion  of  Graves's 
disease  in  many  instances,  and  still  more  in  confusing  the  views 
of  its  pathology.  In  reading  the  numerous  contributions  on  the 
pathology  of  this  interesting  affection,  it  was  striking  to  note 
how  predominantly  the  conception  of  some  textural  lesion  in 
the  nervous  system  that  would  account  for  the  exophthalmia 
and  the  goitre  had  diverted  either  the  investigation  or  the  specu- 
lation, in  seeming  forgetfulness  of  the  fact  that  these  symptoms 
were  not  essential  to  the  affection,  because  they  might  both  be 
present  with  Graves's  disease  absent,  or  both  absent  with  Graves's 
disease  present.  The  safest  rule  to  follow  in  pathological  prob- 
lems was  to  seek  first  for  the  most  constant  characteri.stics  of  a 
given  complaint,  rather  than  for  the  most  obtrusive  ones.  Thus 
the  most  uniform  condition  in  Graves's  disease  was  what  might 
correctly  be  described  as  a  state  of  marked  agitation.  In  many 
instances  it  was  for  a  long  time  a  purely  physical  state,  not  in- 
volving the  mind  or  the  spirits,  and  yet  the  patient  acted  as  if 
greatly  alarmed  about  something.  This  had  led  many  writers 
to  pronounce  fright  to  be  a  leading  cause  of  the  disease.  We 
wei'c  thus  at  the  outset  diverted  from  the  study  of  a  truly  char- 
acteristic condition  to  that  of  a  mere  occasional  element  in  the 
clinical  history  of  the  affection.    While  fright  might  be  the  oc- 


March  25,  1893.] 


PROCEEDINGS  OF  SOCIETIES. 


337 


oasion  of  the  first  manifestation  of  chorea  or  of  Graves's  disease, 
a  blow  the  occasion  of  the  development  of  a  mammary  cancer, 
etc.,  it  was  only  a  hindrance  to  our  progress  toward  a  correct 
pathology  of  these  diseases  to  put  down  any  one  of  the  varying 
occasions  of  their  first  manifestation  as  their  cause. 

Dr.  Thomson  then  gave  the  histories  of  his  last  eight  con- 
secutive cases  of  Graves's  disease  in  private  practice.  In  none 
of  these  cases  had  fright  or  any  other  emotion  been  an  element 
of  the  clinical  history.  With  two  exceptions,  the  patients  h;id 
been  unusually  free  from  causes  of  mental  strain  or  depression. 
Exophthalmia  and  goitre  had  been  wholly  absent  in  one  of  these 
eight  cases.  Exophthalmia  alone  had  been  absent  in  live. 
Goitre  hsd  been  absent  in  one,  while  in  another  it  had  been  only 
slight  and  had  occurred  late  in  the  disease.  Both  exophthalmia 
and  goitre  had  been  marked  in  only  one  ca^^e.  In  all  the  cases 
there  had  been  pronounced  tachycardia  and  muscular  tremor. 
Emaciation  had  been  marked  in  five  and  moderate  in  three.  In 
four  imperfect  inspiratory  power  had  been  noticed. 

The  rapid  heart  action  and  the  muscular  tremor  were  the 
first  symptoms  to  develop  in  this  disease  and  the  last  to  disap- 
pear, and  together  they  constituted  the  most  invariable  elements 
of  the  disease.  Our  attention,  therefore,  should  he  particularly 
directed  to  them  as  the  most  related  to  its  pathology  and  the 
most  important  practically,  as  the  earlier  the  I'ecoguition  of  the 
disease  the  better  for  the  patient.  As  to  its  pathology,  a  para- 
lytic lesion  involving  the  common  nucleus  of  the  glosso-pharyn- 
geal,  vagus,  and  spinal  accessory  nerves,  and  extending  to  the 
neighboring  vaso-motor  center  in  the  medulla,  would  account 
for  the  whole  group  of  symptoms  that  made  up  the  jjicture  of 
Graves's  disease.  Simple  irritation  of  the  lower  branches  of  the 
glosso-pharyngeal  and  the  superior  laryngeal  nerves  was  some- 
times accompanied  by  general  muscular  tremor.  Such  a  bulbar 
lesion  would  also  explain  the  tachycardia  and  the  universal  re- 
laxation and  throbbing  of  the  systemic  arteries.  It  would  also 
explain  the  interference  with  the  inspiratory  expansion.  Such 
a  lesion  would  not,  however,  account  for  the  exophthalmia  or 
the  goitre,  and  when  we  turned  to  pathological  anatomy  we  had 
no  constant  evidence  of  any  textural  lesion  in  the  medulla,  either 
of  the  above-mentioned  centers  or  of  other  parts.  No  charac- 
teristic anatomical  change  had  yet  been  discovered  that  could 
be  causally  associated  with  the  genesis  of  Graves's  disease,  and 
we  must  look  elsewhere  for  the  origin  of  the  malady.  Here  we 
might  be  aided  by  clinical  experience.  Persistent  diarrhoea  was 
a  common  symptom  in  Graves's  disease.  In  the  cases  referred 
to,  astringents  and  other  drugs  had  had  very  little  eS'ect  in  check- 
ing the  diarrhoea,  while  a  change  of  diet  had  at  once  brought  about 
an  improvement  in  all  the  symptoms.  Since  1880  the  author 
had  mainly  relied  on  dietetic  treatment  in  Graves's  disease,  with 
such  favorable  results  that  he  now  had  little  doubt  that  a  spe- 
cific disorder  of  intestinal  (in  distinction  Irom  gastric)  digestion 
was  the  primary  factor  in  the  genesis  of  this  afl'ection.  While 
a  structural  lesion  in  the  medulla  which  would  account  for  the 
phenomena  of  Graves's  disease  was  almost  inconceivable  with- 
out its  sooner  or  later  involving  all  the  vital  functions  of  that 
seat  of  life,  yet  particular  functional  derangements  ])roduced  by 
toxic  agents  of  intestinal  origin  were  just  what  might  be  ex- 
pected, for  nothing  was  more  characteristic  than  the  narrowly 
selective  operation  of  functional  nervous  poisons,  which  might 
go  on  for  years,  as  in  the  case  of  opium,  afl'ecting  certain  func- 
tions without  producing  cither  progressive  changes  in  them  or 
extension  to  other  functions.  One  fact  in  Graves's  disease  that 
pointed  much  more  distinctly  to  a  digestive  disorder  than  to  a 
structural  nervous  lesion  was  that  it  occurred  in  women  about 
ten  times  as  often  as  in  men.  That  the  digestive  apparatus  in 
women  was  subject  to  special  disorders  was  notorious.  The 
author  had  not  yet  seen  a  severe  case  of  Graves's  disease  in 


which  diarrhoea  had  not,  sooner  or  later,  been  a  pronounced 
symptom.  As  regarded  the  diet  in  these  cases  the  amount  of 
meat  taken  should  be  restricted,  and  milk — preferably  in  the 
form  of  matzoon — should  be  substituted.  Medicinally,  the  au- 
thor employed  the  intestinal  antiseptic  remedies,  with  tincture 
of  strophanthus  as  a  vaso-motor  tonic. 

Dr.  E.  0.  Segtjin  said  that,  while  there  were  undoubtedly 
cases  of  Graves's  disease  in  which  one  or  two  of  the  three 
prominent  symptoms — the  exophthalmia,  the  goitre,  and  the 
tachycardia — were  absent,  he  was  inclined  to  believe  that  the 
author  of  the  paper  had  rather  exaggerated  the  number  of  cases 
in  which  the  principal  symptoms  were  those  relating  to  the  cir- 
culation. Unquestionably,  we  saw  cases  in  which  the  only 
gross  symptoms  were  the  rapid  heart  action  and  the  tremor,  but 
these  were  comparatively  rare.  On  the  other  hand,  there  were 
cases  which  presented  these  symptoms  to  which  he  should  hesi- 
tate very  much  to  give  the  name  Graves's  disease.  It  had  ap- 
peared to  him  that  in  many  cases  of  disease  of  the  heart  with 
dilatation  or  tachycardia  there  was  apt  to  be  associated  with  it 
a  mu.scular  tremor  and  considerable  nervousness.  In  arriving 
at  a  diagnosis  of  Graves's  disease,  there  were  other  symptoms 
to  assist  us  to  which  Dr.  Thomson  had  not  referred.  One  was 
the  character  of  the  pulse.  The  mere  fact  of  the  pulse  being 
rajjid  was  not  in  itself  characteristic  of  Basedow's  disease;  it 
should  possess  a  quality  of  tension  and  smallness  which  to  the 
experienced  finger  was  of  value  in  making  the  diagnosis.  Then, 
again,  the  temperature  of  these  patients  was  invariably  raised 
by  from  half  a  degree  to  a  degree  F.  in  the  axilla.  In  making 
a  diagnosis  of  Graves's  disease  without  the  exophthalmia  or  the 
goitre,  the  speaker  said  he  should  wish  to  find,  besides  the 
tachycardia,  the  peculiar  character  of  the  pulse  and  the  slight 
elevation  of  temperature.  As  to  the  pathology  of  the  disease, 
every  theory  of  the  location  of  a  lesion  in  the  central  nervous 
system  had  failed  to  satisfy  him.  As  to  locating  the  general 
cause  of  the  disease  in  the  intestinal  tract,  as  the  author  had  in- 
geniously done,  no  positive  conclusions  could  be  drawn,  for  the 
reason  that  the  diarrhoea  was  by  no  means  a  frequent  symptom 
in  Graves's  disease.  He  had  observed  it  in  only  a  few  cases. 
Furthermore,  it  did  not  resemble  a  fermentative  diarrhoea;  it 
was  of  a  paralytic  nature,  with  large,  liquid,  frequent  evacua- 
tions. In  conclusion.  Dr.  Seguin  referred  to  the  value  of  aconi- 
tine  in  treating  the  disease. 

Dr.  B,  Saohs  agreed  with  Dr.  Seguin  as  regarded  the  symp- 
toms of  the  disease.  He  should  hesitate  to  make  a  diagnosis  of 
Graves's  disease  in  acasein  which  both  the  exophthalmia  and  the 
goitre  were  wanting.  What  we  did  find  with  extreme  frequency 
was  that  one  of  these  two  cardinal  symptoms  only  was  present, 
together  with  the  characteristic  arterial  disturbance.  Another 
symptom  of  the  disease  to  which  attention  had  lately  been  called 
was  that  the  upper  eyelid  did  not  follow  the  motion  of  the 
pupil  downward.  This  did  not  appea^*  to  be  due  to  mechanical 
causes,  but  was  an  independent  symptom.  He  had  seen  it  pres- 
ent in  a  case  where  there  was  hardly  any  exophthalmia.  Se- 
vere diarrhoea  he  had  found  rather  rarely  associated  ith  other 
symptoms  of  Graves's  disease.  A  diarrhoea  due  to  the  condi- 
tion of  the  large  intestine  had  been  present  in  some  cases,  and 
in  these  he  had  been  struck  by  the  peculiar  fact  that  it  had  not 
appeared  to  be  exhausting  to  the  |>atient.  In  regard  to  the  theory 
put  forth  by  Dr.  Thomson,  it  must  bo  remembered  that,  while 
putrefactive  changes  in  the  intestines  were  very  common,  ex- 
ophthalmic guitre  was  a  rare  disease.  Dr.  Sachs  had  found  the 
"rest  treatment"  extremely  beneficial  in  treating  this  atlVction, 
the  heart's  action  becoming  better  and  the  goitre  diminishing  in 
size.  In  addition  to  rest,  he  [)ut  the  patients  on  a  light  diet, 
princi[)ally  milk  and  eggs. 

Dr.  Gkokgk  W.  Jacoby  said  that  in  certain  ciiscs,  where 


338 


BOOK  NOTICES. 


|N.  Y.  Med.  Joue., 


onlj  one  of  the  cardinal  symptoms  was  present,  it  is  often  a 
difficult  matter  to  draw  the  line  between  Graves's  disease  and 
some  other  form  of  neurosis.  In  undeveloped  cases  of  Graves's 
disease  the  "rest  treatment"  was  particularly  beneficial.  As 
regarded  the  ocular  synijjtom,  the  failure  of  the  upper  lid  to  fol- 
low the  pupil  downward,  the  patient  had  perfect  control  over 
the  voluntary  closure,  but  the  reflex  blinking  of  the  lid  was  al- 
most entirely  lost.  There  might  be  loss  of  sensation  of  the 
cornea  associated  with  it. 

Dr.  Mary  Putnam  Jacobi  said  that  most  authors  referred  to 
depressing  emotions  as  a  cause  of  Graves's  disease.  She  men- 
tioned three  cases  that  had  come  under  tier  observation  in  which 
such  an  antecedent  cause  had  been  extremely  obvious.  One  of 
these,  a  very  severe  case,  was  that  of  a  woman,  aged  twenty- 
two  jears,  whose  marriage  engagement  had  been  broken  by  the 
sudden  death  of  her  ^ance.  She  had  rapidly  been  afiected  with 
the  three  typical  symptoms  of  Graves's  disease,  with  intense 
anorexia  and  diarrhoea.  She  had  remained  in  a  state  of  great 
prostration  for  six  montiis,  but  subsequently  had  recovered  and 
married.  Following  her  second  pregnancy,  her  symptoms  re- 
appeared. She  was  living  at  that  time  almost  entirely  on 
champagne,  which  seemed  to  intensify  the  symptoms  greatly. 
The  diarrhoea  did  not  appear  to  add  to  her  i)rostratiun.  She 
was  put  entirely  on  the  use  of  a  meat  diet,  and  the  pulse  rapidly 
fell  from  150  to  90  a  minute,  and  she  regained  her  strength.  In 
another  case,  occurring  in  a  woman  aged  forty-three  years,  the 
symptoms  had  appeared  after  prolonged  family  troubles.  The 
third  case  referred  to  had  also  been  in  a  woman,  a  servant,  who 
had  been  attacked  with  the  symptoms  after  prolonged  nursing 
of  her  mistress,  to  whom  she  had  been  much  attached. 

Dr.  Joseph  Collins  said  that  if  we  could  ascribe  a  toxic  ori 
gin  to  exophthalmic  goitre,  as  suggested  by  Dr.  Thomson,  the 
prognosis  of  the  affection  would  not  be  so  serious  as  it  was. 
The  speaker  referred  to  certain  ex])eriments  he  had  made  on 
the  thyreoid  in  animals.  Complete  extirpation  of  the  gland 
was  almost  invariably  followed  by  death.  This  would  contro- 
vert the  idea  that  its  function  was  a  metabolic  rather  than  a 
secretive  one. 

Dr.  A.  D.  Rockwell  had  been  interested  in  Dr.  Thomson's 
statement  that  only  one  or  two  of  the  cardinal  symptoms  had 
been  present  in  the  cases  narrated.  As  far  as  the  speaker's 
observation  went,  the  three  typical  symptoms  were  usually 
present.  He  referred  to  the  value  of  digitalis  in  cases  where 
there  was  weakness  of  the  myocardium.  He  had  found  the 
drug  very  serviceable  in  combination  with  iron,  zinc,  and 
ergofc.  He  also  referred  to  the  value  of  electricity  ;  in  order  to 
do  any  good  the  current  must  be  sufficiently  powerful.  In  re- 
ply to  a  question.  Dr.  Rockwell  said  that  the  diminished  re- 
sistance to  the  electrical  current  in  these  patients  was  probably 
owing  to  the  perspiration  and  to  the  better  conduction  due  to  the 
rapid  circulation. 

The  PiiEsiDENT  did  not  think  that  any  explanation  thus  far 
given  would  cover  all  the  cases  of  this  disease,  and  it  was 
doubtful  if  there  ever  would  be  found  a  single  explanation  for 
any  functional  nervous  disease.  Different  cases  undoubtedly 
had  a  different  tetiology.  In  two  cases  of  Graves's  disease  that 
had  recently  come  under  his  observation  a  sudden  fright  had 
been  too  immediate  to  be  anything  but  causative.  One  of  the 
patients,  a  woman,  had  seen  her  baby  fall  from  a  second-story 
window.  She  had  immediately  been  seized  with  palpitation, 
and  within  two  weeks  the  exophthalmia  and  the  goitre  had  de- 
veloped. She  had  presented  a  very  interesting  symptom  that 
had  been  referred  to  by  Charcot — a  sudden  giving  out  of  the 
limbs — astaeia.  After  such  a  collapse  she  was  perfectly  able  to 
rise  and  walk  away.  In  another  case  the  symptoms  iiad  sud- 
denly developed  in  a  patient  after  she  had  narrowly  escaped 


being  run  over  by  a  street- car.  The  president  would  follow 
Dr.  Thomson's  suggestions  as  to  diet  in  these  cases.  Strophan- 
thus  he  had  found  very  valuable.  Electricity  had  proved  dis- 
appointing in  his  hands  as  a  remedial  agent  in  Graves's  disease. 

Dr.  Thomson  said  that  in  his  [)aper  he  had  not  intended  to 
go  over  the  entire  symptomatology  of  Basedow's  disease.  Such 
occasional  symptoms  as  the  loss  of  the  hair,  pigmentation  of 
the  skin,  etc.,  he  had  not  referred  to  at  all.  Neither  had  be 
meant  to  imply  that  fright  and  depressing  emotions  were  not 
often  the  occasion  for  the  first  development  of  the  symptoms. 
We  must  try  to  separate  occasions  from  true  causes.  The  tre- 
mor of  Graves's  disease  was  characteristic.  It  was  entirely 
different  from  the  tremor  of  any  cardiac  affection  he  had  ever 
met  with.  He  had  not  maintained  in  his  paper  that  there  was 
any  lesion  in  the  medulla  to  account  for  these  symptoms ;  he  had 
only  meant  to  show  that,  as  no  such  lesion  had  been  demon- 
strated, the  fact  lent  strong  weight  to  the  toxic  theory.  These 
poisonous  ptomaines  miglit  act,  by  selection,  on  certain  parts  of 
the  nervous  systeui.  The  relapsing  nature  of  Graves's  disease 
was  against  the  idea  that  it  depended  on  a  structural  lesion. 

In  reply  to  Dr.  Seguin,  Dr.  Thomson  said  that  in  those  cases 
where  there  was  a  high-tension  pulse  it  was  associated  with 
albuminuria.  In  Graves's  disease  there  was  a  dilatation  of  the 
arteries  throughout  the  body,  and  dilated  arteries  and  a  high- 
tension  pulse  did  not  go  together.  As  regarded  the  tempera- 
ture, there  was  a  slight  elevation,  such  as  was  found  in  any 
serious  neurosis,  hut  it  bore  no  propoi'tion  to  the  rapid  heart 
action,  and  the  affection  might  be  regarded  as  essentially  a  non. 
jebrile  disease. 


A  Text  hook  of  Practical  Therapeutics,  with  Especial  Reference 
to  the  Application  of  Remedial  Measures  to  Disease  and 
their.  Employment  u\)on  a  Rational  Basis.  By  Hobaet 
Amoey  Hare,  M.  D.,  B.  Sc.  Third  Edition,  enlarged  and 
thoroughly  revised.  Philadelphia  :  Lea  Brothers  &  Co., 
1892.    Pp.  698. 

That  this  book  has  reached  its  third  edition  within  two  years 
is  a  sufficient  guarantee  of  its  excellence  and  of  its  popularity 
We  know  of  no  text-book  of  therapeutics  that  is  so  concise- 
simple,  and  practical  in  its  statements  as  this  is,  and  it  repre- 
sents a  radical,  and  yet  valuable,  departure  from  all  previous 
works  of  this  description. 

The  first  part  of  the  book  is  devoted  to  general  therapeutic 
considerations,  the  second  to  drugs,  the  third  to  remedial  meas- 
ures other  than  drugs,  also  foods  for  the  sick,  and  the  fourth  to 
diseases  and  indices. 

The  drugs  are  arranged  in  alphabetical  order,  so  that  refer- 
ence to  any  particul.-ir  substance  is  easy.  The  account  given  of 
each  drug  is  clear  and  concise  and  sufficiently  full,  although  we 
note  occasionally  the  absence  of  some  more  or  less  important 
point,  as,  for  instance,  in  the  article  upon  Warburg's  tincture, 
where  no  mention  is  made  of  the  employment  of  the  capsules 
instead  of  the  tincture,  although  it  is  well  known  that  these  cap- 
sules, which  consist  of  the  evaporated  tincture,  have  almost  en 
tirely  superseded  the  tincture  itself.  In  this  third  edition  mos 
of  the  more  recent  drugs — such  as  salophen,  diuretin,  europiien, 
piperazine,  and  dermatol — are  treated  of. 

In  part  three  we  find  interesting  accounts  of  the  applications 
of  heat  and  cold,  of  the  use  of  antiseptics,  of  disinfection,  of 
counter-irritation,  and  the  like,  together  with  a  short  article  on 
the  rest  cure. 


March  25,  1893.] 


BOOK  NOTICES. 


339 


In  part  four  vfQ  find  the  most  original  feature  of  the  book, 
which  consists  of  short  and  pithy  essays  upon  the  treatment  of 
all  the  well-known  diseases,  the  arranf^ement,  like  that  of  the 
drugs,  being  alphabetical. 

The  indices  are  numerous  and  full,  and  form  a  vahiable 
feature  of  the  book. 


The  Conl-tar  Colors,  with  Especial  Reference  to  their  Injurious 
Qualities  and  the  Restriction  of  their  Use.  A  Sanitary  and 
Medico-legal  Investigation.  By  TnEoooK  "VVeyl.  With  a 
Preface  by  Professor  Sell.  Translated,  with  permission  of 
the  Author,  by  Henry  Leffmann,  M.  D.,  Ph.  D.,  Philadel- 
phia. Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1892.  Pp. 
xii-17  to  154.    [Price,  $1.50.] 

The  numerous  uses  for  the  coal-tar  colors  in  dyeing  food 
stuffs,  wearing  apparel,  and  other  articles  makes  this  transla- 
tion of  Dr.  Weyl's  monograph  a  timely  publication.  A  brief 
synopsis  is  given  of  the  mode  of  preparation  of  these  colors, 
their  classification  in  groups  based  on  the  chemical  constitution 
is  tabulated,  and  there  are  brief  references  to  their  uses,  with 
particular  reference  to  dyeing,  mordanting,  and  printing. 

Attention  is  directed  to  the  fact  that  the  poisonous  qualities 
that  were  formerly  ascribed  to  certain  of  these  colors  were  due 
to  arsenical  and  mercurial  impurities,  the  statistical  evidence 
showing  that  the  workmen  in  aniline-color  factories  suffer  to  the 
extent  of  6'3  per  cent,  only  as  a  consequence  of  their  occupa- 
tion. The  poisonous  colors  are  picric  acid,  Martiu?'s  yellow, 
safranin,  methylene  blue,  and  dinitrocresol.  The  laws  of  Ger- 
many, England,  France,  Italy,  and  Austria- Hungary  concerning 
the  use  of  colors  in  the  preparation  of  food  are  given.  Believing 
that  such  legislation  should  only  have  been  based  upon  more 
comprehensive  information.  Dr.  Weyl  began  his  investigations 
of  as  many  of  these  dyes  as  possible.  The  researches  with  the 
nitro-colors  showed  that  only  the  sulphonated  colors,  naphthol 
yellow  and  brilliant  yellow,  were  harmless  and  applicable  to 
the  coloring  of  food  and  drink.  None  of  the  disazo  colors  were 
found  to  be  poisonous,  although  naphthol  black  had  an  injuri- 
ous effect  when  administered  subcutaneously. 

Weyl  states  that  the  urine  from  animals  fed  or  treated  sub- 
cutaneously with  the  azo-colors  was  generally  colored,  contain- 
ing the  unchanged  color  only  when  cons.iderable  quantities  of 
the  material  had  been  administered.  A  portion  of  the  dye,  es- 
pecially if  it  was  insoluble,  was  found  in  the  ffpces. 

We  agree  with  Professor  Sell  that  the  author  has  made  a 
valuable  contribution  toward  determining  the  physiological  re- 
lation of  the  colors  that  are  applicable  to  foods.  The  transla- 
tor's work  is  satisfactorily  performed. 


Syphilis  and  the  Nervous  System:  Being  a  Revised  Reprint  of 
the  Lettsomian  Lectures  for  1890,  delivered  before  the  Medi- 
cal Society  of  London.  By  W.  R.  Gowers.  M.  D.,  F.  R.  C. 
P.,  F.  R.  S.,  Consulting  Physician  to  University  College 
Hospital.  Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1892. 
Pp.  viii-9  to  131.    [Price,  $1.] 

The  reputation  of  the  author  of  this  little  volume  is  sufficient 
warrant  for  the  publication  of  a  revision  of  his  Lettsomian 
lectures  of  some  three  years  ago.  While  these  were  published  in 
some  medical  journals  at  that  time,  reference  to  the  journals  is 
not  always  convenient  or  possiV)le,  and  the  medical  profession 
•will  undoubtedly  welcome  the  handy  shape  in  which  they  are 
now  presented  for  consideration. 

He  describes  the  classification  and  character  of  tissue  forma- 
tion caused  by  syphilis,  and  calls  attention  to  the  fact  that  be- 
cause there  is  the  history  of  a  former  syphilitic  lesion  we  are  not 
justified  in  concluding  that  a  disease  of  the  nervous  system  is 


due  to  syphilis.  He  believes  that  Striimpell's  law  "that  the 
isolated  impairment  of  nerve  structures  that  have  a  certain 
function,  when  acute,  indicates  a  toxic  influence,  when  chronic, 
a  degenei-ative  process,"  must  be  remembered  in  making  a  diag- 
nosis of  syphilis  of  the  nervous  system,  and  he  calls  attention 
to  the  fact  that  there  are  no  symptoms  or  combinations  of 
symptoms  produced  by  syphilis  that  are  not  also  produced  by 
other  causes.  He  does  not  think  there  is  real  evidence  that  the 
disease  ever  is  or  ever  has  been  cured,  the  word  disease  being 
used  to  designate  that  which  causes  the  various  manifestations 
of  syphilis.  We  do  not  think  that  current  opinion  sustains  this 
position,  or  that  writers  on  syphilis  admit  the  incurability  of  that 
disease.  We  tliink  also  that  Dr.  Gowers  is  in  error  in  holding  that 
long-continued  treatment  with  small  doses  of  mercury  is  a  great 
and  dangerous  mistake,  and  we  can  not  admit  that  the  fact  that 
this  tenet  is  becoming  prevalent  in  Germany  commends  it. 
Withal  the  book  is  interesting  and  will  be  suggestive  to  the 
neurologist  and  to  the  syphilologist. 


A  Manual  of  Clinical  Ophthalmology.  By  Howard  F.  Han- 
sell,  M.  D.,  Lecturer  on  Ophthalmology  in  the  Jefferson 
Medical  College,  and  James  H.  Bell,  M.  D.,  lately  Demon- 
strator of  Anatomy  in  Jefferson  Medical  College.  With  One 
Hundred  and  Twenty  Illustrations.  Philadelphia:  P.  Blakis- 
ton, Son,  &  Co.,  1892.    Pp.  xiv-9  to  231.    [Price,  $1.75.] 

This  little  work  shows  evidence  of  considerable  labor  on  the 
part  of  the  authors,  but  it  presents  the  usual  faults  of  too  great 
condensation.  Students  of  ophthalmology  need  a  larger  and 
more  complete  work  if  they  are  to  understand  the  subject,  and 
the  practitioner  who  wishes  a  book  of  reference  will  hardly  be 
satisfied  with  the  amount  of  information  given  here.  Supple- 
mented by  oral  and  clinical  instruction  on  the  part  of  a  teacher, 
it  is  doubtless  useful,  as  it  furnishes  the  outline  of  study. 


A  Handhool-  of  the  Diseases  of  the  Eye  and  their  Treatment. 
By  Henet  B.  Swanzy,  A.  M.,  M.  B.,  F.  R.  C.  S.  I.,  Surgeon 
to  the  National  Eye  and  Ear  Infirmary,  Dublin.  Fourth 
Edition.    With  Illustrations.    Philadelphia:  P.  Blakiston, 
Son,  &  Co.,  1892.    Pp.  xv-518.    [Price,  $3.] 
Me.  Swanzy's  text-book  is  so  well  known  in  this  country 
that  an  extensive  review  of  it  is  unnecessary.    It  has  been  re- 
vised throughout  and  considerably  enlarged,  and  some  new 
illustrations  have  been  added.  It  seems  strange  that  Mr.  Swanzy 
still  adheres  to  his  erroneous  definition  of  nyctalopia.    He  de- 
fines it  "night  blindness,"  although  the  derivation  of  the  word, 
as  well  as  almost  universal  custom,  shows  it  to  mean  "  seeing 
by  night"  or  "day  blindness,"  a  condition  of  hypersesthesia  of 
the  retina  sometimes  met  with. 

BOOKS,  ETC.,  RECEIVED. 

Cheyne-Stokes  Respiration.  By  George  Alexander  (iibson, 
M.  D.,  D.  Sc.,  etc..  Assistant  Physician  to  the  Royal  Infirmary 
of  Edinburgh.  Edinburgh :  Oliver  &  Boyd,  1892.  Pp.  133. 
[Price,  5s.] 

Etude  clinique  de  la  cardio-sclerose  (cardiopathies  arterielles, 
art6rio-scl6rose  du  coeur).  Par  Henri  lluchard,  President 
d'honneur  de  la  Soci6te  m^dico-chirurgicale  de  Paris,  etc. 
Paris:  Felix  Alcan,  1898.    Pp.  139. 

The  Diseases  of  the  Nervous  System.  A  Text-book  for 
Physicians  and  Students.  By  Dr.  Ludwig  Ilirt,  Professor  at 
the  University  of  Breslau.  •  Translated,  with  Permission  of  the 
Author,  by  August  Iloch,  M.  D.,  assisted  by  Frank  R.  Smith, 
A.M.  (Cantab.),  M.  D.,  Assistant  Physicians  to  the  Johns  Hop- 
kins Hospital.    With  an  Introduction  by  William  Osier,  M.  D., 


3i0 


BOOK  NOTICES. 


[N.  Y.  Med.  Jodb., 


r.  R.  0.  p.,  Professor  of  Medicine  in  the  Johns  IIo|)kins  Univer- 
sity, etc.  With  178  Illustrations.  New  York:  D.  Appleton 
and  Company,  1893.    Pp.  xv-683.    [Price,  $5.00.] 

Traite  de  medecine.  Public  sous  la  direction  de  MM.  Ciiarcot, 
Professeur  de  clinique  des  inaladii  s  nervenses  a  la  Faculte  de 
medecine  de  Paris;  Bouchard,  Professeur  de  pathologie  p-enerale 
a  la  Faculte  de  medecine  de  Paris ;  et  Brissaud,  Professeur  agrege 
a  la  Faculte  de  medecine  de  Paris.  Par  MM.  Babinski,  Ballet, 
Brault,  C'hanteinesse,  Charrin,  Chautt'ard,  (Jourtois-SufHt,  Gil- 
bert, Guinon,  Le  Geiidre,  Marfan,  Marie,  Mathieu,  Netter, 
<Ettinger,  Andre  Petit,  Riohardiere,  Roger,  Ruault,  Tlnbierge, 
Thoinot,  Fernand  Widal.  Tome  IV.  Par  MM.  Ruault,  Bris- 
saud,  Le  Gendre,  Marfan,  Netter.  Avec  figures  en  noir  et  en 
couleurs  dans  le  texte.    Paris:  G.  Masson,  1893.  Pp.1112. 

Proceedings  of  the  Philadeipliia  County  Medical  Society. 
Volume  XIII.  Session  of  1892.  Lewis  H.  Adler,  Jr.,  M.  D., 
Editor. 

Transactions  of  the  American  Orthopsedic  Association. 
Sixth  Session,  held  at  New  York  City,  September  20,  21,  and 
22,  1892.    Volume  V. 

The  Comparative  Physiology  of  Resjiiration.  Address  by 
Simon  Henry  Gage,  Vice-president  Section  F,  before  the  Sec 
tion  of  Biology,  American  Association  for  the  Advancement  of 
Science,  at  the  Rochester  Meeting,  August,  1892.  [Reprinted 
from  the  Proceedingn  of  the  Amer'ican  Association  for  the  Ad- 
vancement of  Science.] 

Intestinal  Antisepsis  in  Enteric  Fever  by  Means  of  Subiodide 
of  Bismuth  and  Salol.  By  J.  D.  Farrar,  M.  D.,  of  Baltimore. 
[Reprinted  from  the  Maryland  Medical  Journal.] 

The  Relation  of  Rheumatism  and  Chorea.  By  Floyd  M.  Cran- 
dall,  M.  D.,  New  Y'ork.  [Reprinted  from  the  Archives  of 
P(ediatrics.] 

Methods  of  Decalcification  in  which  the  Structural  Elements 
are  preservt  d.  An  Aqueous  Solution  of  HtEmatoxylin  which 
•does  not  readily  Deteriorate.  By  Simon  Henry  Gage.  [Re- 
printed from  the  Proceedings  of  the  American  Microscopical 
Society.] 

The  St.  Louis  Medical  Colleire.  An  Historical  Address.  By 
<jr.  Bumgarten,  M.  D.  (Delivered  at  tlie  Semi-centennial  Cele- 
bration of  the  College,  October  18,  1892.) 

An  Analysis  "f  Seventy-two  Cases  of  Ununited  Fracture 
occurring  in  the  Long  Bones  of  Children.  By  D'Arcy  Power, 
M.  A.,  M.  B.,  etc.  [Reprinted  from  the  Medico-chirurgical 
Transactions.] 

Nephrotomy  for  the  Relief  of  Sudden  Total  Suppression  of 
Urine  occurring  Some  Time  after  Nephrectomy.  By  Willy 
Meyer,  M.  D.,  New  Y^ork.  [Reprinted  from  the  Annals  of 
Surgery.] 

Remarks  on  the  Histology  of  Xeroderma  Pigmentosum.  By 
S.  Pollitzer,  M.  D.  [Reprinted  from  the  Journal  of  Cutaneous 
and  Genito-urinary  Diseases.] 

Prickly  Heat,  Lichen  Tropicus,  Miliaria  Papulosa,  M.  Rubra, 
etc.  By  S.  Pollitzer,  M.  D.  [Reprinted  from  the  Journal  of 
Cutaneous  and  Genitourinary  Diseases.] 

The  Treatment  of  Hernia.  By  Alexander  Dallas.  M.  D., 
New  York.  (Read  before  the  Medical  Society  of  the  State  of 
New  York.) 

Gastrostomy  in  Carcinoma  of  tlie  Cardiac  Orifice.  By  Emory 
Lanphear,  M.  D.,  of  Kansas  City,  Mo.  [Reprinted  from  the 
Medical  News.] 

Asheville,  N.  C,  and  its  Advantages  as  a  Climatic  Resort 
for  Pulmonary  Diseases.  By  J.  W.  (xleitsmann,  M.  D.,  New 
York.    [Reprinted  from  the  Journal  of  Balneology.] 

Blood  in  the  Urine — How  to  discover  its  Source  and  what 
to  do  for  it.  By  L.  BoTton  Bangs,  M.  D.,  New  York.  [Re- 
printed from  tlie  Medical  Record.] 


Acromegaly.  By  Joseph  Collins,  M.  D.,  New  York.  [Re- 
printed from  the  Journal  of  Nervous  and  Mental  Disease.] 

Some  of  the  Effects  of  "  Withdrawal."  By  L.  Bolton  Bangs, 
M.  D.    [Reprinted  from  the  Southern  Clinic] 

The  Influence  of  the  Morbid  Conditions  of  the  Uterine 
Adnexa  upon  Reflex  Piienomena.  By  Charles  P.  Strong,  M.  D., 
Boston.  [Reprinted  from  the  Boston  Medical  and  Surgical 
Journal.] 

Observations  on  the  General  Pathology  of  Cancer,  espe- 
cially of  the  Breast.  By  W.  Roger  Williams,  F.  R.  C.  S.  Eng. 
[Reprinted  from  the  Medical  Chronicle.] 

Notes  on  Fibrin,  Oxhsemoglobin  Crystals,  and  the  Collodion 
Method.  By  Simon  Henry  Gage,  Ithaca,  N.  Y.  [Reprinted 
from  the  Proceedings  of  the  American  Society  of  Microsropists.] 

Report  of  the  Adjutant-General  of  the  State  ■)f  Michigan, 
for  the  Y'ears  1891-1892. 

Transactions  of  the  American  Ophthahnological  Society. 
Twenty-eighth  Annual  Meeting,  New  London,  Conn.,  1892. 

The  Year-book  of  Treatment  for  1893.    A  Critical  Review 
for  Practitioners  of  Medicine  and  Surgery.    By  Various  Con- 
tributors.   Pliiladelphia:  Lea  Brothers  &  Co.,  1893.    Pp.  viii 
490. 

A  Case  of  Bilateral  Recurrent  Inflammation  of  Tenon's  Cap- 
sule in  Connection  with  Profound  Mercurial  Poisoning.  By 
Charles  J.  Kii)p,  M.  D.,  Newark,  N.  J.  [Reprinted  from  the 
Tran.sartions  of  the  Am.erican  Ophthalmological  Society.] 

The  Diagnostic  Significance  of  the  Venous  and  Arterial  Mur- 
murs in  the  Neck,  based  on  Examinations  of  Fifteen  Hundred 
Persons.  By  James  K.  Crook,  M.  D.,  New  York.  [Reprinted 
from  the  American  Journal  of  the  Medical  Sciences.] 

A  Case  of  Acute  Purulent  Inflammation  of  the  Middle  Ear, 
with  Double  Optic  Neuritis,  but  without  Tenderness  or  Swell- 
ing of,  or  Spontaneous  Pain  in,  the  Mastoid  Process,  in  which 
the  Opening  of  the  Mastoid  Cells  was  followed  by  a  Rapid  Sub- 
sidence of  the  Optic  Neuritis  and  Cure  of  the  Ear  Disease.  By 
Charles  J.  Kipp,  M.  D.,  Newark,  N.  J.  [Reprinted  from  the 
Transactions  of  the  American  Otological  Society.] 

A  Case  of  Haeraatosalpinx  and  Hasmatoma  resembling 
Ectopic  Gestation.  By  Edwin  B.  Cragin,  M.  D.,  New  York. 
[Reprinted  from  the  New  York  Journal  of  Gynmcology  and  Ob- 
stetrics.] 

Operative  Experience  with  Ectopic  Gestation.  By  Edwin 
B.  Cragin,  M.  D.,  New  Y'ork.  [Reprinted  from  the  American 
Journal  of  Obstetrics.] 

Possibility  of  establishing  Tolerance  for  the  Tubercle  Bacil- 
lus. By  Samuel  G.  Dixon,  M.  D.  [Reprinted  from  the  Medical 
News  ] 

Involution  Forms  of  the  Tubercle  Bacillus  and  the  Effect  of 
Subcutaneous  Injections  of  Organic  Substances  on  Inflamma- 
tions. By  Samuel  G.  Dixon,  M.  D.  [Reprinted  from  the  Pro- 
ceedings of  the  Academy  of  Natural  Sciences  of  Philadeljthia.] 

An  Outline  of  the  Technique  of  Abdominal  and  Pelvic  0[)- 
erations  as  performed  in  the  Medico-chirurgical  Hospital  of 
Philadelphia.  By  William  Easterly  Ashton,  M.  D.  [Reprinted 
from  the  Medical  Bulletin.] 

Consideraciones  sobre  dos  casos  de  anemia  por  ankylostonui 
duodenale,  observados  en  el  Hospital  Victor  Manuel  de  Lima, 
por  el  Dr.  J.  B.  Angoli.    [De  la  Cronica  Medica  de  Lima.] 

Fifteenth  Annual  Report  of  the  Presbyterian  Eye,  Ear,  and 
Throat  Charity  Hospital,  Baltimore,  Md. 

New  York  Eye  and  Ear  Infirmary  Reports.  Volume  I. 
Part  I.    January,  1893. 

The  Twenty-eighth  Annual  Report  of  the  S.  R.  Smith  In- 
firmary, for  the  Year  ending  May  31,  1892. 

Fiftieth  Annual  Rei)ort  of  the  Managers  of  the  Utica  State 
Hospital  at  Utica,  for  the  Y^ear  ending  September  30,  1892. 


March  25,  1893.] 


MISCELLANY. 


341 


IJt  r  s  c  c  1 1  a  n  w . 


Some  of  the  Trophoneuroses  associated  with  Abnormity  of  the 
Thyreoid  Gland. — At  a  nn'Otiii'i  of  tlie  I'liiladelpliiu  ("mmty  Medical 
Society  lield  on  l'Vl)i'Uiiry  ^th  Ur.  Solomon  Solis-Colien  reported  and  ex- 
hibited ])liotographs  of  two  cases  of  acromegalia,  in  both  of  which  there 
was  apparent  absence  of  the  thyreoid  gland,  and  marked  skeletal 
changes  in  addition  to  those  in  the  face,  hands,  and  spine.  The  pa- 
tients were  men — one  twenty-five  years  of  age,  the  other  fifty-one  years 
old.  In  neither  case  was  there  any  eye  lesion.  The  case  of  the  younger 
man  had  been  previously  reported  to  the  College  of  Physicians.  In  the 
elder  man  headache,  drowsiness,  forgetfulne.ss,  thickness  and  scanning 
of  speech,  and  excessive  polyuria  were  present.  The  symptoms  had 
been  partially  relieved  by  picrotoxin,  the  headache  especially.  This 
drug  was  a  vase-motor  regulator  and  useful  in  many  of  the  C(raditions 
to  be  discussed.  It  was  necessary  to  say  "  apparent  absence  "  of  the 
thyreoid  gland,  because  only  post  mortem  coiild  absence  or  atrophy  be 
uncjualitiedly  affirmed.  Embryologically  the  pituitary  body  and  thy- 
reoid gland  were  intimately  related,  and  it  appeared  not  improbable 
that  the  enlargement  of  the  former  and  the  consequent  hemiopia  and 
other  cerebral  symptoms  noted  in  some  cases  of  acromegalia  might  be 
due  to  an  attempt  by  Nature  to  supply  the  absence  of  an  important 
structure  by  compensatory  hypertrophy  of  an  allied  structure. 

A  number  of  cases  in  which  the  thyreoid  gland  could  not  be  demon- 
strated and  which  presented  some,  but  not  all,  of  the  changes  found  in 
typical  cases  of  acromegalia  were  also  related.  In  one  such  case  the 
hands  and  ears  presented  marked  local  asphyxia  (Raynaud's  disease), 
while  the  pain  and  transient  redness  developed  in  the  feet  upon  exer- 
tion were  suggestive  of  the  condition  descril)ed  by  Weir  Mitchell  under 
the  name  of  erythromelalgia.  In  another  case,  in  an  aged  man,  there 
were  cardiac  lesions  and  muscular  tremors,  with  wasting,  as  in  pro- 
gressive muscular  atrophy. 

Other  cases  observed  by  the  speaker  in  which  thyreoid  atrophy  ap- 
parently existed  were :  one  case  of  hypertrophic  osteo-arthropathy  with 
emphysema  and  fibroid  phthisis,  in  a  man  fifty  years  of  age ;  one  case 
of  scleroderma  with  cardiac  lesions,  muscular  tremors,  and  mental 
changes  in  a  woman  apparently  quite  aged,  who  insisted,  however,  that 
she  was  less  than  forty  years  old ;  and  one  case  of  unilateral  spontane- 
ous gangrene  and  ulceration  of  the  toes  and  leg  (Ra3Taaud's  disease), 
with  bilateral  spasmodic  vascular  phenomena  in  a  woman  over  sixtv 
years  of  age.  In  the  latter  case  certain  changes  in  the  fingers  and  nails 
existed,  which  in  one  finger  resembled  those  of  acromegalia,  in  another 
finger  those  of  rheumatoid  arthritis,  in  another  finger  those  of  sclero- 
dactyle,  the  nails  of  all  the  fingers  being  curved  like  those  of  the  Hip- 
pocratic  finger,  as  in  pulmonary  hypertrophic  osteo-arthropathy.  That 
this  latter  condition  of  the  nails  and  finger  tips  could  be  ascribed  to  in- 
terference with  nutrition  through  the  circulation  was  held  to  be  shown 
by  the  occurrence  in  cases  of  cardiac  disease  without  pulmonary  or  o))- 
vious  nervous  lesion  of  fingers  indistinguishable,  and  of  which  pictures 
and  tracings  were  exhibited. 

Taking  up  conditions  of  trophic  and  vascular  disturbance  associated 
with  enlargement  of  the  thyreoid  gland.  Dr.  Cohen  briefly  alluded  to 
exophthalmic  goitre,  myxoedema,  and  cretini.sm,  laying  stress  upon  the 
fact  that  as,  on  the  one  hand,  in  acromegalia  there  might  be  enlarge- 
ment instead  of  apparent  aljsence  or  atrophy  of  the  thyreoid  gland,  so, 
on  the  other  hand,  in  niyxonlema  and  cretinism,  the  goitre  might  be 
lacking,  while  experimental  thyreoidectomy,  as  well  as  the  cachixia 
sirumipriva  that  followed  surgical  extirpation  of  the  gland,  proved 
that  the  symptoms  were  due  to  a  functional  atrophy  of  the  gland, 
whether  or  not  there  was  hyperplasia  of  the  non-essential  anatomical 
elements.  Stress  was  laid  iipon  the  varied  vaso  motor  disturbances  in  all 
these  marked  conditions. 

In  one  case  of  Raynaud's  disease,  an  affection  which,  ,so  far  as  the 
vaso  motor  jdienomena  are  concerned,  was  almost  an  antithesis  of 
Graves's  disease.  Dr.  CoIk'u  had  observed  in  an  anicmic  girl,  with  occa- 
sional tachycardia,  an  intermittent  enlargement  of  the  thyreoid,  just  as 
was  observed  in  certain  cases  of  exophthalmic  goitre,  and  in  certain  ill- 
defined  cases  for  which  he  had  proposed  the  name  of  vano  motor  ataxin, 


which  latter  could  not  be  called  exophthalmic  goitre,  but  in  some  in- 
stances might  readily  develop  into  that  condition.  These  latter  cases, 
observed  both  in  males  and  in  females,  but  principally  in  the  latter,  and 
in  hysterical  subjects  more  often  than  in  others,  showed  as  an  almost 
constant  feature  the  intermittent  presence  of  hsemocytes  in  the  urine  ; 
sonjetimes,  but  rarely,  transient  or  intermittent  albuminuria  as  well.  In 
some  cases  lithuria  and  oxaluria  had  been  noted,  especially  in  those  of 
rheumatic,  gouty,  or  diabetic  families ;  still  more  rarely  casts  or  cylin- 
droids  had  been  found.  These  observations  were  related  with  the  oc- 
currence of  h;emoglobinuria  in  Raynaud's  disease,  and  of  hjematuria 
and  other  haemorrhages,  such  as  purpura,  heemoptysis,  and  hfemateme- 
sis,  all  of  which  the  speaker  had  personally  witnessed,  in  Graves's  dis- 
ease; as  well  as  with  the  occasional  albuminuria  of  the  latter,  and  the 
polyuria,  albuminuria,  and  glycosuria  of  myxoedema  and  of  acromegalia, 
and  the  morbid  perspiration  and  localized  cedemas  and  flushes  of  all 
these  conditions,  and  of  angeio-neurotic  redema — in  which  latter  condi- 
tion he  had  also  found  hicmocytes  in  the  urine  during  and  after  parox- 
ysms affecting  the  throat  in  one  woman  and  the  arms  in  another.  In 
some  of  his  cases  of  vaso-motor  ataxia,  a  condition  which  varied  much 
in  its  severity,  from  but  slight  abnormity  to  such  marked  aifections  as 
those  associated  with  the  name  of  Graves  and  Raynaud,  the  author  had 
observed  hoematemesis,  with  symptoms  suggestive  of  gastric  ulcer, 
anaemia,  menstrual  irregularities,  migraine,  transient  localized  oedema, 
transient  local  blushing,  permanent  dilatation  of  isolated  groups  of  cap- 
illaries and  venules,  stigmata,  local  syncope,  erythema  nodosum,  and 
urticaria ;  in  one  case  there  had  been  transient  blindness.  In  two  other 
cases,  in  which,  however,  no  thyreoid  abnormity  had  been  detected, 
there  had  been  membranous  enteritis.  Subjective  and  objective  cold- 
ness of  the  knees  was  marked  in  one  case  in  which  the  thyreoid  was 
enlarged.  In  another  case,  the  first  ol)served  by  Dr.  Cohen  in  a  male, 
there  had  been  great  rapidity  of  the  heart's  action  and  intermittent 
goitre  as  well,  so  that  the  case  might  well  have  been  called  Graves's 
disease,  and  doubtless  belonged  positively  in  that  category.  Strictly 
circumscribed  erythema  and  factitious  urticaria  could  be  readily  pro- 
duced in  all  these  cases  by  writing  upon  the  skin  with  a  probe,  or  in 
some  instances  applying  cold  to  the  part.  In  a  colored  woman  with 
exophthalmic  goitre  the  effect  was  almost  startling. 

The  connection  of  rheumatism  with  Graves's  disease,  and  the 
heredity  of  both,  was  too  frequent  to  be  a  mere  coincidence.  In  cer- 
tain cases  of  rheumatoid  arthritis  the  thyreoid  gland  was  found  to  be 
enlarged,  and  tracings  were  shown  of  the  fingers  of  an  old  man  with 
rheumatoid  arthritis  and  arthritic  muscular  atrophy,  in  which  the  par- 
rot-beak pad  and  nail  were  shown  in  the  terminal  phalanx  of  the 
thumb,  which  was  hyperextended,  while  the  sharpened  and  atrophied 
terminal  phalanges  of  other  fingers  resembled  sclerodactyle,  and  were 
almost  identical  with  the  tracings  from  the  case  of  Raynaud's  disease. 
Allusion  was  made  to  the  tetany  of  thyreoidectomy  and  the  tremors  of 
exophthalmic  goitre,  some  cases  of  myxcvdema,  the  speakei-'s  cases  of 
scleroderma  and  of  Raynaud's  disease,  and  some  of  his  cases  of  vaso- 
motor ataxia,  as  also  to  the  occurrence  of  phenomena  like  those  of 
Raynaud's  disease  in  certain  cases  of  scleroderma,  the  ana;mia,  and  the 
extreme  susceptibility  to  cold,  which  was  a  feature  of  all  the  conditions 
described.  To  complete  the  list  of  associations  observed,  and  admit- 
ting that  they  might  be  coincidental,  there  were  many  reported  in  con- 
nection with  the  occasional  occurrence  of  epilepsy  in  (iraves's  disease, 
two  cases  of  the  speaker's,  in  one  of  which  petit  iikiI  had  develo|)ed  in 
an  ana>mic  girl  with  enlarged  thyreoid  and  occasional  tachycardia,  and 
in  the  other,  a  male,  with  enlarged  thyreoid,  tachycardia  and  flushed 
face  accompanied  the  epileptic  paroxysm.  The  not  infreciueut  termina- 
tion in  phthisis  of  many  of  the  conditions  alluded  to  might  have  no 
other  significance  than  impaired  nutrition,  but  the  recent  observation 
of  haimoptysis  occurring  only  during  a  paroxysm  in  one  case  of  epi- 
lepsy without  appreciable  pulmonary  lesion,  and  in  one  case  of  local 
asjjhyxia  with  but  trilling  signs  in  the  chest  and  a  few  tubercle  bacilli 
in  the  s])utum,  had  suggested  the  thought  that  vascular  disturbances  in 
the  lung  might  be  the  determining  factor.  Finally,  attention  was  called 
to  the  success  of  various  observers  in  treating  niyxo'dema  by  implanta- 
tion of  a  thyreoid  gland,  by  injections  of  thyreoid  extract,  and  by  feed- 
ing with  fresh  thyreoids.  It  was  suggested  that  the  same  treatment 
might  be  of  benefit  in  many  of  these  varied  conditions  nai'rated. 


342 


MISCELLANY. 


rN.  Y.  Med.  Jouu.. 


Tlie  speaker  desired  to  avoid  prematuie  assertion  of  causal  relation- 
ship, and  bad  therefore  made  use  of  the  words  "  associated  with," 
rather  than  "dependent  upon"  abnormity  of  the  thyreoid  gland,  in  de- 
scribing the  trophic,  neurotic,  and  neuro-vascular  phenomena  discussed  ; 
some  of  the  complicated  associations  he  had  been  unfortunate  enough 
to  meet  with  were  doubtless  purely  fortuitous.  The  tendency  of  diag- 
nosticians was  naturally  to  discriminate  among  groups  of  phenomena 
presenting  similarities,  and  thus  to  divide  rather  than  unite.  Never- 
theless, the  student  of  pathology,  in  its  broad  sense,  must  be  on  the 
alert  for  commonalty  of  phenomena,  and  certainly  the  very  variety  of 
the  nutritional  disturbances  associated  with  abnormities  of  the  thyreoid 
gland  indicated  a  profound  relationship  among  them,  dependent  upon 
the  important  metabolic  functions  of  the  gland. 

The  researches  of  many  observers,  in  particular  Horsley,  had  dojiion- 
strated  this  metabolic  importance,  and  that  the  secretions  of  the  gland 
acted  in  the  organism  in  some  way.  Dr.  Cohen  believed  that  they  wei  e 
in  truth  chemio-tactic  or  regulatory,  and  that  individual  constitution, 
heieility,  environment,  lial)its,  and  the  like,  determined  the  particular 
direction  in  which  failure  of  their  function  would  be  manifested  Most 
certainly  an  intimate  relation  existed  between  the  thyreoid  gland  and 
the  visceral  nervous  system,  more  especially  the  vaso-motor  mechanism. 
Of  course,  under  the  conditions,  it  was  difficult  to  separate  primary 
from  secondary  phenomena — the  mediate  results  of  the  train  of  ac- 
tion of  a  mechanism  from  the  immediate  results  of  the  influences  that 
had  set  the  mechanism  in  action.  The  nuiin  purpose  of  the  paper  was 
to  suggest  more  common  observation  clinically  and  at  autopsies  of  the 
thyreoid  gland,  so  that  sufficient  data  might  be  collected  by  a  numl)er 
of  observers  in  order  to  determine  what  is  accidental  and  what  essential. 

The  Fan-American  Medical  Congress. — The  following  new  by-laws 
have  been  adopted : 

Langctages. — Bylaw  IX:  Papers  may  be  read  in  any  language 
providing  that  authors  of  the  same  shail  furnish  the  Secretary-General 
with  an  abstract  not  exceeding  six  hundred  words  in  length,  in  either 
of  the  official  languages  (English,  Spanish,  French,  or  Portuguese),  by 
not  later  than  July  10,  1893,  and  providing,  further,  that  a  copy  of 
each  such  paper  shall  be  furnished  in  either  of  the  official  languages, 
at  or  before  the  time  of  the  meeting,  to  the  secretary  of  the  section  be- 
fore which  the  same  shall  be  read.  Remarks  upon  papers  may  be 
made  in  any  language  providing  that  members  making  such  remarks 
shall  furnish  a  copy  of  the  same,  in  either  of  the  official  languages,  be- 
fore the  adjournment  of  the  session. 

PuHMC'ATioN. — By-lam  X :  All  papers  read,  either  in  full  or  by  title, 
shall  be  immediately  submitted  for  publication  in  the  Transactions 
(Special  Regulation  3),  but  authors  may  retain  copies  and  publish  the 
same  at  their  pleasure  after  the  adjournment  of  the  congress. 

Constituent  Organizations. — By-law  XI :  All  medical,  dental,  and 
pharmaceutical  organizations,  the  titles  of  which  have  been  transmitted 
with  approval  to  the  committee  on  organization,  or  which  may  here- 
after be  transmitted  with  approval  to  the  executive  committee  by  any 
member  of  the  international  executive  committee,  each  for  his  own 
country,  shall  be  subject  to  election  by  the  executive  committee,  ap- 
proved by  the  president,  as  constituent  bodies  of  the  First  Pan-Ameri- 
can Medical  Congress,  and  each  organization  thus  constituted  shall  have 
the  right  to  designate  as  delegates  all  of  its  members  attending  the 
congress,  hut  no  such  organization  shall  meet  at  the  time  and  place  of 
meeting  of  the  congress  as  a  distinct  body  ;  providing  that  the  secre- 
tary of  each  such  constituent  body  shall  furnish  a  list  of  officers  and  a 
statement  of  the  number  of  members  of  his  respective  organization  to 
the  Secretary-General  not  later  than  sixty  days  before  the  meeting  of 
the  congress,  and  shall  forward  a  list  of  delegates  chosen  to  reach  the 
Secretary-General  before  the  opening  of  the  congress. 

Sfrtinn  in  Medical  PcJayoyicK. — The  pedagogic  section  will  devote 
its  attention  especially  to  the  history  of  the  development  of  medical 
education  in  America. 

In  the  papers  presented  by  leading  teachers  recent  advances  in 
methods  of  instruction  will  be  considered. 

The  art  of  teaching^  which  is  regarded  as  a  study  of  great  interest 
in  other  branches  of  learning,  has  received  hitherto  but  little  attention 
from  the  medical  profession. 


The  Section  in  Medical  Pedagogics  will  therefore  be  made  a  promi- 
nent feature  of  the  congress,  and  it  is  hoped  that  those  interested  in 
medical  education  will  co-operate  in  the  work  of  this  section  by  being 
present  and  by  actively  engaging  in  the  discussion  of  subjects  pre- 
.sented. 

Any  iiupiiries  or  communications  may  be  made  through  the  secre- 
taries undersigned : 

J.  Coi.LiN.s  Warren,  M.  I).,  Executive  President,  Boston,  Mass. 
Charles  L.  Sc'UDDER,  M.  D.,  Enylish-Kpeaking  Secretary, 

Boston,  Mass. 

William  F.  Hutchinson,  M.  D.,  Spanifsh-npeaking  Secretary, 

Providence,  R.  I. 

Section  in  Hygiene,  Climatology,  and  Demography. — Persons  pio- 
posing  to  present  papers  before  this  section  are  requested  to  communi- 
cate with  either  of  the  undersigned  iintnediately,  that  titles  of  subjects 
may  be  properly  classified  for  the  programme  of  the  proceedings  of  the 
congress.  The  only  limitation  as  to  subject  matter  is  that  it  shall  have 
a  sanitary,  climatological,  or  statistical  bearing.  Members  of  the  Sec- 
tion in  State  Medicine  of  the  American  Medical  Association,  of  the 
American  Public  Health  Association,  of  the  American  Climatological 
Association,  of  the  American  Academy  of  Medicine,  and  of  State  and 
Municipal  Boards  of  Health  are  especially  invited  to  contribute  the  re- 
sults of  their  several  experiences.  The  languages  of  the  congress  being 
Spanish,  Portuguese,  French,  and  English,  papers  may  be  presented  in 
either,  to  be  translated  into  the  others,  for  which  reason  their  text 
should  be  in  the  hands  of  the  secretaries  at  the  earliest  possible  date. 
Albert  L.  Gihon,  M.  D.,  Prenident, 

145  East  Twenty-first  Straet,  New  York. 
Pedro  Jose  Salicrui',  M.  D.,  Secretary  (Spanish), 

129  East  Seventeenth  Stieet,  New  York  City. 
Peter  II.  Bryce,  M.  D.,  Secretary  (English),  Toronto,  Canada. 

The  following-named  physicians  have  been  appointed  members  of 
the  advisory  council :  Dr.  F.  Mall,  University  of  Chicago,  Chicago ;  Dr. 
Charles  F.  DoUey,  3707  Woodland  Avenue,  Philadelphia  ;  Dr.  Edward  K. 
Dunham,  Carnegie  Laboratory,  New  York;  Dr.  Elizabeth  R.  Bundy, 
Woman's  Medical  College,  Philadelphia  ;  Dr.  W.  M.  Gray,  Army  Medi- 
cal Museum,  Washington  ;  and  Dr.  II.  C.  Tinkham,  University  of  Ver- 
mont, Burlington,  Vt. 

77t«  Section  in  Dermatology  and  Syp]iilography\\a.i  been  organized  as 
follows  :  Honorary  presidents.  Dr.  Silva  Aranjo,  Rio  de  Janeiro,  U.  S.  of 
Brazil ;  Dr.  L.  Duncan  Bulkley,  New  York ;  Dr.  Juan  C.  Castillo,  Lima, 
Peru;  Dr.  Louis  A.  Duhring,  Philadelphia;  Dr.  Le  Grand  N.  Denslow, 
St.  Paul ;  Dr.  Maximiliano  Golan,  Mexico,  Mexico ;  Dr.  James  Nevins 
Hyde,  Chicago;  Dr.  Prince  A.  Morrow,  New  York;  Dr.  R.  B.  Morison, 
Baltimore  ;  Dr.  D.  W.  Montgomery,  San  Francisco ;  Dr.  A.  Ravogli, 
Cincinnati ;  Dr.  A.  R.  Robinson,  New  York  ;  Dr.  Antonio  Rubio,  Pinar 
del  Rio,  Cuba  ;  Dr.  M.  Lucas  Sierra,  Santiago,  Chile ;  Dr.  R.  W.  Taylor, 
New  York  ;  Dr.  A.  Van  Harlingen,  Philadelphia  ;  Dr.  J.  C.  White,  Bos- 
ton ;  Dr.  Edward  Wigglesworth,  Boston.  Executive  president.  Dr.  A. 
H.  Ohmann-Dumesnil,  No.  5  South  Broadway,  St.  Louis.  Secretaries, 
Dr.  W.  S.  Fottheil  (English-speaking),  2.5  West  Fifty-third  Street,  New 
York ;  Dr.  John  Forrest  (Spanish-speaking),  Charleston  ;  Dr.  Carlos 
Lloveras  [Piedad  944],  Buenos  Aires,  Argentine  Republic;  Dr.  Vis- 
carra  Heredia,  La  Paz,  Bolivia;  Dr.  W.  S.  Barnes  [Leper  Hospital],  Ma- 
haica,  British  Guiana ;  Dr.  Joan  P.  Gabiza,  Rio  de  Janeiro,  U.  S.  of  Bra- 
zil ;  Dr.  J.  E.  Graham,  Toronto,  Canada ;  Dr.  Enrique  Robelm  [Jesus 
Maria  91],  Havana,  Cuba  ;  Dr.  Daniel  E.  Coronado  [Calle  13,  num.  120], 
Bogota,  Colombia;  Dr.  Daniel  Nunez,  San  Jose,  Costa  Rica;  Dr.  Angel 
Rivera  Paz,  Guatemala,  Guatemala ;  Dr.  H.  G.  McGrew,  Honolulu,  Ha- 
waii; Dr.  Strachan,  Kingston,  Jamaica;  Dr.  P.  Numa  Rat,  Antigua, 
Leeward  Islands ;  Dr.  Francisco  Bernaldez  [Escuela  de  Medicina],  Mex- 
ico, Mexico ;  Dr.  Bevan  N.  Rake,  Port  of  Spain,  Trinidad  ;  Dr.  Manuel 
Bonasso  fArapey  Es([uina  Colonia),  Montevideo,  Uruguay;  Dr.  Adolfo 
Briceiio  Picon,  Merida,  Venezuela.  Advisory  council.  Dr.  T.  B.  Keher, 
St.  Louis ;  Dr.  E.  B.  Browson,  New  York  ;  Dr.  Jos.  Zeisler,  Chicago ; 
Dr.  J.  P.  Knoche,  Kansas  City  ;  Dr.  W.  T.  Corlett,  Cleveland  ;  Dr.  M. 
P.  Vander  Horck,  Minneapolis ;  Dr.  B.  Merrill  Rickets,  Cincinnati ;  Dr. 
H.  W.  Blanc,  Sewanee,  Tenn.  ;  Dr.  J.  V.  Shoemaker,  Philadelphia;  Dr. 
J.  H.  Bloom,  Louisville;  Dr.  H.  W.  Stelwagon,  Philadelphia;  Dr.  J. 
C.  McGuire,  Washington.    Communications,  notices  of  papers,  etc.. 


March  25,  1893.J 


MISCELLANY. 


343 


should  be  sent  to  the  secretary,  Dr.  W.  S.  Gottheil,  25  West  Fifty-third 
Street,  New  York. 

The  Section  in  General  Medicine. — -The  following  announcement  has 
been  issued:  "This  unique  assemblage  promises  to  be  one  of  the  most 
important  events  that  has  occurred  in  the  history  of  medicine  in  the 
Americas.  Its  success  is  assured  by  the  large  number  of  valuable 
papers  already  promised.  The  Section  in  General  Medicine,  which  is 
one  of  the  most  important  that  have  been  created,  bids  fair  to  be  one 
of  the  most  successful  in  the  entire  congress,  and  already  many  valua- 
ble contributions  are  in  process  of  preparation  and  will  be  read  at  the 
meeting  in  September.  It  is  hoped,  with  the  hearty  co  operation  of  all 
physicians  living  not  only  in  North  but  also  in  South  and  Central 
America,  that  the  work  in  this  section  will  be  memorable;  and  each 
physician  living  on  this  continent  is  requested  to  join  this  most  impor- 
tant section  and  to  prepare  a  contribution  to  be  read  before  that  body. 
It  is  especially  requested  that  those  intending  to  join  this  section  or  to 
read  papers  shall  at  once  send  their  names,  w  ith  titles  of  papers,  to  the 
secretary,  Dr.  Judson  Daland,  No.  319  South  Eighteenth  Street,  Phila- 
delphia, Pa.,  so  that  they  may  be  noted  on  the  calendar  and  given  their 
appropriate  places." 

77ie  SeciioH  in  Therapeuiicn. — The  president  of  the  section.  Dr. 
Hobart  Amory  Hare,  of  Philadelphia,  writes  as  follows :  "  Will  you 
kindly  state  in  the  columns  of  your  esteemed  journal  that  it  is  the  earnest 
desire  of  the  officers  of  the  Section  in  Therapeutics  in  the  Pan-American 
Medical  Congress  that  both  specialists  and  general  practitioners  should 
contribute  articles  to  its  proceedings  ?  "  Gentlemen  who  desire  to  read 
papers  at  this  meeting,  he  adds,  should  notify  him  at  once  of  their  in- 
tention, and  should  send  him  by  July  lltth  at  the  late.«t  an  abstract  of 
their  paper  in  order  that  it  may  be  translated  into  the  three  official 
languages  of  the  congress  and  announced  in  the  programme.  The  im- 
portance of  this  section  and  the  interesting  papers  which  have  already 
been  promised  give  assurance  of  a  very  successful  meeting. 

An  International  Semmelweis  Memorial. — The  following  ciicular 
has  been  issued  in  the  name  of  an  executive  committee  in  Budapest, 
Hungary  : 

"  The  great  service  that  Semmelw^eis  has  done  for  science,  as 
founder  of  the  doctrine  of  the  origin  and  prevention  of  puerperal  fever 
and  the  antiseptic  treatment  of  child-bearing  women,  is  now  recognized 
by  the  medical  profession  in  all  parts  of  the  world.  The  profession  es- 
timates at  present  not  only  the  scientific  activity  (v.  Die  Ae/ioloffie,  der 
Begriff  nnd  die  Prophylaxis  den  Kindhetifiebers^  \.  I.  Ph.  Semmelweis, 
1861)  of  this  talented  investigator,  but  also  the  extent  of  the  service 
which  he  has  rendered  to  sviffering  humanity. 

"When,  in  April,  1891,  the  mortal  remains  of  Semmelweis,  de- 
ceased 1865,  were  transported  from  Vienna  to  Budapest,  his  birthplace 
and  the  seat  of  his  activity,  the  medical  faculty  of  the  Royal  University 
of  this  town,  in  conjunction  with  the  Budapest  Royal  Medical  Society, 
intrusted  the  undersigned  committee  with  the  duty  of  initiating  pro- 
posals as  to  the  best  way  of  honoring  the  remembrance  of  Semmelweis 
in  a  durable  manner. 

"  The  consideration  that  the  services  of  Semmelweis  are  not  con- 
fined to  the  narrow  sphere  of  a  single  town  or  country  has  induced  the 
committee  to  propose,  together  with  some  pious  tokens  of  appreciation 
of  a  local  character,  the  erection  of  an  international  Semmelweis  Me- 
morial on  a  suitable  site  in  Budapest,  the  capital  of  Hungary,  to  express 
in  this  way  the  importance  of  the  blissful  activity  of  this  ever-memora- 
Ijle  man.  And,  in  order  to  give  the  whole  scientific  world,  in  the  widest 
l  ircles,  the  opportunity  of  participation  in  this  work  of  recognition,  in- 
ternational collections  are  to  be  initiated. 

"As  you  will  see,  by  the  subjoined  list  of  names,  the  executive 
committee  has  succeeded  in  securing  a  number  of  professional  brethren 
of  all  countries,  who  as  an  international  committee  will  co-operate  in 
carrying  out  the  projected  memorial. 

"  We  therefore  beg  to  submit  to  you,  as  well  as  to  the  medical  so- 
cieties, the  medical  press,  and  all  professional  brethren,  our  request  to 
support  our  design  and  to  take  an  active  part  in  this  collection.  We 
have,  besides,  the  conviction  that  among  your  professional  acquaint- 
ances there  may  be  many  grateful  families  who  would  gladly  subscril)e 
a  sum,  however  modest,  to  honor  the  man  whom  they  have  to  thank  that 


the  young  wife,  the  mother,  is  enabled  to  await  her  time  of  difficulty  with 
calmness. 

"  We  beg  to  have  all  subscriptions  addressed  to  the  treasurer  of  the 
Hungarian  executive  committee.  Dr.  Elischer,  IV,  Petofi-ter,  Budapest, 
Hungary. 

"  The  results  of  the  collection  will  be  periodically  published,  and  the 
executive  committee  hopes  to  be  in  the  position  to  submit  a  full  report 
of  its  activity  on  the  occasion  of  the  International  Congress  for  Hygiene 
and  Demography,  to  be  held  in  Budapest,  1894." 

The  committee  is  constituted  as  follows : 

Abegg,  Dr.,  Danzig;  Ahlteld,  Fr.,  Marburg;  Alin,  E.,  Stockholm  ; 
Anderson,  Mrs.  G.,  London;  Balandin,  J.,  St.  Petersburg;  Bar,  P., 
Paris ;  Barnes,  R.,  London  ;  Bigelow,  H.  R.,  Philadelphia  ;  Billings,  J. 
S.,  Washington;  Black,  J.  W.,  London;  Bossi,  L.  M.,  Genoa;  Boxall, 
R.,  London ;  Biirner,  E.,  Graz ;  Braun,  G.,  Vienna ;  Budin,  P.,  Paris  ; 
Calderini,  G.,  Parma ;  Champneys,  F.  H.,  London ;  Chrobak,  R.,  Vienna  ; 
Clark,  Sir  Andrew,  Bart.,  London ;  Cullingworth,  C.  J.,  London ;  Gush- 
ing, E.  W.,  Boston;  Czerny,  V.,  Heidelberg;  Dacarrete  y  Hernandez, 
M.  A.,  Cadiz;  Dohrn,  R.,  Konigsberg;  Duka,  T.,  London  ;  Ehrendorfer, 

E.  ,  Innsbruck ;  Eustache,  G.,  Lille ;  Fabbri,  E.  F.,  Modena ;  Fehling, 
H.,  Basel ;  Fraipont,  F.,  Liege ;  Freund,  W.  A.,  Strassburg ;  Fritsch,  H. 
H.,  Breslau  ;  Frommel,  R.,  Erlangen  ;  Glover,  J.  G.,  London ;  Green,  C. 
M.,  Boston ;  Gusserow,  A.,  Berlin  ;  Guzzoni  degli  Ancarani,  Cagliari  ; 
Haffter,  E.,  Frauenfeld ;  Halbertsma,  T.,  Utrecht ;  Hegar,  A.,  Freiburg 
i.  B.  ;  Hennig,  C,  Leipsic ;  Heinricius,  G.,  Helsingfors  ;  Hergott,  T.  J. 
Nancy ;  Hirst,  B.  C,  Philadelphia ;  Hofmeier,  M.,  Wiirzburg ;  Howitz 

F.  ,  Copenhagen ;  Inverardi,  G.,  Padua ;  Jaggard,  W.  W.,  Chican-o  ■ 
Josephson,  C.  D.,  Stockholm ;  Kaltenbach,  R.,  Halle ;  Kellogg,  J.  H., 
Battle  Creek;  Kehrer,  F.  A.,  Heidelberg;  Ki<ld,  G.  H.,  Dublin;  King, 
A.  F.  A.,  Washington;  Krassnigg,  A.,  Klagenfurt;  Kufferath,  E.,  Brus- 
sels ;  Kiistner,  0.,  Dorpat ;  Lange,  C,  Copenhagen ;  Leopold,  C.  G. 
Dresden;  Lindfors,  A.  O.,  Lund:  Lister,  Sir  Joseph,  Bart.,  London; 
Lobmayer,  A.,  Zagrab;  Lohlein,  H.,  Giessen;  Madurowicz,  M.,  Krakau  • 
Marcy,  Henry  0.,  Boston  ;  Martin,  A.,  Berlin ;  Mendez  de  Leon,  Amster- 
dam ;  Meyer,  L.,  Copenhagen;  Moleschott,  J.,  Rome;  Neugebauer,  Fr., 
Warsaw  ;  Nordau,  M.,  Paris  ;  Olshausen,  R.,  Berlin  ;  Paget,  Sir  James 
Bart.,  London;  Pasteur,  Paris;  Perni(;e,  H.  K.  A.,  Greifswald ;  Pinard, 
A.,  Paris;  PhiinomenofF,  N.,  Kasan ;  Porro,  E.,  Milan;  Potter,  W.  W. 
Buffalo;  Priestley,  W.  0.,  London;  Proehownick,  L.,  Hamburg;  Rein 

G.  ,  Kiew ;  Ribemont  Dessaignes,  A.,  Paris;  Richardson,  L.  W.,  Cam- 
bridge ;  Ronciti,  G.,  Pisa ;  Rosthorn,  A.,  Prague ;  Routh,  C.  H.  F., 
London ;  Runge,  M.,  Gottingen ;  Salin,  M.,  Stockholm  ;  Sanger,  M.,  Leip- 
sic ;  Sanger,  W.  M.  H.,  Groningen  ;  Sae.xinger,  Joh.,  Tiibingen  ;  Schauta, 
FY,  Vienna;  Schoenberg,  E.,  Christiania  ;  Schultze,  B.,  Jena ;  Schwing,  K., 
Prague  ;  Simpson,  A.  R.,  Edinburgh ;  Sinclair,  A.  D.,  Boston ;  Skene,  A.  J. 
C,  Brooklyn  ;  Slawiansky,  K.,  St.  Petersburg ;  Stadfeldt,  A.,  Copenhagen  ; 
Stahl,  C,  Frankfurt  a.  M. ;  Stekoulis,  C,  Constantinople  ;  Storer,  M., 
Boston ;  Subbotic,  V.,  Belgrade  ;  Tarnier,  S.,  Paris  ;  Tilanus,  W.  J.  K. 
Amsterdam  ;  Treul),  H.,  Leyden ;  Valenta,  A.,  Laibach  ;  Veit,  G.,  Bonn  • 
Wallace,  A.,  London;  Welponer,  E.,  Trieste;  Wells,  Sir  Spencer,  Bart., 
London ;  Werth,  R ,  Kiel ;  Winckel,  F.,  Munich ;  Wolczynski,  J. 
Czernovitz;  Wyder,  Th.,  Ziirich ;  Zweifel,  P.,  Leipsic. 

Subscriptions  can  be  forwarded  by  post-office  order  or  check  to  the 
treasurer.  Dr.  J.  Elischer,  Budapest,  Hungary,  Petofi-ter,  No.  1. 

The  late  Dr.  Ceccarelli. — Under  the  heading  of  The  Physician  in 
High  Places  the  Lancet  for  March  4th  prints  the  following : 

"When,  in  February,  1878,  Pope  Pius  IX  was  succeeded  by  Leo 
XIII,  amidst  the  complete  change  in  the  personnel  of  the  Vatican  there 
was  one  eminent  functionary  retained,  and  that  was  Dr.  Alessandro 
Ceccarelli,  body  physician  to  the  late  Pontiff.  Many  were  the  reasons 
given  l)y  the  outside  world  for  this  dcpartme  from  usual  custom  in  the 
constitution  of  the  Pa|)al  Court.  One  was  that  Dr.  Ceccarelli  '  knew 
too  much '  to  be  safely  relegated  to  a  life  of  '  greater  freedom  and  less 
responsibility.'  From  the  close  intimacy  in  which  he  stood  to  Pio  None 
and  also  to  the  leading  cardinals  and  plenipotentiaries  accredited  to  the 
Holy  See,  he  was  necessarily  the  recipient  of  many  secrets,  of  many 
political  schemes,  some  abortive,  some  in  process  of  develo|)mcnt ;  of 
many  intrigues  such  as  i)crmeate  the  complex  life  of  the  Curia  and  of 
which  not  a  whisper  is  allowed  to  reach  profane  circles.    Little  did  the 


344 


MISCELLANY. 


[N.  Y.  Med.  Joib. 


aiitliors  or  propagators  of  this  surmise  know  Dr.  Ceccarelli,  who  needed 
no  subscription  to  the  '  Oath  of  Hippocrates '  to  observe  the  '  fidele 
silentium '  imposed  on  all  physicians — -doubly  on  one  enjoying  oppor- 
tunities such  as  bis  of  looking  behind  the  politico-religious  veil  of  the 
Vatican.  The  gossip  of  society  was  wide  of  the  mark  in  its  accounting 
for  Leo  XIII's  retention  of  his  preiiecessor's  body  physician,  and,  as 
usual,  in  its  anxiety  to  appear  '  knowing,'  missed  the  plain  facts  obvious 
to  all.  In  the  first  place.  Dr.  Ceccarelli  was  a  surgeon  as  well  as 
physician  hors  Ih/ne.  The  French  Ambassador,  to  take  one  instance  out 
of  many,  suffered  from  a  sublingual  cancerous  growth,  and  this  was  ex- 
tirpated so  skillfully  by  Dr.  Ceccarelli  that  on  dining  with  his  Excellency 
shortly  afterward  he  found  under  his  serviette  the  brevet  and  the  insignia 
of  the  Legion  of  Honor.  Even  outside  the  Apostolic  entourage  his  pro- 
fessional skill  was  in  request,  and  his  refusal  of  General  La  Marmora's 
offer  of  the  post  of  '  Generale  Medico '  in  the  Italian  army  was  as  great 
a  disappointment  to  the  (^uiriual  as  it  was  a  gratification  to  the  Vatican. 
With  so  much  to  recommend  him  as  an  able  and  devoted  consultant,  he 
had  other  (pialities  of  the  '  physician  in  high  places '  only  second  in 
importance  for  that  role.  He  had  admirable  self-possession  and  social 
tact — he  was  indeed  scarcely  less  of  a  diplomatist  than  the  ambassadors 
and  ministers  accredited  to  foreign  courts.  That  a  man  cognizant  of 
facts  so  momentous  should  yet  have  the  '  divine  gift  of  silence '  in  such 
perfection  was  a  special  qualification  for  the  post  of  pontifical  consult- 
ant not  likely  to  escape  the  notice  of  Leo  XIII.  Not  that  his  reticence 
was  an  absolute  or  an  indiscriminating  one.  Much  that  has  since  be- 
come history  he  was  able  to  confirm  or  to  supplement ;  much  that  is 
yet  valuable  for  the  historical  or  political  student  to  know  he  has  em- 
bodied in  '  documenti  preziosissimi  per  la  storia  d'ltalia,'  especially  for 
the  dramatic  events  that  preceded  and  followed  September  20,  1870 — 
documents  that  he  would  never  have  committed  to  paper  had  he  not 
meant  them  to  see  the  light.  These,  when  the  time  comes  for  publish- 
ing them,  will  furnish  lively  and  instructive  readmg,  and  they  will 
also  attest  their  author's  capacity  of  distinguishing  between  the  facts 
which  are  common  property  and  those  which  are  '  sacro  digna  silentio.' 
Among  the  latter  may  safely  be  included  the  memorable  encounter  be- 
tween the  Empress  Eugenie  and  Pius  IX,  when  both  exalted  person- 
ages, whose  fates  were  so  closely  and  so  disastroxisly  linked,  succumbed 
to  the  shock  of  long  pent-up  emotion,  the  Empress  admitting  that  it 
was  '  my  war,'  as  she  termed  the  fatal  campaign  of  1870,  that  made  her 
octogenarian  host  '  a  prisoner  in  the  Vatican,'  and  the  invalid  Holy 
Father  vainly  striving  at  much  personal  risk  to  comfort  the  prostrate 
suppliant.  There  are  situations  in  life,  whether  high  or  humble,  from 
which  the  outer  world  must  forever  remain  aloof,  and  of  these  the  above 
indicated  was  one  among  many  on  which  Dr.  Ceccarelli's  lips  were  relig- 
iously sealed.  This  innate  sense  of  professional  honor  was  but  in  keep- 
ing with  the  large  benevolence  he  lavished  on  the  sick  and  helpless 
poor — benevolence,  as  described  in  our  obituary  notice  of  him  in  the 
Lancet  of  last  week,  which  knew  no  distinction  of  party  or  creed,  but 
expended  itself  on  Garibaldian  insurgent  no  less  than  on  Papal  zouave 
or  assumed  the  congenial  form  of  hospital  construction  and  the  multi- 
plication of  clinical  wards.  Even,  we  are  told,  in  the  delirium  of  his 
last  illness  his  thouglits  kept  running  on  the  Congregazione  di  Carita 
and  his  uncompleted  projects  for  the  extension  of  its  usefulness. 
Lives  like  his  are  exemplary  for  their  proof  that  association  with  the 
exalted  of  the  earth  implies  no  necessary  estrangement  from  the  inter- 
ests of  the  lowly  and  the  less  favored,  and  that  active,  unobtrusive  benevo- 
lence has  its  share  as  well  as  diplomatic  reserve  and  scientific  achieve- 
ment in  determining  the  character  and  career  of  '  the  physician  in  high 
places.'  " 

Medico-legal  Points. — In  a  ease  recently  tried  in  the  Supreme  Court 
of  the  State  of  Illinois  the  following  decision  was  given : 

Siebert  vs.  The  People.  Supreme  Court  of  Illinois.  (Opinion  filed 
October  31,  1892.) 

3.  Evidence:  Comprtcncij  of  Expert  to  t/ire  his  Opinion. — A  prac- 
ticing physician  who  is  shown  to  be  a  graduate  of  a  regular  medical  col- 
lege, and  to  have  practiced  his  profession  for  many  years,  is  competent 
to  give  his  opinion  upon  a  hypothetical  question  setting  forth  the  symp- 
toms of  a  deceased  person,  whether  the  death  was  from  the  effects  of 
arsenical  poison,  although  he  may  not  be  shown  to  have  had  any  case 


of  such  poisoning.  A  medical  witness  in  giving  his  opinion  as  an  ex- 
pert, is  not  confined  to  opinions  derived  from  his  own  observation  and 
experience,  but  may  give  an  opinion  ))ased  upon  information  derived 
from  medical  books. 

11.  C'riiiii)iiil  Ldir  :  InslrHi  tioii  as  to  Rensonalile  — ()n  the 

trial  of  a  criminal  case,  it  is  not  error  to  instruct  the  jury  that  it  is  not 
necessary  to  prove  each  link  in  the  chain  of  circumstances  relied  on,  or 
eveiy  fact  in  the  case,  beyond  a  reasonal)Ie  doubt,  but  it  is  sufficient  if, 
taking  the  evidence  as  a  whole,  they  are  satisfied  beyond  a  reasonable 
doubt  of  the  defendant's  guilt. 

15.  Ei'idence :  Offer  of  Vial  and  Box  embraces  Continis. — When  a 
vial  and  box  containing  poison  is  offered  in  evidence  and  admitted,  the 
only  object  of  offering  them  in  evidence  being  to  get  the  contents  to  the 
jury,  an  instruction  to  the  jury  not  to  consider  the  contents  is  properly 
refused. — Jour,  of  the  Am.  Med.  Assoc. 


To  Contributors  and  Correspondents. —  The  uttnitiim  o  f  all  uho  pur/  oxe 
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THE  NEW  YORK  MEDICAL  JOURNAL,  Apbil  1,  1893. 


dPriginal  Communications. 


THE  MENTAL  SYMPTOMS  OF  FATIGUE.* 
By  EDWARD  COWLES,  M.  D., 

MEDICAL  SUPERINTENDENT,  MCLEAN  HOSPITAL,  SOMERYILLE,  MASS. 

The  subject  of  mental  symptoms  carries  witli  it  the 
suggestion  of  something  vague  and  difficult  of  apprehen- 
sion. The  study  of  mental  disorders  is  forbidding  to  the 
general  physician,  who  feels  that  he  has  neither  time  nor 
patience  for  it.  The  present  purpose  is  to  contribute  some- 
thing to  a  better  understanding  and  an  easier  appreciation 
of  the  mental  symptoms  of  fatigue,  which  will  be  consid- 
ered under  the  following  heads :  1.  The  nature  of  mental 
symptoms.  2.  The  physical  conditions  of  fatigue.  3.  Some 
elementary  facts  of  the  nervous  and  mental  mechanism.  4. 
The  alterations  of  mental  functions  that  are  significant  as 
symptoms. 

1.  The  Nature  of  Mental  Symptoms. — It  has  been  the 
fashion  to  regard  this  branch  of  neurology  as  being  slow 
in  its  progress,  having  no  coherent  principles,  resting  upon 
an  indeterminate  basis,  and  as  being  unscientific  in  its 
classification  and  therapeutics.  Krafft-Ebing  admits  that 
the  anatomy  of  the  nervous  system  has  so  far  been  in- 
complete and  unsatisfactory  in  not  enabling  us  to  reason 
from  structure  to  function,  as  has  been  done  in  the  rela- 
tively simple  structure  of  the  vegetative  organs,  and  that 
pathology  has  been  disappointing  in  failing  to  explain  the 
most  marked  disturbances  of  function.  But  he  points  to 
the  fact  that  psychiatry  is  one  of  the  youngest  of  our  spe- 
cial sciences.  He  says  it  seems  almost  exclusively  depend- 
ent on  itself,  and  is  limited  to  the  direct  observation  of 
morbid  mental  phenomena  ;  also  that  it  is  from  the  em- 
pirical valuation  of  these  phenomena  that  we  are  obliged 
to  draw  conclusions  as  to  the  kind  and  degree  of  the  func- 
tional disturbance  in  the  organ  of  mind.  His  conclusion 
is  that  great  progress  has  been  made  in  the  raising  of  psy- 
chiatry to  the  rank  of  a  natural  science  with  methods  of 
empirical  research.  Its  direct  advancement  can  be  accom- 
plished only  by  tireless  observation  and  report  of  clinical 
phenomena,  and  thus  fixing  the  facts  of  the  mental  life. 
While  mental  disease  is  always  brain  disease,  the  course  of 
the  processes  in  mental  disorders  is  discovered  through  ob- 
servation, as  in  any  other  disease. 

The  hope  of  gaining  a  clearer  appreciation  of  mental 
symptoms  lies  in  the  fact  that  we  may  observe  so  much 
more  directly  the  manifestations  of  mind,  and  consequent- 
ly of  nervous  function,  than  we  can  those  of  any  other 
function  of  the  nervous  system.  We  may  study,  by  the 
aid  of  anatomy,  physiology,  pathology,  and  physics,  an  in- 
voluntary mechanism  like  the  heart,  or  the  action  of  the 
muscular  system  as  a  voluntary  mechanism.  In  the  action 
of  the  peripheral  apparatus  we  note  the  expression  of  the 
setting  free  of  central  nervous  energy,  and  can  trace  the 
conducting  path  of  the  motive  energy  back  to  motor  cen- 

*  Read  before  the  New  York  State  Medical  Association,  November 
16,  1892. 


ters.  But  we  can  get  no  further  than  to  speak  of  "  inner- 
vation "  and  "  inhibition,"  with  entire  ignorance  of  the  way 
in  which  nervous  substance  is  stimulated,  and  augments  or 
controls  that  which  stimulates  it  into  activity.  We  are 
conscious  that  the  mode  of  expression  of  the  active  mind 
through  the  peripheral  instruments  is  indirect. 

All  this  is  true  also  of  the  complex  organ  of  speech, 
when  examined  as  an  organ  and  as  one  of  the  minor  mech- 
anisms of  whose  anatomy  and  pathology  we  may  make  the 
most  scientific  study,  as  we  need  to  do  for  a  correct  inter- 
pretation of  any  change  from  normal  action.  But  through, 
this  organ  we  hear,  in  the  articulate  sounds  with  varied 
tone,  pitch,  and  inflection,  and  in  the  words  which  this  in- 
strument produces,  the  direct  expression  of  a  function  by 
which  brain  cells  are  able  to  convey  to  our  understanding- 
the  largeness  and  fineness  of  meaning  that  is  comprehended 
in  the  "  infinite  variety  "  of  the  human  mind.  This  takes 
us  into  a  field  of  phenomena  that  our  kindred  sciences  fail 
to  reach.  Instead  of  lamenting  that  they  do  not  aid  us,  it 
is  perhaps  more  true  to  say  that  we  do  not  need  their  aid 
in  the  interpretation  of  these  manifestations,  which,  by 
a  superior  mode  of  expression,  convey  finer  variations  of 
meaning,  and  make  revelations  of  earlier  and  slighter  de- 
partures from  normal  action,  than  we  can  get  from  any  other- 
function  of  the  human  organism.  Moreover,  it  is  given  us- 
to  make  these  discriminations  by  the  natural  law  of  mind, 
without  any  need  of  laborious  study  and  interpretation  of 
the  working  of  an  intervening  instrument.  We  hear  the- 
expression  of  thought  and  feeling  in  sounds  that  we  come 
to  know,  and  we  need  not  stop  to  note  the  mechanism  of 
their  utterance.  From  the  moment  when  we  are  thrust  into 
this  noisy  world,  the  articulate  sounds  of  the  human  voice  be- 
gin to  be  familiar  to  us.  Every  man  makes  his  way  in  the 
world  largely  by  his  success  in  measuring  the  minds  of  his 
fellow-men.  We  have  by  nature  a  most  intimate  common 
knowledge  of  variations  in  mental  function ;  of  no  science 
have  we  a  more  practical  every -day  knowledge  than  of  psy- 
chology. It  is  true  that  we  have  to  discover  a  way  to  re- 
duce the  data  of  this  knowledge  to  orderly  form,  and  to 
recognize  the  import  of  commonly  observed  mental  mani- 
festations by  observing  their  correspondence  with  recog- 
nized bodily  conditions.  This  must  constitute  a  true  sci- 
ence of  the  health  and  disease  of  a  function  which  has  its 
own  peculiar  character  and  physiological  laws. 

The  nature  of  mental  symptoms,  or  manifestations  of 
departures  from  normal  function,  being  thus  understood, 
we  should  approach  their  study  with  minds  free  from  preju- 
dice, prepared  to  observe  and  fix  the  facts  of  each  kind  of 
manifestation,  and  array  them  in  the  order  of  their  occur- 
rence and  relations  with  each  other.  The  question  now 
comes.  Can  we  set  up  a  plain  and  intelligible  conception  of 
the  normal  mental  mechanism  that  will  serve  as  our  standard 
in  which  to  note  and  localize,  as  it  were,  the  departures  from 
normal  action  ?  We  must  begin  in  an  elementary  way,  and 
deal  first  with  the  slighter  variations  from  conditions  of 
health  in  the  mechanism  and  its  fullness  of  power  to  do 
what  it  can  do.  In  the  brief  time  allotted  here  the  attempt 
will  be  made  to  do  little  more  than  to  point  out  a  method 


346 


G0WLE8:   THE  MENTAL  SYMPTOMS  OF  FATIGUE. 


fN.  Y.  Mbd.  Joub., 


of  observation  and  study,  on  the  basis  of  some  of  the  pri- 
mary facts,  of  the  mental  and  nervous  mechanism. 

2.  The  Physical  Conditions  of  Fatigue. — The  proposi- 
tion may  be  laid  down  to  start  with,  as  a  working  fornmla, 
that  the  org-M  of  the  mind  is  an  apparatus  for  the  storage 
and  discharge  of  nervous  energy,  and  that  all  mental  symp- 
toms indicate  a  failure  of  the  mental  elements  to  fuiu^tion 
with  normal  co-ordination,  because  of  modification  of  the 
power  to  set  free  nervous  energy,  due  to  lack  of  the  dis- 
charging force,  or  the  obstruction  of  it,  or  to  lessened 
power  of  control,  or  as  due  to  excess  of  stimulation  and 
discharge,  which  means  also  relative  weakness  of  inhibitory 
control.  All  of  these  conditions  of  nervous  action  may  ex- 
ist together  or  side  by  side,  and  often  do,  not  only  in  the 
most  manifest  of  mental  diseases,  but  in  the  lesser  degrees 
of  nervous  fatigue.  In  fact,  the  key  to  the  understanding 
of  these  graver  conditions  seems  to  be  in  the  appreciation 
of  the  slighter  degrees  of  nervous  exhaustion  always  to  be 
observed  in  normal  fatigue.  The  condition  of  the  central 
organ  may  be  directly  observed  through  the  mental  symp- 
toms, which  quickly  reflect  the  variations  in  nervous  force 
and  activity.  The  correct  understanding  of  these  symp- 
toms is  essential  to  the  best  treatment  of  nervous  exhaus- 
tion in  all  its  forms.  And  this  is  the  soil  in  which  the 
more  serious  nervous  diseases  take  root  and  grow. 

The  bodily  conditions  of  fatigue  should  first  be  con- 
sidered as  far  as  we  can  know  them,  and  may  be  studied  in 
their  two  forms  or  degrees:  1,  normal  fatigue,  or  the  con- 
dition of  wholesome  tire  from  daily  physiological  use ;  and 
2,  pathological  fatigue,  or  the  condition  of  persistent  "im- 
poverishment of  nervous  tissue  in  excess  of  repair,"  accord- 
ing to  Beard,  which  constitutes  nervous  exhaustion  or 
neurasthenia.  The  mental  symptoms  are  to  be  studied  in 
their  close  and  direct  correspondence  with  these  conditions 
of  fatigue. 

The  effects  of  fatigue  are  produced  by  sufficiently  con- 
tinued exercise  in  the  physiological  use  of  any  function, 
muscular  or  nervous.  The  sense  of  fatigue  is  complex  and 
may  have  a  central  or  peripheral  source  or  both  together. 
In  muscular  tissue  the  condition  of  fatigue  depends  upon 
the  physiological  fact  that  muscular  contraction  is  in  some 
way  or  other  the  result  of  a  clinical  change  whereby  the 
latent  energy  is  set  free  and  expended  in  the  mechanical 
work,  with  also  the  setting  free  of  heat.  The  resultant 
chemical  products  are  toxic  and  obstructive  of  muscular 
function  unless  they  are  duly  washed  away  in  the  blood 
current,  and  time  must  be  given  in  rest  and  sleep  for  this 
process,  as  well  as  for  nutrition  and  repair.  These  toxic 
products  being  variously  irritant  or  benumbing,  doubtless 
thus  affect  tlie  sensory  apparatus  through  which  fatigue  is 
■felt.  It  is  evident  from  this  that  the  condition  of  muscular 
fatigue  has  always  a  dual  character — there  is  direct  ex- 
penditure of  energy  requiring  repair,  and  a  toxic  element 
that  may  be  obstructive  of  function,  both  that  of  discharg- 
ing energy  and  of  taking  up  nutrition. 

In  nervous  substance,  the  nature  of  nerve  force  being  un- 
known, the  effects  of  the  passage  of  a  nervous  impulse 
along  nerve  fibers  are  not  demonstrable  as  attended  by 
chemical  changes,  or  loss  of  normal  irritability  as  a  mani- 


festation of  fatigue.*  But  in  the  central  nervous  organs  it 
is  found  that  their  function  is  dependent  on  an  adequate 
supply  of  oxygen,  and  this  implies  that  "  in  nervous  as  in 
muscular  substance  a  metabolism  mainly  of  an  oxidative 
character  is  the  real  cause  of  the  development  of  energy. f 
In  fact,  we  do  not  doubt  that  toxic  waste  products  attend 
upon  central  nervous  activity,  and  this  accords  with  the 
biological  theory  that  all  function  is  due  to  chemical  changes 
taking  place  within  the  organism,  and  that  the  functional 
activity  of  a  specialized  tissue  depends  primarily  upon  the 
changes  in  its  individual  cells.  The  dual  character  of  all 
conditions  of  primary  fatigue  is  evident,  as  is  also  the  im- 
portance of  recognizing  the  effects  of  the  self-produced 
poisonous  substances  that  regularly  result  from  the  chemi- 
cal changes  in  tissue  metabolism  within  the  body,  as  we 
are  taught  by  the  brilliant  revelations  of  modern  chemical 
physiology  and  pathology. 

Normal  fatigue  from  the  discharge  of  tissue  energy  is 
therefore  shown  to  be  inseparably  accompanied  by  toxic 
products  that  contribute  to  the  effects  of  fatigue.  Patho- 
logical fatigue  represents  a  further  development  and  per- 
sistence of  this  condition  in  the  organism.  Stimulation 
too  soon  repeated,  without  giving  time  for  rest  and  repair, 
finds  nerve  cells  in  fatigued  areas  having  less  power  to  act 
because  of  inanition  from  deficient  rest  and  nourishment ; 
they  are  also  hindered  in  action  by  the  incomplete  removal 
of  the  toxic  products  of  previous  action.  Then  assimilation 
is  further  hindered — first,  by  the  lessened  nutritive  quality 
of  the  blood  from  the  presence  of  non-eliminated  toxic 
materials  ;  and  second,  by  the  probable  toxic  weakening  of 
the  cells'  power  to  assimilate  the  nutrition  that  is  furnished 
to  them.  The  development  of  a  manifestly  morbid  condi- 
tion may  be  very  slow  and  insidious,  or  more  rapid  accord- 
ing as  the  balance  of  the  processes  of  constructive  and  re- 
gressive metabolism  is  more  or  less  on  the  side  of  impover- 
ishment, exhaustion,  and  weakness.  From  the  gradually 
failing  elimination  the  local  inanition  may  become  more 
general,  and  the  first  results  are  an  increased  excitability 
from  weakened  resistance  and  inhibition,  with  a  quick  ex- 
haustion of  the  nervous  system  under  exercise.  These  are 
the  constant  characteristics  of  neurasthenia.  Thus,  as 
Kowalewsky  J  says,  "  a  locally  limited  overstrain  of  a  cer- 
tain part  of  the  nervous  system  may  lead  to  general  ex- 
haustion and  neurasthenia."  Hence  neurasthenia  has  been 
defined  by  Ziemssen  *  as  "a  functional  weakness  of  the 
nervous  system,  varying  from  the  slightest  degrees  in  sim- 
ple localities  to  entire  loss  of  strength  in  the  whole  nervous 
system."  Arndt  ||  states  the  characteristics  of  neurasthenia 
to  be  "  increased  excitability  with  a  tendency  to  rapid  fa- 
tigue, especially  of  the  muscular  system."  He  notes  par- 
ticularly also  the  cerebral  irritability  and  hypersesthesia 
of  the  cranial  nerves,  especially  those  of  the  special  senses. 

The  remarkable  experiments  of  Hodge  ^  are  most  sug- 

*  Bowditch.    Journ.  of  Phys.,  vol.  vi,  p.  133. 

f  Foster.    Physiology,  Fifth  Eng.  Ed.,  1890,  pp.  914-918. 
\  CerUralblittt  f.  Nervenheilkunde,  October,  1890. 

*  Neurasthenia,  Wood's  Monographs,  vol.  i,  1889,  p.  534 

II  Art.  Neurasthenia,  Tuke's  Did.  Psych.  Med.,  1892,  vol.  ii,  p.  843. 
^  Amer.  Jour,  of  Psychol.,  May,  1888,  May,  1889,  and  Feb.,  1891. 


April  1,  1893.] 


(JOWLES: 


THE  MENTAL  SYMPTOMS  OF  FATIGUE. 


347 


gestive  as  demonstrating  the  physiological  shrinkage  and 
recovery  of  cell  contents  in  spinal  ganglion  cells ;  it  is 
shown  that  upon  stimulation  and  upon  normal  exercise  the 
histological  changes  of  breaking  down  and  building  up  of 
cell  contents  are  accompaniments  of  the  physiological  dis- 
charge and  restorage  of  energy,  and  as  being  normally  at- 
tendant upon  fatigue  followed  by  rest. 

The  conditions  of  the  organism  in  normal  and  patho- 
logical fatigue  being  thus  understood,  we  have  a  basis  for 
the  study  of  the  relation  thereto  of  the  mental  symptoms  of 
fatigue.  It  is  agreed  by  all  observers  that  the  symptoms 
of  nervous  exhaustion  are  mainly  subjective.  The  objec- 
tive symptoms  need  not  be  dwelt  upon  here ;  the  com- 
monly noted  manifestations  of  increased  excitability,  ir- 
ritability, and  restlessness  are  readily  recognized  as  repre- 
senting the  internal  hyperjesthesia  so  significant  of  the 
"  irritable  weakness  "  of  nervous  exhaustion.  The  pur- 
pose now  is  to  show  the  significance  of  a  few  easily  and, 
in  fact,  commonly  recognized  subjective  or  mental  symp- 
toms which  stand  as  distinctive  signs  of  fatigue.  They 
furnish  a  ready  index  of  the  fatigue  and  auto-intoxication 
of  nerve  and  muscle  tissues  as  a  guide  for  diagnosis,  pro- 
phylaxis, and  treatment ;  and  the  general  symptoms  of 
nervous  exhaustion  can  be  understood  better  and  earlier  by 
the  proper  interpretation  of  the  mental  symptoms. 

3.  Some  Elementary  Facts  of  the  Nervous  and  Mental 
Mechanism. — In  order  to  make  clear  the  changes  that  we 
call  symptoms  in  the  mental  manifestations,  it  is  necessary 
to  note  some  elementarv  facts  in  the  relations  between  the 


signed  to  represent  the  nervous  and  mental^mechanism,  and 
to  show  some  of  the  relations  of  the  inner  activities  that  we 
call  mental,  to  the  body  in  general,  and  to  the  environment. 

Let  us  suppose  that  we  can  look  into  the  region  of  con- 
scious mind  as  into  an  inclosed  place,  and  a  section  being 
made  of  it,  we  can  see  noted  thereon,  as  in  the  "  field  of 
consciousness,"  the  modes  of  mental  action  as  they  are 
designated  by  common  agreement.  At  the  other  end  of 
the  diagram  are  noted  the  organs  of  special  sense  through 
which  stimuli  from  the  environment  start  impulses  that  are 
conducted  along  sensory  tracts  and  produce  physical  sensa- 
tions in  the  sensory  centers  in  the  entrance  to  the  field  of 
consciousness.  When  these  sensations  are  intense  enough 
to  pass  over  "  the  threshold  "  of  the  field  of  consciousness, 
there  is  a  conscious  mental  perception  of  such  sensations, 
as  of  sight,  hearing,  and  the  like.  This  is  the  initial  event 
of  the  process  by  which  we  mentally  see,  perceive,  and 
know  something  in  the  environment ;  there  is,  through 
sensory  action,  the  presentation  in  our  field  of  conscious- 
ness and  the  perception  of  what  we  call  the  image  or  idea 
of  the  external  thing.  But  we  may  immediately  remember 
that  we  have  seen  the  same  object  before ;  and  we  become 
conscious  of  an  action  of  memory,  by  which  we  retain  im- 
pressions received  before,  and  can  recall  them  by  the  law  of 
association  of  ideas.  We  image  them  again  or  imagine 
them.  Thus  a  complex  mode  of  mental  action  arises — 
there  is  consciousness,  then  conscious  perception  of  a  sensa- 
tion, as  from  the  sense  of  sight  and  memory,  acting  all  to- 
gether.   Hard  upon  this  comes  the  higher  process  of  ide- 


NERVOUS  AND  MENTAL  MECHANISM 


H  u 

"  in 


2  Memory 

( iMAGINATtON  ) 

CoNCEivrNG,  Judging 
,  Reasoning. 


4.  Feelings,  Emotions. 
5    Moral  Sense. 


6.  Willing 

AND 

Acting. 


I 


1 4- ; 


L. 


STOMACH 
HEART 

LUNGS 

Muscles 
Etc  etc 
Etc 


Motor  Centres 


Motor 
Nerves 


Eye 
Ear 
Nose 
Mouth 
Skin 
Etc 


Motor  Organs 


t 
0 

H 


functions  of  the  mind  and  body.  While  they  arc  very 
complex  in  their  detail,  there  are  still  certain  broad  gen- 
eralizations that  we  could  readily  grasp  but  for  the  diffi- 
culty of  keeping  a  number  of  the  elements  alike  prominent 
in  our  minds  at  the  same  time  while  studying  their  inter- 
play. This  may  be  aided,  with  some  exercise  of  the  imagi 
nation,  by  the  tabulated  diagram  here  presented.    It  is  de- 


ation  or  intellection — the  comparing  process,  by  which  we 
conceive  abstract  notions  of  things  ;  judge  them  by  compari- 
son and  reason  about  them.  All  these  may  be  included 
also  in  the  mode  of  consciousness  along  with  perception 
and  memory,  and  form  parts  of  a  complex  process  of  know- 
ing, or  intellection,  althougli  we  name  them  as  separate 
actions.    Whenever  we  talk  with  a  man  we  gauge  and  test 


348 


COWLES:    TEE  MENTAL  SYMPTOMS  OF  FATIGUE. 


[N.  Y.  Mkd.  JoaH., 


minutely  all  these  operations  of  his  mind  with  great  prac- 
tical accuracy.  We  estimate  his  mental  quality  and  power ; 
we  judge  the  man  by  what  his  mind  can  do. 

One  of  the  points  of  present  interest  is  now  before  us ; 
as  the  antecedent  fact  in  the  mental  process  just  described, 
we  must  premise  the  state,  or  existence,  of  consciousness, 
without  which  there  can  be  no  mental  action.  We  may 
say  that  there  is  latent  consciousness  in  an  unborn  infant 
that  soon  after  enters  upon  conscious  life  ;  then  conscious- 
ness springs  into  action,  and  the  first  perception  is  likely  to 
be  of  sensations  from  the  sense  of  touch.  But  active  con- 
sciousness is  always  attending  to  some  presentation  in  its 
field,  to  the  more  or  less  complete  exclusion  of  other  pres- 
entations. While  a  multitude  of  sensations  are  thronging 
into  the  sensorium  through  all  the  organs  of  special  sense, 
the  attention,  being  fixed  upon  some  intensified  perception, 
excludes  all  but  this  intensified  one.  The  same  is  true  of 
a  presentation  of  memory  or  of  a  process  of  reasoning ;  or 
all  these  may  be  involved  in  a  complex  object  of  attention. 
Whenever,  by  the  action  of  what  we  call  the  attention,  we 
hold  in  mind  a  perception,  a  memory,  or  the  data  of  a  pro- 
cess of  reasoning,  we  are  exercising  the  memory  also  in  the 
very  act  of  retaining  all  these  elements  of  the  mental  pro- 
cess. On  the  other  hand,  we  know  that  by  the  attention 
we  can  control  the  memory,  by  controlling  and  changing 
the  flow  of  ideas  it  recalls ;  and  all  this  goes  to  show  the 
inseparable  working  together  of  these  processes. 

The  attention  is  a  mental  element  of  the  greatest  in- 
terest, and  is  commonly  regarded  as  meaning  a  "  concen- 
tration of  consciousness."  According  to  Sully,*  it  may  be, 
defined  as  the  active  intensification  of  consciousness  in  par- 
ticular directions.  Whatever,  at  any  time,  "  occupies  the 
mind  "  is  for  the  moment  the  supreme  object  of  attention. 
The  attention  is  one  with  active  consciousness,  and  is  often 
described  as  accompanying  every  other  mental  action. 

It  is  a  common  experience,  in  reverie  and  in  dreams, 
that  a  spontaneous  flow  of  ideas  is  continually  passing 
through  the  mind ;  one  item  follows  another  in  the  train 
of  associated  ideas,  through  the  working  of  memory  and 
imagination  by  the  laws  of  habit  and  association,  without 
^direction  or  control.  The  attention  is  then  said  to  be  .act- 
ing in  one  of  its  two  forms,  and  this  form  is  spontaneous 
attention.  It  is  also  called  reflex  attention,  as  it  acts  by 
being  attracted  to  the  idea  or  object  in  the  mind  that  most 
interests  it,  or  keeps  it  on  the  alert,  or  stimulates  it.  The 
idea  may  be  intensified  in  interest  by  pleasurable  or  pain- 
ful feeling — by  a  desire  or  a  fear.  The  act  itself  of  atten- 
tion to  such  an  object  of  thought  increases  the  intensi- 
fication of  it  and  tends  to  keep  ideas  of  kindred  nature  in 
the  mind ;  the  mind  dwells  upon  them,  is  absorbed  in 
them. 

Voluntary  attention  is  the  other  form  of  this  mental 
function  ;  and  this  is  at  the  very  center  of  interest  in  this 
inquiry.  It  is  spontaneous  attention  with  the  added  power 
of  direction  and  control ;  the  attention  is  thus  inseparably 
associated  with  the  will,  volition,  or  controlling  power. 
The  essential  fact  is  that  in  voluntary  attention  lies  the 


*  Art.  Attention,  Tuke's  Dirt,  of  Pxych,  Med.,  vol.  i,  p.  106. 


mental  activity  of  inhibition ;  it  is  inhibition  working 
through  attention.  According  to  Foster,  just  as  physio- 
logical inhibition  plays  its  part  in  the  lower  mechanisms  of 
the  body,  so  is  it  important  in  the  whole  work  of  the  cen- 
tral nervous  system.  Also  just  as  all  voluntary  muscular 
actions  are  under  the  control  of  an  attending  will,  so  is  the 
directing  and  concentrating  of  the  attention  upon  a  chosen 
thought  an  act  of  volition.  A  man  controls  his  own  mind 
by  willing  his  attention,  as  it  were,  to  be  fixed  upon  some 
one  item  or  object,  in  the  train  of  presented  ideas,  to  the 
exclusion  of  others.  He  thinks  about  what  he  chodses  to 
think  about,  and  inhibits  mind-wandering.  He  may  make 
the  most  worthy  object  interesting  ;  this  is  intensified  by 
holding  in  mental  view  its  worthiness,  and  thus  the  attrac- 
tions of  less  worthy  interests  and  emotions  are  resisted. 

Sully  says  it  is  pre-eminently  by  acts  of  attention  that 
all  the  elaborative  work  of  thought  is  effected,  and  that  the 
attention  is  the  great  conditioning  factor  in  our  intellectual 
life ;  all  great  intellectual  achievement  involves  energy  of 
will  acting  as  voluntary  attention.  The  student  attains  to 
this  power  by  training  and  education  of  his  higher  mental 
control ;  the  man  who  chooses  the  path  of  wisdom  and 
rectitude  exercises  and  strengthens  his  power  of  voluntary 
attention  by  the  practice  of  self-control  in  inhibiting  the 
impulses  of  his  passions.  Thus  it  is  that  voluntary  atten- 
tion is  in  close  relation  with  the  highest  as  well  as  the 
latest  developed  acquirements  of  the  mind  in  its  power  to 
use  the  force  of  nervous  energy  to  the  best  effect.  It  is 
well  known  that  the  latest  acquirements  are  soonest  im- 
paired with  the  abatement  of  normal  energy. 

Every  exercise  of  the  will  in  attention  is  accompanied 
by  the  expenditure  of  energy,  and  by  the  "  sense  of  effort " 
that  occurs  particularly  when  the  attention  works  against 
some  resisting  motive,  interest,  or  feeling.  This  directing 
and  inhibitory  control  is  at  its  best  in  the  equilibrium  of 
health  of  mind  and  body,  and  therefore  it  is  a  most  impor- 
tant means  of  estimating  mental  health  and  vigor ;  mental 
disorder  is  commonly  attended  with  disturbances  of  the 
normal  process  of  attention,  as  will  directly  appear  in  the 
discussion  of  mental  symptoms.  This  constitutes  one  of 
the  points  of  great  diagnostic  value. 

We  have  so  far  concerned  ourselves  in  this  discussion 
quite  exclusively  with  the  processes  of  knowing,  or  intel- 
lection. But  we  are  always  conscious  of  another  order  of 
mental  phenomena — the  feelings — and  they  are  of  pleasure 
or  of  pain,  or  they  may  be  in  varying  degrees  agreeable  or 
disagreeable.  From  the  lower  forms  of  bodily  pleasure  and 
pain,  upward  in  the  scale  to  those  aroused  by  the  percep- 
tions of  color  and  music,  the  feelings  are  said  to  be  "  cor- 
poreal." But  the  purely  mental  feeling  that  always  attends 
upon  pleasurable  or  painful  ideas  is  inseparable  from  them. 
AVithout  ideas  there  can  be  no  such  feeling;  and  according 
to  its  intensity  a  feeling  of  pleasure  or  pain  intensifies  the 
idea  it  accompanies  and  makes  it  prominent  in  conscious- 
ness, tending  to  attract  more  strongly  and  to  hold  the  at- 
tention. Thus,  as  has  already  been  shown,  there  may  be 
an  antagonism  between  worthy  and  unworthy  ideas  and 
feelings,  or  in  the  moral  sense  of  right  and  wrong,  with  need 
of  the  inhibitory  power  of  voluntary  attention  to  choose, 


April  1,  1893.] 


GO  WLES:   THE  MENTAL 


SYMPTOMS  OF  FATIGUE. 


349 


control,  guide,  and  conduct.  This  brings  out  the  opposing 
factors  in  the  operation  of  will,  attention,  ideas,  and  feel- 
ings. The  feelings  excited  by  ideas  prompt  to  action,  which 
may  be  inhibited  or  augmented  by  an  opposing  or  consent- 
ing will. 

Referring  now  to  the  diagram,  the  relations  of  these  ac- 
tivities are  seen  to  be  noted  in  their  natural  order.  Feel- 
ing follows  upon  intellection,  and  all  the  included  mental 
activities  are  operating  in  the  field  of  consciousness  ;  the 
outcome  of  this  interplay  is  in  the  union  of  willing  with 
acting,  at  the  point  where  the  resultant  of  the  mental  forces 
appears  to  act  upon  the  motor  centers,  or  stimulate  In  them 
the  impulses  that  end  in  the  setting  free  of  muscular  mo- 
tion. Thus  the  picture  of  the  "  nervous  circle  "  is  now  com- 
plete, and  shows  the  working  of  the  nervous  and  mental 
mechanism  under  the  stimulation  of  sensations  through  the 
special  senses.  Then  consciousness,  through  the  attention 
(these  two  being  general  states  or  modes  of  mental  action), 
knows  or  "  sees  "  in  the  very  mind's  eye  the  special  modes 
of  action  which  we  call  sense- perception,  memory,  reason- 
ing, feeling,  and  the  willing  of  motor  impulses  which  end 
in  muscular  motion.    This  completes  the  "  circle." 

The  sensations  from  the  special  senses  are  those  of  which 
we  are  most  conscious  ;  they  are  of  high  intensity,  but  we 
little  realize  that  they  are  small  in  volume  compared  with 
the  great  inflow  of  organic  sensations  of  which,  in  normal 
conditions,  we  are  not  conscious.  These  organic  sensations 
that,  according  to  Ribot,  give  us  the  sense  of  body  or  of  per- 
sonality, are  of  low  intensity  but  vast  in  volume ;  proceed- 
ing from  every  minute  part  of  the  tissues  and  organs  of  the 
body,  their  inflow  along  sensory  tracts  enters  the  sensorium 
beneath  the  "threshold  of  consciousness"  into  the  region  of 
subconsciousness.  Their  origin  is  shown  in  the  sources 
noted  in  the  fainter  letters  in  the  diagram  and  their  course 
by  the  dotted  lines.  The  muscular  sense,  which  is  complex 
in  its  origin,  includes  feelings  that  afford  an  example  of  the 
more  pronounced  of  these  organic  sensations.  Thus  we  get 
the  sense  of  weight  and  posture.  Again,  there  are  those 
not  felt  in  normal  conditions,  but,  like  hunger  and  thirst 
which  are  general  in  their  origin,  may  become  intensified  so 
that  at  times  there  is  consciousness  of  them.  There  are 
still  others,  as  in  the  morbid  conditions  of  hyperaesthesia 
and  paresthesia,  that  appear  as  pain  or  general  feelings  of 
misery ;  they  are  vague  in  character  and  their  sources  often 
can  not  be  determined. 

These  organic  sensations  and  their  alterations  are  of 
such  a  nature  that  they  afford  another  point  in  the  nervous 
and  mental  mechanism  of  great  diagnostic  value.  In  normal 
states,  where  all  is  well  with  the  organism  in  the  equilib- 
rium of  health,  they  constitute  the  sense  of  well-being. 
Here  again  we  have  an  important  means  of  measuring  any 
falling  off  of  nervous  vigor ;  from  the  slighter  alterations 
of  bodily  feelings  in  fatigue  to  those  that  create  a  persist- 
ent sense  of  ill  being,  these  changes  cause  variations  in  the 
"  emotional  tone  "  that  are  the  most  sensitive  indices  of  the 
degree  of  fatigue  and  exhaustion,  both  normal  and  patho- 
logical. The  emotional  tone  is  thus  seen  to  be  affected  in 
two  ways :  There  may  be  in  health  all  degrees  of  pleasura- 
ble or  painful  mental  feeling  be.tween  the  extreme  of  exal- 


tation and  depression,  according  to  what  one  has  to  think 
about ;  in  this  case  a  lowered  emotional  tone  from  grief  or 
care  may  be  a  passing  event,  or,  if  prolonged,  may  have  a 
directly  debilitating  effect  upon  the  organism  through  the 
motor  tract  of  the  nervous  system.  The  stimulant  and  de- 
pressant effects  of  the  natural  emotions  upon  the  circulatory 
system  and  upon  bodily  health  in  general  are  well  enough 
known.  On  the  other  hand,  a  persistent  state  of  morbid  de- 
pression of  feeling  may  be  no  more  than  the  mental  concomi- 
tant of  bodily  ill- being,  however  it  may  have  been  induced. 
There  may  be  three  events  in  the  train  :  first,  undue  care, 
real  trouble,  and  anxiety  or  grief  may  imitate  a  general  con- 
dition of  ill-being,  which  in  turn  may  be  the  cause  of  mor- 
bid depression  as  the  third  event.  The  first  in  this  order 
may  be  entirely  wanting,  but  the  real  condition  of  ill-being, 
through  impairment  of  health  and  nervous  vigor,  must  exist 
from  some  cause  before  the  strictly  morbid  mental  symp- 
toms can  appear. 

4.  The  Alterations  of  Mental  Functions  that  are  Signifi- 
cant as  Symptoms. — It  now  remains  to  describe  the  special 
alterations  in  some  of  these  prominent  factors  of  the  mental 
mechanism  and  their  significance  in  conditions  of  normal 
and  pathological  fatigue.  In  normal  fatigue  it  is  to  be  kept 
in  mind  that  the  dual  physical  condition  is  one  of  the  ex- 
penditure of  nervous  energy  in  work  to  the  immediate  fa- 
tigue of  nerve  cells,  and  the  accumulation,  locally  and  in  the 
circulatory  system,  of  toxic  waste  products,  and  that  the 
processes  of  nutrition  and  elimination  require  time  and  rest. 
The  mental  concomitants  of  this  condition  are  a  dimin- 
ished sense  of  well-being  or  a  feeling  of  fatigue  sometimes 
amounting  to  a  sense  of  ill-being,  which  includes  in  its  com- 
plex causation  the  influence  of  the  toxic  elements.  The 
emotional  tone  is  lowered  and  there  is  less  vivacity  of  feel- 
ing. There  is  also  lessened  mental  activity  in  general. 
Voluntary  attention  is  fatigued — that  is,  the  mental  inhibi- 
tion is  lessened,  with  diminished  control  over  the  attention, 
and  one  is  conscious  of  an  extra  sense  of  effort  in  mental 
work.  There  is  "  mind  wandering."  The  logical  processes 
work  more  slowly  and  with  less  effect  in  making  compari- 
sons and  judgments  and  in  reasoning  to  conclusions — the 
tired  attention  with  effort  holds  on  to  one  member  of  a 
proposition  while  another  slips  away.  There  is  a  conscious- 
ness of  mental  inadequacy  and  difficulty  in  keeping  awake. 
This  is  the  common  experience  of  evening  tire.  Restora- 
tion follows  upon  a  due  amount  of  rest,  sleep,  and  nutrition, 
and  the  somnolence  disappears  when  the  acid  waste  prod- 
ucts, etc.,  in  the  circulation  are  removed. 

The  condition  of  pathological  fatigue  is  induced  when 
the  process  of  restoration  is  continuously  incomplete.  Then 
we  have  to  conceive  of  deficient  nutrition  and  an  irritating 
intoxication,  as  both  contributing  to  the  "  irritable  weak- 
ness "  which  is  a  manifestation  of  the  characteristic  hyper- 
ajsthesia.  We  may  now  note  the  persistence  of  significant 
alterations  of  the  feelings,  the  irritability  of  temper,  the 
weakening  of  the  power  of  voluntary  attention,  and  the 
effects  of  these  alterations.  The  patient  may  complain  of 
painful  or  miserable  bodily  sensations,  hypcrassthesia  and 
restlessness,  and  often  of  para^sthesia  in  various  forms. 
The  symptoms  may  be  analyzed  and  classified  according 


350 


COWLES:   THE  MENTAL  SYMPTOMS  OF  FATIGUE. 


[N.  Y.  Med.  Jodb., 


to  the  order  of  their  appearance  and  the  functions  af- 
fected. 

The  first  order  of  mental  symptoms  of  pathological  fa- 
tigue in  the  importance  and  earliness  of  their  appearance 
may  now  be  noted.  These  most  obvious  mental  signs  are 
the  characteristic  depression  of  feeling,  a  lowering  of  the 
emotional  tone,  and  a  sense  of  ill-being. 

The  symptoms  quickly  reflect  debilitated  bodily  condi- 
tions that  are  the  sources  of  the  "  miserable  feelings." 
These  subjective  indications  are  often  the  only  ones  of  the 
existing  exhaustion  in  its  complex  character;  again  they 
are  corroborative  of  a  suspicion  of  general  neurasthenia 
when  complaint  is  made  of  some  local  functional  disorders. 
In  other  words,  local  disorder  is  often  shown  to  be  simply 
an  expression  of  general  neurasthenia,  of  which  the  only  di- 
agnostic evidence  is  in  the  mental  symptoms. 

The  second  order  of  meijtal  symptoms  in  time  of  appear- 
ance is  usually  the  persistent  decrease  of  the  power  of  volun- 
tary attention  [reflex  attention)  and  sometimes  of  memory ; 
there  is  also  the  sense  of  inadequacy  of  effort. 

These  symptoms  refer  to  the  attention  which  acts  in  a 
more  spontaneous  and  reflex  manner  as  its  control  is  weak- 
ened ;  the  memory  is  weakened  in  its  power  of  retaining 
and  recalling  ideas.  This  lessening  of  inhibitory  power 
and  mental  activity  in  general  shows  the  abatement  of  cere- 
bral energy.  It  does  not  always  appear  to  the  observer  for 
the  reason  that  the  patient  may  draw  upon  the  reserved 
nervous  energy,  and  put  forth  more  effort  in  the  act  of 
controlling  his  attention,  and  succeed  in  doing  it.  But  he 
is  both  expending  energy  more  rapidly  in  so  doing,  and  is 
conscious  of  the  need  of  increased  effort ;  he  will  usually 
readily  confess  it  on  being  questioned.  This  consciousness 
finally  amounts  to  the  very  characteristic  sense  of  inade- 
quacy. This  symptom  of  weakened  voluntary  attention  is 
also  an  early  one  and  very  diagnostic.  The  patient  will 
often  complain  that  he  can  not  keep  his  thoughts  on  his 
work  or  business,  or  has  to  read  over  again  what  he  reads 
and  can  not  remember  it.  One  patient  said  :  "  I  can  not 
sense  it "  ;  and  another  :  "  I  can  not  center  my  mind  on  what 
I  try  to  do." 

A  third  order  of  symptoms  may  now  arise,  and  it  is 
an  interesting  fact  that  they  grow  out  of  the  other  two 
orders  and  are  their  logical  consequence ;  these  are  mor- 
bid introspection,  retrospection,  and  apprehension  [worry  and 
hypochondria). 

These  symptoms,  when  manifestly  developed,  mark  a 
graver  degree  of  fatigue.  The  emotional  tone  being  low- 
ered, the  patient,  in  a  state  of  depression  of  feeling,  is 
prone  to  "  look  on  the  dark  side  of  things."  Ideas  are  in- 
tensified that  are  accompanied  by  painful  feelings,  which 
are  thus  in  harmony  with  the  prevailing  emotional  tone. 
There  being  also  a  lessening  of  nervous  energy  in  voluntary 
attention,  it  can  not  inhibit  the  intensified  painful  ideas 
and  feelings,  and  there  is  consequently  worry  about  the 
present,  past,  and  future.  The  vague  fear  arises  of  being 
unable  to  meet  the  requirements  of  the  future.  The  in- 
creasing sense  of  present  inability  gives  intensification  to 
the  characteristic  sense  of  inadequacy  noted  by  Beard  as 
being  always  so  prominent. 


There  is  one  other  set  of  symptoms  to  be  mentioned  as 
constituting  &  fourth  order.  While  those  previously  noted 
are  purely  mental,  these  are  partly  so,  but  relate  chiefly  to 
alterations  that  cause  peculiar  bodily  effects,  and  are  often 
manifest  to  the  observer.  These  symptoms  are  changed 
organic  sensations,  physical  and  mental  irritability,  and 
restlesssness  ;  diminished  sensitiveness,  dullness,  and  languor. 

There  is  apparent  irregularity  in  these  changes  of  bod- 
ily feelings  and  their  manifestations — the  intensifying  of 
some  and  the  lessening  of  others.  Arndt  *  says  :  "  It  is 
clear  that  the  increased  hypera3sthesia  which  a  degenerating 
nerve  at  first  presents  can  not  last  long,  and  that  soon  de- 
creased excitability,  bluntness,  paresis,  or  whatever  we  call 
fatigue  and  exhaustion,  must  take  its  place." 

There  is  not  alone  hyperaesthesia,  with  the  external 
signs  of  irritability  and  restlessness,  but  there  is  much  di- 
minished sensitiveness.  Some  cases  are  altogether  of  the 
latter  character,  and  many  present  both  conditions  at  the 
same  time  in  some  particulars.  It  may  be  a  question  of 
the  different  effects  of  differences  in  the  toxic  waste  prod- 
ucts. While  chemical  physiology  and  pathology  do  not 
yet  enable  us  to  ascribe  sensory  and  motor  disorder  defi- 
nitely to  the  influence  of  poisons  produced  within  the  organ- 
ism by  its  own  activity,  it  can  not  be  doubted  that  both 
the  conditions  of  nervous  irritability  and  those  of  dullness, 
languor,  and  stupor  may  be  so  caused.  It  is  certain  that 
such  external  manifestations  may  be  caused  as  the  direct 
expression  of  defective  functional  activity  in  cerebral  centers 
that  are  the  source  of  the  nervous  energy  which  innervates 
and  controls  both  the  somatic  and  mental  mechanisms.  The 
study  of  physical  expression,  which  Darwin  raised  to  the 
dignity  of  a  new  science,  shows  that  while  there  is  certain 
voluntary  control  over  it,  still  the  manifestations  in  the 
muscular  movements  of  expression,  whether  occurring  in 
the  face  or  the  extremities,  have  a  direct  automatic  de- 
pendence upon  interior  states  of  the  central  nervous  sys- 
tem, which  are  thus  externally  reflected.  The  inflow  of 
organic  sensations  to  the  sensorium  has  its  complement  in 
the  constant,  regular,  and  subconscious  transmission  of  nerve 
force  from  central  cells  to  the  muscular  periphery.  This 
accords  with  Gowers's  statement  that  every  structure  of  the 
brain  concerned  with  sensation  proper  is  connected  directly 
or  indirectly  with  a  part  concerned  with  motion ;  and,  in 
regard  to  the  unstable  condition  of  brain  cells  in  disease, 
when  the  equilibrium  between  the  discharge  of  energy  and 
the  inhibition  of  it  is  disordered,  "  the  discharge  may  de- 
pend on  the  production  of  force  within  being  increased  in 
excess  of  the  resistance,  or  on  the  resistance  being  duly 
lessened." 

In  the  common  forms  of  insanity  are  seen  the  most 
pronounced  expressions  of  excessive  or  diminished  central 
activity,  and  this  applies  alike  to  innervation  and  inhibition, 
whether  mental  or  somatic.  In  the  belief  of  the  writer  f 
it  is  possible  to  detect  important  variations  in  the  several 
elements  of  mental  activity  in  normal  fatigue  and  nervous 

*  Loc.  cit. 

f  Pathological  Fatigue  or  Neurasthenia.  Amer.  Journ.  of  Insanity, 
July  and  October,  1891.  Also  The  Shattuck  Lecture,  1891,  Trans,  of 
the  Mass.  Med.  Soc. 


April  1,  18VI3.J 


CO  WLES: 


THE  MENTAL  SYMPTOMS  OF  FATIGUE. 


361 


exliaustion  ;  for  example,  the  letting  down  of  mental  power 
in  voluntary  control,  with  the  consequent  lessened  inhibi- 
tion of  verbal  expression  of  grief  and  worry,  or  excitability 
and  aggressiveness.  Bancroft  *  has  made  an  instructive 
application  of  the  physiological  principles  of  expression  to 
the  study  of  facial  expression  of  the  emotions  in  insanity, 
and  of  expression  in  posture,  etc.,  as  the  results  of  habit  in 
automatic  muscular  action.  Ilis  work  gives  definite  value  to 
the  clinical  use  of  photography  in  the  physical  expression 
of  mental  changes. 

All  such  clinical  studies  of  mental  symptoms  demon- 
strate the  value  of  precise  appreciation  of  the  changes  in 
the  elementary  mental  activities.  It  is  common  to  observe 
in  mania  eitlier  excessive  uninhibited  mental  and  motor 
activity,  or  the  quite  normal  control  of  the  latter  along  witli 
the  gravest  deficiency  of  mental  inhibition.  Again,  there 
is  excessive  nerve-muscular  activity  or  tension  in  fixed  atti- 
tudes, in  the  mental  and  motor  expression  of  painful  emo- 
tion in  melancholia,  in  consequence  of  lessened  inhibitory 
will  power ;  and  still,  again,  all  expression  may  be  abolished 
in  the  real  mental  stupor  of  melancholia  and  mania.  This 
apparent  abolition  may  also  be  due  alone  to  the  fact  that, 
while  perception  and  ideation  are  quite  normal,  the  power 
to  give  expression  to  them  is  diminished  or  lost  either  in 
the  failure  of  the  mental  function  of  willing  or  of  excita- 
bility in  the  motor  centers.  A  man  at  the  McLean  Hospi- 
tal, who  was  apparently  in  profound  stupor,  afterward  said : 
"  I  wanted  to  answer  you,  but  couldn't  make  my  jaws  go." 
A  woman,  who  would  stand  in  a  fixed  position  for  hours 
with  almost  entire  loss  of  muscular  movement  and  expres- 
sionless face,  could  respond  to  kind  words  only  by  direct- 
ing her  eyes,  and  they  would  fill  with  tears.  When  she  was 
well,  the  next  year,  she  gratefully  told  what  had  been  said 
and  done  to  her.  The  apparent  stupor  is  often  mistaken 
for  tlie  real  condition. 

These  discriminations  of  the  mental  processes  being 
once  established,  they  liave  the  highest  therapeutic  value  in 
their  preventive  application.    Hence  the  thesis  of  this  pa- 
per— the  importance  of  an  early  appreciation  of  the  mental 
symptoms  of  normal  fatigue  that  tends  to  nervous  exhaus- 
tion, for  they  are  prodromic  of  its  graver  forms.  More- 
over, the  recognition  of  the  significance  of  changes  in  the 
motor  and  sensory  manifestations  in  the  direction  of  lan- 
guor as  well  as  irritability,  anesthesia  as  well  as  hyperajs- 
thesia,  is  of  the  first  importance  in  the  difficult  task  of 
managing  convalescence  from  true  neurasthenia.   The  "  irri- 
table weakness  "  includes  the  liability  to  quick  exhaustion 
of  the  small  increments  of  nervous  energy  that  have  been 
slowly  gained,  and  therewith  the  speedy  reduction  of  sen- 
I  sory  as  well  as  motor  power  to  the  degree  of  "  bluntness," 
I  as  Arndt  has  stated  it.    Pathological  fatigue,  or  nervous 
exhaustion,  being  shown  to  be  a  condition  in  which  there  is 
a  direct  and  constant  relation  between  physical  disorder 
and  mental  symptoms,  these  should  be  noted,  together  with 
both  the  increase  and  the  blunting  of  sensitiveness,  in  any 
comprehensive  definition  of  the  disease.    It  may  therefore 
be  defined  as  follows  :  Neurasthenia  is  a  morbid  condition 

*  Automatic  Miisculiir  Movements  among  the  Insane.    Anier.  Jour, 
of  P.ti/,-h.,  Febnian,  IH'.M. 


of  the  nervous  system,  and  its  underlying  characteristics  are 
excessive  weakness  and  irritability  or  languor,  with  mental 
depression  and  weakened  attention. 

This  method  of  analysis  into  four  orders  of  symptoms 
is  applicable  to  all  cases  of  neurasthenic  disorder  of  the 
physiological  activities  involved,  from  the  passing  over  of 
normal  into  pathological  fatigue,  in  the  simplest  forms,  to 
the  gravest  manifestations  of  emotional  disturbances,  dis- 
ordered attention,  and  sensory  and  motor  irritability  and 
languor.  The  symptoms  included  in  the  first  three  orders 
are  regarded  as  purely  mental ;  those  characterized  in  the 
fourth  order,  while  referring  to  the  well-marked  develop- 
ment of  changes  in  sensitiveness  and  activity  of  bodily 
functions,  imply  the  necessary  association  with  them  of  the 
mental  symptoms  before  noted.  These  changes  of  bodily 
sense  and  activity  may  be  detected,  in  the  slighter  degrees, 
in  the  earlier  stages  of  neurasthenia.  The  value  of  the 
practical  application  of  these  discriminations  in  diagnosis 
may  now  be  illustrated  by  describing  some  of  the  special 
ways  in  which  certain  symptoms  must  be  interpreted.  By 
this  method  of  analysis  we  may  readily  estimate  the  signifi- 
cance of  the  symptoms  of  depression  of  feeling,  of  weaken- 
ing of  voluntary  attention,  and  of  worry.  But  there  are 
certain  more  subtle  effects  of  the  mixed  condition  usually 
found  of  hypersesthesia  and  an.Testhesia. 

One  of  the  most  striking  special  symptoms  which  the 
foregoing  considerations  point  out  and  may  serve  to  explain 
is  a  paradoxical  one,  but  one  most  commonly  presented  for 
clinical  observation.    The  sensory  function  by  which  the 
complex  normal  feelings  of  fatigue  are  appreciated  may 
itself  be  overexercised  to  exhaustion.    There  is  tire  of  the 
power  to  feel  the  tire.    This  condition  may  be  called  fatigue 
ancesthesia,  and,  beginning  with  the  early  stages  of  patho- 
logical fatigue,  there  is  usually  some  degree  of  it.  Every 
physician  has  experienced  this  when,  after  a  night  of  anx- 
ious professional  work,  with  loss  of  sleep,  he  has  a  day  of 
excitable  alertness  of  mind  and  body,  and  there  is  a  sense 
of  nervous  strain,  with,  perhaps,  undue  mental  facility  and 
physical  irritability.    Many  hours'  sleep  may  be  gained  in 
the  following  night,  but,  instead  of  feeling  refreshed,  he 
has  a  sense  of  malaise,  languor,  and  fatigue.    The  real 
fatigue  was  greater  the  day  before,  but  he  could  not  feel  it 
as  such ;  it  is  not  until  the  second  day  after  the  excessive 
effort  that  he  has  recovered  his  exhausted  power  to  feel  the 
fatio'ue.    In  a  lesser  deo-ree  this  fatio'ue  anaesthesia  becomes 
a  constant  accompaniment  of  the  neurasthenic  condition. 
Overworked  women,  professional  and  business  men,  "  work 
on  their  nerves,"  and  say  they  "  don't  feel  tired,  and  noth- 
ing is  the  matter."    They  "  feel  better  "  when  actively  exer- 
cised in  their  customary  labors.    This  condition  comes  on 
insidiously,  and  is  a  most  dangerous  one.    The  patient  is 
neurasthenic  before  anybody  suspects  it ;  with  the  impair- 
ment of  the  natural  fatigue  sense,  the  mental  effect  is  that 
he  will  not  believe  even  his  physician's  diagnosis  of  "  fa- 
tigue."   He  is  therefore  prone  to  look  for  some  other  rea- 
son for  his  sense  of  ill- being  and  inefficiency,  and  finds  in 
retrospection  cause  for  self-  reproach  and  hopelessness  in  the 
future. 

Fatigue  anicsthesia  manifests  itself  in  connection  with 


35'2 


HOUGHTON:   THE  PROPER  DURATION  OF  THE  LYING-IN  PERIOD.    [N.  Y.  Mkd.  Jocb., 


another  special  symptom  peculiar  to  conditions  of  "  fa- 
tigue " — that  of  "  morning  tire,"  sometimes  called  "  morn- 
ing misery."  Flxtreme  examples  of  this  are  seen  in  the 
victims  of  dissipation.  In  ordinary  cases  of  pathological 
fatigue  it  is  a  persistent  symptom  ;  the  patient  is  likely  to 
awake  in  the  early  morning  unrefreshed  by  a  fair  amount 
of  sleep  and  often  in  the  depths  of  depression.  The  phys- 
ical signs  of  exhaustion  are  then  more  manifest.  These 
symptoms  represent  the  truth  as  to  his  neurasthenic  condi- 
tion. After  breakfast  he  feels  better,  and  by  the  middle  of 
the  day  the  stimulation  of  the  daily  interests  and  press  of 
business  has  apparently  restored  his  good  feeling.  At  the 
close  of  the  day  he  is  comfortable  and  cheerful,  laughs  at 
his  morning  fears,  and  is  prone  to  overdo  himself  in  recrea- 
tion or  evening  work.  That  day's  experience  is  regularly 
repeated.  Each  night  he  rests  enough  to  recover  some 
of  the  feelings  that  attend  upon  "fatigue,"  but  he  often 
does  not  recognize  it  in  the  absence  of  the  true  fatigue 
sense.  A  still  further  blunting  of  this  sense  is  caused  by 
the  ill-timed  stimulation  of  unwisely  continued  effort. 
Along  with  the  restlessness  of  his  "  irritable  weakness " 
there  is  a  fictitious  sense  of  well  being  because  of  the  tem- 
porary abolition  of  the  sense  of  ill-being,  as  in  mild  intoxi- 
cation by  alcohol. 

In  the  management  of  convalescence  from  neurasthenia, 
or  of  cases  that  would  get  well  if  they  could  be  managed, 
there  is  nothing  more  discouraging  than  the  succession  of 
relapses  that  they  undergo.  Such  patients,  having  been 
subjected  to  the  rest  treatment,  may  be  fat  enough  and 
maintain  a  fair  degree  of  comfort  when  effort  is  kept  within 
the  limits  of  pathological  fatigue.  They  complain  of  tire 
and  various  discomforts  upon  a  little  effort,  which  must  be 
made  in  order  to  gain  by  physiological  use  the  strength  to 
make  it.  It  seems  a  never-ending  process ;  some  patients 
can  not  abide  its  slowness  and  make  effort  too  soon ;  oth- 
ers resist  great  persuasion  to  make  enough.  But  some 
event  may  occur  that  excites  desire  or  a  sense  of  duty. 
The  undue  quickness  of  response  to  the  stimulation  of 
interest  and  attention  is  to  be  recognized  as  an  evidence  of 
irritable  weakness.  The  apparent  ease  and  unwonted  zest 
of  the  effort  is  not  a  manifestation  of  real  power ;  it  means 
that  there  is  a  speedy  blunting  of  the  sense  of  fatigue. 
The  reaction  of  exhaustion  and  mental  misery  that  follows 
shows  the  real  weakness  and  the  need  of  unfailing  patience 
and  discretion.  Most  patients  of  this  class  have  to  be 
taught  how  to  recognize  the  mental  and  physical  signs  of 
fatigue  peculiar  to  themselves  other  than  the  normal  feeling 
of  it.  They  must  also  be  taught  that  some  degree  of 
fatigue  thus  manifested  must  be  regularly  incurred  as 
wholesome  tire.  But  both  patient  and  physician  must  be 
guided  alone  by  individual  experience  and  judgment  as  to 
the  amount  of  effort.  Feeling  is  often  a  misleading  guide 
for  doing  or  not  doing. 

Many  neurasthenic  people  are  plied  with  recreation  to 
"  distract  the  attention,"  and  go  on  journeys  in  search  of 
health,  when  it  is  not  stimulation,  mental  or  physical,  that 
is  needed,  but  rest.  The  physician  may  save  many  a  pa- 
tient from  such  a  final  strain  that  would  precipitate  a  break- 
down by  recognizing  the  fact  that  his  apparent  ability  to 


do  things  without  fatigue  when  the  mental  signs  of  it  are 
present  is  the  strongest  indication  that  he  has  reached  a 
dangerous  degree  of  nervous  exhaustion  marked  so  plainly 
by  loss  of  the  fatigue  sense.  In  such  cases,  after  a  course 
of  rest  treatment,  which  must  often  be  more  or  less  modi- 
fied, exercise  becomes  most  important  in  the  form  of  gentle 
bodily  effort  and  mental  stimulation  by  recreation  in  gradu- 
ally increased  amount.  The  guide  to  the  limitation  of  exer- 
cise is  to  be  found  in  its  effects,  such  as  the  slight  return  of 
restlessness  and  insomnia  at  night  and  the  mental  and 
bodily  discomfort  liable  to  appear  on  the  following  morning. 
Exercise  may  be  pressed  to  the  extent  of  not  catising  these 
effects ;  it  promotes  nutrition  and  excretion  of  waste  prod- 
ucts, the  free  action  of  the  skin,  etc. 

The  physician  will  look  to  the  therapeutics  of  tonics 
and  nutrition  with  careful  attention  to  all  the  forms  of 
elimination.  But  while  he  is  doing  this  the  successful 
treatment  of  neurasthenia  means  the  careful  recognition  of 
all  its  signs.  The  earliest  indications  for  diagnosis  and  the 
clearest  for  treatment — and  often  the  only  ones — are  the 
mental  symptoms.  It  is  the  conditions  of  fatigue  that  are 
to  be  treated,  and  the  study  of  the  working  of  the  fatigue 
sense  affords  the  safest  and  surest  guide,  although  its  signs 
are  so  often  negative.  A  correct  and  fine  appreciation  of 
what  the  mind  can  do  enters  into  our  commonest  knowledge 
and  experience,  and  we  use  the  most  familiar  words  to  de- 
scribe its  operations.  This  paper  has  been  written  with 
the  hope  that  it  may  be  a  help  to  the  systematic  observa- 
tion of  so7ne  of  the  commonest  and  most  valuable  of  clini- 
cal indications,  both  for  prevention  and  cure. 


THE  PKOPER  DURATION  OF  THE 
LYING-IN  PERIOD.* 
By  H.  SEYMOUR  HOUGHTON,  M.D. 

In  considering  the  subject  of  the  puerperal  state,  or  the 
lying-in  period,  it  is  necessary  to  bear  in  mind  the  fact 
that  although  labor  and  childbirth  are  truly  physiological 
processes,  and  hence  to  be  classed  among  the  normal  func- 
tions of  the  human  body,  nevertheless  the  effects  upon  the 
organism  produced  by  these  normal  functions  are  of  such  a 
character  that  they  must  be  regarded,  from  a  clinical  stand- 
point, as  pathological. 

It  is  for  this  reason  that  the  position  of  the  lying-in 
patient  is  unique — a  position  of  health  so  near  to  disease 
that  the  patient  must  be  regarded  as  a  sick  woman  in  order 
to  prevent  her  from  becoming  one. 

She  is  a  sufferer  from  a  traumatism — has  been  wounded, 
and  therefore  her  condition  is  one  which  properly  belongs 
to  the  domain  of  surgery.  For  example,  a  man  may  under- 
go amputation  of  the  arm  or  thigh  as  a  result  of  injury, 
and  in  a  day  or  two,  with  a  normal  temperature,  good  ap- 
petite, and  undisturbed  function,  lay  as  good  a  claim  to 
perfect  health  as  his  neighbor  in  the  adjoining  house,  who, 
perhaps,  at  the  same  that  his  operation  took  place,  was  un- 
dergoing the  pains  of  maternity.    I  make  this  comparison 

*  Read  before  the  Hospital  Graduates'  Club,  December  29,  1892. 


April  1,  1893.J        HOUGHTON:   THE  PROPER  DURATION  OF  THE  LYING-IN  PERIOD. 


353 


because  tlierein  lies  the  answer  to  the  question,  "  How 
shall  we  classify  childbirth  and  the  puerperal  state  ? " 

The  science  of  midwifery  is  but  one  of  the  divisions, 
though,  indeed,  a  large  and  important  one,  of  the  general 
science  of  surgery.  The  obstetrician,  even  though  he  may 
not  be  able  to  ligate  an  aneurysm  or  perform  a  laparotomy, 
must  be  thoroughly  versed  in  the  principles  of  surgery  in 
order  to  properly  and  safely  conduct  a  case  of  labor.  It  is 
entirely  due  to  the  fact  of  the  discovery  of  pathogenic  or- 
ganisms and  their  relation  to  disease  or  sepsis,  and  to  the 
further  discovery,  which  has  made  famous  the  name  of 
Lister,  of  the  means  of  destroying  these  organisms  or  anti- 
,  sepsis,  that  not  only  has  surgery  in  general  been  nearly 
revolutionized,  but  also  the  treatment  of  the  lying-in  pa- 
tient has  been  made  to  conform  to  the  rules  which  govern 
a  surgical  case.  I  do  not  wish  to  be  understood,  however, 
as  advocating  that  the  same  elaborate  and  necessary  details 
of  antiseptic  surgery  should  be  followed  out  in  a  case  of 
normal  labor  as  is  required  in  a  laparotomy  or  an  amputa- 
tion, except  as  relates  to  the  attendant  himself  and  to  his 
instruments.  Here  the  minutest  detail  of  personal  cleanli- 
ness in  its  broadest  sense  and  of  disinfection  of  his  instru- 
ments are  not  out  of  place  and  should  be  conscientiously 
carried  out.  But  with  regard  to  the  patient  herself,  being 
.  surrounded  by  the  proper  hygienic  and  sanitary  conditions, 
she  is  then  free  from  all  ordinary  dangers  of  infection — 
that  is  to  say,  she  is  in  an  aseptic  condition,  and  hence 
does  not  require  the  applicatioH  of  antiseptic  treatment 
beyond  what  is  essential  as  a  matter  of  cleanliness.  Carried 
beyond  this  point,  it  renders  us  liable  to  the  charge  of  med- 
dlesome midwifery. 

It  is  from  this  point  of  view,  from  the  close  relation- 
ship which  exists  between  midwifery  and  surgery,  that  I 
propose  this  evening  to  consider  the  length  of  time  which 
the  patient  who  has  just  borne  her  child  should  be  under 
the  authority  of  her  attendant  for  the  double  purpose  not 
only  of  recovering  from  her  present  illness,  but  of  having 
that  recovery  so  complete  and  thorough  that  it  will  be  per- 
manent, and  not  the  starting  point  of  an  endless  sequence  of 
pelvic  disease. 

To  this  end,  I  shall  first  briefly  review  so  much  of  the 
changes  which  follow  parturition  as  is  involved  in  a  proper 
consideration  of  the  subject. 

The  patient,  at  the  close  of  the  third  stage  of  labor,  at 
which  point  the  lying-in  period  begins,  has  lost  one  ninth 
of  her  weight  at  term.  As  a  result  of  the  intense  pain,  the 
muscular  efforts,  loss  of  blood,  and  mechanical  injury,  she 
undergoes  a  certain  degree  of  shock  which  may  vary  in 
intensity  from  being  scarcely  appreciable  in  one  patient  to 
a  fatal  condition  in  another.  Her  temperature  at  first 
rises,  then  falls  to  normal,  or  may  sink  below  normal  if 
the  shock  be  very  severe.  The  pulse  becomes  considerably 
slower — a  fact  which  has  attracted  much  attention  and  has 
been  variously  explained.  The  blood  itself  is  more  hydrse- 
mic  and  more  fibrinous,  and  the  secretions,  notably  those  of 
the  skin,  are  much  increased.  This  state  of  affairs — name- 
ly, the  shock  due  to  the  impression  made  upon  the  central 
nervous  system,  the  reaction,  the  sudden  transfer  of  de- 
velopmental energy  from  the  uterus  to  the  breast,  the  con- 


traction of  fibers,  and  closure  of  vessels  in  the  uterus,  and 
finally  the  absorption  of  serous  exudation,  oedema,  etc., 
which  had  previously  existed — all  make  up  a  series  of 
changes  which  occupy  the  first  three  days,  and  constitute, 
according  to  Barnes,  the  period  just  preceding  that  retro- 
grade process  in  the  uterus  and  associated  structures  famil- 
iarly known  as  involution. 

This  most  interesting  process  in  the  uterus  has  been 
studied  by  Heschl,  whose  views  have  been  accepted  by  the 
majority  of  modern  writers.  He  regards  it  as  a  retrograde 
metamorphosis  due  to  a  fatty  degeneration  of  the  muscular 
fibers  which  begins  about  the  fourth  day.  The  regenera- 
tive process  consists  in  the  formation  at  the  periphery  of 
nucleated  cells,  developing  into  muscular  fibers,  and  continu- 
ing thus  until  the  close  of  the  eighth  week,  when  the  pro- 
cess is  complete. 

This  view  is  opposed  by  Sanger  and  Dittrich,  who  re- 
gard the  fatty  degeneration  as  merely  incidental  to  nutri- 
tion, and  describe  the  process  of  involution  as  consisting  of 
a  shortening  and  narrowing  of  the  hypertrophied  muscular 
fibers  until  they  have  reached  their  primitive  size.  The 
gross  appearances  of  these  changes  are  seen  in  the  diminu- 
tion in  the  size  of  the  uterus  from  a  weight  of  two  pounds 
and  a  half  at  delivery  to  one  pound  at  the  end  of  the  first 
week,  twelve  ounces  and  a  quarter  at  the  end  of  the  second 
week,  and  to  normal — which  is  a  little  more  than  two 
ounces — not  until  the  sixth  week,  this  normal  being  always 
somewhat  greater  than  the  weight  of  the  virgin  uterus. 
It  is  an  arrest  of  this  process  at  any  stage  of  its  course 
which  constitutes  subinvolution,  a  condition  immediatehr 
associated  with  inflammation. 

Coincidently  with  the  changes  in  the  uterus  are  the 
changes  in  the  no  less  important  structures  the  supports  of 
the  uterus — namely,  the  ligaments,  vagina,  perinjeum,  rec- 
tum, bladder,  and  pelvic  muscular  tissues.  Any  defects  in 
these  tissues  are  as  disastrous  to  future  comfort  and  well- 
being  as  a  defect  in  the  uterus  itself,  and  their  complete  in- 
volution is  just  as  important.  A  third  factor  is  the  healing- 
of  those  mechanical  injuries  to  the  soft  parts  produced  by 
the  passage  of  the  head  through  the  parturient  canal. 

Such  is  the  picture  presented  of  our  patient  at  the  close  of 
the  third  stage  of  labor,  and  of  the  various  changes  which 
must  take  place  within  her  before  the  pelvic  organs  are  re- 
stored to  their  original  size  and  position.  This  restoi-ation 
rapid  as  it  is,  it  will  be  observed,  requires  for  its  completion  a 
definite  period  of  time — a  period  which,  all  authorities  recog- 
nize, occupies  from  six  to  eight  weeks.  In  other  words,  it  is 
a  healing  process,  just  as  the  union  of  the  broken  ends  of  a 
bone  or  of  the  flaps  of  an  amputated  stump  is  a  healing 
process,  and,  as  such,  I  believe  it  should  be  governed  by  the 
ordinary  laws  of  surgery.  The  first  law  of  surgery  is  rest, 
and  the  lying-in  period  is  consequently  a  period  of  rest,  so 
intelligently  modified  and  subdivided  that  the  patient  is  ena- 
bled to  emerge  from  it  a  well  and  perfectly  healthy  woman^ 

In  carrying  out  this  idea,  it  has  been  my  habit  to  im- 
press upon  my  patient  that  after  the  birth  of  her  child  she 
has  to  look  forward  to  a  period  of  six  weeks  of  convales- 
cence, to  be  devoted  solely  not  only  to  getting  well,  but  to> 
getting  sound  and  strong. 


354 


HOUGHTON:    THE  PROPER  DURATION  OF  THE  LYING-IN  PERIOD.    [xV.  Y.  Meu.  Jo 


This  period  is  conveniently  divided  into  two  weeks  of 
absolute  rest  in  bed,  one  week  of  alternate  rest  in  bed  and 
moving  about  the  room,  a  fourth  in  gaining  every  day  for 
a  time  the  beneticial  effects  of  sunlight  and  fresh  air,  and 
the  last  two  in  resuming  gradually  the  ordinary  household 
duties  with  the  exception  of  lifting  heavy  weights  or  any 
other  severe  muscular  exertion.  While  insisting  upon  four- 
teen days  in  bed,  I  do  not  advise  a  uniform  position  on  the 
back.  On  the  contrary,  I  regard  a  frequent  change  of  po- 
sition from  one  side  to  the  other,  and  of  sitting  upright 
upon  the  vessel  during  defecation  or  urination,  as  very  neces- 
sary, first,  for  comfort  and  physical  ease;  secondly,  for  over- 
coming stagnation  and  hypostatic  congestion ;  and,  finally, 
for  an  opportunity  to  remove  by  gravity  the  clots  and  other 
accumulations  which,  owing  to  the  direction  of  the  outlet 
in  the  dorsal  decubitus,  tend  to  collect  in  the  vaginal  cul- 
de-sac.  This  plan,  carried  out  with  the  appropriate  treat- 
ment, will,  I  believe,  enable  us  to  confidently  anticipate  a 
perfect  result.  Unfortunately,  there  are  two  important  ele- 
ments of  opposition  to  the  successful  implantation  of  these 
views.  One  is  the  widely  divergent  opinions  held  on  the 
subject  by  equally  eminent  practitioners  ;  the  other  is  the 
mass  of  hereditary  and  traditional  ideas  held  by  the  patient 
herself.  Of  the  latter,  the  most  conspicuous  is  the  belief 
that  the  ninth  day  celebrates  the  close  of  the  lying-in  period, 
and  that  any  length  of  time  spent  in  bed  after  this  date  is 
so  much  worse  than  lost  time  on  account  of  the  weakening 
effect  of  the  bed.  These  ideas  patient  teaching  may  over- 
come ;  not  so  when  there  is  no  unanimity  of  views  on  the 
part  of  physicians.  A  careful  jDerusal  of  the  writings  upon 
this  subject  shows  scarcely  a  precise  agreement.  While  the 
majority  of  the  text-books  dismiss  the  subject  with  the  gen- 
eral advice  to  let  the  patient  sit  up  on  the  ninth,  tenth,  or 
twelfth  day,  if  the  uterus  has  disappeared  below  the  brim 
of  the  pelvis,  and  then  to  let  the  patient  gradually  resume 
her  ordinary  avocations,  there  are  a  few  who  emphatically 
insist  upon  practically  no  rest  in  bed  at  all,  and  others  who 
are  equally  emphatic  in  the  opinion  that  the  patient  should 
remain  flat  on  her  back  for  a  month  or  more.  Of  these  two 
extreme  views,  the  first  has  been  upheld  by  Professor 
Goodell,  of  Philadelphia,  who,  in  a  paper  written  a  number 
of  years  ago,  on  The  Prevention  of  Puerperal  Diseases  at  the 
Preston  Retreat,  stated  that  the  patients  were  allowed  to  sit 
up  out  of  bed  the  day  after  delivery,  and  to  repeat  this  once 
or  twice  every  day  while  the  bed  was  being  made  up,  until 
the  fifth  day,  when  they  were  allowed  to  dress  themselves. 
He  claimed  as  his  reasons  for  this  that,  first,  labor  is  physio- 
logical and  should  not  wear  the  livery  of  disease  ;  second, 
that  the  upright  position  tends  to  contraction  of  the  uterus 
and  a  lessening  of  the  lochial  discharge  ;  and,  finally,  that 
uterine  disease  is  nearly  unknown  among  savages  and  those 
nations  which  leave  the  bed  early. 

This  paper  of  Goodell's,  from  whom  I  have  been  unable 
to  discover  any  later  communication  changing  these  views, 
attracted  a  vast  deal  of  comment  and  adverse  criticism.  It 
lias  been  especially  considered  by  Garrigues,*  who  calls  at- 
tention to  the  fact  that  uterine  disease  is  not  unknown 


among  savage  nations ;  that,  on  the  contrary,  it  is  very  fre- 
quent. He  quotes  Johnson,  of  Washington,  who  says  that 
among  the  negresses  of  the  South,  pointed  out  as  remarka- 
ble examples  of  the  beneficial  effects  of  early  rising  after 
childbirth,  he  found  that  these  very  patients  presented 
themselves  more  frequently  for  uterine  displacements, 
hajmorrhages,  and  the  effects  of  subinvolution  than  for  any 
other  complaint.  The  same  can  be  said  of  our  Indian 
squaws,  though  there  is  no  doubt  that  they  can  without 
complaint  endure  an  amount  of  pain  and  disease  which 
would  render  our  more  highly  organized  civilized  woman 
an  invalid. 

While  I  believe  that  there  are  a  very  few  who  coincide 
with  the  views  held  by  Goodell,  I  believe  still  fewer  hold 
the  opposite  extreme  view — that  if  one  week's  rest  is  good, 
four  or  five  are  better.  An  instance  of  this  is  found  in  the 
advice  given  by  Wood,*  who  evidently  looks  upon  parturi- 
tion as  a  most  disastrous  proceeding.  lie  declares  that 
the  patient  should  be  kept  in  bed  on  her  back  for  four 
weeks,  and  should  not  at  any  time  assume  the  upright  posi- 
tion. At  the  end  of  the  fourth  week  an  examination  should 
take  place  and  any  lacerations,  cervical  or  otherwise,  which 
may  exist,  be  repaired.  The  vagina  is  then  to  be  packed 
with  compresses  for  the  support  of  the  uterus  until  the 
eighth  week,  when  the  patient  is  dismissed,  to  return  for  a 
monthly  examination  until  a  year  has  elapsed. 

I  have  said  that  two  weeks  should  constitute  the  length 
of  time  that  our  patient  ought  to  remain  in  bed,  and  that 
the  third  week  should  be  devoted  to  alternate  moving 
about  the  room  and  resting  upon  the  bed  or  a  sofa.  The 
uterus  at  the  close  of  the  second  week  weighs  somewhat 
more  than  twelve  ounces,  which  is  five  times  greater  than 
normal,  and  should  consequently  not  be  regarded  as  yet  in 
fit  condition  to  undergo  the  strains  and  pressures  put  upon 
it  by  a  resumption  of  household  duties.  It  is,  however, 
entirely  contained  within  the  bony  pelvis,  supported  in  its 
proper  position  by  the  soft  tissues  which  surround  it. 
These  supporting  tissues — which  are  made  up,  as  has  been 
said,  not  only  by  the  ligaments,  but  by  all  the  muscular 
structures  within  the  pelvis — should  now  be  the  ones  to  re- 
ceive atttention,  and  be  given  the  opportunity  for  devel- 
opment. 

They  require  for  this  purpose  a  certain  amount  of  func- 
tional activity,  having  reached  a  point  where  any  further 
physiological  rest  would  probably  lead  to  an  atrophic  rather 
than  to  a  developmental  condition.  This  corresponds  to 
the  principle  recognized  in  passive  motion  as  applied  to  a 
limb  after  a  fracture  or  a  dislocation.  The  third  and  fourth 
week  of  the  puerperal  state,  therefore,  represent  a  develop- 
mental period  following  one  of  physiological  rest,  with  the 
additional  factor,  during  the  fourth  week,  of  promoting  by 
outdoor  air  and  gentle  exercise  the  general  health  and  nu- 
trition of  the  patient. 

Having  reached  the  close  of  the  first  month,  there  re- 
main two  weeks  before  the  uterus  resumes  approximately 
its  natural  condition.  The  patient  should  by  this  time  feel 
in  perfect  health,  and  should  have  no  symptoms  referable 


*  Garriguea.    Rest  after  Delivery,  Amer.  Jour,  of  Obst.,  1880,  p.  840. 


*  W.  B.  Wood.    New  York  Medical  .loamal,  1890,  vol.  Hi,  p.  126. 


April  1,  18fl3.J 


LOCKE:  RECTAL  ULCERS  AND  PARAMETRITIS  POSTERIOR. 


355 


to  tlic  pelvic  organs.  The  uterus  is  still,  however,  a  trifle 
enlarged,  the  supports  still  lack  their  full  strength  and  tone, 
and  it  is  at  this  time  that  any  extraordinary  muscular  ex- 
ertion— as  of  lifting  heavy  weights,  climbing  stairs,  or  other 
hard  work — may  result  in  endless  mischief  by  stretching 
the  ligaments  and  displacing  the  supporting  structures.  By 
impressing  this  fact  upon  our  patient,  there  should  be  no 
difficulty  in  securing  from  her  the  resolution  to  avoid  all 
severe  muscular  exertion  during  these  last  two  weeks,  and 
to  engage  in  only  the  lighter  household  duties. 

A  faithful  adherence  to  this  period  of  convalescence, 
combined  with  a  proper  and  appropriate  conduct  of  the 
case,  will,  I  am  confident,  except  in  the  presence  of  extraor- 
dinary complications,  yield  the  gratification  of  seeing  in 
our  patient,  one  or  ten  years  later,  a  woman  free  from  the  so 
frequent  evil  consequences  of  childbirth. 

301  West  Eighty-eighth  Street. 


RECTAL  ULCERS  AS  A  COMPLICATION  OF 
PARAMETRITIS  POSTERIOR.* 
By  HERSEY  G.  LOCKE,  M.D., 

CHIEF  OF  CLINIC,  DEPARTMENT  OF  DISEASES  OF  WOMEN,  VANDERBILT  CLINir. 
COLLEGE  OF  PHTSICIANS  AND  SURGEONS. 

I  BRING  to  you  for  your  consideration  this  evening  a 
question  which  has  been  of  very  considerable  interest  to  me 
for  many  months  past,  and  which,  though  a  minor  point  in 
the  pathology  and  symptomatology  of  pelvic  diseases,  may 
prove  of  assistance  to  us  in  our  treatment  of  this  disorder 
and  the  relief  of  the  pain  resulting  therefrom. 

The  great  majority  of  those  who  come  to  us  for  help  do 
so  because  they  have  pain  ;  and  if  we  relieve  this  more  or 
less  completely,  restore  them  once  again  to  their  old  condi- 
tion of  health  and  strength,  we  shall  find  them  contented 
and  happy,  little  heeding  the  pathological  remnants  of 
which  we  alone  are  cognizant. 

In  the  department  of  gynjecology,  I  believe  I  may  safely 
say  that  those  patients  suffering  from  chronic  inflammma- 
tion  of  the  pelvic  connective  tissue  are  by  far  the  most 
unsatisfactory  and  the  greatest  tax  upon  our  ingenuity  and 
patience.  Prominently  among  these  are  those  suffering 
from  posterior  parametritis,  or  inflammation  of  the  cellular 
tissue  lying  beneath  the  folds  of  Douglas. 

Savage,  in  his  clear  description  of  the  subperitoneal  tis- 
sue, writes :  "  A  plane  extending  from  the  middle  of  the 
posterior  surface  of  the  symphysis  pubis  to  the  point  of 
articulation  of  the  third  with  the  fourth  sacral  vertebra, 
which  intersects  the  uterus  at  the  junction  of  the  body  with 
the  neck,  will,  with  rare  exceptions,  divide  the  pelvic  cavity 
into  two  spaces — a  peritoneal  and  subperitoneal.  The 
parts  lying  below  this  plane  are  imbedded  in  the  cellular 
tissue  which  occupies  that  portion  of  the  pelvis  which 
contains  no  intestine.  The  structure  consists  of  fihro- 
elastic,  muscular,  and  connective-tissue  elements,  and  is  so 
arranged  that  its  meshes  or  cells  communicate  freely  with 
each  other." 

On  carrying  our  examination  further,  we  shall  find  that 
from  the  posterior  surface  of  the  uterus,  a  little  above  the 

*  Read  before  the  Hospital  Graduates'  Club,  January  26,  189.3. 


junction  of  the  cervix  with  that  organ,  the  muscular  bands 
of  the  folds  of  Douglas,  surrounded  by  this  same  cellular 
and  loose  connective  tissue,  pass  to  the  lateral  parts  of  the 
sacrum,  nearly  at  the  level  of  the  second  vertebra.  The 
upper  so-called  posterior  insertion  of  these  muscular  bands 
varies  considerably,  though  it  would  seem  that  they  always 
loose  themselves  in  the  muscular  walls  of  the  rectum  and 
subserous  connective  tissue.  The  anterior  or  lower  inser- 
tion is  formed  by  some  muscular  fibers  from  each  side 
coalescing  behind  the  uterus  and  forming  a  single  unique 
muscle,  called  by  Luschka  the  musculus  retractor  uteri. 

Thus  it  would  seem  that  where  exudation  into  the 
meshes  of  the  cellular  tissue  has  taken  place,  and  where  the 
pathological  condition  has  persisted  sufficiently  long,  the 
perirectal  tissues  must  frequently  be  involved. 

The  pathological  process  in  this  locality  varies  little 
from  that  found  elsewhere  in  the  body.  In  cases  where 
the  poison  is  not  sufficiently  virulent  to  cause  suppuration, 
there  must  be  extensive  exudation  of  albuminous  or  fibrin- 
ous material  in  the  meshes  of  the  cellular  tissue,  as  shown 
by  soft  swellings  that  can  be  observed  shortly  after  the  be- 
ginning of  the  process.  Where  the  case  is  recent,  the  con- 
nective tissue  is  largely  infilt»'ated  with  gelatinous  material 
containing  numerous  small  cells.  In  the  subsequent  chronic 
condition  the  soft  swellings  become  dense,  tlie  fluid  portion 
having  been  absorbed,  and  out  of  the  cellular  tissue  is 
formed  circumscribed  hard  tumors  poorly  supplied  with 
blood,  often  reaching  to  the  inlet  of  the  pelvis,  insinuating 
themselves  between  the  folds  of  Douglas,  to  the  rectum  or 
even  becoming  prolonged  beyond  the  limits  of  the  true 
pelvis.  The  ultimate  cicatricial  contraction  and  hardening 
is  readily  found  with  the  microscope. 

Schultze  is  of  the  opinion  that  parametritis  posterior  is 
generally  either  confined  to  one  side  or  much  more  exten- 
sive on  one  side  than  on  the  other,  preferably  the  left — 
viz.,  the  rectal  side. 

^Etiology. — We  may  roughly  divide  our  patients  into 
three  classes : 

\.  Virgins. 

2.  Nulliparae. 

3.  Parous  women. 

Among  virgins,  the  most  constant  pathological  factor 
is  chronic  pelvic  congestion  due  to  constipation.  Secondly, 
traumatism  followed  by  infection,  such  as  wounds  caused 
by  the  introduction  and  wearing  of  pessaries,  gynecologi- 
cal manipulations,  and  finally  specific  vaginitis  due  to  in- 
fection from  dirty  fingers,  cloths,  sponges,  etc. 

In  regard  to  the  other  two  classes,  Schultze  conclusively 
states  that  the  causes  of  parametritis  posterior,  though  pretty 
often  of  puerperal  origin,  are,  it  must  be  stated,  far  more 
frequently  not  so.  The  occurrence  of  puerperal  parame- 
tritis posterior  is  very  commonly  due  to  infection  after 
laceration  of  the  perimeum,  or  even  after  some  trivial  injury 
to  the  posterior  wall  of  the  vagina.  The  exudation  is  by  no 
means  always  considerable,  the  acute  stage  is  often  very 
short,  and  the  local  phenomena  very  slight.  The  febricula 
of  puerperal  women,  the  single  rise  in  temperature  for- 
merly spoken  of  (milk  fever),  is  often  nothing  but  parame- 
tritis posterior. 


LOCKE:  liECTAL  ULCERS  AND  PARAMETRITIS  POSTERIOR.        [N.  Y.  Med.  Jocr., 


S5o 

In  iininairied  women  and  in  those  who  liave  never  been 
confined,  parametritis  posterior  is  generally  subacute  or 
chronic  from  its  ('ommenccment.  Mechfiiiical  injury,  re- 
peated straining  of  the  folds  of  Douglas  by  the  passage  of 
large  masses  of  faeces  in  habitual  constipation,  perhaps  even 
infection  from  fissures  of  the  rectum,  and  extension  of  the 
processes  of  endometritis  to  the  parametrium,  especially  as 
a  result  of  the  stagnation  of  the  catarrhal  secretion,  appear 
to  be  the  principal  causes  of  parametritis  posterior  chronic 
from  its  commencement  in  persons  of  the  class  just  men- 
tioned, while  acute  non-puerperal  parametritis,  in  the  ma- 
jority of  cases,  is  either  traumatic  or  depends  upon  infec- 
tion which  is  not  infrequently  gonorrhoeal. 

In  a  large  number  of  cases  this  pathological  process, 
exudation,  hardening,  and  contraction  is  not  limited  to  the 
immediate  neighborhood  of  the  uterus,  but  is  concentrated 
at  the  posterior  or  rectal  attachment  of  the  ligament,  and 
contraction  in  this  locality  means  direct  injury  to  the  rectal 
and  perirectal  tissues. 

At  this  level — viz.,  that  of  the  first  and  second  sacral 
vertebra; — the  great  venous  plexus  of  the  rectum  has  be- 
come so  concentrated  that  we  have  left  only  the  superior 
hemorrhoidal  vein  or  its  immediate  tributaries  in  which  any 
obstruction  to  the  onward  fiow  of  blood  results  in  an  over- 
distention  or  varicose  condition  of  the  distal  veins.  The 
morbid  tissue  changes  hitherto  described,  by  their  interfer- 
ence with  the  return  circulation,  doubtless  cause  a  marked 
stagnation  in  and  dilatation  of  the  rectal  plexus,  ultimately 
producing  a  condition  analogous  to  that  found  in  the  lower 
extremity. 

When  to  this  is  added  the  evil  effects  of  habitual  con- 
stipation, irritation,  abrasion,  and  septic  absorption  from 
the  passage  of  large  and  very  frequently  hardened  masses 
of  fajces,  the  ultimate  development  of  a  varicose  ulcer  would 
seem  a  very  natural  result. 

These  ulcers  arc  situated  most  frequently  on  the  poste- 
rior rectal  wall,  from  an  inch  to  an  inch  and  a  half  above  the 
sphincter;  in  a  general  way,  I  should  say  that  they  occur 
half  as  often  on  the  anterior  wall. 

They  vary  in  size  from  that  of  a  dime  to  a  twenty-five- 
cent  piece  and  are  frequently  multiple.  On  examination 
with  the  speculum,  a  smooth  basement  of  granulation  tis- 
sue with  a  well-defined  margin  is  shown.  The  surrounding 
mucous  membrane  is  decidedly  hyperajmic,  and  at  times 
covered  with  a  thin  coating  of  mucus.  So  far  as  I  have 
been  able  to  determine,  they  invariably  lie  in  the  lowest  por- 
tion of  the  rectum,  but  a  short  distance  above  the  sphincter 
ani — a  locality  where,  owing  to  muscular  action  and  impac- 
tion, traumatism  would  be  more  prone  to  occur.  The  ex- 
amination is  almost  invariably  accompanied  by  pain  and 
haemorrhage. 

Symptoms. — Let  me  quote  a  case  from  Mathews's  Trea- 
tise on  Diseases  of  the  Rectum,  Anus,  and  Sigmoid  flex- 
ure* just  published  : 

"  A  lady,  aged  twenty-four,  married,  was  referred  to  me  by 
a  gynaecologist.  She  liad  complained  for  many  months  with 
backache,  pain  down  the  thighs,  general  lassitude,  melancholia, 

*  D,  Appleton  &  Co.,  New  York. 


a  bearing-down  sensation  in  both  vagina  and  rectum,  [lain  over 
the  seat  of  both  ovaries,  constipated  habit,  leucorrboea.  loss 
of  flesh,  irregular  menstruation,  difficult  micturition,  and  a 
slight  discharge  of  mucus  from  the  l>owel.  Ui)on  an  examina- 
tion of  the  womb  and  its  ai)i)endages  l)y  tlie  gyniecohjgist,  there 
had  not  been  enough  trouble  found  to  account  for  her  symp- 
toms. He  treated  her  for  several  months,  however,  and,  her 
case  not  clearing  up,  he  advised  her  to  consult  me.  Upon  ex- 
amining the  rectum  with  a  speculum,  I  found  it  highly  con- 
gested, very  red,  and  sensitive,  and  a  film  of  mucus  covered  the 
entire  circumference  of  the  gut  for  several  inches  up.  The 
cause  for  this  extensive  rongestion  was  not  discernible.  I  was 
satisfied,  however,  that  all  the  symptoms  mentioned  were  pure- 
ly reflex  from  the  rectum,  and  proceeded  to  treat  her.  .  .  .  The 
redness  of  the  mucous  membrane  and  all  pain  gradually  disap- 
peared ;  the  discharge  ceased  and  all  reflex  trouble  vanished." 

I  give  you  this,  not  from  my  own  gynaecological  case 
books,  but  from  a  treatise  on  rectal  surgery.  This  patient 
had  no  rectal  ulcers,  probably  because  the  obstruction  above 
was  not  suflSciently  complete ;  but  there  is  little  doubt  in 
my  mind  that  a  more  careful  examination  would  have 
shown  a  parametritis  posterior.  The  cure  of  the  rectal 
condition  alone  was  sufficient  to  cause  a  disappearance  of 
her  pelvic  symptoms.  With  the  addition  of  ulceration  the 
suffering  would  have  been  more  acute. 

It  is  a  notable  fact  that  ulceration,  very  extensive  in 
character,  may  exist  in  the  rectum  located  above  the  sphinc- 
ter muscles  and  cause  very  little  (rectal)  disturbance,  or  at 
least  the  disturbance  is  out  of  all  proportion  in  its  insig- 
nificance to  the  extent  of  the  ulceration.  It  is  only  where 
the  external  sphincter  muscle  is  involved  in  the  disease  that 
we  have  the  great  distress  following. 

We  have,  then,  a  class  of  patients  suffering  from  pain 
located  in  the  ovarian  and  lumbar  region,  headache,  general 
depression,  etc.  Not  always  is  there  a  distinct  history  of 
habitual  constipation,  and  even  less  frequent  are  complaints 
of  rectal  disease.  On  examination,  we  find  the  parts  fairly 
normal  with  the  exception  of  chronic  metritis  and  parame- 
tritis posterior,  as  shown  by  fixation  and  hardening  of  the 
uterus,  thickening  and  tenderness  of  the  folds  of  Douglas  ; 
the  physical  signs  not  at  all  commensurate  with  the  com- 
plaints of  the  patient.  Place  them  in  Sims's  position,  and, 
on  rectal  examination,  we  shall  frequently  find  the  source  of 
the  reflex  irritation — viz.,  rectal  ulcer. 

The  treatment  is  simply  a  combination  of  the  established 
routine,  respectively,  for  the  two  conditions  ;  for  the  uter- 
ine and  para-uterine  the  use  of  mild  counter- irritation,  deple- 
tion by  means  of  hydragogue  tampons  and  massage — all 
directed  toward  the  relief  of  pelvic  congestion,  the  soften- 
ing and  absorption  of  the  inflammatory  exudate. 

For  the  rectum,  dilatation  so  far  as  is  possible  in  ambu- 
latory cases  ;  where  practicable,  divulsion  of  the  sphincter 
under  ether  with  subsequent  rest  in  bed.  The  treatment  of 
the  ulcer  is  tedious,  nevertheless  it  is  gratifying  to  note  the 
rapid  improvement,  often  apparently  out  of  proportion  to 
the  change  in  the  rectal  condition.  Having  thoroughly  irri- 
gated the  rectum  and  washed  the  ulcer  with  a  solution  of 
bichloride  of  mercury  (1 -to- 1,000),  I  have  found  nothing 
better  than  the  strong  solutions  of  nitrate  of  silver — from 
forty  grains  to  a  drachm  to  the  ounce.    The  pure  stick  and 


April  1,  1S93.) 


SHELLY:  AN  EXENCEPUALUS. 


357 


other  stronger  CMuterants  have,  in  my  experience,  not  proved 
so  serviceable.  The  ulcer  and  mucous  membrane  is  well 
dusted  with  iodoform.  Followinir  each  defecation  the  pa- 
tient is  instructed  to  wash  out  the  bowel  with  warm  water 
and  afterward  with  a  saturated  solution  of  boric  acid.  It 
would  seem  hardly  necessary  to  say  that  careful  attention 
is  paid  to  the  action  of  the  bowels.  So  far  as  I  have  gone 
— and  my  cases  are  now  quite  numerous — my  results  have 
been  very  gratifying. 

Briefly  summarized,  the  points  which  I  have  endeavored 
to  bring  to  your  attention  this  evening  are  : 

1.  That  para-uterine  cellulitis  posterior,  by  its  hardening 
and  subsequent  contraction,  obstructs  the  return  flow  of 
blood  from  the  rectum,  producing  stasis  in  and  a  varicose 
condition  of  the  rectal  plexus. 

2.  By  the  irritation  and  abrasion  of  the  mucous  mem- 
brane, ulceration  follows. 

3.  In  a  large  number  of  cases  the  symptoms  resulting 
therefrom  are  reflex  and  referred  to  the  genital  system  pri- 
marily the  region  of  the  ovaries. 

4.  Treatment  of  the  parametritis  in  most  cases  is  not 
completely  successful  unless  cai'eful  attention  is  directed 
to  the  rectum,  whereby  the  reflex  and  most  troublesome 
symptoms  are  relieved. 

It  has  been  my  desire  this  evening  to  gather  together 
these  little  odds  and  ends  of  the  past  two  years,  and  to  put 
them  into  some  tangible  form  suitable  for  your  considera- 
tion. 

19  West  Thirty-eighth  Street. 


AN  EXENCEPHALITS. 

By  E.  T.  shelly,  M.  D., 

ATCHISON.  KAN. 

The  exencephalic  fcetus  which  is  the  subject  of  the  accom- 
panying illustration  was  born  at  seven  months  of  a  healtliy 
mother  who  had  been  delivered  of  a  normal  child  two  years 


before.  She  is  twenty  two  years  of  age,  and  nothing  abnormal 
was  noted  during  the  course  of  her  recent  pregnancy  excepting 


the  unusually  large  size  of  her  abdomen,  which  was  due  to  the 
great  quantity  of  amniotic  liquid  present — a  condition  usually 
existing  in  this  class  of  cases.  The  child  was  said  by  the  at- 
tendants to  have  gasped  once,  and  its  weight  was  about  four 
pounds  and  a  half.  All  of  its  parts  are  apparently  normally  de- 
veloped witli  the  exception  of  the  head,  neck,  and  back.  The 
face  is  directed  upward  and  the  cranium  is  practically  absent. 
The  brain  rests  as  a  dark  mass  on  the  child's  neck  and  ba<'k,  and 
the  spinal  canal  is  open  for  quite  a  distance  down  the  back.  This 
specimen  of  abnormal  foetal  development  belongs  to  the  class 
of  cleft  formations,  the  growth  of  some  of  the  dorsal  or  neural 
arches  having  been  arrested  by  some  means,  so  that  the  brain 
and  the  upper  portion  of  the  spinal  cord  failed  to  receive  their 
usual  bony  coverings.  The  specimen  was  sent  undisturbed  to 
the  museum  of  the  University  Medical  College  at  Kansas 
City,  Mo. 

Foetal  malformations  and  monstrosities  have  always  ex- 
cited the  wonder  and  awe  of  the  illiterate  and  superstitious, 
and  many  have  been  the  explanations  offered  in  regard  to 
their  origin  and  the  significance  of  their  occurrence.  Am- 
broise  Pare,  the  father  of  French  surgery,  said,  in  1579,  re- 
ferring to  such  human  monstrosities  as  were  thought  to  re- 
semble animals  in  appearance  :  "  For  of  the  various  and 
promiscuous  confusion  of  seedes  of  different  kinde,  mon- 
sters have  been  generated  and  borne  who  have  been  partly 
men  and  partly  beasts  "  ;  but  he  stoutly  resisted  the  claim 
that  the  paternity  of  any  of  them  could  reasonably  be  as- 
cribed to  the  devil,  an  hypothesis  more  absurd  but  no  more 
foundationless  than  his  own. 

Malformations  in  animals  were  formerly  thought  to 
portend  calamities.  Even  Martin  Luther  once  called  atten- 
tion to  the  relation  existing  between  a  monstrous  calf  and 
a  catastrophe.  The  occurrence  of  human  monstrosities  was 
considered  an  evidence  of  divine  wrath,  as  they  were  sup- 
posed to  be  sent  as  punishments  to  particularly  sinful  par- 
ents— a  ghastly  anthropomorphic  notion  which  it  is  feared 
is  even  at  this  late  day  entertained  by  not  a  few  ultra-pious 
persons.  The  influence  of  the  mind  of  the  mother  upon 
the  child  in  utero  is  also  frequently  urged  as  a  cause  for 
the  occurrence  of  fa'tal  abnormities,  particularly  of  the 
more  common  forms.  Although  a  nervous  connection  be- 
tween the  child  in  utero  and  the  mother  can  not  be  demon- 
strated to  be  any  more  real  than  a  nervous  connection  be- 
tween the  setting  hen  and  her  unhatched  chicks,  still  every 
child  that  is  born  with  a  "  mark "  is  accused  by  the 
neighborhood  "  grannies  "  (medical  as  well  as  lay)  of  hav- 
ing been  harmfully  influenced  by  maternal  mental  impres- 
sions. And  yet  if  it  were  possible  for  such  influence  to  be 
exercised,  it  is  doubtful  whether  there  would  be  any  "  un- 
marked "  children  born.  For  where  is  the  child  whose 
mother  did  not  fear  at  its  birth  that  it  would  be  "  marked," 
because  of  something  she  had  seen  or  heard  or  dreamt  or 
imagined  or  wanted  during  the  child's  intra-uterine  exist- 
ence ? 

Of  course  there  are  a  great  man}'  things  connected  with 
the  subject  of  teratology  that  are  still  to  be  found  out,  and 
this  fact  no  doubt  accounts  for  the  halo  of  supernaturalisra 
in  which  the  subject  is  even  yet  more  or  less  enveloped — a 
halo  which  can  be  dissipated  only  by  earnest  and  persistent 
research. 


358 


HAMILTON:  REMOVAL  OF  A  MELANOSARCOMA  OF  THE  GROIN.    [N.  Y.  Mkd.  Jb 


REMOVAL  OF 
A  MELANOSARCOMA  OF  THE  GROIN 
WITH  A  PORTION  OF  THE  FEMORAL  VEIN. 
By  CHARLES  S.  HAMILTON,  M.  D., 

COLUMBUS,  OHIO, 

PROFESSOR  OF  PRINOrPLES  OF  SURGERY,  STARLING  MEDICAL  COLLEGE. 

Mrs.  P.,  of  Circleville,  Ohio,  was  referred  to  the  writer  in 
September,  1891,  by  Dr.  Conrtright,  of  that  place.  She  was  a 
stout,  muscular  subject,  sixty-nine  years  of  age.  Two  of  her 
brothers  and  a  sister  had  died  of  malignant  growths.  Another 
sister  had  had  a  tumor  removed  from  the  breast  several  years 
before  and  still  survived.  It  was  impossible  to  learn  the  precise 
nature  of  the  tn  mors  in  the  various  cases  alluded  to.  Exami-  I 
nation  of  the  patient  disclosed  an  irregular  lump  occupying  the 
right  groin  and  front  of  the  thigh,  which  had  developed  within 
the  previous  five  months.  Its  greatest  diameter  was  five  inches 
in  length,  parallel  to  Poupart's  ligament.  It  was  only  slightly 
movable,  and  evidently  involved  both  superficial  and  deep 
inguinal  lymphatic  glands.  Veins  of  considerable  size  coursed 
over  it,  and  the  extremity  was  much  swollen.  The  commenc- 
ing infiltration  of  skin  over  the  growth,  the  rapidity  of  its  de- 
velopitient,  and  the  bad  family  history  gave  striking  clinical 
evidence  of  its  cancerous  nature.  Removal  of  the  growth  was 
advised  and  performed  at  the  patient's  home  on  September  4th, 
with  the  assistance  of  Dr.  W.  I).  Hamilton,  Dr.  Conrtright,  and 
Dr.  Bowers.  An  incision  eight  inches  in  length  was  made 
parallel  to  and  slightly  beneath  Poupart's  ligament.  On  expos- 
ing it,  the  tumor  was  found  to  be  about  the  color  of  liver,  lobu- 
lated,  and  intimately  related  to  adjacent  structures.  The  super- 
ficial veins,  including  the  saphenous,  being  closely  connected  with 
the  mass,  were  ligated  and  divided.  A  deeply  located  portion 
of  the  tumor  surrounded  and  involved  the  femoral  vein  in  such 
a  manner  that  separation  was  impossible.  Therefore  that  por- 
tion of  the  vein,  three  quarters  of  an  inch  in  length,  immedi- 
ately beneath  Poupart's  ligament  was  removed  after  the  appli- 
cation of  ligatures.  Two  or  three  enlarged  retroperitoneal 
glands  along  the  course  of  the  external  iliac  vessels  were  de- 
tected with  the  finger  and  dissected  out.  Lastly,  a  nodule  in- 
volving the  skin  over  the  gracilis  was  excised  and  the  operation 
concluded.  All  steps  were  taken  with  due  regard  to  cleanli- 
ness. The  patient  recovered  speedily,  and  on  October  31st  her 
physician  reported  that  slight  swelling  of  the  limb  still  per- 
sisted. Later  on  an  elastic  stocking  reaching  to  the  garter  was 
worn,  and  with  this  assistance  the  patient  was  able  to  go  about 
like  any  other  woman  of  her  age.  The  entire  mass  removed  was 
as  large  as  a  fist.  The  diagnosis  of  melano-sarcoma  was  con- 
firmed by  the  microscope. 

In  September,  1892,  the  patient  detected  a  painful  lump  in 
the  regifm  of  the  sigmoid  flexure,  and  it  was  supposed  by  her 
physician  that  a  recurrence  had  taken  place,  though  the  seat  of 
operation  was  entirely  free  from  any  sign  of  disease.  Within  a 
short  time  inflammatory  symptoms  set  in,  and  finally  the  lump 
disappeared  coincidently  with  a  free  discharge  of  pus  from  the 
rectum.    She  regained  her  health,  and  is  to-day  as  well  as  ever. 

There  are  two  points  in  the  history  of  this  case  which 
seem  to  the  writer  worthy  of  attention  : 

1.  The  comparatively  long  period — eighteen  months — 
that  has  elapsed  without  recurrence  when  the  tumor  be- 
longed to  so  malignant  a  class  as  the  melano- sarcomata. 

2.  The  very  trifling  disturbance  of  circulation  in  the 
leg  and  thigh  after  excision  of  portions  of  tlie  femoral  and 
saphenous  veins  and  ligation  of  numerous  superficial  veins 
in  an  old  subject. 


A  CASE  OF  POISONING  FROM 
FOUR  DRACHMS  OF  FLUID  EXTRACT  OF  ACONITE. 
By  HENRI  E.  R.  ALTENLOH,  M.  D., 

CHICAGO. 

Mrs.  J.  C,  aged  thirty,  having  had  some  misunderstanding 
with  her  husband,  and  therefrom  feeling  despondent,  took  at  a 
dose,  with  suicidal  intentions,  four  drachms  of  fluid  extract  of 
aconite.  She  immediately  felt  a  burning  sensation  and  pain  in 
her  stomach,  followed  by  lost  power  of  standing,  and  became 
very  restless.  She  called  her  husband,  who  was  in  the  adjoin- 
ing room,  and  he,  after  finding  out  what  she  had  taken,  sent 
for  me.  I  arrived  about  twenty  minutes  after  the  poi.son  had 
been  taken,  and  found  her  held  up  by  friends  over  the  pol  de 
chamhre.  She  had  no  control  over  her  bowels,  and  was  in 
agony  from  the  fearful  burning  sensation  in  the  stomach.  After 
she  had  filled  the  pot  for  the  second  time,  I  ordered  her  un- 
dressed and  laid  on  the  bed,  and  administered  emetics  and  atro- 
pine hypodermically.  In  spite  of  emetics,  she  could  not  vomit. 
Her  skin  was  cold  and  clammy,  with  a  feeling  of  numbness. 
With  the  aid  of  two  assistants,  I  began  rubbing  her  with  brandy, 
which  was  the  only  thing  at  hand.  She  complained  of  swell- 
ing about  the  tongue  and  throat,  and  had  convulsive  twitchings 
of  the  muscles  about  the  face  and  neck,  also  dimness  of  sight; 
pupils  widely  dilated.  I  gave  her  another  hypodermic  injection 
of  atropine.  Now  the  symptoms  grew  rapidly  worse.  She 
was  unable  to  move,  and  almost  lost  consciousness.  She  had 
foaming  at  the  mouth,  and  could  not  swallow.  Lockjaw,  deaf- 
ness, and  complete  loss  of  sight  followed ;  the  breathing  was 
slow  and  regular;  the  pulse  w'as  imperceptible;  the  hands  were 
clinched. 

All  this  time  the  assistants  were  rubbing  her  with  brandy, 
and  in  the  mean  time  I  sent  for  emi  sedative  (Raspail's)  and 
tincture  of  belladonna,  of  which  I  gave  her  a  dose,  and  ordered 
the  sedative  water  to  be  used  for  rubbing  in  place  of  the  brandy. 
She  began  to  improve  a  little ;  her  sisjht  was  restored  to  a  certain 
extent,  she  was  now  able  to  hear,  lockjaw  had  disappeared,  and 
she  began  moving  a  little.  But  now  she  began  to  have  attacks 
of  the  most  violent  description;  breathing  became  very  difl[i- 
cult.  She  was  complaining  of  pain  in  the  heart  and  constric- 
tion of  the  chest.  Her  eyes  were  brilliant  and  sparkling  and 
glared  wildly,  sometimes  resting  with  a  fixed  stare.  She  felt  a 
feeling  of  death,  and  appeared  to  suffocate.  She  was  gasping 
for  air  and  became  very  violent,  and  it  was  difficult,  with  the 
united  force  of  three,  to  keep  her  in  bed.  The  pain  in  the 
heart  was  fearful.  She  wanted  to  tear  the  breast  of  the  left 
side,  and  it  was  a  hard  task  to  keep  her  from  injuring  herself. 
Asphyxia  was  all  along  expected,  until  all  at  once  came  a  little 
improvement.  She  had  repeated  attacks  of  pain  in  the  heart 
and  suffocation.  She  wanted  to  be  rubbed  over  the  chest  con- 
tinuously, for  she  said  it  relieved  her,  and  she  was  rubbed  for 
over  four  hours  constantly  until  her  skin  was  sore,  and  I  gave  her 
several  doses  of  belladonna.  She  was  improving  fast,  but  still 
had  no  power  to  move  her  hands  and  feet,  the  former  being  still 
clinched,  and  there  was  no  sensation  in  the  fingers.  We  began 
then  rubbing  her  hands  and  feet,  and  in  a  few  minutes  she  was 
again  able  to  move  them.  Five  hours  after  she  had  taken  the 
poison  I  left  her  feeling  quite  well,  but  greatly  exhausted.  She 
had  not  vomited  a  particle,  but  was  well  purged.  Next  morn- 
ing she  had  vomitings,  headache,  and  a  slight  fever,  and  still  had 
slight  numbness  in  the  fingers,  but  on  the  following  day  she  was 
up  and  around,  feeling  as  well  as  ever. 

48  Pierce  Avenue. 


April  1,  1893.J 


LEADING  ARTICLES. 


359 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Applbton  &  Co.  Frank  P.  Foster,  M.I). 


NEW  YORK,  SATURDAY,  APRIL  1,  1893. 


EXOTHYREOPEXY. 

At  a  recent  meeting  of  tbe  Lyons  Societe  nationale  de  mede- 
cine,  tlie  proceedings  of  which  are  reported  in  Lyon  medical  for 
March  12t!i,  M.  Poncet  presented  a  lad,  fifteen  years  old,  on 
whom  his  a.ssistaiit,  M.  Jaboiilay,  had  operated  for  goitre  by  a 
new  procedure.  In  his  enthusiasm,  M.  Poncet  proposed  to 
call  the  procedure  Jabonlay's  operation,  although  he  mentioned 
several  ether  names,  including  exothyreopexy  and  supraclavi- 
sternal,  or  supracostosternal,  luxation  of  the  thyreoid  gland.  It 
seems  that  the  patient  came  from  Chambost,  in  the  department 
of  the  Rh6ne,  and  that,  although  [his  family  was  not  goitrous, 
there'was  goitre  in  his  canton.  For  some  months  his  disease 
had  been  grave,  giving  rise  to  suffocative  attacks,  persistent 
dyspnoea,  an  almost  continuous  feeling  of  anxiety,  tachycardia, 
and  palpitation.  M.  Poncet  stated  that  the  goitres  met  with  in 
the  region  in  which  the  patient  belonged  were  usually  (four 
times  out  of  five)  encysted  and  enucleable,  but  that  in  this  in- 
stance the  disease  was  absolutely  parenchymatous,  so  that  its 
enucleation  was  impossible,  and  removal  of  the  entire  thyreoid 
was  avoided  on  account  of  the  excessive  vascularity  of  the 
goitre. 

What  was  really  done — and  what  appears  to  have  been  deter- 
mined upon  beforehand  by  M.  Jaboulay,  in  case  matters  should 
turn  out  as  they  did — was  to  free  the  thyreoid  from  surround- 
ing parts  as  far  as  practicable  and  bring  it  forward  through  the 
external  wound,  which  extended  down  to  the  suprasternal 
notch,  to  a  situation  where  it  gradually  underwent  atrophy, 
partly,  perha|)s,  as  the  result  of  constriction  of  its  pedicle  by 
the  lips  of  the  wound  in  the  process  of  healing,  and  partly  by 
its  connection  with  its  normal  surroundings  being  restricted. 
It  is  plain  that  with  strict  antiseptic  i)recautions  such  a  plan 
of  treatment  can  be  carried  out  without  great  danger  from  re- 
sorption of  septic  matter.  As  to  what  would  ultimately  be- 
come of  the  shrunken  remains  of  the  tumor  it  is  not  easy  to 
judge,  for  M.  Poncet's  report  was  made  at  a  time  when  only 
two  months  had  elapsed  since  the  operation. 


THE  CURATIVE  SERUM  OF  TETANUS. 

The  Berlin  correspondent  of  the  Medical  Presn  and  Circular 
for  February  8th  notices  the  last  publication  by  Behring  on 
tetanus,  in  which  he  announces  that  an  immunizing  serum,  pre- 
pared under  his  direction,  may  he  procured  from  Meinliardt,  of 
Berlin.  A  case  of  cure  by  the  serum  is  reported  in  the  same 
publication.  This  case  was  one  of  traumatic  tetanus  that  was 
treated  by  injections  of  curative  blood  serum  from  the  horse. 


250  grammes  of  a  solution  of  l-to-1,000,000  intensity  having 
been  administered  in  five  injections.  The  author  states  that, 
as  the  symptoms  were  progressing  and  aggressive  during  the 
day  before  the  treatment  was  begun,  and  as  these  symptoms 
first  became  stationary  and  next  rapidly  subsided  under  treat- 
ment, it  was  held  to  be  proper  that  the  injections  should  be 
credited  with  the  favorable  outcome  of  the  case. 

He  gives  it  as  his  opinion  that  the  effects  of  tetanus  serum 
on  man  and  on  the  lower  animals  do  not  vary  greatly  in  respect 
to  [the  ease  or  difficulty  in  obtaining  results.  For  example,  if 
the  serum  is  to  exert  a  curative  effect  upon  the  human  patient 
having  tetanus,  the  dose  must  be  proportioned  to  the  differ- 
ences in  weight  between  man  and  the  test  animals,  such  as  the 
mouse,  etc.  Furthermore,  it  is  evident  that  the  curative  po- 
tency of  this  serum  is  in  constant  proportion  to  its  inimunizing 
power;  that  the  serum  is  be^t  by  far  em[)loyed  for  the  latter 
object ;  that  when  it  is  used  for  curative  purposes  the  varying 
intensity  of  the  disease  must  be  taken  into  the  account;  also 
that  the  differences  growing  out  of  the  stages  of  the  disease 
make  the  determination  of  the  value  of  the  treatment  very 
difficult  at  the  outset  of  its  employment.  Roughly  estimated, 
in  regard  to  man,  if  one  part  of  the  remedy  is  efficient  for 
prophylactic  ends,  a  thousand  parts  at  least  will  be  necessary 
to  a  curative  effect,  and  if  the  disease  is  somewhat  advanced  a 
.still  higher  proportion  will  be  indicated.  The  author  hopes 
and  expects  to  soon  produce  a  serum  ^intensified  to  a  degree 
tenfold  higher  than  that  now  possessed  by  him,  and  with  this 
he  believes  that  he  will  be  enabled  to  "  reduce  the  mortality  of 
tetanus  from  eighty  or  eighty-five  per  cent,  to  five  or  ten  per 
cent."  He  emphasizes  the  point  that  this  sort  of  treatment  dif- 
fers from  others  that  have  been  propo.sed  in  the  fact  that  this 
tetanus  serum  contains  a  protective  substance  already  prepared 
for  introduction  into  the  circulation ;  and  that  when  the  pres- 
ence of  this  substance  in  the  ui-ine  of  a  subject  of  the  disease 
can  be  ascertained  it  is  to  be  regarded  as  a  favorable  sign  of  the 
curative  action  of  the  treatment. 


"TRUE  ISOPATHY." 

In  the  American  Therapist  for  February  there  is  an  inter- 
esting editorial  on  Isopathy,  in  which  the  writer  calls  attention 
to  the  fact  that  the  practice  originated  at  about  the  dawn  of 
history,  and  met  with  favor  at  the  hands  of  Nicander,  Ze- 
nocrates,  Galen,  Serapion,  Paulus  .Egiueta,  Dioscorides,  and 
Paracelsus.  It  is  stated  that  precisely  the  same  doctrine  that 
is  now  advanced  by  scientific  men  was  promulgated  just  sixty 
years  ago  by  Ilerr  Lux,  a  veterinary  surgeon  of  Leipsic,  name- 
ly:  "All  infectious  diseases  contain  in  their  infectious  matters 
the  remedies  capable  of  curing  themselves."  Briefly  stated, 
isopathy  taught  that  any  disease  would  be  cured  by  its  own 
morbid  products,  and  its  followers  adopted  the  motto  Ajjua- 
lia  wqualihus,''^  to  distinguisii  their  practice  from  honia>oi)athy 
{similia  similihus)  on  the  one  hand,  and  allopathy  (contraria 
contrariis)  on  the  other. 

Some  of  the  remedies  then  introduced  were  morbilline, 


360 


MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Jouh., 


scarlatinine,  varioline,  syphiline,  sycosine,  psorine,  anthracine, 
hydroi)hobine,  etc.,  this  crude  practice  running  in  lines  parallel 
to  that  subsequently  suggested  by  Koch,  Pasteur,  and  others, 
that  is  based  on  the  discovery  of  the  causative  agent  of  an  in- 
fectious disease  and  the  existence  of  its  ptoraainic  products. 

The  editorial  refers  to  a  recent  article  by  Dr.  William  A. 
Hammond,  published  in  this  journal,  and  states  that  the  book 
to  which  Dr.  Hammond  therein  referred  was  written  by  Sur- 
geon Herrmann  in  1848,  and  was  entitled  True  Isopathy ;  or, 
on  the  Employment  of  Organs  of  Healthy  Animals  as  Remedies 
in  Diseases  of  the  Same  Organs  in  the  Human  Subject.  For  ex- 
ample, "hepatine"  was  a  tincture  prepared  from  the  liver  of 
the  fox  or  dog,  and  employed  in  the  treatment  of  various  liver 
diseases  and  hydrophobia;  "lienine,"  a  tincture  prepared  from 
the  dog's  spleen,  was  used  in  treating  enlargement  of  the 
spleen;  " renine,"  a  tincture  prepared  from  a  healthy  kidney, 
afforded  relief  from  spasmodic  retention  of  urine;  "pulmo- 
nine"  was  used  in  treating  pneumonia  and  haemoptysis;  and 
"dentine"  was  used  in  treating  toothache. 

Whether  this  almost  forgotten  practice  will  be  rescued  from 
the  limbo  of  oblivion  and  serve  for  the  erection  of  a  permanent 
and  worthy  therapeutical  structure,  as  suggested  by  Dr.  Ham- 
mond, remains  to  be  seen.  Even  if  these  things  happen,  the 
practice  will  not  be  "true  isopathy." 


MINOR  PARAGRAPHS. 

BROMOFORM  IN  THE  TREATMENT   OF  WHOOPING-COUGH. 

In  the  February  number  of  the  Practitioner  Mr.  F.  W. 
Burton-Fanning,  of  the  Jenny  Lind  Infirmary,  Norwich,  reports 
his  experience  in  the  treatment  of  thirty  cases  of  whooping- 
cough  with  bromoform.  Except  for  one  death — that  of  an  in- 
fant whose  whooping-cough  was  complicated  with  capillary 
bronchitis,  whose  condition  was  desperate  when  the  treatment 
was  begun,  and  who  retained  only  one  dose  of  the  medicine — 
the  results  are  said  to  have  been  uniformly  gratifying.  The 
dosage  of  bromoform  recommended  is  as  follows:  For  children 
under  a  year  old,  half  a  minim,  three  times  a  day;  for  those 
from  a  year  to  three  years  old,  a  minim  ;  and  for  those  from 
three  to  six  years  old,  two  minims.  If  necessary,  these  doses 
may  safely  be  increased  gradually  until  they  are  doubled.  The 
mixture  used  by  Dr.  Burton-Fanning  consisted  of  a  minim  of 
bromoform,  half  a  drachm  of  compound  powder  of  tragacanth, 
half  a  fluidrachm  of  syrup,  and  water  enough  to  make  half  a 
fluidounce.  Bromoform,  which  should  be  colorless,  becomes 
brown  on  exposure  to  light ;  then  it  should  on  no  account  be 
used.  The  mixture  mentioned  should  be  thoroughly  shaken 
before  a  dose  is  given. 


MEASURES  FOR  CHECKING  THE  VOMITING  EXCITED  BY 
ANyESTHETICS. 

The  Union  medicale  for  February  28th  has  a  short  article  on 
this  subject,  relating  more  particularly  to  cases  in  which  chloro- 
form is  the  anaosthetic  employed.  The  first  measure  mentioned 
for  arresting  chloroform  vomiting  is  to  increase  the  ansestliesia 
to  the  point  of  abolishing  all  reflex  sensibility.  This,  the  writer 
says,  does  not  always  succeed ;  he  might  have  added  that  on 
other  grounds  it  was  not  to  be  commended.  Another  ])lan, 
.I)ropo8ed  by  Joos,  of  Winterthnr,  but  said  by  the  writer  to  have 


been  borrowed  from  Leloir,  of  Lille,  who  used  it  in  cases  of  in- 
tractable hiccough,  is  that  of  compression  of  one  or  both  of  the 
phrenic  nerves  by  means  of  the  thumb  placed  immediately 
above  the  sternal  end  of  the  clavicle.  The  compression  should 
be  kept  up  for  several  minutes  after  the  vomiting  has  ceased. 
If  it  does  not  succeed,  recourse  may  be  had  to  the  very  simple 
measure  of  applying  a  compress  wet  with  very  cold  water  to 
the  neck.  The  compress  should  be  changed  as  soon  as  it  begins 
to  get  warm.  The  writer  has  found  it  very  serviceable,  and  he 
supposes  that  it,  too,  acts  on  the  phrenic  nerves.  Tlie  area  of 
refrigeration  is  so  small  that  there  is  no  danger  of  chilling  the 
patient. 


STRONTIUM  LACTATE  IN  PUERPERAL  ECLAMPSLA. 

In  recent  French  journals  several  instances  have  been  men- 
tioned of  the  favorable  action  of  strontium  in  kidney  troubles. 
In  the  Gazette  medicale  de  Nantes  for  March  12th  Dr.  Manager 
gives  an  account  of  a  case  of  puerperal  convulsions  in  the  eighth 
month  of  gestation  in  which  the  lactate  exerted  a  very  evident 
diuretic  effect  and  may  have  affected  the  disease  favorably.  It 
was  given  in  doses  of  fifteen  grains,  in  a  cupful  of  milk,  night 
and  day,  on  account  of  pronounced  albuminuria  with  oedema. 
Abundant  diuresis  was  produced,  together  with  subsidence  of 
the  dropsy.  Nevertheless,  violent  convulsions  occurred  subse- 
quently, but  they  were  treated  with  leeches  to  the  legs  and  ene- 
mata  of  chloral,  and  tiiey  gradually  yielded.  The  use  of  stron- 
tium lactate  v\  as  then  resumed,  and  again  its  diuretic  action  was 
prompt  and  decided.  In  five  or  six  weeks  after  the  eclamptic 
attack  the  patient  was  delivered  of  a  four-pound  child,  and  at 
the  end  of  seven  weeks  more  both  mother  and  child  were  seen 
by  the  author  and  found  to  be  in  good  condition. 


A  REMARKABLE  CASE  OF  CARBOLIC- ACID  POISONING. 

In  the  Bulletins  de  la  Societe  anatomique  de  Paris,  1893, 
No.  2,  there  is  a  brief  account,  by  M.  Jayle,  of  the  case  of  a  girl, 
eleven  years  and  a  half  old,  who,  having  a  little  excoriation  of 
the  right  index  finger,  wrapped  the  finger  in  a  piece  of  cloth 
moistened  with  a  few  drops  of  a  mixture  of  nine  parts  of  car- 
bolic acid  and  one  part  of  glycerin.  On  the  following  day  the 
finger  was  of  a  grayish  hue,  and  subsequently  it  became  black, 
but  without  pain.  The  finger  was  amputated  at  the  metacarpo- 
phalangeal joint,  and  not  only  the  soft  parts,  but  also  the  pha- 
langes, were  found  to  be  black.  The  child's  general  health  was 
good  and  an  examination  of  the  urine  showed  nothing  abnormal. 
These  facts,  together  with  the  small  amount  of  the  drug  used» 
make  the  poisoning  difficult  of  explanation. 


PURULENT  OTITIS  MEDIA  CAUSED  BY  A  PINCH  OF  SNUFF. 

In  the  March  number  of  the  Annalesdes  maladies  de  Voreille, 
etc.,  there  is  an  account  condensed  from  an  article  by  Dr.  Haug, 
published  in  the  Archiv  filr  Ohrenheilkunde,  xxxii,  2,  of  the  case 
of  a  young  man  who,  although  not  in  the  habit  of  taking  snuff, 
took  a  pinch.  Being  seized  with  sneezing,  he  sought  to  over- 
come it  by  closing  his  mouth  and  lowering  his  head.  He  was 
attacked  witii  otitis  media,  from  which  he  recovered  after  para- 
centesis. In  the  purulent  discharge  the  author  found  some  lit- 
tle grains  of  tobacco  which  had  been  forced  into  the  tympanum 
and  caused  the  inflammation.  A  similar  case  is  said  to  have 
been  reported  by  Kessel. 

WELANDER'S  ABORTIVE  TREATMENT  OF  BUBO. 

In  the  Montpellier  medical,  1893,  No.  7,  Dr.  Brousse  gives 
his  experience  with  this  treatment  in  five  cases,  in  only  one  of 


April  1,  1893.] 


MINOR  PARAORArHS. 


361 


which  lie  was  successful.  In  a  summary  of  Dr.  Brousse's 
article  given  in  the  Union  medicale  for  March  4th  the  metliod 
is  described  as  having  the  prevention  of  su|)paration  for  its  ob- 
ject, and  as  consisting  in  injecting  a  cubic  centimetre  of  a  one- 
per-eent.  solution  of  benzoate  of  mercury  into  the  bubo  and 
then  employing  compression.  Welander  and  Letnik  are  cited 
as  having  succeeded  in  ninety  per  cent,  of  cases  in  which  sup- 
puration had  not  already  begun.  Dr.  Brousse  finds  that  the 
injection  always  produces  a  well-marked  local  and  especially  a 
systemic  reaction,  the  latter  characterized  by  headache,  loss  of 
appetite,  malaise,  and  rise  of  temperature.  In  some  of  his  cases 
there  was  intense  fever  lasting  two  or  three  days.  All  things 
considered,  the  treatment  seems  not  altogether  free  from 
danger. 

A  DEATH  ATTRIBUTED  TO  ETHER. 

The  recent  death  of  a  well-known  citizen  of  New  York, 
Colonel  Elliott  F.  Shepard,  with  symptoms  coming  on  suddenly 
during  the  administration  of  ether  as  an  anassthetic  and  fol- 
lowed by  the  fatal  termination  in  the  course  of  two  or  three 
hours,  has  been  made  the  occasion  of  a  good  deal  of  gossip  and 
newspaper  comment  that,  we  think,  may  be  called  unnecessarily 
if  not  unjustifiably  censorious  toward  the  physicians  connect- 
■ed  with  the  case.  It  is  to  be  feared,  too,  that  the  public  will 
become  to  a  certain  extent  and  for  some  considerable  length  of 
time  prejudiced  against  the  use  of  ether.  This,  as  well  as  the 
unfavorable  comment  to  which  we  have  alluded,  might,  it 
seems  to  us,  have  been  prevented  in  a  measure,  or  at  least  the 
means  of  combating  it  furnished,  had  the  coroner  insisted  on  a 
post-mortem  examination. 


MAMMARY  HYPERTROPHY  IN  A  BOY. 

The  Wiener  Minische  Wochenschrift  for  March  16th  con- 
tains the  report  of  a  meeting  of  the  Imperio-royal  Society  of 
Physicians  of  Vienna  at  which  Dr.  von  Eiselsberg  related  the 
case  of  a  boy,  fourteen  years  old,  in  whom  hypertro[)liy  of  the 
right  breast  had  begun  about  a  year  before.  The  progress  of 
the  overgrowth  had  been  rather  rapid  at  first,  and  the  size  of 
the  breast  had  since  remained  stationary.  A  curious  circum- 
stance was  that  the  boy's  brother,  a  few  years  older,  had  been 
affected  with  a  swelling  of  the  left  breast,  most  pronounced 
about  the  nipple,  shortly  after  the  inception  of  the  first  boy's 
hypertrophy,  but  it  had  subsided  in  the  course  of  a  few  months. 


CHLORAL  AND  CAMPHOR  IN  THE  TREATMENT  OF 
CHANCROID. 

In  the  March  number  of  the  Annates  des  maladies  den  or- 
^anes  genito-urinaires  there  is  a  summary  of  an  article  by  Dr. 
E.  Cavazzani,  published  in  the  Giornale  italiano  delle  malattie 
veneree  e  della  pelle,  on  the  treatment  of  soft  chancre  with  a 
mixture  of  five  parts  of  chloral  hydrate,  tliree  of  camphor,  and 
twenty-five  of  glycerin.  The  author  reports  twenty-six  cases 
treated  with  this  application  in  whicli  a  cure  was  attained  in 
from  two  to  eighteen  days.  It  is  said  that  the  secretion  dimin- 
ishes rapidly  and  soon  ceases  altogether,  that  the  local  inflam- 
mation subsides  notably,  that  the  epithelium  is  regenerated 
speedily,  and  that  suppurating  buboes  are  a  rarity. 


AORTITIS  AS  A  CAUSE  OF  SUDDEN  DEATH. 

In  the  Gazette  medicale  de  Paris  for  February  25th  there  is 
an  interesting  critical  review  of  the  subject  of  aortitis,  f(iunded 
largely  on  the  teachings  of  Potain  and  Ilucliard  and  especially 


on  a  recent  work  by  Bureau.  The  causes  of  aortitis  are  ob- 
scure, especially  in  chronic  cases.  The  acute  form  may  be  due 
to  infectious  diseases,  such  as  ty|>hoid  fever  and  small-pox,  or 
to  rheumatism.  Among  its  symptoms  angina  pectoris  is  the 
most  striking,  and  by  it,  by  rupture  of  tiie  aorta,  or  by  asystole 
aortitis  often  proves  the  cause  of  sudden  death. 


EXCISION  OF  THE  UMBILICUS  IN  LAPAROTOMY. 

In  the  Province  medicale  for  March  11th  Dr.  R.  Condamin 
advocates  anew  the  procedure  of  excising  the  navel  in  cases  of 
laparotomy  in  which  a  median  incision  extends  above  it.  He 
thinks  the  advantages  of  omphalectomy  are  that  it  does  away 
with  the  cutaneous  infundibulum  of  the  navel,,  always  difficult 
to  disinfect;  that  it  shortens  tiie  process  of  suturing  by  simpli- 
fying it;  and  that,  by  allowing  of  the  same  method  of  suturing 
in  the  umbilical  portion  of  the  incision  as  elsewhere,  it  provides 
an  almost  absolute  safeguard  against  subsequent  eventration. 


PUBIC  SYMPHYSEOTOMY. 

On  Friday,  March  24th,  at  midnight,  in  a  tenement  house, 
Dr.  J.  Clifton  Edgar,  of  the  Lying-in  Hospital  in  Broome  Street, 
performed  this  operation  in  the  presence  of  the  stafl'of  that  in- 
stitution. The  patient  was  a  primipara  with  a  flattened  pelvis. 
She  had  been  in  labor  for  two  days,  and  her  family  demanded 
the  sacrifice  of  the  child.  This  Dr.  Edgar  refused  to  accede  to, 
and  by  means  of  symphyseotomy  ho  was  able  to  deliver  her 
of  a  living  child.  On  the  third  day  after  the  operation  both 
mother  and  child  were  reported  to  be  doing  well. 


PRENATAL  MEASLES. 

At  a  recent  meeting  of  the  Obstetrical  Society  of  Edin- 
burgh, reported  in  the  Edinhurgh  Medical  Journal  for  March, 
a  case  was  related  as  having  occurred  in  the  practice  of  Dr.  T. 
B.  Darling,  in  which  a  woman  was  attacked  with  measles  when 
she  was  at  the  close  of  the  fifth  month  of  gestation.  When  the 
eruption  was  beginning  to  fade  she  gave  birth  to  a  foetus  on 
which  spots  of  the  eruption  were  to  be  seen,  especially  on  the 
face,  back,  and  legs. 


NEW  YORKERS  AND  CURRENT  MEDICAL  LITERATURE. 

Foe  a  number  of  years  it  has  seemed  to  us  that  the  contri- 
butions of  New  York  practitioners  to  current  medical  literature 
were  growing  more  and  more  numerous  in  proportion  to  those 
emanating  from  other  American  physicians.  A  striking  exam- 
ple is  to  be  found  in  the  April  number  oi'  the  American  Journal 
of  the  Medical  Sciences,  published  in  Philadelphia.  The  num- 
ber contains  seven  original  communications,  five  of  which  are 
by  New  York  authors. 


EPISTAXIS  BY  WAY  OF  THE  LACRYMAL  PUNCTA. 

At  a  recent  meeting  of  the  Paris  Societe  de  biologie,  report- 
ed in  the  Progres  medical  for  March  11th,  Dr.  Malbec  gave  an 
account  of  a  case  of  nasal  haemorrhage  in  which,  after  plugging 
of  the  nares,  the  flow  of  blood  continued  from  the  puncta  lacri- 
malia.  He  added  that  such  an  occurrence,  although  it  had 
rarely  been  observed,  showed  the  inetticiency  of  the  various 
valves  that  had  been  described  as  existing  in  the  lacrymal  i)as- 
sages. 

PHOTOGRAPHY  OF  THE  INTERIOR  OF  THE  BLADDER. 

At  a  recent  meeting  of  tlie  Berliner  tnediziniscke  Gesell- 
schaj't,  reported  in  the  Deutsche  Mediginal-Zeitung,  llerr  Nitze 


362 


MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Med.  Joce., 


announced  that  he  had  succeeded  in  photogiajihinj;  the  interior 
of  the  bladder  through  tlie  cystoscope.  Such  i)liotograph9 
.showing  normal  and  pathological  conditions  are  said  to  portray 
the  differences  very  strikingly. 


BETA-NAPHTHOL  AND  CAMPHOR  IN  THE  TREATMENT  OF 
gj^-..^,  TUBERCULOUS  GLANDS. 

In  the  Journal  de  luedecine  de  Bordemtx  Dr.  Courtin  has  re- 
ported good  results  in  the  treatment  of  tuberculous  lyinpli- 
adenitis  by  injections  of  a  mixture  of  one  part  each  of  beta- 
naphthol  and  camphor  and  four  i)arts  of  60°  alcohol.  The  pain 
caused  is  slight,  and  it  disap])ears  in  a  few  minutes.  There  is 
moderate  swelling  tor  two  or  three  days.  Dr.  Courtm's  article 
is  summarized  in  the  MonatslieJXe  fur  jn-aletiHche  Dcrmtitologie 
for  March  loth. 


THE  PERSIAN  DRUG  "  MARV." 

In  the  Pharmuceiitical  Journal  and  Truiisactiorus  for  March 
nth  Dr.  O.  Stapf  states  that  this  name  (written  also  merw  and 
marw)  is  perhai)s  an  Arabic  form  of  the  \iapov  of  Diofcorides, 
and  that  it  is  applied  in  the  Persian  liazaars  to  the  nutlets  of 
various  species  of  Sahia. 


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  28,  1893 : 


DISEASES. 

Weelj  ending  Mar.  SI. 

Weelj  ending  Mar.  28. 

Casas. 

Eeaths. 

Cases. 

Deaths. 

10 

5 

5 

2 

21 

8 

17 

6 

161 

12 

172 

13 

Cerebro-spinal  meningitis.  .  . 

12 

13 

9 

111 

96 

4 

97 

50 

lis 

41 

Small-pox  

ti 

0 

9 

3 

The  Medical  Association  of  Georgia  will  lujld  its  forty-fourth  an- 
nual meeting  in  Araericus,  on  April  19th,  20th,  and  21st,  under  the 
presidency  of  Dr.  A.  A.  Smith,  of  Hawkinsville.  Besides  the  presi- 
dent's annual  addiess,  the  preliminary  programme  announces  the  fol- 
lowing papers  :  Woman's  Relations  to  the  Practice  of  Medicine  (Orator's 
Address),  by  Dr.  Frank  Ridley,  of  La  Grange ;  Diffuse  Traumatic  Aneu- 
rysm of  the  Anterior  Tibial  Artery — Ligation  of  the  Femoral,  by  Dr.  F. 
R.  Calhoun,  of  Cartersville ;  Multiple  Neuritis,  "  Alcoholic,"  by  Dr. 
Mark  H.  O'Daniel,  of  Macon;  Salpingitis:  its  Pathology  and  Treat- 
ment, by  Dr.  R.  R.  Kime,  of  Atlanta ;  Puerperal  Eclampsia,  with  Sjjc- 
cial  Reference  to  its  Cause  and  Treatment,  by  Dr.  A.  C.  Davidson,  of 
Sharon ;  Asphyxia  Neophytorum,  by  Dr.  R.  J.  Nunn,  of  Savannah  ;  Stab 
of  the  Stomach — the  Organ  protruding  thi-ough  the  Abdominal  Wall — 
Laparotomy — Recoveiy,  by  Dr.  J.  W.  Griggs,  of  West  Point ;  Opera- 
tion for  Fistula 'in  Ano  by  Ligation,  by  Dr.  John  J.  Hill,  of  Washing- 
ton ;  The  Contagiousness  of  Consinnption,  by  Dr.  J.  G.  Hopkins,  of 
Thomasville ;  The  Disappointment  of  the  Menopause,  by  Dr.  J.  ( '. 
Avery,  of  Atlanta  ;  Headache  versus  Glaucoma,  l)y  Dr.  W.  T.  Bullard, 
of  Columbus;  "Shot-gun"  Prescriptions,  ))y  Dr.  C.  C.  Hart,  of  Cross 
Keys  ;  A  Review  of  Dr.  Senn's  Views  on  Elastic  ( "onstructions,  by  Dr. 
W.  H.  Elliot,  of  Savannah;  The  Practice  of  Medicine  in  Georgia,  by 
Dr.  A.  C.  Blain,  of  Macon  ;  Hernia,  by  Dr.  W.  F.  Westmoreland,  of 
Atlanta ;  Antipyretics  (translated  from  the  German  of  Cantani),  by  Dr. 
S.  B.  Poland,  of  Griswoldville ;  Science  in  Medicine  and  Surgery,  by  Dr. 
J.  McFadden  Gaston,  of  Atlanta;  Ophthalmia  of  the  New-born,  hy  Dr. 
S.  Latimer  Phillips,  of  Savannah  ;  Periproctitis  with  an  Abscess,  and 
Report  of  a  Case,  by  Dr.  M.  L.  (Jurric,  of  Mt.  Vernon ;  The  Necessity 
for  a  Medical  Exaininim:  Board  in  (icorgia,  bv  Dr.  L.  B.  (iiandv,  of 


Atlanta;  Im])ure  and  Pure  Mineral  Waters,  t)y  Dr.  T.  S.  Hoijkins,  of 
Thomasville;  State  and  Municipal  Hygiene,  by  Dr.  .1.  C.  Avery,  of  At- 
lanta; A  Rare  Case  in  01)stetric  Practice,  by  Dr.  O.  H.  Buford,  of  Car- 
tersville ;  Sterility  in  the  Male,  by  Dr.  C.  Evans  Johnson,  of  Atlanta ; 
Conditions  indicating  Abdominal  Operations,  and  Report  of  Cases,  by 
Dr.  Frank  M.  Ridley,  of  La  Grange ;  Pneumonia,  by  Dr.  O.  T.  Kenyon, 
of  Weston;  The  Function  and  Nutritive  Value  of  Foods,  by  Dr.  Louis 
H.  Jones,  of  Atlanta  ;  Stone  in  the  Bladder,  with  Report  of  Cases,  hy 
Dr.  F.  W.  McRae,  of  Atlanta ;  The  TVon-surgical  Treatment  of  Typli- 
litis,  by  Dr.  E.  H.  Richardson,  of  Atlanta;  Drainage  in  Pelvic  Surgery, 
by  Dr.  G.  H.  Noble,  of  Atlanta ;  Specialism  in  Medicine,  by  Dr.  A.  S. 
Hawes,  of  Atlanta ;  Partial  Tenotomy  a  Radical  Cure  for  Heterophoral- 
gia,  by  Dr.  C.  H.  Peete,  of  Macon  ;  The  Pathology  of  Gynecic  Neuroses, 
by  Dr.  Ross  P.  Cox,  of  Rome ;  Persistent  Remittent  or  So-called  Typho- 
malarial  Fever,  with  Report  of  Cases,  by  Dr.  W.  P.  Williams,  of  Black- 
shear;  Some  Remarks  on  Aseptic  Surgery,  with  Exhibition  of  Steriliz- 
ing Methods,  by  Dr.  T.  M.  Mcintosh,  of  Thomasville ;  The  Mechanical 
Treatment  of  Some  Skin  Anomalies,  by  Dr.  M.  B.  Hutchins,  of  Atlanta; 
and  Three  Women  who  refused  Laparotomy,  by  Dr.  H.  McIIatton,  of 
Macon. 

The  Abuse  of  Tobacco. — The  Deutxehe  Medizinal-Zdtvng  states  that 
the  Soiiete  centre  Vahns  du  (abac  has  established  two  prizes:  1.  One  of 
200  francs  and  a  medal  for  an  essay  comprising  at  least  four  unpub- 
Ushed  accounts  of  cases  of  disease  due  exclusively  to  the  al)use  of 
tobacco.  2.  One  of  100  francs  for  an  effective  and  practicable  means  of 
preventing  the  ill  effects  of  tobacco  in  persons  who  can  not  renounce 
the  habit  of  immoderate  smoking.  Fmther  information  may  be  had 
from  the  president  of  the  society,  2U3,  rue  Saint-Beuvet,  Paris. 

The  Arizona  Medical  Association. — At  the  annual  meeting,  held 
on  Feliruary  27th  and  2Sth  and  JIarch  1st,  we  leain  from  the  Journal 
of  the  American  Medical  Association ^  officers  for  the  ensuing  year  were 
elected  as  follows :  President,  Dr.  H.  A.  Hughes ;  vice-presidents,  Dr. 
R.  C.  Dryden,  Dr.  C.  H.  Jones,  and  Dr.  A.  H.  Hoeffer ;  secretary. 
Dr.  L.  D.  Dameron ;  treasurer.  Dr.  W.  T.  Barry. 

The  French  Society  of  Otology  and  Laryngology,  it  is  announced  m 
the  Arc/lives  genernles  de  medccine,  will  hold  its  annual  meeting  on  the 
12th  of  May.  The  subjects  of  discussion  are  :  The  Treatment  of  Otor- 
rhoea,  The  Treatment  of  Laryngeal  Tuberculosis,  and  Affections  of  the 
Cavities  Accessory  to  the  Nose. 

The  Buffalo  Academy  of  Medicine. — At  the  next  meeting  of  the 
Surgical  Section,  on  Tuesday,  the  4th  inst..  Dr.  Herman  Mynter  is  to 
read  a  paper  on  Fractures  and  Competent  Surgical  Treatment,  and  Dr. 
William  L.  Marcy  one  on  The  Legal  Aspects  and  Responsil)ilities  [of 
Fractures 

The  University  of  Dorpat. — We  learn  by  the  Wiener  kliniuhe 
Wochcnschrift  that  the  Russification  of  the  name  of  the  town  to  Jurjew 
involves  tlie  withdrawal  of  the  German  profes.sors.  The  director  of  the 
pathological  institute,  Professor  Thoma,  offered  his  resignation  a  short 
time  since. 

The  American  Climatological  Association  will  liold  its  tenth  annual 
meeting  in  Pliiludeli)hia  on  Tliursday,  Friday,  and  Saturday,  May  25th, 
2(3th,  and  27th,  under  the  presidency  of  Di'.  R.  G.  Curtin,  of  Philadel- 
phia. 

The  College  of  Physicians  of  Philadelphia. — The  Deutsche  Medizinal- 
Zeitung  announces  that  Dr.  v(m  Jaksch,  of  Prague,  has  been  made  an 
as.sociate  fellow. 

The  State  Lunatic  Hospital  at  Poughkeepsie. — It  is  announced  that 
Dr.  Cleaveland  has  resigned  the  office  of  superintendent  and  that  Dr. 
Charles  W.  Pilgrim  has  been  appointed  to  succeed  him. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army,  from  March  12  to  March  18,  1893  : 

Happersett,  John  C.  (i..  Major  and  Surgeon.  The  extension  of  leave 
of  absence  granted  on  surgeon's  certificate  of  disability  is  further 
extended  three  months  on  account  of  sickness. 


April  1,  1893.] 


ITEMS.— LETTERS  TO  THE  EDITOR. 


363 


Wii.LCox,  OiiAiu.KS,  First  Lieutenant  and  Assistant  Surgeon.    The  leave 

of  absence  granted  is  extendeii  one  montli. 
Taylor,  Blair  D.,  Captain  and  Assistant  Surgeon,  is  granted  Jleave  of 

absence  for  one  luontli,  to  take  effect  wlien  his  services  can  l)e 

spared  by  the  post  commander. 
Jarvis,  N.  S.,  Captain  and  Assistant  Surgeon,  Fort  Apache,  Arizona,  is 

granted  leave  of  absence  for  one  montli. 

Naval  Intelligence. — Official  List  of  Changes  in  the  Mcdiral  Corps 
of  the  United  States  Navij  for  the  week  ending  March  25,  1893 : 
Flint,  J.  M.,  Surgeon.    Detached  from  the  U.  S.  Steamer  Miantononioh 

and  granted  one  month's  leave  of  absence. 
Dickinson,  Dwiuiit,  Surgeon.    Ordered  to  the  U.  S.  Steamer  Mianto- 
nonioh. 

Waggener,  J.  R.,  Surgeon.    Ordered  to  the  Norfolk  Navy  Yard. 

Drennan,  M.  C,  Surgeon.  Detached  from  the  Navy  Yard,  Norfolk,  and 
ordered  to  the  U.  S.  Receiving-ship  Vermont. 

Babin,  H.  J.,  Surgeon.  Detached  from  the  U.  S.  Receiving-ship  Ver- 
mont and  to  wait  orders. 

Rush,  C.  W.,  Passed  Assistant  Surgeon.  Sick  leave  of  absence  ex- 
tended three  months. 

Society  Meetings  for  the  Coming  Week : 

Monday,  ^-I/;/77  New  York  xVcadeiuy  of  Sciences  (Section  in  Bi- 
ology) ;  German  Medical  Society  of  the  City  of  New  York  ;  Mor- 
risania  Medical  Society  (private) ;  Brooklyn  Anatomical  and  Surgical 
Society  (private) ;  Utica  Medical  Library  Association ;  Corning- 
N.  Y.,  Academy  of  Medicine ;  Boston  Society  for  Medical  Observa- 
tion ;  St.  Albans,  Vt.,  Medical  Association  (annual) ;  Providence,  R. 
L,  Medical  Association ;  Hartford,  Conn.,  Medical  Society ;  South 
Pittsburgh,  Pa.,  Medical  Society ;  Chicago  Medical  Society  (annual). 

Tuesday,  April  J^th :  New  York  Obstetrical  Society  (private);  New 
York  Neurological  Society  ;  Elmira  Academy  of  Medicine ;  Buffalo 
Academy  of  Medicine  (Surgical  Section) ;  Buffalo  Medical  and  Sur- 
gical Association  (annual) ;  Ogdensburgh  Medical  Association  ;  Medi- 
cal Societies  of  the  Counties  of  Broome  (quarterly)  and  Niagara 
(quarterly — Lockport),  N.  Y. ;  Essex  (annual — Newark),  Hudson 
(Jersey  City),  and  Union  (annual — Elizabeth),  N.  J.,  County  Medical 
Societies ;  Androscoggin,  Me.,  County  Medical  Association  (Lewis- 
ton) ;  Chittenden,  Vt.,  County  Medical  Society;  Baltimore  Academy 
of  Medicine. 

Wednesday,  April  5th:  Society  of  the  Alumni  of  Bellevue  Hospital; 
Society  of  the  Alumni  of  Charity  Hospital ;  Harlem  Medical  Asso- 
ciation of  the  City  of  New  York ;  Medical  Microscopical  Society  of 
Brooklyn  ;  Medical  Society  of  the  County  of  Richmond  (Stapleton), 
N.  Y. ;  Penobscot,  Me.,  County  Medical  Society  (Bangor);  Bridge- 
port, Conn.,  Medical  Association ;  Philadelphia  County  Medical 
Society. 

Thursday,  April  Gth :  New  York  Academy  of  Medicine;  Brooklyn 
Surgical  Society  ;  Society  of  Physicians  of  the  Village  of  Canan- 
daigua ;  Boston  Medico-psychological  Association ;  Obstetrical 
Society  of  Philadel[)hia ;  United  States  Naval  Medical  Society 
(Washington);  Washington,  Vt.,  County  Medical  Society. 

Friday,  April  7th :  Practitioners'  Society  of  New  York  (private) ;  Balti- 
more Clinical  Society. 

Saturday,  April  8th  :  Obstetrical  Society  of  Boston  (private). 


fetters  to  tijc  €bitor. 


MAGGOTS  IN  THE  NOSE. 

Galveston,  Texas,  Murrh  18,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal  : 

Sir:  The  article  of  Major  James  P.  Kimball,  entitled  Mag- 
gots in  the  Nose  successfully  treated  by  Injections  of  Chloro- 


form, published  in  the  Journal  of  March  11th,  was  particularly 
interesting  to  me  from  the  fact  tliat  I  have  had  some  experience 
in  the  observation  and  treatment  of  tliis  comparatively  rare 
disease. 

During  a  practice  of  eight  years  in  the  town  of  San  Buena- 
ventura, State  of  Coahuila,  Mexico,  I  had  op[)ortunity  of  ob- 
serving four  well  marked  cases  of  maggots  in  the  nose,  precisely 
of  the  same  nature  as  that  of  the  one  so  excellently  described 
by  Dr.  Kimball.  Three  of  my  cases  occurred  in  women  aged 
eighteen,  twenty-two,  and  forty-one  years,  respectively,  and 
the  fourth  in  a  young  man  twenty-three  years  old. 

The  symptoms  manifested  in  such  cases  were  those  of  a 
slight  rise  of  the  bodily  temperature,  ])ain  in  the  forehead  and 
in  the  orbital  region,  at  first,  followed,  in  the  course  of  from 
tweuty-four  to  forty-eight  hours,  by  the  bloody-serous  dis- 
charge from  the  nostrils,  accompanied  with  "  pain  at  the  root 
of  the  nose  and  over  the  frontal  region."  An  internal  exami- 
nation of  the  nose  made  the  diagnosis  an  easy  one. 

I  tried  all  the  remedies  mentioned  by  Kimball,  with  the  ex- 
ception of  chloroform,  and  the  only  one  that  gave  satisfactory 
results  was  calomel.  All  my  four  patients  recovered  promptly 
and  without  exhibiting  any  untoward  after-effects.  The  calo- 
mel was  employed  solely  by  insufflations. 

Tlie  maggots,  though  not  killed  afiparently  by  this  remedy, 
were  certainly  dazed,  as  it  were,  by  the  drug,  and  were  all  ex- 
pelled in  less  than  twenty-four  hours  from  the  beginning  of  the 
treatment.  In  one  of  the  cases — that  of  the  elderly  lady— I 
counted  three  hundred  and  eighty-eight  maggots!  The  drug 
was  insufflated  in  all  instances  three  or  four  times  a  day  ad  libi- 
tum. 

From  the  careful  report  of  Dr.  Kimball  I  am  inclined  to  be- 
lieve in  the  efflcacy  of  chloroform  administered  in  the  manner 
described  by  him  and  suggested  by  other  authorities;  but  I  am 
also  convinced  by  personal  experience  that  calomel  is  likewise 
an  excellent  remedy  in  the  disease  under  consideration,  not  in- 
ferior to  the  anaesthetic,  and  possessing,  besides,  the  advantages 
of  being  cheap,  non-poisonous,  and  easily  applied  as  described. 

Another  point.  I  can  not  agree  with  Kimball  that  the  "fly 
deposits  its  larvae  only  on  the  unsound  mucous  membrane."  Of 
my  three  patients,  for  instance,  only  one  (the  elderly  lady)  had 
been  a  jirevious  sufferer  from  nasal  catarrh  of  several  years' 
standing.  The  three  others  had  been  absolutely  free  from  any 
local  or  constitutional  taint  so  far  as  a  critical  examination 
could  reveal. 

The  beneficial  influence  of  calomel  in  this  disorder  can  not 
be  doubted.  I  may  add  that  this  seems  to  be  the  experience 
of  other  practitioners  residing  in  other  parts  of  the  State  men- 
tioned. 

I  may  also  state  that  the  chronic  case  referred  to  was  ap- 
parently much  relieved  of  the  old  affection  after  the  calomel 
treatment ;  but  I  can  not  positively  affirm  that  this  drug  exer- 
cised in  this  instance  the  good  effects  noticed  in  the  catarrhal 
disease.  David  Cerna,  M.D.,  Ph.D. 

March  15,  1893. 
To  the  Editor  of  the  New  Yorh  Medical  Journal: 

Sir:  In  connection  with  the  paper  in  your  issue  of  March 
11th  on  the  treatment  of  maggots  in  the  nose,  I  beg  to  say  that 
in  such  cases  the  administration  by  the  mouth  of  sulphate  of 
quinine  in  five-grain  doses  every  second  hour  until  perhaps 
thirty  grains  shall  have  been  taken  was  a  routine  treatment 
with  me  during  a  tour  of  service  in  Texas  had  some  years  ago. 
Notes  of  my  cases  were  not  taken,  but  the  good  results  from 
(piinino  seemed  to  bo  not  accidental  in  the  expulsion  of  the 
larvae.  U.  S.  A. 


364 


LETTERS  TO  THE  EDITOR.— BOOK  NOTICES. 


[N.  Y.  Mkd.  Jodh., 


NITROGLYCERIN. 

Skankateles,  N.  Y.,  March  27,  1893. 
To  the  Editor  of  the  New  York  Medical  Jovrnal  : 

Sir:  In  your  editorial  on  Nitroglycerin  in  the  last  issue  of 
the  Journal  you  state  that  "two  minims  and  a  half  of  the  one- 
per-cent.  solution  given  to  a  lady  for  neuralgia  have  been 
known  to  produce  faintness,  pallor,  stertorous  breathing,  and 
unconsciousness  for  a  few  minutes."  I  produced  syncope  with 
lividity  and  stertorous  breathing  in  a  young  woman  to  whom  I 
gave  a  one  one-liundredth-grain  tablet  for  brachial  neuralgia. 
The  tablet  was  placed  upon  the  tongue,  and  the  syncope  oc- 
curred almost  before  the  tablet  was  dissolved.  The  neuralgia 
was  cured.  You  state  also  that  "  Hale,  in  his  text-book  on 
therapeutics,  says  that  no  more  than  a  fiftieth  of  a  grain  should 
ever  be  used,  but  those  who  habitually  employ  the  drug  find 
that  such  a  dose  is  rarely  sufficient  to  produce  its  effects." 

I  "  habitually  employ  "  the  drug  for  neuralgia,  as  a  diuretic, 
in  asthma,  in  emphysema,  and  in  other  affections.  During  the 
past  year  I  have  used  it  veri/  frequently,  yet  scarcely  find  it  pos- 
sible to  give  as  much  as  one  one-hundredth  of  a  grain  without 
producing  its  physiological  effect;  generally,  in  fact,  I  find  it 
necessary  to  stop  short  of  that  dose. 

I  use  tablet  triturates,  dissolving  them  on  the  tongue,  and 
giving  one  four-hundredtli  of  a  grain  doses  at  intervals  of  five 
minutes  until  I  find  the  amount  necessary  to  produce  the 
physiological  effect.  Two  of  the  worst  cases  of  neuralgia  I 
have  met  with  (one  supra-orbital,  the  other  intercostal)  I  cured 
within  fifteen  minutes  with  a  single  hundredth- of-a-grain  tabletl 
used  in  this  way — i.  e.,  in  divided  doses.  Marked  physiologica 
effect  was  produced  in  both  cases.  I  can  recall  only  two  pa- 
tients who  seemed  tolerant  of  larger  doses.  The  one  could  take 
one  fiftieth  of  a  grain ;  the  other,  contrary  to  my  orders,  took 
at  one  dose  five  one-hundredth-of-a-grain  tablets  without  any 
perceptible  physiological  effects.  It  has  occurred  to  me  that 
the  use  of  divided  doses  and  the  administration  on  the  tongue 
may  account  for  the  difference  between  my  results  and  those 
quoted  in  your  editorial.  I  should  be  glad  if  others  would  pub- 
lish their  results  in  your  columns,  because  I  am  sure  the  average 
patient  I  meet  with  can  not  stand  nearly  the  doses  your  article 
recommends.  Is  it  possible  that  the  smaller  dose  can  be  more 
effective  than  the  larger?        George  Edward  Clark,  M.  D. 

NEWSPAPER  MEDICINE. 

New  York,  March  26,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  It  i.s  gratifying  to  find  the  growing  interest  shown  by 
the  daily  press  in  questions  of  scientific  moment,  especially  when 
medicine  is  the  theme.  I  therefore  read  with  some  care  the  ac- 
counts of  the  illness  of  little  Miss  Marthena  Harrison,  thedaugh 
ter  of  Mr.  Russell  Harrison,  which  appeared  in  the  JSew  York 
Times  of  to-day.  After  describing  the  child's  illness,  which  was 
scarlet  fever,  and  referring  to  the  nervous  prostration,  "  which 
in  one  so  young  is  a  dangerous  thing,"  it  says : 

"  Dr.  William  J.  Morton,  of  this  city,  a  specialist  of  note,  was 
communicated  with.  He  suggested  electricity  as  the  most  feasi- 
ble and  enei'getic  means  of  effecting  a  cure,  and  young  Miss  Har- 
rison was  accordingly  brought  here.  The  treatment  consists  of 
subjecting  the  patient  to  what  is  known  as  the  static  bath.  The 
static  current  is  a  form  of  electricity  not  in  very  general  use. 
Only  specialists  use  it,  for  it  possesses  a  power  very  great  in  pro- 
portion to  that  developed  in  the  ordinary  way.  The  little  girl 
is  satisfactorily  recovering  her  nervous  equilibrium,  and  as  soon 
as  she  is  entirely  well  will  be  taken  to  her  Western  home." 

Comment  seems  unnecessary.  San  Gkado. 


TUBERCULOUS  HONE  DI.SEASE. 

43  Mortimer  Street,  Rochester,  N.  Y.,  March  20,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  In  your  report  of  the  proceedings  of  the  Medical  So- 
ciety of  the  State  of  New  York,  published  in  the  issue  of 
March  11th,  the  remarks  I  made  are  so  distorted  that  I  must 
request  a  correction. 

Expectant  treatment  in  tuberculous  jbone  disease  was  not 
advocated.  1  distinctly  stated  that  pnre  expectancy  was  never 
justifiable;  conservatism,  however,  was  advisable  in  many 
cases. 

At  the  close  of  my  remarks  I  presented  tJiree  questions  for 
di.scussion.  According  to  the  official  stenographer's  notes,  of 
which  I  have  a  transcript,  they  were  substantially  as  follows: 
Does  operative  interference  destroy  the  centers  of  ossification 
and  produce  or  increase  shortening  in  certain  cases?  Is  short- 
ening a  more  serious  matter  than  the  risk  of  destiuctiou  of  the 
joint?  AVhat  is  the  probability  of  joint  infection  without 
operation,  and  does  operative  interference  prevent  general  in- 
fection ? 

By  comparing  these  questions  with  the  ones  quoted  in  your 
report,  you  will  observe  that  they  differ  very  materially  in  sub- 
stance and  form.  Louis  A.  Weigel,  M.  D. 

In  so  far  as  the  allusion  to  expectant  treatment  is  con- 
cerned, our  corres[)ondent  has  misinterpreted  the  report  we 
published  of  his  remarks. 


13ook  ^oticts. 


Lehriueh  der  Hehammenkunst.  Von  Dr.  Bernhaed  Sigmtjnd 
ScHULTZE,  Geheimhofrath  off.  orb.  Professor  der  Geburts- 
hiilfe,  etc.  Zehente  Auflage.  Mit  98  Holzschnitten.  Leip- 
sic  :  Wilhelm  Engelmann,  1891.  Pp.  xxiii  to  380. 
The  tenth  edition  of  this  work  seems  not  only  to  have  ex- 
hausted the  author's  capacity  for  writing  prefaces  to  it,  but  also 
the  critical  faculty  on  the  part  of  its  readers.  The  material 
contained  in  it  is  much  more  extensive  than  is  usual  in  such 
works,  as  is  also  the  author's  belief  in  the  midwife's  under- 
standing. To  a  man  living  in  a  country  where  education  is 
general  and  the  brain  cultivated,  Schultze's  paternal  manner  of 
addressing  his  midwives  as  if  the  faint  glimmerings  of  their  in- 
telligence might  be  extinguished  if  too  much  light  were  thrown 
>uddenly  upon  it,  seems  somewhat  droll  and  decidedly  out  of 
place.  A  visit  to  the  German  hospitahs,  however,  would  soon 
convert  one  from  this  New-World  belief  and  incline  one  to  won- 
der at  Schultze's  faith  in  the  midwife's  capacity  and  to  under- 
stand the  necessity  of  the  minuteness  of  his  instructions  to  her. 
As  a  rule,  the  midwives  are  countrywomen  totally  untrained, 
and  for  all  acquired  knowledge  they  possess  a  bundle  of  tradi- 
tional lore  and  curious  prejudice.  Inasmuch  as  the  instruction 
they  receive  at  the  hospital  is  their  all  and  is  without  a  founda, 
tion  of  general  knowledge,  there  is  danger  of  their  enhancing  its 
relative  value  to  the  detriment  of  their  patients.  Schultze, 
therefore,  to  guard  against  a  possible  ditficulty  of  this  nature, 
cautions  them  at  every  turn  as  to  the  limits  of  their  capacity,  of 
their  requirements,  and  of  their  responsibility,  imposing  upon 
them  couftantly  the  necessity  of  calling  in  the  accoucheur  in  all 
cases  beyond  their  ascertained  skill.  That  they  may  properly 
learn  to  judge  of  the  importance  of  what  they  have  before  them, 
numerous  diagrams  of  normal  and  pathological  conditions  are 


April  1,  1893.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


365 


placed  attlieirdis[)osaland  the  process  of  childbirth  is  illustrated 
at  all  its  periods. 

The  various  mananivres  devolving  upon  midwives  are  clearly 
described,  so  that  the  didactic  instruction  given  them,  combined 
with  their  practical  hospital  training,  enables  them  to  master 
any  of  the  ordinary  possibilities. 


JU{)orls  on  i\t  jProgress  al  UleiJinnc. 

OPHTHALMOLOGY. 

Bt  CHARLES  STEDMAN  BULL,  M.  D. 
{Concluded  from  page  313.) 

Glaucoma  after  Discission  of  Secondary  Cataract,  and 
its  Successful  Treatment  by  Iridectomy.— Knapp  (Arch,  of 
Ophthiil.,  xsi,  '2)  reports  ten  ca>es  of  this  unnsual  complication. 
He  considers  them  as  exam]iles  of  experimental  glaucoma  in 
aphakial  eyes.  Some  of  the  cases  had  mm-inflamniatory  poste- 
rior synechire  where  the  capsule  had  been  opened.  There  was 
no  incarceration  of  iris  in  the  cornea!  section.  Thinking  that 
his  method  of  operating  in  opening  the  capsule  may  have  fa- 
vored the  outbreak  of  glaucoma,  he  has  returned  to  the  T- 
shaped  opening  of  the  capsule.  Some  of  tliese  cases  of  trau- 
matic glaucoma  may  recover  without  operation,  but  an  iridec- 
tomy always  cures  them.  In  all  the  cases  normal  vitreous, 
which  partially  or  totally  filled  the  anterior  chamber,  flowed 
out.  All  the  cases  bore  the  same  stamp — pain,  swelling  of  lids 
and  conjunctiva,  dullness  of  cornea,  bulging  of  the  periphery 
of  the  iris,  increase  of  tension,  impairment  of  sight,  and  gen- 
eral systemic  disturbance. 

Optic-nerve  Atrophy  in  a  Child  following  a  Fall  on 
the  Head,  with  Severe  Cerebral  Symptoms.— Kohn  {Arch. 

of  Ophthal..,  xxi,  3)  reports  the  case  of  a  child  who  had  fallen 
over  the  balustrade,  a  height  of  five  stejis  from  the  floor,  and 
had  struck  the  carpeted  floor  on  the  lett  side  of  his  head, 
in  the  parieto-temporal  region.  Kohn  saw  him  the  same  day, 
and  found  his  pulse  and  respiration  normal,  pupils  equally  di- 
lated, and  irides  irresponsive — almost  complete  coma.  There 
was  little  or  no  reflex  action  in  the  extremities.  Diagnosis 
made  of  htemorrhage  into  the  brain  from  a  fracture  of  the  inner 
table  of  the  skull  on  the  right  side  by  contre-coup.  Calomel 
and  jalap  were  administered  in  large  doses,  and  the  next  morn- 
ing, after  thorough  purging,  consciousness  returned,  the  boy 
answered  questions,  and  rapidly  recovered.  After  a  few  days 
it  was  found  on  examination  that  he  was  blind  in  the  left  eye. 
The  ophthalmoscopic  examination  was  negative.  There  was 
a  depressed  fracture  of  the  skull  at  the  junction  of  the  left  ex- 
ternal angular  process  of  the  frontal  hone  with  the  frontal  pro- 
cess of  the  malar  bone.  This  depressed  fracture  must  have  re- 
sulted in  a  haemorrhage  on  the  anterior  surface  of  the  frontal 
lobe,  becMuse  the  coma  came  on  slowly.  The  crusliing  in  of 
the  skull  at  this  point  must  have  produced  such  a  narrowing  of 
the  optic  foramen  that  the  nerve  was  completely  compressed  or 
cut  through.  The  hsemorrhage  could  not  have  been  extensive 
because  the  recovery  without  permanent  paralysis  was  too 
rapid.  One  year  later  there  was  marked  atrophy  of  the  optic 
nerve. 

On  Synergetic  Ocular  Movements.— O.  Bull  {Arch,  of  Oph- 
thal., xxi,  3)  thinks  thiit  to  doubt  the  existence  of  cortical  cen- 
ters for  the  movements  of  the  eyes  would  necessarily  lead  one  to 
doubt  the  whole  doctrine  of  cortical  localization.  The  doctrine 
of  cortical  centers  for  volitional  movements  of  the  eyes  is  just 
as  certainly  founded  on  i)hysiological,  pathologico  anatomical. 


and  clinical  observations  as  those  for  any  other  volitional  move- 
ments. The  situation  of  the  centers  for  the  volitional  eye 
movements  is  most  probably  at  the  base  of  the  first  and  second 
frontal  gyri.  It  is  probable  that  all  the  centers  for  each  eye 
lie  on  the  opposite  side  of  the  hrain.  This  does  not,  however^ 
involve  the  independent  action  on  each  side.  The  predominant 
influence  of  the  visual  impressions  is  to  counteract  unsymmet- 
rical  movements  as  being  repugnant  to  binocular  vision.  From 
the  mode  of  the  movements  it  must  be  inferred  that  impulses 
are  not  forwarded  to  each  muscle  separately,  but  to  sets  of 
muscles  acting  synergetically.  Both  experiments  and  clinical 
facts  argue  in  favor  of  the  theory  that  both  cortical  centers  for 
the  muscles  acting  synergetically,  and  the  fibers  leading  the 
synergetic  impulses,  are  in  close  local  relationship.  Mott  and 
Schaefer  have  produced  conjugated  deviations  up  and  down,  as 
well  as  ad<luclion  and  abduction,  by  irritating  at  the  same  time 
corresponding  places  of  the  cortex.  They  have  found  in  the 
motor  region  three  zones:  1.  The  uppermost,  governing  the 
movements  downward.  2.  An  intermediate  zone  for  movements 
to  the  opposite  side.  3.  A  lower  zone  for  the  movements  up- 
ward and  to  the  opposite  side. 

In  the  congenital  and  acquired  cases  of  palsy  of  the  differ- 
ent muscles  we  have  a  chain  of  symptoms  which  can  be  ex- 
plained only  by  assuming  an  aff'ection  of  central  paths  through 
which  the  impulses  are  led  to  sets  of  muscles  acting  synergetic- 
ally. In  congenital  cases  we  might  assume  a  nuclear  lesion. 
The  defect  in  the  nuclei  being  intercalary  ganglia,  must,  how- 
ever, be  explained  as  secondary,  depending  on  a  defect  of  the 
cerebral  centers.  In  acquired  cases  a  nuclear  aff'ection  may  be 
excluded,  as  it  would  be  very  improbable  to  suppose  that  ex- 
actly the  corresponding  points  of  the  nuclei  on  both  sides  could 
be  affected  and  the  rest  remain  sound.  The  petiology  of  these 
palsies  can  only  be  explained  by  supposing  that  the  centers  for 
the  muscles  acting  synergetically  and  the  fibers  from  the  center 
lie  in  a  close  local  relation.  We  must  infer  that  impulses  to 
synergetic  movements  are  transmitted  through  separate  fibers 
within  the  cerebrum,  both  from  the  character  of  the  physiological 
movements  and  from  the  above-described  palsies  caused  by 
affections  beyond  the  nuclei.  We  must  also  conclude  that  the 
fibers  through  which  impulses  to  movements  are  conducted  are 
almost  wholly  developed  at  the  time  of  birth,  from  the  fact  that 
children  but  a  few  days  old  move  their  eyes  symmetrically. 

The  Pathology  of  Circumbulbar  Dermoid  Cysts.— Mit- 

valsky  {Arch,  of  Ophth..^  xxi,  3)  considers  that  the  physiological 
structure  of  dermoid  cysts  varies  within  wide  limits.  In  all 
the  varieties  the  wall  is  composed  of  a  connective-tissue  coriutn 
and  an  overlying  layer  of  epidermis,  the  variation  consisting 
in  the  presence  or  absence  of  papillte,  muscle,  and  the  various 
annexa  of  the  skin.  The  variety  showing  hairs  and  glands  is 
the  most  common.  In  most  cysts  the  epidermis  resembles  that 
of  the  external  skin,  though  there  may  he  only  a  single  layer. 
The  corium  also  presents  variations,  the  papillae  being  rare  and 
often  being  entirely  absent.  The  nearer  the  cyst  is  to  foetal 
life,  the  smaller  it  is,  and  the  more  regular  its  structure  and  the 
distribution  of  the  annexa.  The  first  enlargement  of  the  cyst 
occurs  with  the  distention  of  its  lumen  by  the  secretion  from 
the  sebaceous  and  sweat  glands.  The  distention  of  the  cyst 
wall  may  be  uniform  and  the  annexa  distributed  regularly  over 
all  ])ortions  of  the  cyst  wall,  or  some  parts  of  the  wall  regain 
their  original  structure.  As  regards  the  contents  of  the  cysts, 
there  are  no  dermoid  cysts  without  atheromatous  material  and 
epithelium.  Dermoid  cysts  are  congenital;  atheroma  is  ac- 
quired and  occurs  mostly  in  adult  life.  The  former  begins  with 
the  dipping  in  and  cutting  oft'  of  a  portion  of  the  epithelium  in 
the  embryo.  The  atheroma  arises  from  the  plugging  and  dis- 
tention of  a  hair  follicle  or  sebaceous  gland.    Clinically,  the 


366 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Joue., 


dermoid  cysts  are  covered  with  a  movable  skin  aud  lie  close  to 
the  bone.  An  atheroma  is  a  retention  tumor  of  the  annexa  of 
the  skin,  and  as  such  moves  witli  the  skin.  The  cysts  with  oily 
contents  are  transparent ;  the  atlieroniata  are  always  opaque.  In 
anatomical  structure  the  dermoid  cysts  resemble  tlie  skin  in 
every  particular,  while  the  atheromata  show  a  very  simple 
structure,  consisting  of  a  thm  connective-tissue  layer  lined  witli 
layers  of  flattened  epithelial  cells.  The  contents  of  the  athe- 
romata consist  for  the  most  part  of  concentrically  arranged 
layers  of  horny  epithelial  cells,  mixed  with  fatty  material  from 
the  sebaceous  glands. 

Sympathetic  Ophthalmia.— Randolph  {Arch,  of  Ophth., 
xxi,  3)  reports  the  case  of  a  farmer,  aged  forty-one,  whose 
right  eye  was  injured  by  a  ))iece  of  steel  tiying  from  a  pick 
on  June  1,  1891.  lie  was  seen  on  the  fifth  day  after  the 
accident,  at  which  time  vision  was  reduced  to  perception  of 
light,  and  the  eye  was  excessively  sensitive.  He  left  the  hos- 
pital on  the  tliird  day  and  went  home,  but  sufi'ered  greatly 
all  the  time,  and  six  weeks  later  the  other  eye  began  to  show 
signs  of  sympatliy  and  vision  fell  ra[>idly.  He  was  treated  at 
his  home  by  blisters  and  cold  applications,  and  the  sight  im- 
proved. He  came  again  to  the  hospital  on  August  13,  1892. 
The  injured  eye  was  entirely  blind,  the  sclera  injected,  the 
pupil  occluded  and  secluded,  and  the  sensitiveness  very  marked. 
The  other  eye  had  vision  of  jYtt  showed  evidences  of 
old  iritis,  with  posterior  synechiie  and  spots  of  exudation  on 
the  anterior  cnpsiile  of  the  lens.  The  fundus  could  scarcely 
be  distinguished.  The  injured  eye  was  enucleated,  and  after 
sterilizing  with  a  hot  knife  a  point  at  the  sclero-corneal  junc- 
tion not  far  from  the  wound,  the  anterior  chamber  was  opened 
with  a  lance-knife,  which  had  been  sterilized  by  passing 
it  through  an  alcohol  tiame.  The  knife  was  then  withdrawn 
and  a  platinum-wire  loop  was  introduced  and  stirred  round  in 
the  anterior  and  posterior  chambers  of  the  eye,  and  smear  cul- 
tures on  agar  were  made,  as  well  as  three  Esmarch  tubes. 
These  tubes  were  subjected  to  the  proper  temperature  in  an 
oven  for  ten  days,  but  no  growth  api)eared.  A  small  opening 
was  then  made  in  the  anterior  chamber  of  a  rabbit  with  steril- 
ized instruments.  An  iris  forceps  was  introduced  into  the  an- 
terior chamber  of  the  enucleated  eye  and  a  regular  iridectomy 
was  performed.  The  piece  of  iris  thus  removed  was  forced 
into  the  anterior  chamber  of  the  rabbit's  eye  and  moved  about 
several  times  in  the  chamber  and  then  partly  drawn  out  and 
left.  In  one  week's  time  the  rabbit's  eye  showed  no  evidence 
of  disease,  except  a  slight  prolapse  of  the  iris  at  tliis  point.  Tlie 
cornea  remained  clear  throughout,  and  tlie  prolapsed  iris  was 
simply  the  result  of  manipulation. 

Changes  in  the  Ophthalmoscopic  Appearances  of  the 
Ciliary  Region  in  Constitutional  Diseases  and  in  Myopia  — 
Galezowski  {Ann.  cVoc,  September,  ]892j  draws  the  following 
conclusions  from  his  observations:  1.  Lesions  of  the  ciliary  re- 
gion or  circle  are  intimately  connected  with  certain  constitutional 
diseases,  such  as  syphilis,  tuberculosis,  and  gout.  2.  In  chorioi- 
ditis accompanied  by  floating  opacities  in  the  vitreous  humor, 
the  presence  of  atrophic  patches  is  a  positive  indication  of  the 
syphilitic  nature  of  the  lesion.  8.  If  the  region  of  the  ora 
serrata  be  examined  by  the  aid  of  a  lens-prism,  constructed  of 
several  layers  of  Hint  and  crown  glass,  lesions  may  be  discovered 
which  hitherto  have  entirely  escaped  observation. 

Two  Cases  of  Death  following  Enucleation  in  Chronic 
Panophthalmitis. —  Kalt(/1///*.  (roc,  Seiitcnihcr,  1882)  reports 
two  cases.  In  the  first  case  the  chill  of  inenmgitis  a[)peared 
twenty-four  hours  after  the  removal  of  the  eye,  and  in  four  days 
the  patient  was  dead.  In  the  second  case  the  meningitis  appeared 
on  the  twentieth  day.  The  autopsy  in  the  first  case  showed 
the  orbit  to  be  intact.    Tlie  chiasm  was  normal ;  there  was  no 


pus  at  the  base  nor  in  the  sheath  of  the  optic  nerves  nor  in  the 
sinuses.  The  convexity  of  the  hemispheres  showed  a  sub- 
arachnoid purulent  exudation,  extending  from  the  anteri(jr  part 
of  the  anterior  lobes  to  the  fissure  of  Rolando.  This  exudation 
was  very  thick  over  the  two  frontal  convolutions.  There  was 
no  abscess.  Microscopical  examination  of  the  meninges  showed 
a  pure  culture  of  pneumococci.  In  the  second  case  vomiting 
began  on  the  twentieth  day,  followed  by  delirium,  carphology, 
coma,  and  death  in  forty-eight  hours.    There  was  no  autojjsy. 

The  Local  Treatment  of  Diseases  of  the  Deeper  Tissues 
of  the  Eye.— Van  Moll  {Kl.  Mon.f.  Aug.,  October,  1892)  draws 
the  following  conclusions  from  his  observations :  Irrigation  of 
the  eye  with  solutions  of  sodium  salicylate  produces  good  re- 
sults in  episcleritis.  Subconjunctival  injections  of  sublimate 
solutions  are  especially  indicated  in  most  cases  of  iritis  and 
iridocyclitis,  and  in  diffuse  keratitis.  Injections  of  sodium  sali- 
cylate are  very  useful  in  scleritis  and  in  slight  cases  of  diffuse 
keratitis.  The  injections  must  be  carried  out  under  the  strictest 
antisei)tic  precautions. 

Considerations  on  the  Vitreous  New  Formations  on 
Descemet's  Membrane  and  on  the  Iris,  and  Changes  in  the 
Corneal  Endothelium.  — Wagenmann  {Arch,  fur  Ojihthal., 
xxxviii,  2)  considers,  among  other  points  in  this  paper,  that  ad- 
hesions of  the  iris  with  the  posterior  surface  of  the  cornea,  the 
membrane  of  Descemet  being  intact,  will  certainly  lead  to  pro- 
liferation of  the  endothelium  and  exudation  of  a  vitreous  or 
glass-like  substance,  and  that  by  proliferation  of  this  endothe- 
lium there  results  a  homogeneous,  lamellated  tissue  resembling 
in  structure  the  tissue  of  an  anterior  capsular  cataract. 

Experimental  Observations  on  the  Diminution  of  Intra- 
ocular Tension  met  with  in  Purulent  Chorioiditis. — Riud- 

Heisch  {Arch,  fur  Ophthal..,  xxxviii,  2)  draws  the  following  con- 
clusions from  his  experiments  on  rabbits'  eyes:  Immediately 
after  injection  of  the  mercury  into  the  vitreous  the  intra-ocular 
tension  increased  and  there  was  intense  circumscribed  opacity 
of  the  retina.  Then  followed  diminution  of  the  tension  below 
normal,  with  commencing  opacity  of  the  vitreous.  This  was 
followed  by  continuous  lessening  of  tlie  tension  in  the  injected 
eye  with  increasing  suppuration  in  the  vitreous,  and  simultane- 
ous increase  of  tension  in  the  fellow  eye,  lasting  till  phthisis 
bulbi  was  established  in  the  injected  eye. 

On  Skiascopy. — Ruppell  {Arch,  fur  Ophthal.,  xxxviii,  2) 
has  considered  here  the  mathematical  proof  of  the  so-called  iris 
theory,  and  the  influence  of  the  accommodation  of  the  observer's 
eye.  In  regard  to  the  images,  the  second  image  has  the  char- 
acteristics of  one  directly  opposed  to  the  first,  or  in  the  oppo- 
site direction,  when  the  latter  is  in  front  of  the  pupil  of  the  ob- 
server, and  the  characteristics  of  one  in  the  same  direction  as 
the  first  when  the  latter  stands  behind  the  pupil.  The  eye  of 
the  observer  must,  of  course,  be  constantly  accommodated  for 
the  pupil  of  the  patient.  All  complete  circles,  arising  from 
whatever  points  of  the  inner  zone,  have  their  centers  in  the 
optic  axis,  and  are  of  the  s.ime  size  at  a  given  distance  of  the 
first  image.  The  complete  circles  entirely  fill  the  oplithalmo- 
scopic  visual  field.  The  figures  of  dispersion  give  a  definite  di- 
rection to  the  second  image.  The  direction  of  the  second  image 
is  opposed  to  that  of  the  first  when  the  latter  is  before  the 
pupil,  and  corresponds  with  that  of  the  first  when  the  latter  is 
behind  the  pupil.  The  skiascopic  examination  of  an  eye,  so  far 
as  exact  results  are  concerned,  depends  upon  the  smallness  of 
the  pupil  iu  tiie  observer  and  the  greatness  in  diameter  of  the 
pupil  in  the  iiatient. 

The  Development  of  Pterygium.— Fuchs  {Arch.fiir  Oph- 
thal.,  xxxviii,  2)  draws  the  following  conclusions  from  his  in- 
vestigations:  Clinical  observation  of  numerous  cases  of  ptery- 
gium ])roves  that  it  originates  in  the  pinguecula,  which  accounts 


April  1,  1893.] 


REPORTS  ON  TEE  PROGRESS  OF  MEDICINE. 


367 


for  its  usual  appearance  on  the  nasal  and  temporal  margins  of 
the  cornea,  as  well  as  its  occurrence  at  the  time  of  life  which 
naturally  leads  to  the  growth  of  pingnecula.  In  front  of  the 
grayish  margin  of  the  pterygium  the  cornea  shows  small  gray 
dots  or  streaks  without  loss  of  substance.  The  margin  of  the 
pterygium  is  the  only  part  tirmly  adherent  to  the  underlying 
cornea.  The  ocular  conjunctiva  is  firmly  united  with  the  mar- 
gin of  the  pterygium  and  by  it  is  drawn  over  the  cornea.  This 
tension  causes  the  lateral  folds  and  the  spaces  beneath  them. 
Microscopical  examination  confirms  the  result  of  clinical  ob- 
servation. The  origin  of  the  pterygium  from  tlie  conjunctiva  is 
proved  by  its  epithelial  covering.  Beneatli'  the  pterygium, 
Bowman's  membrane  is  usually  almost  entirely  destroyed,  but 
the  corneal  infiltration  in  front  of  the  edge  of  the  pterygium 
proves  that  a  corneal  lesion  precedes  the  growth  of  the  ptery- 
gium. To  explain  the  latter,  a  possible  hypotljesis  is  that  patho- 
logical changes  at  the  limbus  may  interfere  with  the  nutrition 
of  the  corneal  tissue.  The  conjunctiva  is  pushed  forward  and 
pressed  together  by  the  flaps  of  the  pinguecnia,  and  is  reduced 
to  a  thin,  almost  homogeneous  membrane,  which  contains  no 
vessels.  The  tissue  of  the  pinguecula  has  also  but  few  vessels, 
and  thus  there  is  a  very  marked  diminution  of  nutrient  vessels 
at  the  limbus.  Fuchs  thinks  also  that  the  presence  of  the  Pin- 
guecula produces  a  chemical  change  in  the  blood  plasma  which 
passes  from  the  vascular  loops  at  the  limbus  into  the  cornea. 
He  thinks  also  that  proliferation  at  the  limbus  will  produce  the 
same  effect  on  the  cornea  as  atrophy.  This  change  in  the 
blood  plasma  may  cause  the  deposit  of  hyaline  flakes  in  the 
cornea  similar  to  those  met  with  in  arcus  senilis,  and  these  are 
the  changes  noticed  in  the  cornea  in  front  of  the  edge  of  the 
advancing  pterygium.  He  admits,  however,  that  at  present  all 
this  is  pure  hypothesis. 

The  Operation  for  Intra-ocular  Cystieercus.— Seyfert 

{Arch,  fur  Ophthal.^  xxxviii,  2)  presents  the  results  of  six 
operations  for  the  removal  of  intra-ocular  cystieercus.  In 
all  six  operations  the  meridional  section  was  made.  The 
wounds  all  healed  antiseptically,  and  the  eyes  remained  free 
from  inflammatory  accidents.  In  half  of  the  operations  one  of 
the  tendons  of  the  muscles  was  divided,  in  order  to  assist  in 
rotating  the  eyeball  better  to  one  side.  The  cystieercus  was 
removed  in  five  cases.  In  three  cases  it  was  subretinal,  and  in 
three  cases  it  was  free  in  the  vitreous.  In  one  case  the  retina 
was  totally  detached.  In  three  cases  the  existing  amount  of 
vision  was  retained  or  slightly  improved.  In  one  case  the  vision 
was  made  worse  by  the  operation. 

Embolism  of  the  Arteria  Centralis  Retinae.— Foster  {Arch, 
of  Ojjhthal.^  xxi,  4)  reports  an  interesting  case  of  this  nature  in 
a  man,  aged  twenty-nine,  who  gave  a  liistory  of  inflammatory 
rheumatism  accompanied  by  endocarditis,  which  resulted  in  mi- 
tral stenosis  and  regurgitation.  At  the  time  of  the  stoppage  of 
the  artery  the  patient  was  making  his  toilet,  and  immediately 
noticed  th.at  he  had  lost  the  sight  of  his  left  eye.  There  was  no 
pain  and  no  sensation.  The  sight  was  reduced  to  perception  of 
light.  The  pupil  reacted  in  sympathy  with  the  other  eye,  but 
when  the  latter  eye  was  covered  it  dilated  immediately  and  re- 
mained passive.  An  ophthalmoscopic  examination  was  made 
within  two  hours  of  the  occurrence  of  the  embolism.  Particu- 
larly noticeable  was  the  dense,  grayish-white  efl'usion  that 
marked  the  macula  lutea  and  optic  disc.  The  arteries  were  very 
attenuated  and  almost  invisible.  There  was  no  indication  of  in- 
terruption of  current  or  pulsation,  but  a  .short  distance  below 
the  eff"u8ion  the  blood-vessels  were  again  interrupted  for  a  small 
space  by  the  grayish  etfusion.  On  the  third  day  following  the 
embolism  the  effusion  became  more  pronounced,  and  whitish 
striations  radiated  from  the  region  of  the  macula.  At  this  time 
there  was  no  perception  of  light.    The  patient  was  confined  in 


a  darkened  room,  the  temple  was  leeched  every  fourth  day, 
and  potassium  iodide  was  administered.  In  ten  days  clearing 
began  at  the  upper  and  outer  edge  of  the  disc  and  continued 
without  change  in  the  vision  till  the  thirty-third  day,  when  faint 
perception  of  light  was  noticed.  Vi.sion  subsequently  improved 
to  difierentiation  between  fingers  closed  or  held  apart  near  the 
eye. 

A  Remarkable  Case  of  Pseudo-trachoma.— Greeff  {Arch, 
of  Ophthal.,  xxi,  4)  reports  the  case  of  a  boy,  aged  fourteen, 
whose  left  eyelids  had  been  swollen  for  several  months,  with 
lacrymation  and  burning  sensation.  Both  lids  were  thickened 
and  reddened  and  the  upper  lid  drooped  perceptibly.  Cornea 
clear,  refraction  emmetropic,  and  vision  was  f.  Slight  injec- 
tion of  ocular  conjunctiva.  On  eversion  of  upper  and  lower  lids 
the  retrotarsal  fold  bulged  as  an  intensely  swollen  and  red  mass. 
The  conjunctiva  of  both  lids  from  fornix  to  ciliary  border  was 
completely  and  densely  covered  with  numerous  miliary  granu- 
lations, projecting  like  hemispheres  from  the  swollen  conjunc- 
tiva. The  granules  were  grayish-red  and  but  slightly  trans- 
parent. The  right  eye  was  normal  in  every  respect.  An  attempt 
was  made  to  remove  the  contents  of  the  follicle  by  squeezing, 
but  little  was  effected.  Eight  months  later  not  a  trace  remained 
of  the  former  huge  granulations,  during  which  period  there  had 
been  no  treatment  whatever. 

Immature  Cataract  and  the  best  Method  of  hastening 
Maturity. — White  {Arch,  of  Ophthal.,  xxi,  4)  advises  the  thor- 
ough evacuation  of  the  aqueous  humor  with  the  ordinary  para- 
centesis needle,  and  vigorously  rubbing  the  lens  through  the 
cornea,  up  and  down,  out  and  in,  as  well  as  in  a  circle,  varying 
the  direction  of  the  rubber  or  tortoise-shell  spoon  to  avoid  stri- 
ated opacities  of  the  cornea.  These  movements  are  to  be  con- 
tinued until  the  irritation  of  the  eye  warns  the  surgeon  to  desist. 
Atropine  is  instilled  immediately  and  cold  applied  to  the  eye 
until  the  eye  aches.  No  bandage  is  used.  He  has  never  seen 
any  unpleasant  complication  result.  In  the  majority  of  his  cases 
the  lens  showed  increased  cloudiness  the  next  day.  He  usually 
waits  two  weeks  before  proceeding  to  the  extraction  of  the 
lens. 

Homonyinous  Superior  Hemianopsia.  —  Bo6  {Arch,  of 
Ophthal..,  xxi,  4)  reports  a  case  of  this  nature  occurring  in  a 
man  aged  forty-three.  In  the  right  eye  there  was  emmetro- 
pia  with  normal  vision  ;  in  the  left  eye  there  was  hyperme- 
tropia  with  vision  of  |.  The  superior  half  of  the  visual  field 
was  wanting  in  both  eyes.  There  was  no  detachment  of  the 
retina  and  the  fundus  was  normal.  There  was  marked  impair- 
ment of  the  sense  of  smell.  For  two  months  the  patient  had 
complained  of  a  dull,  persistent  ache  in  his  right  eye  with  lanci- 
nating pains  at  night.  The  acuteness  of  vision  in  both  eyes  and 
the  state  of  the  visual  fields  were  the  same  six  years  ago  that 
these  were  when  Bo6  examined  him.  Bo6's  theory  was  that  it 
was  a  classical  case  of  homonymous  hemianopsia  simply  re- 
versed, which  was  caused  by  an  alteration  of  a  single  occipital 
lobe,  the  cause  of  which  was  specific  disease.  The  hypothesis 
of  an  abnormal  distribution  of  the  nerve  fibers  to  the  two  retins 
would  explain  the  fact  better  than  a  compression  of  the  optic 
nerves,  commissure,  or  tracts,  better  than  a  double  symmetrical 
disease  of  the  optic  nerves,  or  than  double  and  symmetrical 
changes  in  both  occipital  lobes. 

Keratoconus  treated  with  the  Galvano-cautery. — Knapp 
{Arch,  of  OphthaL,  xxi,  4)  favors  the  use  of  the  galvano-cau- 
tery, but  considers  that  it  has  great  dangers.  If  the  cauteriza- 
tion is  only  superficial  or  consists  in  a  more  j)erforation  of  the 
apex,  it  is  insufficient  and  must  bo  repeated.  If  the  cauteriza- 
tion is  deep,  especially  with  a  large  perforation,  the  closure 
is  slow,  and  the  inflammation  and  its  consequences  may  be 
more  or  less  severe,  including  sloughing  of  the  cornea.  Thr 


I 


368 

cauterization,  which  acts  by  the  contraction  of  the  cicatrix, 
seems  the  safest  method.  It  is  better  to  cauterize  carefully, 
and  if  relapses  occur,  repeat  the  operation  in  the  same  place. 

The  Anatomy  of  the  Crystalline  Lens.— Barabaschew 
{Arch,  far  Ophthal.,  xxxviii,  3)  draws  the  following  conclu- 
sions from  his  observations:  1.  The  mosaic  network  seen  upon 
the  surface  of  the  anterior  capsule  of  the  lens  of  frogs,  rabbits, 
and  man,  colored  witli  silver-nitrate  solution,  is  formed  by  the 
contours  of  the  epithelial  cells,  which  thrust  their  processes 
over  each  other,  thus  giving  the  appearance  of  several  layers. 
2.  In  transverse  sections  of  such  anterior  capsules  the  contours 
of  both  the  outer  and  inner  cells  appear  as  a  black,  jagged,  and 
and  in  places  interrupted  line.  3.  On  the  posterior  capsule  are 
three  kinds  of  figures — viz.,  (a)  reagent  precipitates];  (J)  fig- 
ures formed  by  tlie  exit  of  fluid  from  the  substance  of  the  lens; 
(c)  impressions  of  the  broadened  ends  of  the  lens  fibers. 

Follicular  Conjunctival  Ulcers;  Natural  Transplanta- 
tion of  Epithelium  and  Glandular  Development  in  Tra- 
choma.— Raehlmann  (Arch,  fur  Ophthal.,  xxxviii,  3)  thinks 
that  if  at  the  time  of  the  ulceration  of  the  softened  follicle 
there  is  a  very  marked  tension  in  the  conjunctival  tissue,  not 
only  do  the  softened  contents  of  the  follicle  come  out,  but  the 
active  living  part  of  the  follicle  is  driven  out  with  it.  As  re- 
gards the  epithelium,  he  was  enabled  to  demonstrate  in  numer- 
ous preparations  that  the  bits  of  epithelium  met  with  in  the 
tissue  of  tlie  conjunctiva  may  grow  and  increase  in  number  and 
size,  and  may  actually  give  off  lateral  processes  by  budding. 
As  regards  the  so-called  "  trachoma  glands,"  Eaehlmann  ad- 
raits  that  new  glandular  development  may  occur  in  trachoma, 
but  only  under  fixed  pathologico-anatomical  conditions,  which 
are  induced  by  the  disease  itself.  Still,  neither  these  new- 
formed  glands  nor  the  epithelial  invaginations  resulting  from 
the  folds  of  the  mucous  membrane  have  anything  to  do  with 
the  causation  of  the  trachoma. 

The  Microbic  Nature  of  the  Deep  Inflammations  of  the 
Eye.— Gillet  de  Grandmont  {Arch.  (Tophthal.,  October,  1892) 
draws  the  following  conclusions:  1.  In  deep  inflammation  of 
the  posterior  hemisphere  of  the  eyeball  the  origin  of  the  affec- 
tion may  be  sought  in  the  infectious  diseases  contracted  by  the 
anterior  hemisphere.  2.  In  cases  of  difficult  diagnosis,  in  order 
to  aid  our  decision,  we  should  have  recourse  to  paracentesis  of 
the  eyeball,  followed  by  a  bacteriological  culture. 

The  Surgical  Treatment  of  Granular  Conjunctivitis.— 
Abadie  {Arch.  iVophthal.,  October,  1892)  reports  the  results  of 
Dr.  Viger  in  Algeria,  which  were  better  than  by  any  other 
means  of  treatment  employed.  Great  care  should  be  taken  to 
rid  the  new  brush  employed  in  "grattage"  entirely  of  fatty 
substances  by  long  boiling  in  water  or  by  alcohol  and  ether, 
and  then  disinfect  it  by  leaving  it  for  an  hour  in  a  solution  of 
sublimate  (1  to  500). 

A  New  Operation  for  the  Treatment  of  Symblepharon. 
— Rogman  (Arch.  tVophthal.,  October,  1892)  describes  the  oper- 
ation as  follows:  After  having  divided  the  adhesions  of  the 
symblepharon  so  as  to  form  an  artificial  cul-de-sac,  having  at 
least  a  depth  equal  to  the  natural  fornix  conjunctivte,  a  flap  of 
skin  of  quadrangular  shape  and  of  the  size  of  the  lid  is  cut  from 
the  cheek,  its  summit  or  top  being  downward  and  its  base  ad- 
herent to  the  skin  of  the  lid  at  the  level  of  the  bottom  of  the 
fornix.  Lifting  the  flap,  we  cut  through  the  underlying  raw 
surface,  detaching  the  tissues  on  all  sides  into  the  artificial  cul- 
de-nac.  Through  this  opening  the  flap  is  introduced  and  its 
summit  or  apex  attached  by  sutures  to  the  intei-nal  palpebral 
margin.  The  lid  then  presents  the  appearance  of  a  broad  han- 
dle, attached  only  at  the  nasal  and  temporal  sides,  entirely  free 
at  its  center,  and  covered  anteriorly,  posteriorly,  and  along  its 
edges  by  skin.     The  operation  is  finished  by  ai)[)roxmiating 


[N.  Y.  Med.  Jooh., 

laterally  the  edges  of  the  wound  in  the  cheek.  Three  or  four 
weeks  later  the  ocular  surface  of  the  artificial  cul-de-mc  is  again 
freshened  by  the  knife,  and  all  cicatricial  bands  between  the 
eyeball  and  the  external  wound  are  destroyed.  The  inferior 
opening  communicating  with  the  cul-de-sac  may  then,  if  neces- 
sary, be  enlarged  by  lateral  incisions.  A  horizontal  incision  is 
then  made  about  the  middle  of  the  anterior  face  of  the  palpe- 
bral handle  and  throughout  its  entire  length,  the  skin  is  dissect- 
ed up  from  above  downward  as  far  as  the  lower  border  of  the 
handle,  to  which  it  remains  attached,  and  the  flap  thus  formed 
is  drawn  within  the  cul-de-sac,  thus  reversing  it.  The  summit 
is  then  attached  by  two  suture  points  to  the  eyeball,  close  to 
the  corneal  margin. 

The  Canthoplast.— Gaz6py  {Arch,  d'ophthal,  October, 
1892)  has  devised  an  instrument  for  performing  canthoplasty, 
which  he  describes  as  follows:  1.  A  spatula,  ending  in  a  round- 
ed angle,  having  about  the  shape  of  the  external  angle  of  the 
orbit,  is  inserted  between  the  lids  and  pushed  toward  the 
ascending  apophysis  of  the  superior  maxilla.  On  the  anterior 
face  of  the  instrument  and  two  centimetres  from  its  end  are 
fixed  on  each  side  two  small  fins  for  separating  the  edges  of 
the  lids.  2.  On  the  posterior  surface  of  the  instrument  is  a 
groove  in  which  glides  a  curved  needle,  which  may  be  pushed 
forward  by  a  button,  intended  for  the  passage  of  a  suture  for 
fixing  the  conjunctiva  at  the  angle  of  the  skin  incision.  The 
eye  of  the  needle  is  two  millimetres  from  the  point.  3.  On  the 
anterior  and  median  surface  of  the  spatula  there  is  a  second 
groove  in  which  glides  the  lower  branch  of  a  pair  of  scissors 
with  three  articulations.  This  inferior  branch  is  fixed  to  the 
spatula,  but  glides  as  far  forward  as  the  extremity  of  the  spatu- 
la. The  upper  branch,  which  opens,  glides  forward  with  the 
lower,  and  bears  on  its  widest  part  a  ring,  through  which 
passes  the  thumb  of  the  surgeon,  who  raises  it  when  he  wishes 
to  open  the  branches. 


The  Medical  Examination  of  Children, — In  a  clinical  lecture  pub- 
lished in  the  March  number  of  the  Fractiiioner  Dr.  A.  Ernest  Sansom, 
of  London,  says : 

"  The  first  thing  that  you  have  to  do  is  to  try  to  get  the  knack  of 
dealing  with  children,  to  obtain  their  confidence,  and  to  learn  the  meek 
language  of  their  suffering.  Assume  that  the  mother,  relative,  or 
guardian  brings  the  child,  and  sits  near  you  with  the  child  on  her  lap. 
In  the  first  place,  avoid  even  looking  at  the  little  patient ;  if  it  is  asleep, 
let  it  remain  so ;  if  still,  do  not  interfere  with  it.  Address  yourself  in 
quiet  tones  to  the  mother :  ask  what  she  has  brought  the  child  for, 
what  she  has  noticed  in  respect  to  it.  Her  answer  may  be  fanciful ; 
for  instance,  a  sturdy  child  may  be  brought  because,  in  the  opinion  of 
the  mother,  '  it  is  wasting  ' ;  but  do  not  be  in  a  hurry — patience  and, 
above  all,  good  temper,  are  essential  if  you  are  to  do  your  work  prop- 
erly. Having  made  a  mental  note  or  written  a  memorandum  of  the 
signs  noted  by  the  mother,  try  to  obtain  from  her  a  date  approximately 
at  which  symptoms  began  to  be  manifested,  and  what  symptoms  she 
has  observed  as  marking  the  rise  and  progress  of  the  malady.  Then 
inquire  concerning  certain  circumstances  preceding  the  birth  of  the 
child — How  many  confinements  has  the  mother  had  ?  Any  miscar- 
l  iages  ?  Any  deaths  among  the  previous  children  ?  And  if  so,  what 
their  supposed  causes  ?  Were  the  children  healthy,  or  did  they  waste 
or  manifest  in  infancy  peculiar  signs  or  symptoms,  such  as  snuffing, 
thrush,  or  sores  about  the  posteriors  or  the  face  ?  Did  she  suckle  her 
children  wholly  or  partially,  or  were  they  '  brought  up  by  hand  '  ?  Then 
adapt  a  modification  of  such  questions  to  the  case  of  the  child  now  under 
consideration. 


MISCELLANY. 


April  1,  1893.J 


MISCELLANY. 


36^ 


"  Having  obtained  as  clear  a  history  as  you  can  from  an  unskilled 
observer,  proceed  to  the  more  important  duty  of  your  own  investigation. 
Disturb  the  child  as  little  as  possil)le,  use  all  gentleness,  observe  it  as 
if  not  observing.  Let  any  covering  be  removed  from  the  head,  and 
look  at  the  cranium  and  face.  Note  as  to  the  head,  whether  it  is  large 
(megacephalic),  small  (microcephalic),  or  moderate  and  seemingly  nor- 
mal, whether  the  vertex  is  flat  or  otherwise,  whether  the  cranium  is 
symmetrical  or  unequal,  or  presenting  '  bosses '  or  elevations  in  certain 
situations.  You  may  now  perhaps  gently  press  the  cranium  with  your 
finger,  and  feel  whether  it  is  resistant  or  easily  compressed,  or  whether 
you  find  any  softish  spots  here  and  there.  Pass  your  finger  around  the 
borders  of  the  anterior  fontanelle ;  observe  whether  this  be  widely  or 
moderately  open,  or  closed.  Notice  its  edges :  are  they  gradually  softer 
and  thinner  as  you  approach  the  open  portion,  or  is  the  opening  sur- 
rounded by  irregular  ridges  ?  Then  as  to  the  face :  is  it  tranquil,  as  in 
sleep,  or  do  convulsive  movements  flit  over  it  ?  Is  there  any  expression 
of  intelligence,  or  the  vacancy  of  the  idiot '?  Are  the  eyeballs  symmet- 
rical and  quiet,  or  are  there  oscillatory  movements  of  the  globes 
(nystagmus)  or  squinting  ?  Are  the  actions  of  the  facial  muscles  equal 
on  the  two  sides  ?  Do  you  see  that  the  muscles  of  one  side  are  less  pro- 
nounced and  rounded  than  those  of  the  other  ?  Then,  if  the  child  should 
happen  to  cry,  the  condition  may  be  shown  unmistakably,  for  the  one  side 
of  the  face  will  be  contorted,  while  the  other  will  be  placid  and  unmoved. 
If  the  child  shows  no  disposition  to  move  the  facial  muscles,  tickle  the 
soles  of  the  feet.  Probably  it  will  laugh,  and  it  is  better  -  to  make  a 
child  laugh  than  to  make  it  cry.  It  will  almost  certainly  contract  its 
face  muscles,  so  that  you  can  distinguish  deficient  movement  on  one 
side  if  there  be  any  unilateral  impairment.  There  is  paralysis  of  the 
portio  dura  (Bell's  paralysis).  Is  the  brow  contracted  ? — a  sign  of  pain. 
Is  the  hand  lifted  to  the  head,  or  pulling  at  the  ears  ?  Are  there  mean- 
ings or  a  querulous  cry,  or  occasionally  a  piercing  shriek  ?  Note  the 
hue  of  face :  is  it  pale  or  rosy,  or  '  hectic  '  and  flushed  ?  Is  it  of  the 
•deep-yellow  or  orange  tint  indicating  jaundice — the  conjunctiva  being 
tinged  w  ith  a  like  color  ?  Is  it  very  markedly  pale  or  lemon-colored 
(such  lemon-color  is  often  to  be  noted  in  syphilis)  ?  Is  it  puffed  and 
(edematous  ?  Such  may  be  the  case  in  children  not  only  in  the  usual  form 
of  dropsy  affecting  the  adult,  but  in  the  general  dyscrasia  of  syphilis.  Is 
it  blue,  of  a  leaden  color,  perhaps  almost  black  above  the  lips  and  con- 
junctivae ?  Then  you  will  find  the  tips  of  the  fingers  cold,  violet  in  color, 
and  perhaps  clubbed ;  the  child  is  the  subject  of  cyanosis. 

"  Observe  the  nose  :  is  it  squat,  depressed,  as  it  may  be  in  a  syphi- 
litic child,  and  does  an  unhealthy  ichor  flow  from  the  nostrils,  the  thick 
mucous-covered  membrane  causing  the  child  to  snuffle  ?  If  there  be 
signs  of  dyspnoea,  notice  the  nostrils,  for  it  is  an  important  sign  if  they 
dilate  with  each  inspiration.  Note  any  eruptions  about  the  head  or 
face,  behind  the  ear,  or  around  the  nostrils  and  mouth.  Then  at  the 
end  of  this  stage  of  the  examination  you  must  look  at  the  tongue.  It 
does  not  answer  to  be  too  timid ;  depress  the  lower  jaw  with  thumb 
and  finger  of  the  right  hand,  while  you  steady  the  upper  jaw  and 
sUghtly  incline  the  head  backward  with  the  left.  It  may  be  that  the 
child  will  make  an  effort  of  inspiration  at  the  moment,  and  enable  you 
to  see  at  a  glance  the  natural  contents  of  the  mouth.  You  will  see 
whether  the  tongue  is  clean  or  otherwise,  whether  white  patches  of 
oidium  (thrush)  cover  it,  whether  the  circumvallate  papilla;  at  the  back 
of  the  tongue  are  large  and  rough,  whether  the  fauces  are  congested, 
or  ulcers  or  sloughs  appear  upon  the  tonsils  and  adjacent  mucous 
membrane.  You  will  observe  the  lining  membrane  of  the  mouth, 
whether  white  (aphthous)  spots  appear  scattered  over  it ;  whether  the 
gums  are  swollen,  what  teeth  have  appeared,  and  whether  they  are 
sound  or  otherwise.  Notice  also  the  relation  between  the  stage  of  the 
dentition  and  the  age  of  the  child. 

"  And  now  I  advise  you  to  have  the  child  removed  from  the  room  in 
which  you  are  in  order  to  be  undressed.  Do  not  look  on  while  this  op- 
eration is  going  forward,  for  then  there  is  much  more  chance  of  active 
resistance  <and  noisy  lamentation,  terrors  concerning  possible  tortures  to 
he  inflicted  presenting  themselves  vividly  before  the  child's  mind. 
Alone  with  its  mother  or  nurse  the  difficulty  is  far  less,  and  when  once 
the  clothes  are  off,  and  the  child  wrapped  in  blanket  or  flannel,  you  may 
with  circumspection  make  your  examination.  Approach  the  back  first, 
the  child  sitting  on  the  mother's  or  nurse's  lap,  amused  if  possible  by 


anything  to  which  its  attention  may  be  directed.  Notice  any  deformity 
of  spine  or  thorax.  Place  your  warm  hand  gently  upon  the  surface,  and 
feel  the  rate  of  breathing  ;  you  may  be  sensible  of  the  tactile  fremitus 
which  sometimes  accompanies  bronchitis.  Then  gently  percuss  from 
base  to  apex  upon  your  outstretched  finger  or  Angers  closely  applied  to 
the  chest ;  in  a  vast  majority  of  cases  the  child  will  not  in  the  least  ob- 
ject to  this  operation,  if  you  commence  at  the  back,  while  if  you  per- 
formed the  percussion  first  in  front,  in  full  view  of  the  child,  there  would 
be  active  resistance. 

"  Having  percussed,  you  will  now  begin  to  auscultate,  and  remember 
that  it  is  from  the  back  of  the  chest  that,  so  far  as  the  lungs  are  con- 
cerned, you  will  obtain  the  most  valuable  evidence.  You  may  apply 
your  ear  directly  to  the  back,  or  a  warm  covering  may  intervene.  An 
ordinary  wooden  stethoscope  does  not  answer  ;  you  can  not  readily  fol- 
low any  chance  movement  of  the  child,  and  (juite  unwittingly  you  may 
by  the  pressure  of  the  instrument  inflict  pain  or  cause  alarm.  It 
is  quite  otherwise,  however,  with  the  binaural  stethoscope,  which 
for  localizing  the  auscultatory  signs  in  infants  and  children  is  indis- 
pensable. 

"  Having  investigated  the  back,,  let  the  child  be  turned  round  so  as 
to  face  you.  Probably,  inasmuch  as  your  examination  has  hitherto 
caused  neither  terror  nor  pain,  there  will  be  no  resistance  to  the  rest  of 
the  investigation.  Notice  the  general  nutrition.  Are  the  arms  and 
thighs  fairly  plump,  or  do  the  muscles  hang  flaccidly  upon  the  bones, 
the  whole  body  showing  marked  attenuation  ?  Is  there  paralysis  or 
wasting  of  a  limb  or  of  groups  of  muscles  ?  Are  there  any  twitchings, 
or  the  disordered  movements  of  chorea  ?  Are  the  thumbs  drawn  con- 
Tidsively  inward  to  the  palm,  or  the  toes  flexed  (carpo-pedal  convul- 
sions) ?  Observe  the  shape  of  the  thorax,  and  pass  your  fingers  over 
the  ribs  and  their  cartilages  ;  at  the  junction  you  may  find  unmistaka- 
ble bossy  prominences,  the  '  chaplet '  of  rickets,  and  you  may  observe  a 
well-marked  groove  at  the  lower  part  of  the  thorax  from  the  sinking  in 
of  the  too  soft  ribs.  At  the  same  time  notice  whether  the  ends  of  the 
long  bones  at  the  wrists,  elbows,  knees,  or  ankles  are  thickened.  Ob- 
serve whether  the  priecordium  is  unduly  prominent,  for  it  may  bulge 
over  an  enlarged  heart,  the  strong  pulsations  of  which  may  be  evident. 
Notice  the  condition  of  the  respiration  ;  is  it  tranquil  or  embarrassed  ? 
Are  the  intercostal,  episternal,  or  epigastric  spaces  drawn  in  with  in- 
spiration ?  You  may  perhaps  better  determine  the  pulse-rate  by  count- 
ing the  heart  pulsations  than  by  feeling  the  radial  pulse.  Remember, 
of  course,  that  the  pulse-rate  is  very  quick  in  children.  Note  the  ratio 
to  respiration  ;  this  should  be  about  three  pulsations  to  a  respiration — 
/.  e.,  P  :  R  =  3  :  1. 

"  Then  observe  the  abdomen,  whether  it  is  disproportionately  large 
and  tympanitic,  or  full  and  fluctuating  (ascites),  or  manifesting  promi- 
nences which  palpation  shows  to  be  tumors,  or  whether  it  is  flat  and  re- 
tracted. Of  course  you  will  notice  whether  there  is  abdominal  tender- 
ness, or  whether  the  child  habitually  lies  in  such  a  position  as  to  relieve 
it  from  pressure,  whether  the  abdominal  muscles  perform  any  part  in 
respiration  or  are  motionless.  See  whether  there  is  umbilical  hernia  or 
any  sore  about  the  navel.  Observe  whether  any  rash  exists  on  the  chest 
or  body  generally,  and,  if  so,  what  are  its  characters.  Are  there  proper 
marks  of  vaccination  in  the  normal  situations  ? 

"  Particularly  observe  the  perinipum,  whether  there  is  a  diffuse  ery- 
thematous redness  in  this  situation,  or  whether  copper-colored  blotches, 
papules,  or  abrasions  are  manifested.  Do  white  patches  or  exuberant 
growths  of  mucous  tubercles  appear  about  the  anus,  or  is  tjie  skin  around 
the  orifice  puckered  in  such  manner  as  to  suggest  that  the  mucous  mem- 
brane has  been  diseased  at  a  period  anterior  to  your  examination  ?  If 
there  has  been  looseness  of  the  bowels,  try  to  obtain  a  napkin  stained 
with  the  evacuations,  and  notice  whether  the  dejecta  are  pale  or  deep- 
colored,  green,  or  mingled  with  mucus,  pus,  or  blood.  Observe,  too, 
whether  the  urine  has  stained  the  napkin  ;  it  may  be  advisable  to  re- 
serve some  cut-out  portions  of  it  for  microsco|)ic  examination,  especially 
if  you  are  doubtful  whether  blood  is  passed  in  the  urine. 

"  Now,  as  you  have  percussed  and  auscultated  the  back,  so  you  must 
percuss  and  auscultate  the  front  of  the  chest ;  note  any  patches  of  dull- 
ness in  axilla;  or  the  anterior  thoracic  regions ;  outline  the  priecordial 
dullness.  For  auscultation  you  must,  as  I  have  said,  use  the  flexible 
l)inaural  stethoscope.    Note  modifications  of  respiration  and  localities 


370 


MISCELLANY. 


[N.  Y.  Med.  Joub., 


of  adventitious  sounds  ;  notice  the  conduction  of  the  voice,  if  the  child 
should  happen  to  cry.  It  is  often  very  difficult  to  get  definite  articula- 
tion for  the  purpose  of  auscultating  the  voice  as  in  the  adult ;  do  not 
worry  the  child  for  this  purpose  till  a  future  time,  when  coaxing  may 
extract  a  few  articulated  words." 

Oophorectomy  and  Insanity. — Apropos  of  a  recent  disagreement 
between  one  of  the  physicians  of  a  Pennsylvania  lunatic  asylum  and 
the  I)oard  of  trustees  of  the  institution,  in  which  the  latter  were  re- 
ported to  have  taken  a  somewhat  arbitrary  stand  in  virtually  f()r))idding 
the  further  performance  of  oophorectomy  on  the  inmates,  save  as  a 
life-saving  measure,  the  American  Journal  of  Insanity  says  : 

"  There  would  seem  to  be  two  questions  at  issue — one,  in  regard  to 
the  propriety  of  the  operations  ;  the  other,  as  to  the  proper  authority 
to  decide  such  questions.  With  respect  to  the  former,  we  believe  that 
insane  women  are  entitled  to  the  same  relief  from  suffering  as  sane 
women.  We  do  not  altogether  agree  with  the  opinion  that  the  only 
justification  for  such  operations  is  their  necessity  to  the  saving  of  life. 
We  believe  there  is  a  pretty  general  agreement  among  those  best  quali- 
fied to  judge  that  the  suffering  and  impairment  of  health  due  to  disease 
of  the  organs  in  question  may  be  such  as  to  warrant  the  risk  involved. 
At  the  same  time,  it  ia  notorious  that  the  operation  has  not,  in  practice 
among  the  insane,  always  been  confined  to  cases  in  which  there  was 
such  suffering  as  would  be  held  to  justify  it  in  general  practice.  The 
results  in  the  relief  of  insanity  have  not  seemed  to  us  to  be  calculated 
to  inspire  so  nnich  enthusiasm  as  has  been  shown  in  some  quarters,  and 
we  are  decidedly  of  the  opinion  that,  for  the  present  at  least,  such  op- 
erations should  be  strictly  limited  to  cases  in  which  the  surgeon  would 
feel  it  his  duty  to  urge  them  upon  private  patients  of  sound  mind. 

"  On  the  other  hand,  it  is  our  opinion  that,  if  the  medical  officers  of 
a  hospital,  with  their  professional  knowledge  and  their  acquaintance 
with  the  condition  of  their  patients,  are  not  better  judges  of  their  needs 
than  any  persons  who  do  not  possess  these  qualifications,  they  are  not 
fit  for  their  positions.  To  undertake  to  hedge  in  persons  in  their  place 
BO  that  they  can  not,  if  so  disposed,  find  scope  for  any  disposition  they 
may  have  toward  brutal  and  inhuman  acts,  would  be  rather  a  hopeless 
task.  It  seems  to  us  that,  in  a  case  in  which  there  is  such  a  radical 
disagreement  as  in  this,  the  proper  course  would  be  to  submit  the  cases 
in  question  to  some  one  of  acknowledged  competency  in  such  matters, 
and  abide  by  his  decision.  If,  for  instance.  Dr.  Goodell  should  certify 
that  all  or  any  of  the  proposed  operations  are,  in  his  opinion,  de- 
manded by  the  physical  condition  of  the  patients,  we  doubt  if  the  Board 
of  Charities  would  persist  in  refusing  to  sanction  them.  At  all  events, 
in  case  of  such  a  refusal,  it  would  be  plain  where  the  responsibility 
rested,  and  the  medical  officers  could  wash  their  hands  of  the  blood  of 
the  victims,  if  they  felt  it  consistent  with  their  self-respect  to  continue 
to  hold  office  under  such  circumstances." 

The  Administration  of  Iron. — In  the  first  of  his  Goulstonian  Lec- 
tures, published  in  the  ISriti.sh  Medical  Journal  for  March  11th,  Pro- 
fessor Halliburton,  of  King's  College,  London,  says: 

"  It  [iron]  is  usually  given  in  the  form  of  an  inorganic  salt,  and  the 
success  of  the  treatment,  especially  in  chlorosis,  is  no  doubt  immediate 
and  marked.  The  simplest  method  of  explaining  the  benefit  is  that  the 
drug  given  supplies  the  iron  which  was  before  so  scanty  in  the  blood; 
but  there  are  certain  a  priori  reasons  for  doubting  the  accuracy  of  this 
simple  explanation.  Such  a  simple  modus  operandi  would  be  at  any 
rate  an  unusual  occurrence.  Metabolic  phenomena  are  as  a  rule  noted, 
not  for  their  simplicity,  but  for  their  complexity ;  and  it  would  be  very 
improbable  that  the  power  of  synthesis  in  animal  cells  would  be  able  to 
build  a  complex  organic  molecule  like  haemoglobin  from  the  simple  iron 
salts  given.  Moreover,  there  is  abundant  experimental  proof  that  iron 
salts,  unless  given  in  very  large  doses,  are  not  absorbed  from  the  stom- 
ach or  intestine  (Hamburger)  ;  and,  if  very  large  doses  are  given,  the 
small  amount  which  is  absorbed  accunndates,  like  many  other  metals, 
in  the  liver  (Zaleski).  The  feeding  experiments  on  young  animals, 
where  hicmoglobin  formation  is  most  active,  to  which  I  just  alluded, 
also  tend  in  the  same  direction.  Whether  feeding  on  hsemoglobin  will 
cause  haemoglobin  formation  is  a  subject  which  merits  renewed  re- 
search. When  haemoglobin  is  given  it  is  broken  up  in  the  stomach  into 


globin  and  the  pigment  haematin.  The  haematin  is  further  changed  in 
the  intestine,  and  appears  to  contribute  to  the  formation  of  the  facal 
pigment.  Whether  any  is  absorbed  is  at  present  unknown.  Leaving 
out  the  doubtful  case  of  haemoglobin,  physiologists  have  arrived  at  the 
conclusion  that  the  only  form  of  iron  compound  available  for  the  needs 
of  the  economy  is  the  complex  organic  molecule  which  Bunge  terms 
hiiematogen.  If  this  be  granted,  what  then  is  the  ex|)lanation  of  the 
benefit  derived  from  iron  as  it  is  usually  given  in  drugs  ?  The  quan- 
tity of  iron  in  the  whole  body  is  only  three  grammes,  and  this  amount 
is  taken  many  times  over  during  treatment.  Bunge  explains  the  useful- 
ness of  iron  in  chlorosis  by  its  forming  iron  sulphide  in  the  intestines, 
removing  in  this  way  excess  of  sulphur  from  the  body ;  in  chlorosis 
there  are  excessive  fermentation  processes  in  the  alimentary  canal,  and 
large  ((uantities  of  sulphureted  hydrogen  are  formed  which  destroy  the 
organic  compounds  of  iron  that  form  haemoglobin ;  the  administration 
of  iron  thus  prevents  this  destruction  of  hai'matogen.  I  can  not  but 
think  that  this  explanation,  though  accounting  for  the  facts  in  part, 
does  not  contain  the  whole  truth.  As  Landwehr  points  out,  it  hardly 
explains  the  limitation  of  the  disease  to  the  female  sex  and  the  period 
of  early  adolescence.  Landwehr's  own  explanation,  in  which  the 
substance  he  discovered  and  named  animal  gum  plays  a  conspicu- 
ous part  (and  according  to  him  it  plays  a  conspicuous  part  in  most 
physiological  processes),  is  certainly  not  so  feasible  as  Bunge's,  and 
thus  it  becomes  of  great  scientific  importance  that  the  truth  of  the 
hypothesis  should  be  put  to  the  test  of  experiment.  This  has  already 
been  done  in  a  few  cases  by  Dr.  Hale  White.  He  has  treated  cases  of 
chlorosis  with  hydrochloric  acid,  a  substance  which  undoubtedly  lessens 
putrefaction  processes  ;  but  although  the  patients  improved  somewhat, 
they  did  not  mend  any  more  rapidly  than  others,  who  were  simply 
treated  with  rest  in  bed  and  wholesome  food.  Dr.  Mott  suggested  to 
me  that  attempts  should  be  made  with  bismuth ;  this,  like  iron,  forms 
an  insoluble  sulphide,  and,  if  Bunge's  theory  is  true,  ought  to  be  as 
beneficial  in  anaemia  as  iron  itself.  I  am  not  aware  that  this  has  yet 
been  done.'*' 

The  Hamburg  Rag  Matter. — In  our  issue  for  March  18th  we  re- 
printed from  the  N^cw  York  Herald  a  certificate  by  Dr.  Paul  Gibier 
relative  to  his  examination  of  certain  rags  said  to  have  been  imported 
from  Hamburg.  That  newspaper  has  since  published  Dr.  George  M. 
Sternberg's  reply  to  Dr.  Gibier,  in  the  form  of  a  letter  to  Dr.  Jenk- 
ins,  the  health  officer  of  the  port.    Dr.  Sternberg  says : 

"  I  have  read  the  report  of  Dr.  Paul  Gibier  with  reference  to  the 
bacteriological  examination  of  a  sample  of  rags  submitted  to  him.  The 
bacteria  described  are  such  as  are  commonly  found  on  the  surface  of 
the  body  of  healthy  individuals  and  attached  to  soiled  underclothing. 
No  doubt  samples  of  domestic  rags  collected  in  the  city  of  New  York 
would  show  similar  bacteria. 

"  Bordoni-Uffreduzzi,  in  his  researches  relating  to  the  bacteria  of 
the  skin  in  healthy  persons,  obtained  five  different  species  of  micrococci 
and  two  bacilli.  Maggiori  isolated  twenty-two  species  of  bacteria  from 
his  cultures  inoculated  with  epidermis  from  the  foot.  Miquel,  the  dis- 
tinguished French  bacteriologist,  found  that  '  wash  water '  from  the 
floating  laundries  on  the  Seine  contained  more  bacteria  than  water  from 
any  other  source,  even  than  water  from  the  Paris  sewers.  His  enu- 
meration gave  twenty-six  million  germs  per  cubic  centimetre. 

"  In  view  of  the  consular  certificates  relating  to  the  invoices  of  rags 
imported  by  Solomon  &  Co.,  and  of  all  the  facts  in  the  case,  I  am  of 
the  ojiinion  that  you  were  fully  justified  in  admittmg  them,  and  that 
the  public  health  has  been  in  no  way  endangered  by  your  action.  As 
to  the  danger  from  imported  rags  in  general,  I  would  say  that  in  the 
absence  of  an  epidemic  in  the  country  in  which  they  are  collected  or  at 
the  ports  from  which  they  are  shipped,  there  is  no  more  danger  than 
from  rags  collected  in  our  own  country,  and  I  know  of  no  evidence 
which  justifies  the  requirement  that  such  rags  should  be  disinfected 
before  they  are  shipjied. 

"  The  disease  wliich  is  most  likely  to  be  communicated  by  rags  is 
small-pox,  because  the  virus  of  this  disease  retains  its  infecting  power 
for  a  long  time  when  attached  to  articles  of  wearing  apparel.  But,  as. 
a  matter  of  fact,  the  evidence  that  this  disease  has  been  communicated 
through  the  handling  of  rags  is  extremely  scanty. 


April  1,  1893.] 


MISCELLANY. 


371 


"  As  regards  cholera,  the  clanger  is  much  less  on  account  of  the 
ease  with  which  the  cholera  spirillum  is  destroyed,  and  the  fact  that  it 
does  not  resist  desiccation. 

"  My  own  recent  exi)eriments,  made  with  a  culture  obtained  from  a 
case  of  cholera  taken  to  .Swinburne  Island  from  one  of  the  Hamburg 
steamers  in  September  1892,  show  that  when  pieces  of  a  woolen 
blanket  are  moistened  with  a  pure  culture  of  the  cholera  spirillum  and 
exposed  for  a  few  hours  to  the  direct  rays  of  the  sun  the  '  germ '  is  de- 
stroyed, and  that  when  exposed  freely  to  the  air  in  a  dark  closet  they 
do  not  survive  longer  than  forty-eight  hours.  Similar  results  were  ob- 
tained when  pieces  of  white  blotting  paper  were  moistened  with  a 
culture  of  the  cholera  spirillum  and  exposed  in  the  same  way. 

"  The  Imperial  Board  of  Health  of  Germany  has  recently  published 
the  results  of  an  extended  series  of  experiments  made  to  determine  the 
length  of  time  the  cholera  spirillum  will  survive  upon  the  pulp  of 
various  kinds  of  fruit  and  upon  the  surface  of  fresh  or  salted  fish,  etc. 

"  I  give  below  a  brief  summary  of  the  results  reported  :  Upon  fresh 
flounder,  carp,  and  shellfish  the  spirillum  died  out  in  two  days ;  upon 
smoked  or  salted  herring,  in  twenty-four  hours.  Upon  confectionery  of 
sugar,  chocolate,  or  almonds  no  developments  occurred  after  twenty- 
four  hours.  At  the  room  temperature  upon  sweet  cherries  the  spirillum 
survived  from  three  to  seven  days;  upon  sour  cherries,  three  hours; 
strawberries,  one  day ;  pears,  two  to  five  days ;  cucumbers,  five  to  seven 
days. 

"  At  a  temperature  of  37"  C.  the  time  during  which  the  spirillum 
retained  its  vitality  was,  as  a  rule,  somewhat  less.  Upon  the  surface 
of  the  dried  fruits — cherries,  apricots,  peaches,  and  plums — the  spiril- 
lum could  not  be  recovered  after  one  or  two  days.  When  the  dried 
fruit  was  moistened  the  time  was  longer — one  day  on  apricots,  two 
days  on  peaches,  five  days  on  cherries,  six  days  on  cucumbers. 

"  Uffelmann,  in  a  recently  published  article,  gives  some  additional 
data  of  interest  in  this  connection.  In  his  experiments  the  cholera 
spirillum  was  found  to  survive  upon  the  surface  of  slices  of  rye  bread 
freely  exposed  to  the  air  for  twenty-four  hours ;  when  the  bread  was 
wrapped  in  paper  for  three  days,  and  when  it  was  placed  under  a  bell 
jar  for  seven  days  upon  slightly  acid  butter,  the  spirillum  survived  for 
from  four  to  six  days. 

"  In  Uffelmann's  experiments  the  time  of  survival  upon  textile  fab- 
rics which  were  apparently  dry  is  said  to  have  been  four  days  ;  upon 
moist  goods  the  spirillum  was  found  to  be  still  living  at  the  end  of 
twelve  days. 

"  In  view  of  the  experimental  data  referred  to,  it  is  evident  that  we 
have  nothing  to  fear  from  dry  rags  which  have  been  stored  for  a  month 
or  more.  But  during  the  prevalence  of  cholera  in  any  part  of  Europe 
or  elsewhere  I  think  it  prudent  to  exclude  old  rags  which  have  been 
collected  in  the  infected  area  or  which  are  shipped  from  an  infected  port, 
as  there  are  possibilities  of  danger  if  the  rags  are  not  thoroughly  dry 
when  packed  in  bales." 

"  Coughing  Downward." — Under  the  title  of  Coughing  made  Easy 
in  Bronchiectasis,  Dr.  H.  D.  Didama,  of  Syracuse,  N.  Y.,  relates  the 
following  in  the  Journal  of  the  American  Medical  Association  for 
March  18th: 

"  Recently  Mrs.  H.,  of  C,  about  thirty-five  years  of  age,  came  under 
my  observation.  She  had  had  bronchial  catarrh  for  a  year  and  a  half, 
and  a  few  slight  haemorrhages. 

"  After  a  time  the  cough  became  paroxysmal,  and  during  these  vio- 
lent fits,  which  la.sted  without  sensible  mitigation  from  sixty  minutes  to 
three  hours,  the  copious  expectoration  was  so  offensive  that  the  win- 
dows had  to  be  kept  open.  The  disease  was  thought  to  be  tuberculous, 
cancerous  ulceration,  or  gangrene  which  involved  the  stomach,  for 
vomiting  was  of  frequent  occurrence,  and  the  odor  of  the  vomited  ma- 
terial was  also,  as  the  patient  expressed  it,  enough  to  knock  anybody 
down. 

"  At  my  first  visit  the  patient  was  found  weak  and  emaciated,  but 
without  the  tuberculous  or  cancerous  facial  expression.  The  scent  of 
the  expectoration  fairly  justified  the  description  given.  The  history 
showed  that  enough  food  was  taken,  but  that  two  or  three  times  a  day 
it  was  all  vomited,  and  that  these  vomiting  spells  coincided  with  the 
severe  coughing  ones.    There  was  some  diarrhoea,  but  the  odor  of  the 


alvine  discharges  was  entirely  unlike  that  of  the  vomited  material. 
There  was  no  gastralgia,  no  tenderness  in  the  epigastric  region.  The 
diagnosis,  of  course,  was  uncouiplieated  bronchiectasis.  The  ra- 
tionale of  the  symptoms  was  obvious.  If  the  stomach  had  been  in- 
volved the  stools  would  have  possessed  the  peculiar  odor  of  the  sputa. 
Nausea  and  vomiting,  which  were  excited  by  the  violent  coughing  and 
the  repulsive  smell,  increased  mechanically  the  amount  of  the  putrid 
material  expectorated,  and  this,  mingled  with  the  ejected  food,  per- 
fumed the  whole  mass  and  led  to  the  mistaken  diagnosis  of  gastric 
ulceration  or  gangrene. 

"  Proper  explanations  were  made  and  encouragement  given  to  the 
intelligent  patient,  and  a  therapeutic  plan  was  instituted  which  in- 
cluded tonics  of  iron,  strychnine,  Venice  turpentine,  santal,  etc.,  and 
the  use  with  a  steam  atomizer  of  a  deodorizing  spray. 

"  Perhaps  the  most  important  element  in  the  treatment  of  this  case 
and  the  one  at  the  junction  was  the  emphatic  and  iterated  direction  to 
cough  downward.  The  usual  and  proper  information  was  given  to  the 
patient  that  a  pocket  was  formed  in  the  tubes  of  the  hmgs,  and  that 
when  this  pocket  became  filled  and  running  over,  as  it  did  two  or  three 
times  a  day,  the  unpleasant  and  irritating  material  caused  the  terrible 
fits  of  coughing.  The  walls  of  the  pocket,  it  was  further  explained, 
were  so  thick  that  even  the  most  violent  and  long-continued  attacks 
could  not  compress  them  enough  to  empty  the  pocket  entirely,  and  so  a 
portion  of  the  putrid  matter  remained  to  contaminate  future  collec- 
tions. Now,  by  lying  in  bed  (the  patient  was  told)  or  on  the  lounge, 
with  one  hand  on  the  floor  and  the  head  almost  reaching  there,  the 
pocket  would  be  inverted  and  the  fluid  would  run  out  almost  of  itself, 
and  its  expulsion  would  be  hastened  by  a  short  spell  of  coughing.  The 
direction  was  given  not  to  wait  until  the  pocket  became  wholly  filled 
again,  but  to  anticipate  this  period  by  inversion  four  or  five  times 
daily. 

"  The  injunctions  were  obeyed.  The  result  was  favorable.  In  five 
minutes  the  pocket  was  emptied  more  completely  than  when  she  had 
formerly  '  coughed  her  head  off '  for  an  hour  or  longer.  The  odor  dis- 
appeared, vomiting  and  diarrhoea  ceased,  the  flesh  came  back,  and  to- 
day, with  the  exception  of  a  slight  cough  and  a  few  mucous  rales  in 
the  left  infra-axillary  region,  the  grateful  patient,  who  rides  twenty 
miles  to  town  for  inspection  every  two  weeks,  is  decidedly  convalescent. 

"  It  is  proper  to  add  that  the  idea  of  coughing  down  hill  was  de- 
rived from  a  small  pamphlet  published  nearly  fifty  years  ago  by  the 
fost  N.  P.  Willis,  who  claimed  that  he  had  cured  himself  of  consump- 
tion by  this  original  device  and  by  horseback  exercise.  In  all  proba- 
bility the  supposed  consumption  of  the  poet  was  bronchiectasis,  but 
his  suggestion  is  noAe  the  less  valuable ;  and  the  writer  of  this  paper 
has  known  great — even  if  temporary — relief  and  comfort  to  be  obtained 
by  this  gravity  treatment  in  cases  of  phthisis,  when  large  cavities  and 
excessively  annoying  coughs  existed. 

"  Recently  I  was  invited  to  see  a  patient  who  had  a  cavity  in  the 
light  infraclavicular  region  capacious  enough  to  hold  a  teacupful  of 
muco-pus.  He  discovered  that  he  could  sleep  three  or  four  hours  with 
but  little  disturbance  while  lying  on  his  right  side,  but  that  if — after 
this  period  of  repose — he  turned  upon  his  left  side,  a  brief  fit  of 
coughing  ensued.  If  he  attempted  to  sleep  lying  on  his  left  side,  the 
cough  was  incessant,  and  the  sputa  only  moderate  in  amount.  Every 
one  can  see  without  explanation  that  while  in  one  position  the  secretion 
accumulated,  exciting  in  the  nerveless  pocket  little  or  no  cough  till  the 
reservoir  was  filled,  when,  on  turning  over,  the  irritating  material  ran 
out  by  gravity  into  the  sensitive  bronchi  and  produced  an  easy  cough, 
sufficiently  prolonged  to  secure  thorough  evacuation  ;  in  the  other  po- 
sition— on  the  left  side — there  was  a  continual  dri])ping  from  the  ab- 
scess cavity  and  a  wearing  cough  which  bauisheil  sleep.  Two  mornings 
after,  as  I  learn,  the  patient,  after  a  prolonged  sleep  which  lasted  all 
night,  turned  upon  his  left  side.  The  large  amount  of  pus  which  had 
been  permitted  to  accumulate  during  this  long  period  poured  out  sud- 
denly into  the  tubes  and  produced  strangulation  and  almost  instant 
death. 

"  It  is  respectfully  submitted  that  this  facilis  descensm  treatment 
might  be  so  beneficial  in  some  cases  of  real  or  supposed  gangrene  of 
the  lung,  communicating  with  a  bronchus,  that  pneumonectomy  might 
be  unnecessary." 


3Y2 


MISCELLANY. 


[N.  Y.  Med.  Jocb. 


Some  Current  Fallacies. — In  concluding  an  article  on  The  Course  of 
the  Inferior  Laryngeal  Nerve,  in  the  Lancet  for  March  11th,  Mr.  W. 
Ramsay  Smith,  of  Edinburgh,  mentions  a  number  of  theoietical  as- 
sumptions that  are  easily  overthrown  by  practical  tests.    He  says: 

"  Theories  of  this  description  are  very  fascinating.  They  are  often 
wrong,  but  criticism  of  them  not  infrequently  points  the  way  to  a  truer 
explanation.  The  works  of  old  masters  in  science,  medicine,  and 
philosophy  are  full  of  them,  some  fanciful  in  the  extreme,  some  evi- 
dently erroneous,  some  seemingly  true,  yet  all  requiring  rigorous  test- 
ing. To  mention  many  of  those  theories  would  be  tedious  and  useless. 
I  may  take,  however,  from  my  note-books  a  few  instances  of  tl*eories 
taught  even  now  that  have  probably  as  little  foundation  in  fact  as  the 
theories  that  have  been  exploded  ages  ago : 

"  1.  Normal  knock-knee  in  women  is  said  to  be  due  to  the  greater 
width  of  the  pelvis.  Let  it  be  granted  that  the  pelvis  is  wider  in 
women,  as  it  is  granted  that  women  possess  ovaries — how  does  width  of 
pelvis  explain  knock-knee  ?  Does  width  of  pelvis  explain  the  greater 
degree  of  knock-elbow  in  women  ? 

2.  "  In  the  act  of  swallowing,  the  lower  jaw,  it  is  said,  is  firmly  ap- 
plied to  the  upper.  This  is  said  to  be  necessary  in  order  that  the  mus- 
cles attached  to  the  lower  jaw  may  have  a  fixed  point  to  act  from.  But 
swallowing  is  possible  without  fixing  the  lower  jaw  to  the  upper.  It  is 
not  possible,  however,  without  fixing  the  tongue. 

"  3.  Spigelius  says  that  the  function  of  the  buttocks  is  to  form  a 
cushion  on  which  the  body  may  be  softly  supported,  for  the  purpose  of 
divine  cogitation.    Is  there  any  real  advance  on  this  theory  ? 

"4.  It  is  taught  that  the  great  preponderance  of  muscles  inserted 
on  the  inner  aspect  of  the  tibia  is  to  be  explained  in  relation  to  the  un- 
screwing of  the  knee  joint  at  the  beginning  of  the  movement  of  flexion. 
I  have  examined  this  theory  in  the  Journal  of  Anatomy  and  I'hyiiwlogy^ 
and  have  ventured  an  explanation  that  may  also  cast  some  light  upon 
the  function  of  the  buttocks. 

"  5.  The  '  reflex  pain '  in  the  knee  in  cases  of  hip-joint  disease  is  ex- 
plained by  the  fact  that  the  obturator  nerve  supplies  both.  Is  this  a 
real  explanation  ?  In  this  connection  I  may  state  that  I  have  found 
that  stimulation  of  a  spot  of  skin  about  an  inch  to  the  left  of  the  ex- 
ternal occipital  protuberance  is  associated  with  a  corresponding  sensa- 
tion at  the  same  instant,  referred  to  a  spot  just  over  the  tip  of  the 
twelfth  rib  on  the  left  side. 

"  These  are  only  a  few  instances,  but  they  illustrate  how  very  neces- 
sary it  is  to  apply  a  little  logical  criticism  to  every  theory  in  anatomy 
and  physiology,  however  well  established  it  may  appear  to  be.  Medical 
science  appears  to  suffer  more  from  want  of  well-trained  minds  than 
from  want  of  the  spirit  of  investigation." 

The  American  Academy  of  Medicine  will  meet  in  Milwaukee  on 
Saturday,  June  3d.  The  preliminary  programme  includes  the  following 
titles :  The  Attitude  of  our  Medical  Schools  in  Relation  to  Preliminary 
Studies,  by  Dr.  R.  Lowry  Sibbet,  of  Carlisle,  Pa.  ;  What  Mental  Facul- 
ties should  be  specially  trained  for  the  Study  of  Medicine?  by  Dr. 
James  W.  Moore,  of  Lafayette  College ;  The  Classics  and  the  Common 
Schools,  by  Dr.  J.  Berrien  Lindsley,  of  Nashville,  Tenn. ;  What  should 
be  required  in  an  Entrance  Examination  to  a  Medical  School,  by  Dr. 
James  W.  Holland,  of  Jefferson  Medical  School ;  Should  there  be 
Elective  Studies  in  a  Medical  Course,, by  Dr.  P.  S.  Conner,  of  Dart- 
mouth College ;  On  the  Endowment  of  Medical  Schools,  by  Dr.  George 
M.  Gould,  of  Philadelphia ;  The  Duty  of  the  State  to  Medicine,  by  Dr. 
Benjamin  Lee,  of  Philadelphia ;  and  The  Importance  of  the  Study  of 
Medical  Sociology,  by  Dr.  Charles  Mclntire,  of  Easton,  Pa. ;  also  the 
president's  address  and  a  paper  (title  to  be  announced)  by  Dr.  C.  C. 
Bombaugh,  of  Baltimore. 

The  Action  of  Coca. — The  Trained  Nurse  rejuints  from  the  London 
Hospital  an  article  in  which  the  writer,  who  states  that  he  has  had  con- 
siderable experience  with  Mariani's  coca  wine,  concludes  as  follows: 

"  The  scientific  study  of  cocaine  has  led  to  a  better  comprehension 
of  the  mysterious  qualities  of  the  coca  leaf.  The  first  efl:ect  is  seda- 
tive, rapidly  followed  by  stimulation,  in  which  the  heart  beats  are 
quickened,  the  nervous  system  becomes  more  active,  the  intelligence 
more  acute,  and  the  muscles  pass  more  easily  into  a  state  of  contrac- 


tion. Dr.  Mantagazza  says  that  when  he  was  under  the  influence  of 
coca  he  had  an  irresistible  inclination  to  gymnastic  exercise.  The  ab- 
sence of  the  sense  of  hunger  seems  to  be  due  not  only  to  the  ana3stbetic 
effect  of  the  cocaine  on  the  nerve  ends  of  the  stomach,  but  also  to  the 
fact  that  coca  is  an  actual  economizer  of  food,  and  so  modifies  the  vital 
processes  in  muscle  as  to  affect  its  chemical  activity  and  render  it  capa- 
ble of  performing  an  eipial  and  greater  amount  of  work  with  a  lesser 
consumption  of  carbohydrates  (Stockman).  The  absence  of  emaciation 
or  subsequent  debility  or  other  bad  results  after  the  most  exalted 
powers  of  the  organism  have  been  called  forth  points  to  coca  being 
more  than  a  nerve  stimulant,  but  also  an  actual  economizer  of  the 
bodily  expenditure.  If  it  diminishes  the  consumption  of  carbohydrates 
during  muscular  activity — that  is  to  say,  enables  the  machine  to  work 
with  less  fuel — less  oxygen  will  be  required,  and  hence  is  explained  the 
effect  coca  has  in  preventing  breathlessness  when  ascending  high 
mountains.  Too  much  stress  can  not  be  laid  on  the  importance  of 
using  only  a  reliable  preparation  of  the  drug." 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follov- 
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  se7U  to  this  jour- 
nal, a  similar  manuscript  or  any  abstract  thei-eof  must  not  be  or 
haoe  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  lis  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no- 
new  conditions  can  be  considered  after  the  tnanusa-ipt  has  been  put 
into  the  type-setters'  haiids.  We  are  often  constrained  to  declitte- 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  became  they  are- 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  ptihlication  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  givittg^ 
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  ansioer  to  his  note- 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
tinder  the  author's  name  are  treated  as  strictly  confdential.  We  can 
7iot  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  notiji- 
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  publicatioiis  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  intei-est 
to  our  readers  will  be  considered  as  doing  them  and  ns  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

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

All  communications  relating  to  the  business  of  the  journal  should  be  ad- 
dressed to  the  publishers. 

Contributors  who  wish  to  order  REPRINTS  of  their  articles  should  d(h 
so  on  a  blank  prepared  for  that  purpose,  which  wid  be  sent  to  them. 
*by  the  publishers  on  recapt  of  a  request  to  that  effect.  The  orderr 
should  be  sent  to  the  publishers,  and  NOT  to  the  editor. 


THE  JVTEW  YORK  MEDICAL  JOURlSrAL,  Apbil  8,  1893, 


Original  Communkations. 


MOTOR  NEUROSES  OF  THE  HEART.* 
By  GEORGE  W.  J  A  COB  Y,  M.  D. 

In  a  very  large  number,  probably  in  more  than  half,  of 
the  persons  who  consult  us  on  account  of  some  n^otor  dis- 
order of  the  heart,  no  anatomical  lesion  is  clinically  discov- 
erable and  no  mechanical  cause  can  be  found.  In  such  cases 
it  is  reasonable  to  seek  for  the  cause  of  the  altered  function 
in  some  disorder  of  the  complicated  nervous  apparatus  of 
the  heart.  Although  our  knowledge  of  neurotic  cardiac  dis- 
order has  been  materially  enlarged  by  the  progress  made  in 
cardiac  physiology,  upon  many  points  we  are  still  insuffi- 
ciently informed  and  have  nothing  but  unsubstantiated 
theories  to  guide  us  in  our  clinical  estimate  of  these  condi- 
tions. If  we  consider  how  intimate  is  the  connection  of  the 
heart  with  the  brain  and  other  organs  by  means  of  the  vagi 
and  the  sympathetic  nerves,  we  should  not  wonder  at  the 
frequency  of  functional  cardiac  disorders,  and  must  acknowl- 
edge that  the  subject  is  one  of  great  practical  and  theoret- 
ical interest  and  one  which  is  eminently  suited  for  discus- 
sion by  this  society.  The  subject  before  us  is  a  very  large 
and  elastic  one,  so  that,  in  order  to  even  approximately  do 
it  justice,  we  must  confine  the  discussion  strictly  to  the  ques- 
tion before  us.  The  subject  of  motor  neuroses  excludes  all 
disorders  dependent  upon  organic  disease  of  the  heart,  ves- 
sels, or  central  nervous  system.  I  will  admit  that  it  is  pos- 
sible for  patients  with  organic  disease  of  the  heart  to  pre- 
sent symptoms  which  are  of  neurotic  production  and  inde- 
pendent of  the  organic  change,  and  such  cases  have  been 
included  in  our  subject  by  other  observers ;  but  I  deem  it 
practical  to  exclude  their  consideration  from  this  discussion, 
as  their  causation  must  be  more  or  less  obscure,  and  instead 
of  aiding  they  can  only  serve  to  confuse  us.  The  consid- 
eration of  all  the  points  connected  with  such  motor  neuroses 
would  require  more  time  than  has  been  allotted  to  me,  so 
that  my  remarks  will  necessarily  be  incomplete  and  frag- 
mentary. 

The  subject  as  I  will  present  it  may  conveniently  be  di- 
vided into  intermittent,  irregular,  abnormally  slow  (brady- 
cardia), and  abnormally  frequent  (tachycardia)  heart's  ac- 
tion. Intermittency  is  that  form  of  arrhythmia  in  which 
from  time  to  time  there  is  complete  cessation  of  the  heart's 
action,  usually  followed  by  a  stronger  or  more  forcible  beat. 
This  is  generally  described  by  the  patient  as  a  sudden  jerk 
and  gives  rise  to  a  very  disagreeable  sensation.  This  inter- 
mittency may  be  true  or  false  ;  in  the  latter  form  the  pulse 
fails,  but  the  heart  is  regular,  while  in  the  former  the  heart 
beat  is  actually  dropped,  so  that  there  is  no  evidence  of  any 
contraction  at  the  heart  itself  or  at  the  arteries.  This  false 
intermittency  has  been  occasionally  confounded  with  brady- 
cardia, because  the  heart  itself  was  not  examined,  the  pulse 
alone  being  taken,  and  this  representing  but  one  half  or  one 

*  Read  in  opening  a  discussion  upon  this  subject  at  the  New  York 
Neurological  Society,  February  1,  1893. 


third  of  the  actual  number  of  heart  beats.  Irregularity  may 
be  incomplete  or  complete.  There  is  in  both  forms  an  ir- 
regularity of  rhythm  and  of  tension,  but  in  the  first  form 
the  number  of  pulsations  varies  from  minute  to  minute,  or 
a  number  of  high  pulsations  is  followed  by  a  greater  or 
lesser  number  of  low  pulsations  ;  in  the  second  form  the 
pulsations  follow  each  other  entirely  irregularly  with  a  con- 
tinuous changeability  of  height  and  tension.  In  contradis- 
tinction to  intermittency,  irregularity  rarely  gives  rise  to 
any  subjective  feeling.  There  has  been  an  attempt  made 
by  most  writers  to  make  a  marked  distinction  between  in- 
termittency and  irregularity,  and  it  has  been  variously 
claimed  that  irregularity  is  more  serious  than  intermittency, 
and  by  others  that  the  reverse  holds  true.  It  has  never 
seemed  to  me  as  though  any  marked  dividing  line  could  be 
drawn  between  the  two,  as  their  occurrence  in  one  and  the 
same  patient  is  not  uncommon.  These  forms  of  arrhythmia 
may  be  persistent  or  only  temporary  ;  when  persistent  I 
consider  it  probable  that  they  are  due  to  some  organic  dis- 
ease of  the  heart,  whether  such  can  be  detected  or  not  ; 
when  they  are  temporary,  they  are  either  dependent  upon 
defective  blood  mixture  or  are  purely  neurotic.  Very  fre- 
quently the  cause  is  to  be  sought  in  some  disorder  of  digest- 
ion, not  only  of  the  stomach  but  also  of  the  intestines,  and 
the  arrhythmia  is  then  explicable  by  a  reflex  from  the  abdo- 
men to  the  vagus  ;  caused  in  the  same  manner,  these  symp- 
toms are  often  found  as  part  and  parcel  of  a  general  neuras- 
thenia. Frequently  we  find  that  an  arrhythmia  is  caused 
by  psychic  influences ;  in  this  connection  it  must  be  stated 
that  such  arrhythmias  always  occur  in  the  form  of  inter- 
mittencies  and  are  produced  only  by  psychic  influences  of  a 
depressing  nature. 

Arrhythmias  have  been  noted  during  chorea  and  also 
after  sudden  fright.  Webber,  of  Boston,  has  described  two 
cases  occurring  from  the  latter  cause.  As  a  prodromal  symp- 
tom of  psychoses  (acute  mania)  they  are  said  not  to  be  rare. 
Of  all  the  causes  which  I  have  found  to  be  potent  in  the 
production  of  arrhythmias,  toxic  influences  associated  with 
sexual  excesses  (natural  or  unnatural)  have  been  the  most 
frequent.  The  toxic  influences  consisted  in  the  excessive  use 
of  tea,  coffee,  tobacco,  and  alcohol.  AH  these  elements  in  the 
production  of  arhythmias  are  well  known,  but  I  would  like  to 
lay  stress  particularly  upon  the  influence  of  alcohol  in  their 
production.  I  have  many  times  noticed  arrhythmias,  par- 
ticularly intermittency,  occurring  in  people  addicted  to  only 
a  moderate  use  of  alcohol,  but  as  they  were  generally  also 
users  of  tobacco,  it  was  difficult  to  estimate  the  precise  in- 
fluence of  the  alcohol  in  the  production  of  the  trouble.  Two 
cases  were,  however,  conclusive  in  proving  to  me  that  alco- 
hol in  itself  must  be  considered  a  direct  cause.  Both  of 
these  patients  were  females  who  in  consequence  of  domestic 
affliction  indulged  in  the  immoderate  use  of  alcoholic  stimu- 
lants. In  both  of  them  there  was  developed  a  multiple  al- 
coholic neuritis  with  motor  symptoms,  and  in  both  of  them 
at  a  time  when  otherwise  only  sensory  disturbances  were 
present  a  marked  intermittency  of  the  heart's  action  set  in, 
so  that  in  one  patient  about  four  intermissions  per  minute 
occurred,  while  in  the  other  every  fifth  or  sixth  beat  was 


374 


J  AGO  BY:  MOTOR  NEUROSES  OF  THE  HEART. 


[N.  Y.  M.ED.  JOQB., 


lost.  This  condition  kept  up  for  months,  until,  in  conse- 
quence of  the  absolute  withdrawal  of  alcohol,  the  condi- 
tion entirely  disappeared.  No  doubt  an  alcoholic  neuritis 
of  some  of  the  cardiac  nerve  endings  was  here  at  fault. 

Slow  Heart  [Bradycardia). — Although  the  term  brady- 
cardia has  only  been  used  in  recent  years  and  was  applied 
by  Grob  in  opposition  to  the  term  tachycardia,  the  slowing 
of  the  heart's  action  in  consequence  of  disease  has  long  been 
recognized. 

According  to  Riegel,  the  term  should  be  applied  only  to 
such  cases  in  which  the  pulse  falls  below  60  a  minute,  and 
Taylor  wishes  it  applied  to  such  pulses  only  as  do  not  rise 
above  40  a  minute.  All  in  all,  T  consider  the  term  an  un- 
fortunate one,  as  it  represents  one  symptom  only,  and  this 
may  be  due  to  a  variety  of  causes.  If  we  make  use  of  the 
term  at  all,  we  ought  to  limit  it  to  such  cases  in  which  the 
infrequency  of  the  pulse  is  due  to  a  disorder  of  innervation. 
An  examination  of  the  fairly  extensive  literature  of  the  sub- 
ject can  leave  no  doubt  upon  our  mind  that  abnormal  con- 
ditions in  the  innervation  of  the  heart  may  produce  a  slow- 
ing of  that  organ  without  it  itself  being  alfected.  Whether, 
liowever,  bradycardia  ever  occurs  as  a  pure  neurosis  in  the 
rsame  sense  as  paroxysmal  tachycardia  does,  is  more  than 
■doubtful.  Certain  it  is  that  slow  heart  occurs  usually  as  a 
symptom  of  organic  disease,  whether  this  be  confined  to  the 
heart  and  its  arteries  or  to  the  brain.  A  slight  reduction 
in  the  frequency  of  the  pulse  is  very  common  in  disturb- 
ances of  the  digestive  tract.  Particularly  is  this  the  case 
in  dilatation  of  the  stomach.  These  cases  have  been  ex- 
plained by  assuming  a  reflex  action  upon  the  cardiac  vagus 
branches  or  from  the  abdominal  sympathetic.  Certainly 
from  the  experiments  of  Goltz  and  others  this  assumption 
in  not  without  physiological  basis,  but  I  have  been  wont  to 
ascribe  these  conditions  to  processes  of  self  intoxication, 
and  I  am  not  prepared  to  say  that  I  am  wrong. 

In  patients  otherwise  healthy,  the  occurrence  of  slow 
heart  is,  in  my  experience,  an  exceedingly  rare  condition, 
and  if  the  use  of  the  term  bradycardia  is  limited  to  such 
cases,  I  do  not  think  that  my  experience  will  be  considered 
■exceptional. 

By  others,  bradycardia  as  a  neurosis  has  been  described, 
and  is  said  to  occur  transitorily  as  well  as  permanently. 

It  will  hardly  be  maintained,  as  has  been  asserted,  that 
cases  of  slow  heart  occurring  in  "  angina  pectoris,"  so 
called,  belong  to  this  category,  for  this  term  also  only 
specifies  a  symptom  complex  found  in  disorders  of  various 
nature.  Illustrative  of  this  remark  is  a  case  of  angina  pec- 
toris with  bradycardia  described  by  Heine.  In  this  pa- 
tient the  heart  would  come  to  a  complete  standstill  for  a 
space  of  time  equivalent  to  four  to  six  beats.  Upon 
autopsy  the  right  phrenic  nerve  was  found  imbedded  in  a 
calcareous  mass  and  the  nervus  cardiacus  magnus  and  the 
branches  of  the  left  vagus  were  implicated  in  anatomical 
disease.  As  a  true  neurosis  of  the  heart,  bradycardia 
seems  to  occur  in  that  form  described  by  Seeligmuller  as 
"  neurasthenia  cordis."  Here  there  is  weakness  of  the 
heart  impulse  and  of  the  heart  sounds  with  marked  slow- 
ing. Upon  rising  in  the  morning,  the  pulse  does  not  ex- 
ceed 40  a  minute  ;  later  it  rises  to  50  or  60,  but  rarely 


higher.  In  severe  cases  this  weakness  is  permanent,  in 
others  it  is  intermittent.  Seeligmuller  attributes  these  cases 
to  disorder  of  innervation,  but  whether  it  is  the  vagus,  the 
sympathetic,  or  the  medulla  oblongata  which  is  at  fault  can 
not  be  stated. 

Of  all  forms  of  bradycardia,  that  which  is  best  known 
is  the  slow  pulse  which  occurs  in  organic  disease  of  the 
nervous  system.  We  can  not  draw  such  cases  into  this 
discussion  any  more  than  those  of  bradycardia  due  to  dis- 
ease of  the  heart  or  vessels.  I  may,  however,  be  pardoned 
for  speaking  of  a  class  of  cases  which  are  exceedingly  in- 
teresting and  not  at  all  rare,  but  whose  pathology  is  still 
sadly  at  fault.  I  refer  to  the  occurrence  of  slow  heart 
with  convulsions.  This  combination,  according  to  See,  is 
seen  in  fatty  heart  and  atheroma  of  the  arteries,  and  he 
noted  the  occurrence  seven  times  in  men  and  three  times  in 
women,  all  the  patients  being  between  twenty-five  and 
forty  years  of  age.  The  cases  to  which  I  refer  differ  from 
these  inasmuch  as  they  presented  no  discoverable  signs  of 
heart  or  brain  disease.  I  have  notes  of  two  such  cases, 
but  both  of  these  lose  much  of  their  interest  through  not 
being  verified  by  an  autopsy.  The  one  case  occurred  in  a 
man,  aged  forty,  who  had  for  two  years  suffered  from 
marked  epileptic  attacks.  His  pulse-rate  was  about  48  a 
minute  whenever  I  had  occasion  to  examine  him.  There 
were  no  other  signs  of  disease  of  the  heart,  kidneys,  or 
brain. 

The  second  case  occurred  in  a  man  aged  forty-five.  He 
had  attacks  of  unconsciousness  which  I  considered  epilep- 
tic and  which  occurred  at  varying  intervals  for  a  space  of 
about  nine  months.  His  heart  beat  was  60  per  minute 
and  intermittent.  No  murmur.  Kidneys  normal.  No 
symptoms  of  organic  brain  disease.  This  patient  died 
while  away  from  my  observation,  and  Dr.  Irwin,  who  saw 
him,  writes  me  that  his  pulse  ranged  from  17  to  26  beats 
per  minute  for  five  days.  No  autopsy  was  permitted.  I 
am  far  from  maintaining  that  there  was  no  organic  disease 
in  these  cases,  but  mention  them  on  account  of  the  interest- 
ing symptom  complex  without  any  clinically  discoverable 
cause.  Whether  the  experiments  of  Landois,  which  showed 
that  venous  stasis  in  the  medulla  could  produce  epileptoid 
attacks  and  reduced  pulse,  cast  any  light  upon  these  cases 
is  questionable. 

Furthermore,  I  should  like  to  call  attention  to  the  prac- 
tical point  raised  by  Dehio — namely,  that  cases  of  slow 
pulse  due  to  disease  of  the  heart  itself  (cardial  cases)  can 
be  clinically  distinguished  from  those  in  which  the  slow 
pulse  is  due  to  direct  or  indirect  excitation  of  the  inhibitory 
vagus  center  in  the  medulla — extra-cardial  cases. 

Inasmuch  as  atropine  paralyzes  the  vagus  terminations 
in  the  heart,  an  injection  of  this  alkaloid  will  increase  the 
heart's  action  in  those  cases  which  are  of  extra-cardial 
origin,  while  in  the  cardial  cases  it  remains  without  effect. 
A  single  injection  is  said  to  be  sufficient.  I  have  had  no 
experience  in  ihis  direction. 

Paroxysmal  Tachycardia. — Before  entering  upon  the 
very  interesting  cases  of  tachycardia,  I  should  properly  re- 
fer to  cases  of  nervous  palpitation,  particularly  as  it  has 
been  claimed  that  tachycardia  is  only  an  attack  of  excessive 


April  8,  1893.] 


JAGOBY:  MOTOR  NEUROSES  OF  THE  HEART. 


375 


palpitation.  The  cases  of  palpitation  are,  however,  so  well 
known  that  I  may  be  excused  from  speaking  of  them. 
Whoever  has  witnessed  a  tachycardiac  attack  after  having 
seen  many  cases  of  palpitation  will  at  once  recognize  that 
he  is  in  the  presence  of  a  condition  which  in  every  way  is 
totally  different  from  anything  before  witnessed.  Since 
the  article  of  Bouveret,  published  in  1889,  which  gave  a 
summary  of  all  previous  work  upon  the  subject,  several  im- 
portant contributions  have  been  published.  It  can  not  be 
a  question  here  of  going  into  the  very  large  literature  of 
the  subject,  but  I  desire  particularly  to  mention  the  paper 
read  by  Debove  and  Boulay  at  the  Societe  medical  des 
hopitaux  in  December,  1890,  and  to  the  discussion  which 
followed,  as  herein  much  is  contained  which  is  of  value  in 
explaining  these  cases. 

I  shall  not  speak  of  the  many  varieties  of  tachycardia, 
and  will  be  particular  to  exclude  from  my  remarks  all 
cases  of  symptomatic  tachycardia,  restricting  myself  to  a 
consideration  of  those  cases  of  violent  heart's  action  only 
which  occur  paroxysmally  and  without  obvious  reason. 

The  tachycardiac  attack  is  always  sudden  in  its  onset 
and  usually  unexpected.  Prodromal  symptoms  are  rarely 
present,  and  if  any  are  observed  they  are  vague  and  unre- 
liable, and  are  not  the  same  in  the  different  attacks.  The 
first  symptom  is  the  sudden  increase  in  the  pulse  from 
normal  to  180,  to  240,  or,  if  the  count  can  be  relied  upon, 
even  to  300.  There  is  never  any  irregularity  of  rhythm  as 
there  is  in  cases  of  excessive  palpitation.  There  is  no  in- 
termittence,  but  the  beats  are  all  of  the  same  intensity,  so 
that,  as  in  the  foetal  heart,  you  can  not  distinguish  systole 
from  diastole ;  at  the  same  time  the  single  beats  are  clear, 
distinct,  and  very  short.  The  heart  beats  in  a  strong  and 
energetic  manner,  so  that  it  is  easily  felt.  There  may  be 
no  other  symptom  present,  so  that  the  patient  keeps  up  and 
and  is  around  during  the  attack.  Usually  other  symptoms 
oblige  the  patient  to  lie  down.  During  or  between  fre- 
quently recurring  attacks  the  apex  may  be  displaced,  car- 
diac dullness  increased,  and  a  systolic  murmur  heard  at  the 
apex.  These  signs  are  always  transitory  and  are  not  of 
any  organic  import.  In  direct  contrast  to  the  rapid  and 
strong  heart's  action  is  the  extreme  diminution  of  arterial 
tension.  As  shown  by  Debove  and  Boulay,  this  symptom 
is  quite  as  important  as  the  rapidity  of  the  heart's  action ; 
the  pulse  may  become  almost  imperceptible,  even  in  the 
femoral,  while  the  heart  beats  clearly  and  distinctly.  In 
all  the  attacks  which  I  have  witnessed  this  distinction  has 
been  marked  at  some  period  of  the  attack  ;  it  is  not  neces- 
sarily present  throughout  the  entire  attack,  and  the  tension 
may  change  under  the  finger  of  the  examiner.  These 
authors  believe  this  symptom  to  be  of  distinctive  value 
in  the  diagnosis  between  symptomatic  and  essential  tachy- 
cardia. The  cessation  of  the  attack  is  as  sudden  as  its 
onset ;  it  may  be  preceded  by  one  or  more  forcible  and 
slower  beats  and  is  accompanied  by  a  disagreeable  sensa- 
tion, which  is  variously  described  by  the  patient.  One  of 
my  patients,  whose  knowledge  of  the  pathogeny  of  the 
affection  had  been  enriched  by  previous  medical  advisers, 
told  me  he  felt  "  the  vagus  go  back  into  place."  Others 
speak  of  a  "  shock  "  in  the  cervical  region.    The  paroxysms 


vary  in  duration  from  a  few  minutes  to  several  hours,  and 
occasionally  last  even  for  days.  Bouveret  has  attempted 
to  distinguish  cases  with  long  attacks  from  those  with 
short  attacks,  but  this  is  purely  artificial  and  can  find  no 
practical  application.  The  patient  above  referred  to  has 
carefully  noted  down  the  time  of  onset  and  of  cessation  of 
all  attacks  occurring  during  a  period  of  two  years — name- 
ly, from  February,  1889,  to  February,  1891 — and  this  list 
shows  how  variable  the  duration  may  be.  In  all,  he  had 
during  these  two  years  sixty-three  attacks,  and  while  of 
these  the  great  majority  lasted  from  a  few  minutes  to 
twenty-four  hours,  several  lasted  over  thirty-six  hours,  and 
one  attack,  which  occurred  since  the  list  was  made  up, 
lasted  three  days. 

The  intervals  between  the  attacks  vary  in  duration  even 
more  than  do  the  attacks  themselves.  Another  symptom 
which  is  generally  present  is  some  disorder  of  the  urine. 
During  the  attack  the  excretion  of  urine  is  generally  dimin- 
ished ;  but  in  one  of  the  cases  which  I  have  observed  the 
termination  of  the  attack  was  always  followed  by  the  pas- 
sage of  a  very  large  quantity  of  clear,  limpid  urine.  In  a 
case  described  by  Huber  this  polyuria  occurred  during  the 
attacks.  In  some  of  the  published  cases  there  have  also 
been  pupillary  symptoms  (myosis  or  dilatation).  Sweating 
is  frequent,  and  if  the  attack  lasts  very  long  a  rise  of  tem- 
perature may  occur.  Whether  this  rise  of  temperature  is 
not  only  a  secondary  symptom  due  to  pulmonary  complica- 
tion is  not  decided.  These  are  the  essential  symptoms  of 
the  attack  ;  other  symptoms  are  secondary,  dependent  upon 
the  duration  of  the  attack  and  upon  the  psychic  condition 
of  the  patient,  and  are  very  variable.  The  affection  is 
characterized  by  its  paroxysmal  nature,  and  the  patient  is 
always  in  danger  of  a  recurrence  of  the  attack. 

Subjectively  and  objectively  the  patient  is  perfectly  well 
during  the  intervals  of  these  paroxysms.  Above  all,  and 
this  is  essential,  no  cardiac  disorder  can  be  discovered. 

The  aetiology  of  these  cases  must  remain  obscure  so 
long  as  our  knowledge  of  their  pathogeny  is  as  theoretical 
as  it  still  is.  Psychic  influences,  fright,  errors  of  diet, 
bodily  exertion,  have  all  been  assigned  as  causes  of  the 
affection  and  as  excitants  of  the  single  attacks.  Ail  that 
we  can  say  positively  is  that  it  is  an  affection  of  adult  life 
(it  has  never  been  noted  in  infants  or  small  children),  and 
that  the  best- established  causes  are  bodily  and  cerebral 
overwork. 

That  nervous  predisposition,  hysteria,  and  neurasthenia 
have  any  particular  influence  upon  its  produ.'tion  is  very 
doubtful.  Essential  to  a  consideration  of  the  pathology  of 
these  cases  is  a  brief  review  of  the  status  of  our  physio- 
logical knowledge.  The  nervous  mechanism  of  the  heart 
is  exceedingly  complicated,  and  its  study  is  surrounded  by 
difficulties,  so  that  our  understanding  of  the  subject  is  still 
imperfect.  What  we  do  know  is  as  follows :  The  contrac- 
tion of  the  heart  is  automatic  and  rhythmically  regular.  The 
rhythmical  action  is  due  either  to  the  action  of  the  cardiac 
ganglia,  most  of  which  are  situated  superficially  in  the  walls 
of  the  auricles,  in  the  auriculo- ventricular  groove,  and  in  the 
basal  portion  of  the  ventricles,  or  to  an  inherent  contractile 
power  of  the  muscular  tissue  independent  of  all  ganglia.  It 


376 


J  A  GO  BY:  MOTOR  ITEUROSES  OF  THE  HEART. 


[N.  Y.  Mkd.  Jodb., 


is  probable,  from  the  experiments  of  Gaskell  upon  lower  ani- 
mals and  from  the  embryological  researches  of  His  and 
Romberg,  that  the  latter  assumption  is  correct.  His  and 
Romberg  were  able  to  show  that  all  the  ganglia  of  the  heart 
are  sympathetic ;  inasmuch  as  all  sympathetic  ganglia  are 
purely  sensory,  these  heart  ganglia  must  be  sensory,  and 
can  not  have  any  motor  functions  which  would  entitle  them 
to  be  considered  as  automatic  heart  centers  which  actively 
influence  the  inhibition  or  acceleration  of  the  heart's  ac- 
tion. 

Physiologically,  also,  a  great  deal  speaks  against  the 
motor  qualities  of  these  ganglia  and  for  their  sensory  na- 
ture. If  these  ganglia  in  any  way  control  the  rhythm  of 
the  heart,  this  is  done  only  reflexly  by  means  of  their  sen- 
sory qualities.  However  this  may  be,  the  heart  is  easily 
affected  in  its  action  by  general  nervous  influences,  through 
its  intimate  connection  with  the  sympathetic  and  cerebro- 
spinal nervous  centers.  This  connection  is  established  by 
two  seta  of  fibers  going  to  the  heart  from  the  central  nervous 
system,  which  belong  to  the  vagus  proper  and  to  the  cer- 
vical sympathetic.  These  two  sets  of  fibers  have  opposite 
and  antagonistic  effects  upon  the  heart,  the  one  set  reduc- 
ing its  action,  inhibiting  it,  not  to  speak  of  other  effects, 
and  the  other  increasing  or  accelerating.  Both  of  these 
sets  of  fibers  may  be  traced  to  the  central  nervous  system, 
and  the  heart  may  be  inhibited  or  accelerated  by  excitation 
of  this  central  nervous  system,  whether  such  excitation  is 
produced  directly  or  indirectly  by  an  afferent  (reflex)  im- 
pulse. Inhibition  of  the  heart's  action  may  therefore  be 
produced  by  impulses  starting  in  the  medulla  oblongata,  by 
stimulation  of  the  vagus  trunk  (spinal  accessory  fibers),  and 
by  stimulation  which  reaches  the  cardio-inhibitory  center 
in  a  reflex  manner.  This  cardio-inhibitory  center  is  con- 
tinually exerting  its  restraining  power  upon  the  heart,  and 
its  action  is  intensified  by  excitation. 

The  details  of  the  process  concerned  in  the  production 
of  accelerating  impulses  are  not  so  well  known,  but  there 
can  be  no  doubt  that  this  production  is  also  governed  by 
the  central  nervous  system.  It  is  probable  that  there  exists 
in  the  medulla  oblongata  a  center  the  excitation  of  which 
produces  acceleration  of  the  heart's  action.  This  center  is 
supposed  to  be  intermittent  in  its  action,  in  contradistinc- 
tion to  the  action  of  the  cardio-inhibitory  center,  which  is 
constant. 

The  assumption  that  the  action  of  the  accelerating  cen- 
ter is  also  constant  would  enable  us  to  explain  much  which 
is  now  not  clear  in  the  antagonistic  action  of  the  inhibitory 
and  accelerating  nerves. 

What  changes  occur  in  the  heart  itself  in  consequence 
of  this  inhibiting  or  accelerating  action  is  still  a  matter  of 
speculation. 

The  chief  interest  in  these  cases  must  lie  in  the  ques- 
tion as  to  their  nature.  That  we  are  really  dealing  with  a 
nervous  affection  can,  I  think,  not  be  doubted,  but  whether 
this  affection  is  of  a  functional  nature  is  not  so  clear.  What 
has  done  much  to  obscure  our  knowledge  upon  this  point 
has  been  the  classing  of  cases  of  permanent  tachycardia 
together  with  those  of  paroxysmal  tachycardia.  Cases  of 
permanent  tachycardia  arc  undoubtedly  always  dependent 


upon  muscular  disease  of  the  heart,  or  upon  anatomical  dis- 
order of  the  nervous  system.  But,  even  in  paroxysmal 
cases  without  any  clinical  signs  of  organic  disease,  it  has 
been  contended  that  the  cause  must  be  sought  in  mural  dis- 
ease of  the  heart.  West  is  the  chief  champion  of  this 
view.  Pathological  findings,  however,  do  not  furnish  very 
much  weight  to  this  assumption,  for  all  the  changes  which 
have  been  found  in  the  heart  may  be  secondary  to  the  affec- 
tion itself,  caused  by  the  overtaxation  of  the  heart  or  by 
disordered  innervation.  In  no  case  of  essential  paroxysmal 
tachycardia,  in  which  the  nervous  system  has  been  ex- 
amined, could  any  lesion  be  found.  Neither  should  this 
absence  of  lesion  surprise  us,  as  it  is  in  accordance  with  the 
paroxysmal  character,  the  sudden  onset  and  sudden  cessa- 
tion of  the  attacks,  and  with  the  absence  of  clinical  signs 
in  the  intervallary  periods. 

Nor  can  we  legitimately  assume  that  the  tachycardia  is 
part  and  parcel  of  any  known  general  neurosis.  Hysteria 
and  neurasthenia  can  be  discarded  ;  Basedow's  disease  has 
been  thought  of,  and  in  some  cases  with  tremor  and  perspi- 
rations the  idea  is  apparently  not  unnatural ;  but  never  in 
Basedow  do  we  have  a  pulse  of  this  kind  with  such  marked 
subtension  of  the  arteries. 

The  disorder  must  lie  at  some  definite  point  of  the  nerv- 
ous system.  These  parts  may  be  the  vagus,  the  sympa- 
thetic, the  cerebral  inhibitory  or  accelerator  centers,  or  the 
intrinsic  cardiac  ganglia.  From  the  present  status  of  our 
physiological  knowledge  we  may  exclude  these  latter.  Va- 
rious theories  exist  as  to  whether  the  vagus  or  the  sympa- 
thetic is  at  fault,  and  there  is  a  great  deal  to  be  said  in 
favor  of  both  views.  Transitory  disturbances  of  equi- 
librium— as  psychic  influences,  which  are  able  to  cause  palpi- 
tation— are  not  sufficient  to  cause  these  attacks.  There  must 
be  injury  of  greater  intensity  ;  therefore  the  assumption  is 
that  the  attacks  are  due  either  to  paralysis  of  the  vagus  or 
to  irritation  of  the  accelerans  of  the  sympathetic,  or  to  both 
combined.  An  excitation  of  the  sympathetic  is  not  diflS- 
cult  to  understand,  for  we  are  able  to  find  analogies  in  other 
nerve  territories.  The  production  of  an  attack  by  percus- 
sion of  the  thorax  (as  often  occurs),  the  occurrence  with 
pallor  of  the  face,  dilatation  or  variability  of  the  pupils, 
profuse  sweating  (as  in  a  case  of  Bramwell's)  which  is 
sometimes  unilateral,  prominent  eyeballs,  coldness  of  the 
extremities,  point  to  the  accelerator  of  the  sympathetic. 
Furthermore,  the  possibility  of  stopping  an  attack  by  taking 
a  few  deep  breaths  points  in  the  same  direction,  for  if  the 
inhibitory  function  of  the  vagus  were  suspended,  it  could 
probably  not  be  so  readily  aroused. 

Brannan  believes  that  we  are  dealing  with  a  temporary 
disorder  in  the  innervation  of  the  heart  caused  by  excita- 
tion of  the  sympathetic,  and  Wood  assumes  the  paroxysms 
to  be  due  to  a  discharge  of  nerve  force  analogous  to  what 
occurs  in  an  epileptic  paroxysm,  the  discharging  lesion 
affecting  the  accelerator  center  of  the  sympathetic.  Cases 
which  point  entirely  to  a  sympathetic  disorder,  but  which 
are  accompanied  by  polyuria  during  the  attack  (Huber's 
case),  raise  a  doubt  in  our  mind  concerning  the  pure  sym- 
pathetic influence,  for  it  is  doubtful  whether  we  can  explain 
this  increase  of  urine  by  sympathetic  irritation.    It  would 


April  8,  1893.] 


BODENHAMER:  DISEASES 


OF  TEE  FCETUS  IN  UTERO. 


37T 


ia  such  cases  seem  as  though  a  more  general  irritation  of 
the  medulla  existed.  On  the  other  hand,  Lehr,  as  well  as 
Dehio,  leave  the  sympathetic  entirely  out  of  the  question, 
and  take  the  position  adopted  by  many — that  regulation  of 
the  heart's  action  takes  place  exclusively  from  the  vagus 
center. 

That  the  trouble  is  not  due  to  a  lesion  of  the  pneumo- 
gastric  nerves  themselves  is  to  be  assumed  from  the  fact 
that  under  such  circumstances  the  trouble  would  be  perma- 
nent from  the  beginning  or  soon  become  so.  Nothnagel 
and  others — and  perhaps  the  majority  of  clinical  cases  point 
in  this  direction — assume  that  the  trouble  lies  in  the  vagus 
center,  and  that  we  are  not  dealing  with  a  paralysis  of  the 
vagus,  which  would  be  difficult  to  understand,  but  with  a 
paroxysmal  interruption  of  the  normal  continuous  excita- 
tion of  the  vagus,  this  being  analogous  to  the  sudden  loss 
of  consciousness  in  epileptics  or,  a  better  comparison,  to 
the  periodical  interruptions  in  the  function  of  the  central 
nervous  apparatus  of  hysterical  patients. 

Clinically  we  find  that  cases  vary  and  that  it  is  difficult, 
even  impossible,  to  say  in  a  given  case  what  nerve  influence 
is  at  fault.  All  in  all,  I  do  not  think  that  we  can  take  sides 
with  one  party  or  the  other,  but  that  we  must  be  satisfied 
with  the  explanation  that  we  are  dealing  with  a  bulbar  neu- 
rosis. Let  us  remember  the  antagonism  between  the  accel- 
erating and  inhibitory  nerves,  and  this  antagonism  becomes 
all  the  more  evident  if  we  assume  that  the  action  of  the 
accelerans  is  not  rhythmical  but  continuous,  the  same  as  that 
of  the  vagus.  Then  any  interference  with  this  opposed  action 
of  the  two  nerves,  either  one  being  temporarily  below  its 
normal  strength,  would  destroy  the  equilibrium  and  pro- 
duce a  disorder  in  the  normal  rhythm  of  the  heart. 

Certainly  the  assumption  of  a  bulbar  neurosis  explains 
all  the  symptoms  encountered  in  the  various  cases.  Some 
of  these  cases  are  exceedingly  complicated  and  can  not  be 
understood  by  any  hypothesis  which  attempts  to  more 
closely  localize  the  process.  Thus  in  a  case  described  by 
Bunzl-Federn,  in  addition  to  the  paroxysmal  tachycardia, 
there  was  paralysis  of  the  left  trochlearis,  paresis  of  the 
right  levator  palpebrarum  and  complete  immobility  of  the 
pupils  to  light,  convergence  and  accommodation,  with 
normal  fundus.  These  paralytic  symptoms  were  undoubt- 
edly neuritic  or  nuclear ;  but  if  the  tachycardia  were  due  to 
the  same  cause  it  would  necessarily  be  constant.  I  am 
able  to  report  even  a  more  instructive  case,  which  I  shall 
publish  in  extenso  at  some  future  time. 

It  is  briefly  this :  A  male  patient,  aged  forty-six,  with 
a  history  of  rheumatic  pains  (he  calls  them  so),  at  the  age 
of  forty-three,  after  years  of  excessive  worry  and  mental 
excitement,  had  an  attack  of  paroxysmal  tachycardia  which 
lasted  several  hours,  and,  from  his  description,  differed  in 
no  way  from  other  typical  cases.  lie  was  carefully  exam- 
ined at  that  time,  but  no  organic  disease  detected.  These 
tachycardiac  attacks  recurred  at  varying  intervals,  and 
lasted  from  a  few  minutes  to  several  hours.  In  some  he 
was  able  to  be  up,  while  during  others  he  was  obliged  to 
take  to  his  bed.  His  pulse  during  these  attacks,  he  says, 
was  so  fast  that  his  physician  could  not  count  it.  He  came 
to  me  at  the  age  of  forty-six  for  other  symptoms,  which 


had  come  on  during  the  preceding  three  months.  They 
consisted  in  a  diplopia  due  to  a  left  abducens  paralysis,  and 
occipital  headache.  Furthermore,  I  was  able  to  note  in- 
equality of  the  pupils  and  a  slight  bilateral  atrophy  of  the 
tongue.  His  pulse-rate  was  120  a  minute.  The  heart  and 
kidneys  were  apparently  normal.  Since  then  two  years  have 
elapsed.  lie  now  presents  a  double  abducens  paralysis, 
myosis  and  immobility  of  the  pupils,  and  marked  atrophy 
of  the  tongue,  and  his  pulse  is  never  lower  than  120,  some- 
times slightly  higher.  He  has  had  no  tachycardiac  attack 
for  nearly  three  years.  That  we  are  here  dealing  with  a 
case  of  bulbar  nuclear  degeneration  will,  I  think,  not  be 
questioned,  and  that  the  primary  tachycardiac  attacks, 
which  have  given  way  to  a  continuous  fast  pulse  of  120, 
were  the  first  symptoms  of  this  disease  is  also  certain. 
This  case,  which  now  is  one  of  organic  disease,  I  certainly 
would,  had  I  seen  it  in  the  beginning,  have  classed  as  a 
neurosis.  In  my  experience — and  the  more  I  see  the  more 
do  I  become  fortified  in  this  position — neuroses  are  often 
the  precursors  of  organic  disease.  I  have  now  under  treat- 
ment a  girl  with  all  the  symptoms  of  organic  spinal-cord 
disease  who  years  ago  was  treated  for  and  cured  of  hys- 
terical paraplegia.  The  celebrated  case  of  Charcot,  that  of 
an  old  hysterical  patient  with  long-standing  contractures,  in 
which  upon  autopsy  a  sclerosis  of  the  lateral  columns  was 
found,  and  neurasthenic  patients  who  after  a  time  become 
paretics,  are  known  to  us  all.  These  things  can  hardly  be 
coincidences.  It  seems  to  me  that  it  is  more  reasonable  to 
assume  that  organic  disease  was  a  direct  outcome  of  the 
functional  disorder. 

So  long  as  the  equilibrium  of  the  nervous  system  can 
be  re-established  after  functional  disorder,  so  long  as  repair 
outbalances  waste,  so  long  can  we  speak  of  functional  dis- 
order. As  soon,  however,  as  waste  is  in  excess  of  repair, 
so  soon  do  we  have  lesion  and  with  it  organic  disease.  So 
in  all  these  cases  of  motor  neuroses  of  the  heart,  what  to- 
day we  look  upon  as  a  pure  neurosis  may  remain  so  for  a 
period  of  time  and  then  get  well,  or  may  develop  into 
organic  disease.  Their  prognosis,  therefore,  is  not  to  be 
estimated  from  the  cardiac  symptoms  alone. 


OBSERVATIONS  UPON  THE 
LIABILITY  OF  THE  FCETUS  IN  UTERO  TO 
THE  VARIOUS  DISEASES  OF  POST-NATAL  LIFE, 

AND  ALSO  UPON  THE  GREAT  IMPORTANCE  OF  THEIR  MORE  DILIGENT  STUDT, 
WITH  A  VIEW  TO  THEIR  PREVENTION  OR  CURE. 

By  WILLIAM  BODENHAMER,  M.  D.,  LL.D. 

The  object  of  the  writer  in  selecting  this  particular 
subject  for  discussion  on  this  occasion  is  briefly  to  call 
attention  to  a  much-neglected  subject — namely,  to  that  of 
the  diseases  of  the  foetus  in  utero.  The  great  importance 
of  their  energetic  investigation  and  study  no  one  will  deny, 
for  it  relates  to  the  very  beginning  of  our  existence,  and  is 
not  inferior  in  importance  to  any  other  in  the  whole  range 
of  medical  science.  And  it  may  here  be  observed  of  the 
many  medical  works  and  medical  periodicals  of  the  day 
that,  although  they  abound  in  the  most  valuable,  able,  and 


378 


BODENHAMER:  DISEASES  OF  THE  FCETUS  IN  UTERO. 


[N.  Y.  Mkd.  Jowh., 


scientific  disquisitions,  dissertations,  and  communications 
upon  almost  every  disease,  etc.,  yet,  notwithstanding,  it 
can  still  in  truth  be  stated  that,  with  all  the  pathological  in- 
quiries of  the  day,  the  diseases  of  the  foetus  are  the  least 
studied  and  investigated,  and  consequently  are  the  least 
understood. 

In  the  consideration  of  this  very  complex  and  difficult 
subject,  the  writer  will  confine  himself  chiefly  to  the  plain 
results  of  observation,  feeling  too  incompetent  to  enter  into 
the  wide  field  of  speculation  and  conjecture  concerning  the 
hidden  processes  of  nature,  etc.,  which  it  yields,  but  the  in- 
utility of  much  of  this  is,  indeed,  already  known  and  ad- 
mitted. 

It  will  at  once  be  observed  that  this  subject,  in  all  its 
bearings,  is  too  vast  and  complicated  to  be  disposed  of  in 
a  brief  article ;  nothing  but  the  most  salient  points,  with 
the  importance  of  their  diligent  study,  can  be  strictly  ad- 
hered to  in  it,  leaving  much  to  be  sought  for  by  the  inquir- 
ing student  in  the  very  numerous  theoretical  and  hypo- 
thetical works  extant  on  this  fruitful  subject,  a  few  of 
which  will  be  named  in  the  appended  bibliography  with  the 
view  to  direct  his  inquiries  by  consulting  original  authori- 
ties. 

The  writer  wishes  it  to  be  distinctly  understood  that 
this  humble  eilort  is  only  intended  as  a  mere  prelude  to  the 
more  energetic  study  of  the  foetal  diseases,  exclusive  of  the 
congenital  abnormities,  solely  for  the  purpose  of  their  pre- 
vention or  cure  if  possible ;  and  he  hopes  that,  so  far  as 
it  goes,  it  may  be  found  useful  as  such,  and  he  further 
hopes  that  some  genius  may  arise  who  will  take  up  the 
treatment  of  foetal  diseases  in  a  complete  and  systematic 
treatise,  giving  their  nature,  causes,  pathology,  diagnosis, 
and  treatment,  and  thus  lay  the  foundation  at  once  of  mak- 
ing the  study  of  those  diseases  both  attractive  and  profit- 
able. The  only  recent  work  of  the  kind  extant,  so  far  as 
the  knowledge  of  the  writer  extends,  is  that  of  the  very  ex- 
cellent little  work  of  Mr.  Madge,  of  London,  which  was 
published  forty  years  ago,  and  to  which  the  writer  is  in- 
debted for  much  he  has  to  say  upon  this  subject. 

It  is  a  well-known  and  established  fact  that  most,  if 
not  all,  the  diseases  of  post-natal  life  may  and  do  some- 
times attack  the  foetus  in  utero  ;  that  it  is  in  danger  of 
nearly  if  not  the  whole  catalogue  of  human  maladies — con- 
stitutional, idiopathic,  epidemic,  and  accidental.  Who  has 
not  seen  some  of  these  diseases  which  accompany  the  foetus 
in  its  transit  from  intra-uterine  to  extra-uterine  life  ?  and 
who  has  not  seen  in  such  either  ascites,  hydrocephalus, 
pulmonary  lesions,  syphilitic  and  scrofulous  eruptions,  va- 
riola, hypertrophy  of  the  liver,  enteritis,  peritonitis,  proc- 
titis, preternatural  tumors,  specific  fevers,  etc.  ? 

It  is,  indeed,  just  as  well  known  that  children  may  be 
born  sick,  convalescing,  or  entirely  recovered  from  former 
disease  as  that  they  may  be  born  healthy.  It  is  therefore 
obvious  that  it  is  not  after  birth  only  that  the  infant  or  the 
adult  is  liable  to  and  experiences  for  the  first  time*a  suc- 
cession of  affections  which  may  more  or  less  afflict  him  in 
his  future  life.  The  origin  of  diseases  may,  however,  be 
traced  to  a  much  more  remote  source,  even  to  the  very  com- 
mencement of  embryotic  or  fa'tal  existence ;  and  in  such 


instances  such  diseases  or  their  consequences  may  even  ac- 
company the  foetus  into  the  world,  unless  previously  re- 
lieved. The  researches  of  Simpson,  Rokitansky,  Cruveil- 
hier,  Billard,  Velpeau,  and  others  clearly  show  that  the 
embryo  is  liable,  besides  arrest  of  development,  to  intra- 
uterine disease. 

It  may  be  proper  to  remark  here  that  Aristotle,  Hippoc- 
rates, Galen,  Celsus,  Paulus  ^gineta,  and  some  other  an- 
cients scarcely  allude  to  diseases  of  the  foetus,  but  give 
much  attention  to  the  various  foetal  vices  of  conformation 
which  they  attributed  to  the  influence  of  maternal  imagina- 
tion. 

Classification. — All  the  diseases  of  the  foetus  may,  for 
the  sake  of  convenience,  be  distinguished  into  those  which 
are  derived  from  the  parents,  those  which  originate  in  and 
are  peculiar  to  the  foetus  and  its  membranes  as  a  real  organ- 
ized entity,  and  those  which  arise  from  or  are  the  result  of 
accidents  or  other  causes. 

Diseases  transmitted  by  Both  Parents. — That  some  dis- 
eases of  either  of  the  parents  may  be  communicated  to  the 
embryo  is  a  fact  long  since  established,  and  will  not  be 
called  in  question.  The  method,  however,  through  which 
such  affections  are  imparted,  or  are  communicated  to  the 
embryo  or  foetus,  is  not  so  well  understood,  and  is  still  a 
subject  of  controversy  into  which  it  is  not  the  object  of 
this  article  nor  the  design  of  the  writer  to  enter  were  he 
ever  so  desirous  or  capable. 

Diseases  transmitted  by  the  Father. — It  was  once  the 
opinion  that  the  diseases  of  the  father  could  not  be  im- 
parted to  the  foetus,  but  it  is  now  well  known  that  the  em- 
bryo is  liable  to  inherit  the  diseases  of  both  parents.  The 
actual  diseases  transmitted  by  the  father  to  the  embryo  or 
foetus  through  the  ovum  are  syphilis  and  scrofula,  which 
develop  and  manifest  themselves  during  intra-uterine  life. 
The  exact  method,  however,  in  which  the  syphilitic  virus 
finds  its  way  into  the  constitution  of  the  foetus  is  a  ques- 
tion to  which  as  yet  no  satisfactory  answer  has  been  given 
and  over  which  great  obscurity  still  hangs.  The  student, 
however,  should  read  on  this  particular  subject  the  very 
able  memoir  of  the  French  professor,  M.  Depaul. 

It  has  been  proved  that  men  broken  down  in  health  by 
dissipation  and  debauchery,  when  married  to  sound  and 
healthy  women,  were  incapable  of  procreating  living,  healthy, 
and  vigorous  children.  It  is  also  well  known  that  great  fa- 
tigue, depression,  intoxication,  etc.,  on  the  part  of  the  father, 
at  the  time  of  coition,  have  an  injurious  effect  on  the  men- 
tal as  well  as  the  bodily  development  of  the  offspring. 

Hereditary  Predisposition.  —  The  hereditary  diseases 
most  generally  exist  as  predispositions  to  disease,  which 
only  develop  and  manifest  themselves  under  favorable  cir- 
cumstances, not  in  intra-uterine,  but  in  extra-uterine  life. 
Mr.  Allen  Thomson,  as  quoted  by  Mr.  Madge,  says  that 
"haemorrhoids,  hypochondriasis,  scirrhus,  apoplexy,  hernia, 
catarrh,  amaurosis,  and  urinary  calculi  may  be  mentioned  as 
examples  of  diseases  more  or  less  directly  transmitted  as 
predispositions  from  parent  to  offspring." 

It  is  unusual  to  find  chronic  and  hereditary  affections 
of  the  parents,  with  the  exception  of  syphilis  and  scrofula, 
to  manifest  themselves  very  evidently  in  the  foetus ;  but  the 


April  8,  1893.] 


BODENEAMEE:  DISEASES  OF  THE  FCETUS  IN  UTERO. 


379 


chronic  affections,  without  being  hereditary,  may  so  affect 
the  foetus  in  utero  as  to  deprive  it  of  healthy  sources  of  nu- 
trition, and  in  this  manner  induce  or  generate  debility  and 
disease. 

Professor  Hirschfeld,  of  Leipsic,  on  The  Predisposi- 
tion to  Tuberculous  Infection,  says :  "  Inherited  predis- 
position is  strengthened  by  the  fact  that  up  to  the  present 
time  the  evidence  of  the  direct  consequence  of  the  disease 
from  mother  to  foetus  in  utero  has  not  been  well  established 
in  the  human  species,  although  undoubted  instances  have 
been  reported  as  occurring  among  certain  animals.    He  re- 
lates a  case  in  which  a  foetus  was  removed  from  the  uterus 
of  a  woman  aged  twenty-three  years,  within  a  few  minutes 
after  her  death  from  general  tuberculosis,  without  any  dam- 
age being  done  to  the  placenta.   Portions  of  the  liver,  spleen, 
and  kidney  of  the  foetus  produced  tuberculous  disease  when 
inoculated  into  rabbits  and  guinea-pigs,  but  only  in  the  cap- 
illaries of  the  liver  could  any  tubercle  bacilli  be  discovered. 
In  the  placenta,  however,  the  villous  spaces  were  crowded 
with  bacilli.    The  very  limited  evidence  of  tuberculous  ma- 
terial in  the  foetus  might  serve  as  an  explanation  of  the  fact 
that  children  of  tuberculous  parents  are  often  born  without 
any  manifestations  of  tuberculous  disease  during  the  first 
few  years  of  life.    A  limited  infection  by  the  maternal  ba- 
cilli, perhaps  during  the  process  of  birth,  might  remain  la- 
tent in  one  or  more  organs  until  other  circumstances  con- 
tribute to  their  development.    It  is  thus  possible  that 
confusion  may  exist  between  '  latent  tubercle  '  and  '  tuber- 
culous predisposition.'     That  latent  tubercle  may  remain 
quiescent,  especially  in  bronchial  glands,  until  awakened  by 
an  attack  of  acute  disease,  such  as  measles  or  whooping- 
cough,  is  well  known.    The  frequent  occurrence  of  such  la- 
tent tuberculous  foci  without  any  other  evidence  of  tubercu- 
lous disease  goes  far  to  prove  that  resistance  to  tubercle  is 
as  powerful  a  factor  as  predisposition.    The  congestive  in- 
fluences of  valvular  disease  of  the  heart  and  emphysema 
upon  the  connective  tissues  of  the  lungs  are  examples  of 
some  of  the  mechanical  causes  which  constitute  resistance  " 
(^Medical  Record,  October  10,  1881,  p.  452.    From  Wiener 
medizinische  Wochenschrift). 

Maternal  Diseases  affecting  the  Foetus. — Any  disease 
whatever  which  affects  the  mother  will,  as  a  general  rule, 
more  or  less  affect  the  foetus  in  utero  ;  indeed,  every  dis 
ease,  either  acute  or  chronic,  attacking  the  mother,  by  dis- 
turbing and  deranging  the  uterine  functions  must  conse- 
quently affect  the  foetus,  but  it  does  not  always  result  in  the 
destruction  of  the  foetus,  as  many  examples  could  here  be 
given  to  prove  the  contrary.  The  maternal  diseases  or  pre- 
dispositions to  disease  which  may  affect  or  be  communicated 
to  the  foetus  are  either  acute  or  chronic,  or  the  mechanical 
pressure  upon  the  foetus  by  abnormal  growths  in  the  pelvis. 
In  protracted  cases  of  acute  disease  of  the  mother,  in  which 
the  sources  of  nutrition  are  exhausted  or  dried  up,  the  effect 
upon  the  foetus  must  consequently  be  serious,  if  not  fatal. 
In  many  of  the  acute  or  the  chronic  diseases  of  the  mother 
it  is  often  difficult  to  determine  positively  whether  the  dis- 
ease of  the  foetus  in  such  a  case  is  the  result  of  the  genera) 
disturbance  of  the  mother,  or  whether  the  foetus  is  affected 
by  the  very  same  disease  of  the  mother.    It  may  be  proper 


to  remark  here  that  there  is  a  question  among  authors 
whether  the  foetus  in  utero  is  injuriously  affected  or  not  by 
the  scanty,  poor  living,  and  bad  nourishment  of  the  mother. 
While  some  maintain  the  former — that  such  condition  of 
the  mother  must  necessarily  exert  a  pernicious  influence 
upon  the  health  of  the  foetus — others  again  assert  that  it 
is  not  uncommon  among  the  lower  classes  to  find  sickly  and 
half-starved-looking  women  giving  birth  to  plump,  vigor- 
ous, and  healthy  children.  Mr.  Denman  says  that  he  found 
that  women  who  emaciated  during  pregnancy  bring  forth 
healthier  children  and  have  easier  labors  than  others,  while 
with  those  who  grow  corpulent  the  children  are  generally 
small  [A  Collection  of  Engravings  tending  to  Illustrate  the 
Generation  and  Parturition  of  Animals  and  of  the  Human 
Species,  folio,  London,  1Y87).  Mr.  Ramsbotham  considers 
that  no  system  of  diet  of  the  mother  would  have  any  effect 
in  controlling  the  growth  of  the  foetus  in  utero  [The  Prin- 
ciples and  Practice  of  Obstetric  Medicine  and  Surgery,  p.  296, 
8vo,  London,  1841). 

Diseases  which  originate  in  the  Foetus  itself. — Can  it  be 
said  to  a  certainty  that  some  of  the  diseases  of  the  foetus 
in  utero  originate  in  primary  disease  in  its  own  structures  ? 
Can  it  be  maintained  that  the  foetus — with  its  external  in- 
tegument, its  bony  fabric,  its  internal  conformation  of  vis- 
cera, muscles,  arteries,  veins,  nerves,  etc. — is,  strictly  speak- 
ing, not  a  part  of  the  maternal  system,  but  is  in  itself  an 
independent  organism,  liable,  like  the  various  organs  of  our 
bodies,  to  its  own  derangements  and  diseases  ?    And  can  it 
also  be  affirmed  that  the  foetus  in  utero  has  its  own  princi- 
ple of  life  independent  of  the  mother  ?    These  rital  ques- 
tions, the  writer  believes,  may  be  safely  answered  in  the 
affirmative.    Who  will  deny  that  the  diseases  which  are 
epidemic  or  contagious  do  not  attack  the  mother  and  the 
foetus  as  independent  entities  ?    The  foetus  may  be  attacked 
and  die,  while  the  mother  may  escape,  or  vice  versa.  For 
instance,  it  is  a  well-known  fact  that  when  Asiatic  cholera, 
prevailing  as  an  epidemic,  attacks  the  mother,  the  foetus  but 
seldom  escapes  ;  but  it  is  not  always  certain  how  it  is  affect- 
ed, whether  by  the  terrible  disease  itself  or  by  the  exhausted 
state  of  the  mother.    What  is  very  remarkable,  however, 
it  is  also  well  known  and  stated  upon  the  best  authority 
that  during  an  epidemic  of  cholera  the  foetus  has  been  de- 
stroyed by  the  disease  while  the  mother  has  escaped  it  alto- 
gether.   This  is  a  positive  evidence  of  the  independent 
liability  of  the  foetus  to  epidemical  diseases.    It  is  stated 
upon  the  authority  of  Mr.  Madge  that  it  has  been  observed 
that  both  the  mother  and  the  foetus,  having  intermittent 
fever  at  the  same  time,  the  paroxysms  in  the  foetus  have 
been  found,  by  tumultuous  movements  in  the  uterus,  not  to 
correspond  with  those  of  the  mother,  so  that  one  may  have 
a  quotidian  and  the  other  a  tertian,  or  both  may  have  the 
same  type  of  the  disease,  with  paroxysms  showing  them- 
selves on  different  days.    In  the  Edinburgh  Medical  Jour^ 
nal  of  June,  1889,  Dr.  Felkin  relates  two  cases  in  which  he 
observed  malarial  paroxysms  in  the  fa'tuses  of  healthv 
women.     He   suggests   the  rather  striking  explanation 
that  the  malarial  poison  was  introduced  in  the  semen 
of  the  diseased  father  at  the  time  of  conception  o£  the 
foetus. 


kl 


380 


BODENIIAMER:  DISEASES 


OF  THE  F(ETUS  IN  UTERO. 


[N.  Y.  Mkd.  Joub., 


In  one  of  the  two  cases,  the  mother,  an  Entjlisli  hidy  more 
than  eight  months  pregnant  with  her  first  cliild,  fonsulted  him 
for  "  pain  and  a  curious  sensation  in  her  abdomen."  Slie  said 
••■she  had  Lad  several  such  attacks  during  her  pregnancy,  but 
they  had  never  been  accompanied  by  pain.  The  attack  was 
sudden.  On  palpating  her  abdomen.  Dr.  Felkin  distinctly  felt 
the  foetus  shaking.  The  next  niglit,  and  again  the  next 
the  same  thing  occurred  at  the  same  hour.  On  the  fourth 
night  he  found  her  again  in  the  same  condition.  Labor  had  set 
in,  the  head  presenting  at  the  dilated  mouth  of  the  womb.  As 
the  pains  became  feeble  and  progress  ceased,  he  put  on  the  for- 
ceps and  easily  delivered  the  head.  The  body  was  extracted 
with  difficulty,  on  account  of  the  great  distention  of  the  abdo- 
men by  an  enlarged  spleen.  The  child  lived,  and,  after  seven 
attacks  of  ague,  with  cold,  hot,  and  sweating  stages,  recovered 
health,  the  spleen  returning  to  about  its  normal  size.  The 
mother  of  this  child  had  never  suffered  from  malaria  in  any 
form  whatever;  the  father  had  experienced  very  severe  inter- 
mittent and  remittent  ague  attacks  while  living  at  a  distant 
part  of  the  country,  and  was  suffering  from  them  at  the  time 
of  the  conception  of  the  child. 

In  the  aecond  case,  a  Scotch  woman,  seven  months  and  a 
half  pregnant,  was  ill  with  pleurisy  and  bronchitis  and  the  effects 
of  a  beating  which  Ler  husband  had  given  her.  At  one  of  Dr. 
Felkin's  visits  the  nurse  told  him  that  she  had  suffered  on  the 
previous  night  from  "a  pain  and  fluttering  in  her  abdomen  like 
a  bad  quickening,"  Being  called  the  evening  of  the  same  day, 
at  the  same  hour  he  found  her  in  a  condition  very  like  that 
observed  in  the  former  case.  Two  evenings  later,  after  another 
similar  paroxysm,  labor  set  in  and  the  child  was  born  before  he 
could  reach  the  house.  Its  abdomen  was  slightly  enlarged. 
On  the  night  after  its  birth  it  had  a  cold  spell,  with  shivering, 
lasting  half  an  hour,  succeeded  by  a  hot  stage  of  two  hours  and 
a  stage  of  free  perspiration.  The  temperature  during  the  attack 
ran  up  to  102'6°  F.  On  the  second  night  after  its  birth  it  died 
in  the  cold  stage  of  a  similar  paroxysm.  On  post-mortem  ex. 
amination,  the  kidneys  showed  marked  cloudy  swellings  in  the 
epithelium  of  the  convoluted  tubules,  the  nuclei  of  the  cells  con- 
tinuing to  stain,  while  the  surrounding  protoplasm  was  highly 
granular.  The  nuclei  of  the  glomerular  cells  stained  distinctly. 
In  the  liver  many  leucocytes  were  seen  to  contain  very  numer- 
ous fine  granules  of  a  dark-brown  color.  The  venous  sinuses 
of  the  spleen  were  dilated.  Dark  pigment  granules  were  ob- 
served in  many  of  the  leucocytes  contained  in  the  sinuses,  as 
well  as  the  endothelial  cells  lining  them,  and  in  the  cells  of  the 
surrounding  connective  tissue.  The  mother  of  the  child  had 
never  suffered  from  ague.  She  had  three  healthy  children  by 
her  husband.  lie  then  went  abroad  and  contracted  severe  ma- 
larial fever.  Ten  months  after  his  return  a  feeble  child  was 
born  which  soon  died.  About  a  year  later  a  second  child  was 
born,  which  was  sickly  and  had  an  enlarged  spleen.  In  these 
two  pregnancies  the  mother  had  the  same  strange  feelings,  like 
quickening.  Dr.  Felkin  thinks  these  cases  show  that  malaria 
is  a  specific  disease,  due  to  a  micro  organism,  which  may 
be  transmitted  by  the  father  to  his  offspring  just  as  syphilis 
may  he  transmitted  (New  York  Medical  Record,  July  27, 
1889,  p.  99). 

It  is  known  that  enteritis  during  foetal  life  is  by  no 
means  an  uncommon  occurrence.  M.  Desormeaux  records 
the  case  of  a  child  that  at  birth  presented  all  the  evi- 
dences of  violent  enteritis,  but  afterward  recovered.  He  is 
of  opinion  that  the  congenital  contractions  and  obliterations 
of  hollow  canals — such  as  the  oesophagus,  intestinal  canal, 
anus,  urethra,  etc. — ought  to  be  referred  to  the  influence  of 


previous  inflammation  (IJictionnaire  de  medecine  de  Parin, 
tome  XV,  p.  40:?). 

Peritonitis  may  occur  during  ftetal  life,  and  give  rise  to 
adhesions  between  the  intestines  and  to  effusion  of  lymph 
and  serum  into  the  abdominal  cavity,  and  thus  occasion 
malformations,  if  not  the  death,  of  the  foetus.  Duges  re- 
lates the  case  of  a  new-born  child  in  whom  the  abdominal 
viscera  were  found  agglutinated  by  a  yellow- colored  and 
firm  lymph.  There  were  false  membranes  on  the  liver,  the 
spleen,  the  bladder,  etc.  The  epiploon  was  adherent  to  the 
intestines,  which  were  firmly  united  into  a  mass,  and  were 
yellow,  hard,  and  thick  [Recherches  sur  les  maladies  les  plus 
importantes  et  les  moins  connues  des  en/ants  nouveaux-nes, 
8vo,  Paris,  1821). 

Rectitis  is  known  to  have  attacked  the  fffitus  in  utero, 
and  to  have  resulted  in  a  convalescence  of  the  parietes  of 
the  rectum. 

Proctitis  (inflammation  of  the  anus)  is  frequently  ob- 
served in  new-born  children.  The  writer  himself  has  seen 
several  such  cases,  which  were  evidently  the  result  of  pre- 
vious inflammation. 

Other  instances  of  the  effects  of  former  inflammation  in 
the  intestines  of  newly-born  children  are  related  by  the  fol- 
lowing authors : 

M.  Billard  {Traite  des  maladies  des  en/ants  nouveaux-nes 
et  a  la  mamelle,  p.  444,  8vo,  Paris,  1828). 

Cams  (Lehrbuch  der  Oynakologie,  etc.,  Band  ii,  S.  251, 
8vo,  Leipsic,  1820). 

M.  Cruveilhier  [Anatomic  pathologique  du  corps  humain, 
tome  ii,  livraison  xv,  pi.  xi,  p.  2,  Obs.  2,  folio,  Bruxelles, 
1833). 

Croup  is  known  to  attack  the  foetus  in  utero,  as  several 
German  authors  declare. 

Pertussis  is  also  liable  to  attack  the  foetus.  Mr.  Wat- 
son, in  his  Treatise  ori  the  Principles  and  Practice  of  Medi- 
cine, relates  the  following  case  of  whooping-cough  which 
he  supposed  existed  before  the  birth  of  the  child.  He 
says :  "  My  bed-maker's  daughter  in  Cambridge  had  a 
child  ill  of  whooping-cough  in  the  house  with  her  during 
the  last  week  of  another  pregnancy,  and  the  newcomer 
whooped  the  first  day  he  came  into  the  world." 

Taenia,  in  several  species,  have  been  found  in  the  intes- 
tines of  the  foetus,  and  some  authors  have  attributed  to 
them  the  convulsions  which  the  foetus  seems  sometimes  to 
experience  in  the  uterus.  Hippocrates,  Bremser,  and  Bren- 
delius  speak  of  worms  in  the  intestines  of  newly- bom  chil- 
dren. 

The  writer  has  now  enumerated  a  sufficient  number  of 
examples  of  diseases  peculiar  to  the  foetal  organism  for 
practical  purposes. 

Injuries  of  the  Foetus  the  Result  of  Accidents. — The  acci- 
dents of  the  enceinte  mother,  which  may  affect  the  health 
or  the  death  of  the  foetus,  are  blows  on  her  stomach  or  ab- 
domen, falls  on  her  nates,  or  the  various  other  falls  with 
which  pregnant  women  sometimes  meet.  The  practitioner, 
however,  will  at  once  appreciate  the  cause  and  the  charac- 
ter of  these  admitted  accidents  and  act  accordingly ;  con- 
sequently, it  is  not  necessary  to  dwell  upon  this  obvious 
subject. 


April  8,  1893.] 


BODENHAMER:  DISEASES  OF  THE  FCETUS  IN  UTERO. 


381 


Etiology. — The  {etiological  origin  or  primordial  cause 
of  some  of  the  diseases  of  the  foetus  in  utero  is  not  easy  to 
discover  ;  indeed,  it  is  difficult  soinetimdfe  to  trace  the  causes 
and  the  modus  operandi  of  some  of  the  diseases  even  of 
post  natal  life,  and  it  is  extremely  so  with  regard  to  those 
of  ante- natal  life ;  hence  these  causes  and  their  modus  oper- 
andi, although  of  the  greatest  importance,  are  not  as  well 
understood  as  they  should  be  or  might  be,  even  with  their 
attending  difficulties,  but  are  still  a  subject  of  much  specu- 
lation, and  have  been  from  time  immemorial.  It  is,  how- 
ever, of  the  highest  importance  that  the  fons  and  origo  of 
those  diseases  should,  if  possible,  be  known,  for  such  knowl- 
edge would  enable  the  practitioner  to  adopt  suitable  treat- 
ment through  the  mother,  to  arrest,  to  mitigate,  or  to  cure 
the  affection,  and  also  to  advise  proper  measures  to  avoid, 
ward  off,  or  prevent  some  of  these  diseases.  But,  to  re- 
peat, it  is  not  an  easy  matter  to  determine  sometimes  to 
what  cause  or  causes  some  of  these  diseases  of  the  foetus 
in  utero  should  be  attributed — at  a  period,  too,  when  it  is  so 
completely  protected,  as  it  were,  from  all  those  influences 
from  without  which  may  and  do  produce  such  diseases  after 
birth. 

Physical  Diagnosis. — It  may  truly  be  said  that  the  dis- 
eases of  the  foetus  in  utero  are  to  a  considerable  extent  a 
sealed  book,  as  it  were,  the  causes  of  which  may,  however, 
be  largely  owing  to  the  difficulty  attending  their  diagnosis, 
which  is  principally  derived  through  the  mother,  and  the 
reatment  of  which  must  also  pass  through  the  same  me- 
dium. Hence,  in  these  instances  our  method  of  diagnosis 
differs  entirely,  being  much  more  inconvenient,  troublesome, 
and  laborious,  for  we  can  neither  see  nor  interrogate  the  pa- 
tient himself,  to  know  or  to  tell  in  a  minute  what  the  mat- 
ter is.  Another  cause,  however,  why  the  foetal  diseases  are 
so  much  neglected,  may  be  attributed  to  a  general  as  Well 
as  a  manifest  want  of  interest  in  and  an  inclination  to  their 
study,  etc. ;  consequently  these  diseases  are,  doubtless  from 
the  several  circumstances  already  mentioned,  generally 
neglected,  and  are  only  detected  or  revealed  after  birth  ;  but 
they  certainly  are  susceptible  of  being  successfully  studied 
and  diagnosticated,  and  in  the  same  manner  as  are  the  dis- 
eases of  the  chest  and  abdomen,  and  by  the  same  measures 
— namely,  by  palpation,  percussion,  auscultation,  etc.  These 
invaluable  means,  so  greatly  improved  at  the  present  day, 
when  employed  by  an  expert  for  this  especial  purpose,  what 
might  they  not  detect  or  reveal  ? 

Upon  the  important  subject  of  the  auscultation  of  the 
foetus  in  utero  the  student  should  consult  the  very  able 
Traite  d' auscultation  du  foetus  in  utero,  by  the  French  pro- 
fessor, M.  Depaul,  and  also  the  excellent  treatise  of  Mr. 
Kennedy  {^Observations  on  Obstetric  Auscultation,  with  an 
Analysis  of  the  Evidences  of  Pregnancy,  and  an  Inquiry  into 
the  Proofs  of  the  Life  and  Death  of  the  Foetus  in  Utero,  Bvo, 
Dublin,  1833).  A  greatly  improved  edition  of  Mr.  Ken- 
J  nedy's  treatise  was  ably  produced  by  Dr.  Isaac  E.  Taylor, 
of  New  York,  some  years  ago,  but  this  emended  edition, 
not  being  now  in  the  possession  of  the  writer,  he  cited  as 
above  the  original  work,  which  was  before  him. 

Treatment. — When  any  disease  of  the  foetus  is  detected 
the  attempt  should  at  once  be  made  to  cure  or  to  mitigate 


it  through  the  mother.  At  the  present  day  there  is  quite 
sufficient  evidence  to  prove  most  positively  that  specific  and 
general  treatment  are  certainly  capable  of  reaching  the  foetus 
through  the  mother's  system;  hence,  by  administering  reme- 
dies to  the  mother,  either  per  os,  per  rectum,  by  hypoder- 
mic injection,  by  cutaneous  inunction,  etc.,  the  disease  of 
the  foetus  may  be  cured,  its  health  preserved,  and  its  life 
saved.  Upon  the  authority  of  Mr.  Madge,  M.  Moreau  re- 
lated the  case  of  an  officer  of  the  Royal  Guard  who,  after 
having  been  apparently  cured  of  an  old  syphilis,  married  a 
young  lady  in  perfect  health.  In  the  first  three  confine- 
ments which  followed,  the  children  were  dead.  The  anti- 
syphilitic  treatment  was  then  adopted,  and  the  result  was 
that  in  the  three  subsequent  confinements  the  children  were 
born  alive  and  healthy. 

Now,  at  the  present  time,  with  the  numerous  and  valu- 
able new  therapeutical  remedies,  and  their  various  scientific 
combinations  and  methods  of  application  and  administra- 
tion, now  made  so  available  to  us,  we  ought  to  be  so  much 
better  able  to  grapple  with  the  diseases  of  the  foetus  than 
were  our  predecessors  of  half  a  century  ago. 

Preventive  Treatment. — In  order  to  preserve  the  health 
and  the  life  of  the  foetus,  much  may  be  accomplished  by  the 
adoption  of  judicious  preventive  measures.  The  health  of 
both  parents  should  strictly  be  attended  to.  The  mother 
during  the  period  of  gestation  should  be  separated  from  all 
those  causes,  both  from  without  and  from  withjn,  which 
might  tend  to  disturb  and  impair  the  uterine  functions.  But 
how  seldom  is  this  attended  to  ! 

The  writer  will  now  conclude  by  repeating  the  hope  that 
the  numerous  difficulties  consequent  upon  this  subject  will 
be  ultimately  overcome,  and  that  the  diseases  of  the  foetus 
in  utero  will  form  a  part  of  strict  medical  observation  and 
practice,  for  in  point  of  interest  it  yields  ta  no  other. 

Bibliography. 

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382 


HUBBELL:  AN  ELECTRO-MAGNET  FOR  THE  EYE. 


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New  York,  December  Z2,  1892. 


AN  ELECTEO-MAGNET 
FOR  THE  EXTRACTION  OF  STEEL  FROM  THE 
INTERIOR  OF  THE  EYE. 

By  ALVIN  a.  HUBBELL,  M.  D., 

BUTFALO.  N.  Y., 
PROFESSOR  OF  OPHTHALMOLOGY  AND  OTOLOGY 
IN  THE  MEDICAL  DEPARTMENT  OF  NLAQARA  UNIVBHSITY  ; 
SirROEON  TO  THE  CHAR  TT  EYE,  BAR,  AND  THROAT  HOSPITAL; 
OPHTHALM.C  BUROBON  TO 
THE  BUFFALO  HOSPITAL  OF  THE  SISTERS  OF  CHARITY,  ETC. 

Several  forms  of  the  electro-magnet  for  the  extraction 
of  steel  from  the  interior  of  the  eye  have  been  offered  to 
the  profession  during  the  past  fifteen  years,  and  among 
them  one  which  was  made  for  me  in  1884  and  published 
in  1888.*  This  magnet  has,  at  my  suggestion,  been  re- 
cently improved  somewhat  by  George  Tiemann  &  Co.,  of 
New  York,  and,  as  it  seems  to  me  to  possess  certain  supe- 
rior advantages,  I  venture  to  call  the  attention  of  the  pro- 
fession to  it. 

In  its  new  form  the  core  is  solid  soft  iron  instead  of 
a  bundle  of  wires,  and  the  connecting  posts  are  inclosed  in 
a  hard-rubber  mold,  which  carries  a  device  or  slide  by 
which  the  electric  circuit  may  be  closed  when  the  magnet 
is  being  used,  and  opened  when  not  being  used.  The  in- 
sulated wire  surrounds  the  core  in  eight  layers,  and  this 
coil  is  incased  by  a  light,  hard-rubber  jacket. 

Some  of  the  extension  points  have  been  squared  or 
flattened  at  their  ends,  by  which  more  surface  of  contact  is 
presented  and  their  holding  power  increased.  The  accom- 
panying cut  gives  an  excellent  representation  of  the  magnet 
and  extension  points  in  actual  size  as  now  manufactured 
by  George  Tiemann  k,  Co. 

The  instrument  is  three  inches  and  a  half  in  length,  in- 
cluding the  connecting  posts,  the  body  being  two  inches 
and  seven  eighths  long ;  it  is  a  little  less  than  three  quar- 

*  Buffalo  Medical  and  Surgical  Journal,  July,  1888. 


April  8,  1898.] 


MAJOR:  NASAL  SMPTUM  KNIVES. 


383 


ters  of  an  inch  in  diameter,  and  it  weighs  three  ounces  and  I  as  to  secure  a  satisfactory  hold  on  the  outgrowth  at  its  pos- 
a  quarter.    In  power  of  attraction  it  seems  equal  to  that  of  |  terior  edge  or  margin.    A  firm  and  steady  traction  toward 

the  operator  will  in  the  majority 
of  cases  sever  the  prominence. 

A  universal  handle  arranged 
with  a  lever  and  spring  attach- 
ment can  accommodate  any  num- 
ber of  knives  varying  in  size, 
shape,  and  curvature. 

These  knives  have  been  spe- 
cially designed  for  that  class  of 
cases  in  which  a  long  crest  or 
spur  is  found  running  in  a  hori- 
zontal direction  from  before  back- 
ward along  the  lower  third  of  the 
saeptum  narium  near  the  floor  of 
the  nasal  chamber.    These  out- 
growths frequently  occupy  the  saeptum  throughout  its  en- 
tire length.     These  latter,  composed  of  bony  and  carti- 
laginous tissue,  vary  in  density  at  different  points  in  their 
course. 

Often,  owing  to  vertical  or  oblique  deflection,  the  line  of 
the  sajptum  is  somewhat  irregular ;  under  such  conditions  a 
nasal  saw  can  not  be  so  manipulated  as  to  remove  at  one 
section  this  shelf-like  prominence  throughout  its  entire 


Electro-magnet,  actual  size.  A,  A,  ends  of  cords  connecting  magnet  with  battery  ;  B,  slide  for  opening  and  closing 
electric  circuit  through  the  coil ;  C",  end  of  core  tapped  to  receive  extension  points.  Extension  points  of  dif- 
ferent sizes,  lengths,  and  shapes  are  also  shown  in  the  cut. 


the  original  one  which,  when  connected  with  an  ordinary 
single  quart-cell  battery,  was  found,  by  careful  tests,  to  sus- 
pend thirty-one  ounces  of  iron  with  an  extension  point  a 
quarter  of  an  inch  long  (measuring  from  the  face  of  the 
magnet)  and  six  thirty-seconds  of  an  inch  in  diameter  at 
its  end;  twenty- eight  ounces,  with  one  half  an  inch  long 
and  five  thirty-seconds  of  an  inch  in  diameter  ;  twenty-four 
inches,  with  one  the  same  length  and  four  thirty-seconds 
of  an  inch  in  diameter ;  and  eighteen  ounces,  with  one  the 
same  length  and  three  thirty-seconds  of  an  inch  in  di- 
ameter. 

The  power  of  attraction  diminishes  very  rapidly  as  the 
size  of  the  point  is  lessened  or  its  length  increased.  There- 
fore, in  using  the  magnet,  as  short  and  large  an  extension 
point  should  be  selected  as  is  consistent  with  the  case  in 
hand.  The  length  need  never  exceed  three  quarters  of  an 
inch.  The  points  may  be  curved  or  straight  and  of  any 
shape  desired. 

The  electric  circuit  should  always  be  opened  by  push- 
ing the  slide  toward  the  end  receiving  the  connecting 
wires  when  the  magnet  is  not  being  used,  as  the  current 
heats  the  wire  of  the  coil  if  allowed  to  pass  too  long.  The 
magnet  can  be  used  with  any  galvanic  battery  by  not  turn- 
ing on  too  strong  a  current ;  but  the  manufacturers  supply 
a  cell  suitable  for  the  instrument. 

The  size,  shape,  and  lightness  of  this  magnet,  the  form 
of  its  extension  points  and  their  close  proximity  to  the 
coil,  and  its  great  power  of  attraction,  render  it  most  con- 
venient and  reliable,  and  commend  it,  it  seems  to  me,  to 
the  purposes  for  which  such  an  instrument  is  desired. 
212  Franklin  Strebt. 


NASAL  SEPTUM  KNIVES. 
By  GEORGE  W.  MAJOR,  M.  D., 

MONTKEAL. 

The  accompanying  woodcut  will  convey  a  clear  and  defi- 
nite idea  of  the  nasal  sicptum  knives  introduced  for  the  pur- 
pose of  removing  certain  forms  of  crests  or  spurs  frequently 
met  with  on  the  nasal  saeptum. 

These  hooked  knives  (rights  and  lefts)  are  furnished  with 
a  chisel  edge  and  are  bent  on  their  s;eptal  lateral  aspect  so 


length.  The  time  necessarily  consumed  in 
making  several  cuts  with  the  saw  is  considera- 
ble, while  the  view  of  the  operator  is  also  ob- 
structed by  the  bleeding  consequent  on  the 
first  wound. 

The  whole  crest  may  be  removed  at  one 
sweep,  if  a  properly  selected  knife  is  in  the 
hand  of  one  experienced  in  its  use,  in  a  few  seconds  with- 
out pain,  while  the  whole  procedure  is  under  full  control  of 
the  eye  of  the  surgeon. 

The  operation  is  so  speedily  performed  that  bleeding 
does  not  occur  until  after  the  section  is  complete. 

Some  skill  is  requisite  in  the  use  of  these  sseptal  knives, 
and  if  suitable  cases  for  operation  are  selected  the  results 
will  be  satisfactory. 

In  nervous  persons  where  the  use  of  a  saw  or  trephine 
is  occasionally  difficult  and  sometimes  impossible,  these 
knives  will  supply  a  long-felt  need,  in  that  the  operation 
may  be  performed  before  the  patient  is  aware  of  any  at- 
tempt at  interference. 

In  the  cases  of  dense  pyramidal  outgrowths  of  bone  of 
almost  ivory  hardness,  found  so  frequently  on  the  vomer 
near  its  posterior  margin,  these  knives  are  not  at  all  applica- 
ble.   Recourse  must  be  had  to  the  slow  process  of  sawing. 

These  instruments  should  be  constructed  of  very  good 
material,  as  the  strain  upon  the  hook  is  sometimes  consider- 
able, and  it  is  essential  that  they  should  not  be  too  bulky. 
The  i)oint  of  the  knife  should  be  hlunt,  so  as  not  to  wound 


384 


KENNEDY:   OPIUM  INEBRIETY. 


[N.  Y.  Mkd.  Jour., 


should  the  knife  slip  on  traction,  and  the  shaft  should  be  so 
thin  through  from  above  downward  as  to  be  readily  passed 
between  the  crest  and  the  floor  of  the  nasal  chamber. 


OPIUM  INEBRIETY. 

CASE  TREATED  WITH  CODEINE. 
By  J.  H.  KENNEDY,  M.  D., 

ABERDEEN,  HD. 

Me8.  a.,  aged  thirty-seven,  two  children,  youngest  one 
month  old,  consulted  me  September  22,  1892,  regarding  her 
opium  habit,  she  having  used  opium  in  some  form  several  years. 

It  was  first  given  when  she  was  sixteen  years  old  by  a  phy- 
sician, himself  addicted  to  it,  used  irregularly,  and  during  the 
past  six  years  taken  steadily,  reaching  two  ounces  of  laudanum 
daily. 

Her  ancestral  record  was  faulty,  and  her  physical  condition 
bad.  She  told  a  story  of  long  suffering  from  articular  rheuma- 
tism, neurasthenia,  neuralgia,  dyspepsia,  and  middle-ear  disease. 
What  with  her  damaged  physique  and  post-puerperal  status, 
the  outlook  for  success  in  treatment  was  not  brilliant,  but  it 
was  begun  by  giving  a  grain  of  morphine  four  times  daily  in 
lieu  of  laudanum,  which  she  could  not  longer  retain.  In  three 
weeks  this  was  reduced  to  four  eighth-grain  doses  a  day. 
Meantime  she  had  taken  a  triple  tonic — quinine,  strychnine, 
and  arsenic— with  coca  wine,  and  forced  feeding  of  most  nutri- 
tious food,  all  of  which,  however,  did  not  prevent  decided 
reflex  reaction. 

At  this  juncture  I  asked  the  advice  of  Dr.  Mattison,  of 
Brooklyn,  whose  experience  specially  fitted  him  to  give  counsel 
in  a  case  like  mine.  He  gave  me  prompt  reply,  and  in  accord 
therewith  my  patient  was  at  once  placed  on  half-grain  doses  of 
codeine  sulphate  morning,  noon,  night,  and  bedtime,  continuing 
the  tonic  and  full  feeding,  with  massage  and  as  much  open-air 
exercise  as  possible  without  fatigue. 

In  a  week  the  noon  dose  of  codeine  was  omitted ;  in  an- 
other week  the  night  one ;  after  the  third  week  the  morning 
portion ;  and  at  the  end  of  the  fourth  week  that  at  bedtime. 
Bromide  of  sodium,  twenty  to  thirty  grains,  once  or  twice 
daily,  was  sometimes  used,  and  for  the  insomnia  twenty  to 
thirty  grains  of  sulphonal  worked  well.  The  epigastric  "gone- 
ness" was  relieved  by  a  drachm  or  two  of  alcohol  in  hot  milk, 
and  for  the  morphine  craving,  which  at  times  was  marked, 
nitroglycerin  in  hundredth-grain  tablets  on  the  tongue,  hourly, 
three  or  four  times,  was  used  with  success.  Improvement  per- 
sisted, and  in  seven  weeks  the  patient  had  gained  ten  pounds, 
looked  several  years  younger,  and  said  she  felt  like  her  old- 
time  self. 

Five  months  have  gone  since  the  last  dose  of  morphine  was 
given,  and  Mrs.  A.'s  health  is  much  improved,  despite  domestic 
snrroundings  not  well  fitted  to  enhance  a  good  result. 

This  case  was  highly  unpromising.  The  patient's 
physical  condition  was  much  impaired,  her  morale  dam- 
aged, and  her  environment  not  conducive  to  success ;  yet 
against  all  these  drawbacks  success  was  secured. 

I  am  of  the  opinion  that  had  more  time  been  taken  for 
the  morphine  reduction,  the  attendant  nervous  discomfort 
would  have  been  largely  lessened,  and  should  a  similar  case 
present  I  would  make  the  rate  of  decrease  not  more  than 
half  a  grain,  and  even  less,  a  week. 

There  is  no  doubt  that  the  lowered  general  health  of 
this  patient  was  a  decided  bar  to  rapid  withdrawal.  Festina 


lente  is  the  rule  that  should  obtain  where  the  inroads  along 
somatic  lines  are  marked ;  but  when  the  reverse  condition 
presents,  total  abstinence  from  opium  can  be  reached  and 
normal  sleep  secured  under  the  codeine  treatment,  it  is  said, 
in  from  four  to  six  weeks. 

There  is  no  question  as  to  the  good  of  codeine  in  these 
cases,  and  its  advent  in  the  treatment  of  morphinism  marks 
a  decided  advance  in  the  cure  of  this  disease. 
February  S7,  1893. 


SPONTANEOUS  CURE  OF 
A  PAPILLOMA  OF  THE  NASAL  _  SEPTUM. 
By  JOHN  DUNN,   M.  D., 

RICHMOND,  VA. 

In  February,  1891,  I  was  consulted  by  Mr.  W.,  aged  thirty^ 
in  regard  to  a  nervous  twitching  of  the  right  eyelid.  In  ex- 
amining the  nasal  cavities  to  see  if  I  could  find  any  condition 
that  might  serve  as  a  probable  cause  of  this  affection,  I  found 
on  the  left  side  of  the  cartilaginous  saeptum,  at  its  inferior  por- 
tion, near  the  floor  of  the  nose,  about  three  quarters  of  an  inch 
from  the  nasal  entrance,  a  papilloma.  In  size  it  was  about  as 
large  as  the  common  white  bean.  Its  surface  resembled  an  or- 
dinary skin  wart  that  had  "gone  to  seed,"  except,  of  course, 
that  it  was  softer  and  had  the  pinkish  color  that  the  mucous 
membrane  would  naturally  give  it.  Mr.  W.  had  noticed  it  about 
three  months  previously,  but,  as  it  gave  him  no  especial  incon- 
venience, he  paid  no  attention  to  it.  It  itched  occasionally,  and 
would  bleed  if  he  rubbed  it  too  hard.  He  declined  to  have  it 
removed.  In  February,  1893,  Mr.  W.  a  second  time  came  to 
consult  me.  In  examining  his  nose,  I  found  that  there  was  no 
trace  of  the  papilloma  to  be  seen.  I  asked  Mr.  W.  if  he  had  had 
it  removed.  He  replied  that,  about  three  months  after  he  had 
seen  me,  he  was  one  day  rubbing  the  growth  in  his  nose  with 
the  tip  of  his  little  finger  and  the  growth  "  fell  off',"  since  which 
time  he  bad  experienced  no  trouble  with  it. 

Nasal  papillomata  are  comparatively  rare.  Mackenzie 
says  [Diseases  of  the  Nose  and  Throat,  p.  265) :  "  I  have 
met  with  only  live  undoubted  examples  of  intranasal  papil- 
loma." Bosworth  [Diseases  of  the  Nose  and  Throat,  Part  I, 
p.  422) :  "My  own  records  include  something  over  two 
hundred  cases  of  benign  tumors  of  the  nose,  but  one  of 
which  was  a  case  of  papilloma."  A  few  other  cases  have 
been  reported.  The  point  of  interest  in  connection  with 
the  above-reported  case  was  the  spontaneous  separation, 
thereby  showing  the  relation  between  this  form  of  intra- 
nasal papilloma  and  the  ordinary  skin  warts.  And  this  fact 
may  further  explain  why  so  few  of  these  growths  come  un- 
der observation.  In  Mr.  W.'s  case  there  was  no  apparent 
accompanying  nasal  afl:'ection  which  might  have  acted  as  a 
determining  factor  in  the  causation  of  this  papilloma.  Nor 
would  this  case  have  come  under  observation  had  there  not 
supervened  an  annoying  twitching  of  the  eyelid,  with  which 
the  presence  of  the  papilloma  in  the  nose  had  nothing 
to  do. 


The  Kings  County  Medical  Association. — The  next  meeting  of  t\m 

society  will  be  held  on  the  11th  inst.  The  subject  to  be  discussed  will 
be  the  medical  care  of  inebriates,  to  be  opened  with  a  paper  by  Dr.  C. 
F.  Barber  and  continued  with  papers  or  remarks  by  Dr.  L.  D.  Ma.«on, 
Dr.  J.  C.  Shaw,  and  others. 


l|     April  8,  1893,J 


LEADING  ARTICLES. 


385 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Applbtom  i&  Oo.  Frank  P.  Foster,  M.  D. 

- 

NEW  YORK,  SATURDAY,  APRIL  8,  1893. 


I  THE  LESIONS  AND  SYMPTOMS  OF  CATARRHAL  PNEUMONIA. 
At  the  meeting  of  the  Section  in  Paediatrics  of  the  New 
York  Academy  of  Medicine,  on  March  9th,  Dr.  Francis  Dela- 
field,  speaking  upon  the  pathology  of  catarrhal  pneumonia,  re- 
ferred to  the  close  dependence  of  the  symptoms  of  that  disease 
upon  the  lesions.    He  said  that  it  was  a  well-recognized  fact 

j  that  the  ordinary  form  of  that  disease  in  children  was  catar- 
rhal.   In  adalts  the  lobar  form  was  the  rule,  broncho-pneu- 

I    monia  being  the  exception,  while  in  adolescents  both  catarrhal 

I    and  lobar  pnenmonia  were  frequent.    It  had  been  satisfactorily 

I  proved  that  the  same  germ  was  concerned  in  primary  broncho- 
pneumonia and  lobar  pneumonia.  In  secondary  pneumonia  a 
streptococcus  was  commonly  the  exciting  cause.    The  lesions 

I  observed  in  broncho-pneumonia  were  of  two  distinct  sorts, 
essential  and  accessory.  The  essential  lesions  were  few  in  num- 

I    ber.    The  inflammation  present  in  broncho-pneumonia  involved 

\  the  walls  of  the  bronchioles  and  the  air  spaces  immediately  sur- 
rounding them.  It  was  necessary  for  a  complete  understand- 
ing of  pneumonia  as  it  appeared  in  the  child  that  the  difference 
between  these  lesions  should  be  fully  appreciated.  Its  most 
characteristic  feature  was  the  fact  that  it  was  not  only  exuda- 
tive, but  productive  in  character.  Formation  of  new  tissue  was 
the  invariable  result  of  this  kind  of  inflammation.  Of  the  vari- 
ous accessory  lesions,  general  catarrhal  bronchitis  was  the  most 

I  frequent  and  important.  It  was  hard  to  do  away  with  the  idea 
that  catarrhal  pneumonia  could  be  present  without  bronchitis, 
but  that  was  the  fact.  Consolidation  of  lung  tissue  due  to  exu- 
dative pneumonia  was  also  an  accessory  lesion.  Atelectasis 
was  frequently  present  in  limited  areas,  but  was  by  no  means 
essential  to  the  disease.    The  same  was  also  true  of  fibrin  on 

j  the  pleura  and  dilatation  of  the  bronchi.  Infiltration  of  the 
bronchial  glands  was  also  a  frequent  but  not  an  essential  lesion. 
One  or  all  of  these  accessory  lesions  might  be  present  in  any 
case.    In  rare  instances  the  essential  lesions  only  were  present. 

The  physical  signs  in  the  course  of  the  disease  could  be  ex- 
plained in  a  striking  way  by  a  study  of  the  lesions.  If  the  es- 
sential lesions  only  were  present,  the  only  sign  of  pneumonia 

!    would  be  rapid  and  im[)erfect  breathing.    RMes  and  consolida- 

'  tion  would  not  be  present.  Most  physicians  were  willing  to 
acknowledge  this  fact  theoretically,  but  practically  the  average 

[  physician  was  not  satisfied  with  his  diagnosis  until  he  observed 
r&les  and  evidences  of  consolidation.  If  accessory  lesions  were 
also  present,  tiio  signs  and  symptoms  were  modified  according- 
ly. When  fibrin  was  present,  crepitant  rftles  would  be  heard  ; 
if  bronchitis,  moist  rilles;  if  consolidation  had  occurred,  bron- 
chial breathing  and  dullness  would  be  detected.  If  the  con- 
solidation was  diffuse,  physical  signs  might  be  lacking  for  days 


or  weeks.  An  exudative  inflammation  tended  to  rapid  recov- 
ery; a  productive  inflammation  was  slow  and  lingering,  and 
complete  recovery  did  not  quickly  take  place.  This  was  the 
history  of  croupous  and  catarrhal  pneumonia.  The  one  was 
rapid  in  its  cour.se,  and  recovery  was,  as  a  rule,  complete.  The 
other  was  slow  in  its  course,  and  was  not  infrequently  followed 
by  a  partial  recovery.  Cough  and  expectoration  continued 
long  after  the  active  symptoms  had  disappeared,  while  the 
physical  signs  persisted  in  the  chest,  owing  to  the  formation  of 
connective  tissue. 

Dr.  J.  E.  Winters  referred  to  the  fact  that  the  early  diag- 
nosis of  pneumonia  in  young  children  must  usually  be  made  by 
rational  symptoms  rather  than  by  physical  signs.  The  disease 
was  almost  invariably  secondary  to  bronchial  catarrh,  and 
when  the  diagnosis  of  capillary  bronchitis  was  made  pneumonia 
was  already  present.  Physical  examination  of  the  chest  during 
the  first  few  days  was  usually  of  but  little  assistance.  It  was 
common,  however,  to  find  very  fine  rales  over  limited  areas 
long  before  evidence  of  consolidation  could  be  elicited.  Of  the 
rational  symptoms,  the  cough  was  one  of  the  first  evidences  of 
pneumonia.  It  was  inclined  to  change  from  the  ordinary 
cough  of  bronchitis  to  a  short,  hard,  dry  hack,  and  was  fre- 
quently painful.  If  the  child  feared  to  cough  or  appeared  to 
have  pain  when  coughing,  it  was  suggestive  of  pneumonia.  In- 
creasing elevation  of  temperature  was  also  an  important  symp- 
tom. The  respiration  frequently  became  distinctive,  the  in- 
spiration and  the  expiration  being  prolonged  and  often  sighing. 
The  respiration  was  labored  in  its  character,  and  recessions  at 
the  base  of  the  chest  usually  occurred.  The  child  was  uncom- 
fortable when  lying  down  and  insisted  upon  being  raised  erect. 
Apathy  and  listlessness  were  very  characteristic  of  pneumonia. 
A  child  who  had  resisted  examination  would  become  passive 
and  examination  could  be  made  with  readiness.  A  careful  his- 
tory should  be  elicited  in  every  suspected  case,  and  often 
proved  of  great  assistance  in  reaching  a  diagnosis. 


THE  RADICAL  CURE  OF  INGUINAL  HERNIA. 

Dr.  William  S.  Halsted,  professor  of  surgery  in  the  Johns 
Hopkins  University,  gives,  in  the  Bulletin  of  the  Johns  HopMns 
Hospital  for  March,  an  account  of  the  first  eighty-two  cases  of 
hernia  operated  on  at  the  hospital.  The  operation  for  the  radi- 
cal cure  of  inguinal  hernia  performed  by  him  was  that  described 
by  him  more  than  three  years  ago  in  the  first  number  of  the 
Bulletin.  The  description  of  the  operation  of  Bassini,  of  Padua, 
nearly  identical  with  Dr.  Ilalsted's,  was  published  six  or  eight 
months  later.  Bassini's  article  included  a  report  of  two  hun- 
dred and  fifty  operations  with  only  seven  relapses  and  only  one 
death  (on  the  fifteenth  day,  by  pneumonia,  and  after  the  wound 
had  \\Q&\&<X  j)er  primum).  The  points  of  ditferenco  between  the 
two  procedures  are  chiefly  in  the  manngement  of  the  spermatic 
cord.  Bassini  theoretically  seeks  to  re-establish  tlie  inguinal 
canal,  through  the  middle  of  which  the  cord  passes.  Halsted 
looks  upon  such  a  theoretical  purpose  as  a  kind  of  limitation  of 
the  operation,  since  it  is  not  always  best  to  transmit  the  cord 


386 


MINOR  PARAGRAPHS. 


[N.  Y,  Mbd.  Jouk., 


through  the  so-called  new  "  internal  ring."  The  point  at  which 
the  author  gives  exit  to  the  cord  is  governed  by  the  state  of  the 
muscular  walls  at  or  near  the  internal  abdominal  ring.  If  the 
walls  in  that  locality  are  attenuated  and  present  thin  edges,  the 
transplantation  is  better  made  lower  down.  Halsted  also  seeks 
to  reduce  the  size  of  the  cord  by  excision  of  the  superfluous 
concomitant  veins.    This  is  not  an  object  in  Bassini's  operation. 

During  three  years  and  a  half  since  the  opening  of  the  Johns 
Hopkins  Hospital,  Dr.  Halsted  and  his  associates  have  had 
eighty-two  radical  operations  for  hernia  and  no  deaths.  Sixty- 
four  of  the  patients  were  males,  and  all  had  inguinal  hernia 
save  one.  Halsted's  operation,  with  or  without  modification, 
was  performed  on  fifty-eight  patients.  When  the  wound  has 
healed  by  first  intention  in  these  cases  there  has  been  no  recur- 
rence. When  the  wound  has  suppurated,  it  has  been  laid  open 
immediately  and  allowed  to  heal  by  granulation.  The  number 
of  recurrences,  where  this  latter  condition  has  obtained,  lias 
been  six;  not  all  the  cases  could  be  traced  in  order  to  ascertain 
their  later  condition;  not  all  have  been  performed  at  a  sufli- 
ciently  remote  date  to  furnish  undeniable  data  of  success  or  the 
want  of  it ;  not  all  of  the  wounds  openly  treated  have  been  the 
occasion  of  failure  to  relieve  the  patient.  Of  five  of  the  Ynales 
who  were  operated  on  by  Dr.  Brockway  by  the  McBurney 
method,  two  are  known  to  have  had  recurrences.  The  time 
has  now  come,  thinks  Dr.  Halsted,  when  the  surgeon  can  speak 
more  confidently  of  his  hernial  work  and  may  use  the  word 
"cure"  in  regard  to  that  more  fortunate  series  of  cases  where 
the  wound  heals  kindly  and  by  first  intention.  To  have  been 
able  to  record  eighty-two  reconstructive  abdominal  operations 
without  one  fatal  accident  is  no  mean  accomplishment.  It  is 
a  feat  creditable  alike  to  the  surgeons  and  to  their  rising  insti- 
tution. As  to  the  question  of  what  the  number  of  undeniable 
successes  in  the  series  was,  more  time  is  required  to  take  the 
count;  but  it  is  not  too  early  to  predict  that  the  proportion  of 
successes  will  prove  to  be  a  high  one. 


MINOR  PARAGRAPm. 

THE  REMOVAL  OF  A  TUMBLER  FROM  THE  VAGINA. 

In  the  Wiener  hliniscJie  Wochemchrift  for  March  2d  Dr.  V. 
Bazzanella,  of  Innsbruck,  relates  the  case  of  a  woman,  forty- 
four  years  old,  the  mother  of  three  children,  to  wliom  he  was 
called  in  August,  1892,  on  account  of  severe  sacral  pains  that 
had  come  on  suddenly  after  a  mountain  tour.  He  found  that 
her  vagina  harbored  a  drinking-glass,  and  she  told  him  that  it 
had  been  placed  there  ten  years  before  by  her  husband,  who, 
being  about  to  obtain  a  divorce,  was  resolved  that  no  other 
man  should  have  connection  with  her.  When  she  hud  carried 
the  glass  for  about  four  years  a  physician  tried  to  remove  it, 
but  failed.  Dr.  Bazzanella  found  its  mouth  situated  al)out  two 
centimetres  within  the  iutroitus  vagina  and  its  base  lying 
against  the  cervix  uteri.  There  was  a  dirty,  foul  discharge 
from  the  vagina,  and  some  foetid  gas  escaped  during  the  ex- 
amination. Projecting  into  the  glass  there  was  a  granular, 
fungous,  turnor-like  outgrowth  from  the  vagina.  This  was 
crushed  away,  and  then  the  glass  was  extracted  with  a  small 
obstetrical  forceps  between  the  blades  of  which  a  napkin  was 


stuffed  in  such  a  fashion  as  to  include  the  fragments  in  case  the 
glass  should  break.  The  vagina  was  irrigated  and  drained  with 
strips  of  iodoform  gauze  for  a  few  days,  and  the  patient  was 
then  able  to  be  out  of  bed.  Several  superficial  ulcerations  of 
the  vaginal  wall  had  been  found,  and  perforation  of  the  recto- 
vaginal or  vesico-vaginal  sajptum  was  thought  to  have  been 
imminent  at  the  time  the  glass  was  removed.  The  glass  was 
eight  centimetres  in  height,  and  measured  seventeen  centime- 
tres and  a  half  in  circumference  at  its  base  and  twenty  centi- 
metres and  a  half  at  its  top. 


INTESTINAL  WORMS. 

It  has  been  said  that  the  ideas  of  some  i)liy8ician8  upon  dis- 
eases of  children  are  summed  up  in  three  terms — teething, 
worms,  and  water  on  the  brain.  The  first  of  these  has  in  recent 
years  been  relegated  to  a  position  of  minor  importance  in 
aetiology,  and  the  second  has  fallen  sadly  into  disrepute.  It  is 
possible  that  in  former  times  intestinal  worms  were  more  preva- 
lent than  at  present.  In  some  regions,  perhaps,  they  are  still 
prevalent,  but  in  New  York  they  are  so  infrequently  seen  as  to 
cause  much  wonder  that  they  should  have  attained  so  much 
importance  in  public  estimation.  It  is  certainly  a  fact  that 
proprietary  vermifuges  still  have  a  very  large  sale.  In  the 
Lancet  for  February  11th  Dr.  Henry  Alston  vigorously  combats 
the  doctrine  that  worms  cause  death  by  refiex  irritation.  lie 
points  out  the  necessity  of  excluding  various  pathological  condi- 
tions and  of  examining  the  brain  before  the  idea  of  reflex  irritation 
from  worms  can  be  rationally  accepted  in  any  given  case.  The 
difficulties  surrounding  a  belief  in  reflex  irritation  from  this  cause 
are  numerous.  Only  by  a  careful  autopsy  could  it  be  proved 
that  such  irritation  of  the  intestinal  tract  had  not  been  caused 
by  scybala  or  foreign  bodies.  Strong  purgative  medicines  con- 
gest and  irritate  the  intestinal  mucous  membrane  to  an  extreme 
degree,  but  death  from  reflex  action  does  not  follow.  In  intus- 
susception also  great  irritation  of  the  mucous  membrane  occurs, 
but  reflex  convulsions  are  not  the  cause  of  death.  We  should 
expect  that  diarrhoea  would  be  a  marked  symptom,  but  consti- 
pation is  very  frequent,  perhaps  the  rule.  Opinions  difl'er  as  to 
the  number  of  worms  required  to  produce  serious  results. 
Certainly  the  passing  of  one  or  two  worms  should  not  be  con- 
sidered sufiicient  explanation  for  serious  digestive  disturbances 
or  nervous  symptoms. 


A  HASTY  ASSUMPTION  OF  CRIMINALITY. 

We  print  elsewhere  in  this  issue  an  authentic  summary, 
mainly  from  the  stenographic  report  of  the  inquest,  of  the  case 
of  a  physician  of  good  standing,  a  member  of  the  Medical  So- 
ciety of  the  County  of  New  York,  and  a  contributor  to  the 
Journal,  who,  as  will  be  found  stated,  was  twice  arrested  upon 
the  17th  of  January  last,  imprisoned,  and  held  to  bail  upon 
charges  of  criminal  abortion  and  manslaughter.  The  news  was 
widely  circulated  by  the  daily  press  at  the  time.  For  some  six 
weeks  he  remained  under  this  accusation.  On  the  6th  of  March, 
however,  after  an  exhaustive  hearing  before  Coroner  Messemer 
and  a  jury  composed  entirely  of  medical  men,  and  comprising 
some  of  the  most  eminent  gynaacologists  of  New  York,  with  Dr. 
Paul  F.  Mund6  as  foreman,  the  charges  were  admitted  by  the 
public  prosecutor  to  lack  the  slightest  particle  of  proof,  and  the 
doctor  was  acquitted  by  a  verdict  of  unusual  fullness  and  em- 
phasis. We  believe  the  summary,  which  is,  as  far  as  possible, 
chronological,  will  readily  enable  the  reader  to  place  the  re- 
sponsibility for  the  hardship  and  injustice  borne  by  Dr.  Reid. 
The  case  should  be  of  great  interest  to  medical  men,  for  it  fur- 
nishes a  striking  illustration  of  the  alarming  ease  with  which 


April  8,  1893.] 


MINOR  PARAGRAPHS. 


387 


official  carelessness,  either  of  word  or  of  act,  may  endanger  and 
perhaps  irretrievably  impair  the  professional  interests  and  the 
reputation  of  the  most  respectable  physician  in  the  community. 


TOLYPYRINE. 

This  is  the  name  of  a  new  antipyretic  and  analgesic  that  was 
brought  to  the  notice  of  the  Berlin  Medical  Society  recently  by 
Dr.  P.  Guttmanu.  From  the  report  published  in  the  Mercredi 
medical  for  March  15th  it  appears  that  tolypyrine  differs  chem- 
ically from  antipyrine  by  the  substitution  of  CHa  for  an  atom 
of  hydrogen.  It  forms  colorless  crystals  which  melt  at  from 
136°  to  137°  C,  have  an  acrid  taste,  and  are  soluble  in  alcohol 
and  in  ten  parts  of  water,  but  insoluble  in  ether.  With  per- 
chloride  of  iron  and  nitric  acid  it  shows  the  same  color  reac- 
tions as  antipyrine.  As  an  antipyretic  it  has  been  used  in 
typhoid  fever,  pneumonia,  erysipelas,  scarlet  fever,  etc.,  to  the 
«stent  of  a  drachm  in  twenty-four  hours.  The  size  of  the  indi- 
vidual doses  and  the  frequency  of  their  administration  are  not 
mentioned.  It  lowers  the  temperature  gradually,  and  the  reduc- 
tion continues  for  about  six  hours;  at  the  same  time  the  pulse 
is  slowed  and  free  perspiration  shows  itself.  It  seems  to  be  al- 
most a  specific  in  mild  cases  of  acute  articular  rheumatism  ;  in 
severe  cases  its  action  is  slower  and  it  stands  about  on  a  par 
with  sodium  salicylate  and  antipyrine.  It  is  no  less  efficacious 
than  antipyrine  in  headache  and  neuralgia. 


THE  RELATION  OF  SWELLED  TESTICLE  TO  GONORRHCRA 
AND  TO  MUMPS. 

At  a  recent  meeting  of  the  Societe  de  dermatologie  et  de 
syphiligraphie,  a  report  of  which  is  published  in  the  Union 
medicate  for  March  14th,  M.  Barth61emy  read  an  account  that 
had  been  sent  to  him  by  M.  Bogdun  of  a  case  in  which  a  vio- 
lent gonorrhoea  had  been  suspended  for  ten  days  by  an  attack 
of  pneumonia,  and  had  shown  all  its  previous  severity  on  the 
subsidence  of  the  pulmonary  inflammation.  M.  Barth61emy 
added  that  he  himself  had  observed  cases  of  the  interruption  of 
gonorrhosa  by  typhoid  fever.  One  of  his  patients  had  died, 
but  another  had  been  attacked  with  violent  orchitis  on  the  sev- 
enteenth day,  although  he  had  not  left  his  bed.  Several  cases 
of  the  same  sort,  together  with  others  of  the  opposite  kind  in 
which  excessive  exertion  had  failed  to  give  rise  to  orchitis,  had 
led  him  to  doubt  the  theory  tliat  swelled  testicle  was  caused  by 
simple  i)ropagation.  The  state  of  the  parts  was  no  doubt  a 
factor  in  the  production  of  this  complication,  also  the  condition 
of  infection,  as  in  mumps,  in  which  disease  he  had  lately  ob- 
served orchitis  preceding  the  parotid  affection  by  four  days,  and 
that,  too,  without  any  previous  gonorrhoea. 


SPONTANEOUS  CLOSURE  OF  A  RUPTURE  OF  THE  UTERUS. 

In  the  Centralblatt  fur  Gyndkologie  for  March  18th  there 
is  a  summary  of  an  account  by  Dr.  Richter,  published  in  the 
Deutsche  medicinische  Wochenschri/t,  1892,  No.  45,  of  a  case  of 
labor  in  which  sudden  collapse  occurred,  followed  by  cessation 
of  the  pains  and  the  manifest  presence  of  foetal  parts  immedi- 
ately beneath  the  abdominal  wall.  The  case  had  been  under 
the  care  of  a  midwife,  and  her  story  was  that  when  the  col- 
lapse had  come  on  the  head  had  been  well  advanced  in  its  de- 
scent. Nevertheless,  the  vagina  was  found  empty.  Version 
was  performed.  Extraction  of  the  head  was  difficult,  and  the 
child  was  deeply  as])liyxiated.  The  placenta,  which  was  lying 
loose  in  the  uterus,  was  removed  with  the  hand,  and  then  there 
was  found  a  rent  in  the  uterine  wall,  situated  anteriorly  and 
to  the  left,  through  wiiich  three  fingers  could  be  passed.  No 


irrigation  was  employed,  but  a  sand-bag  was  applied  to  the 
abdomen.  Ergot  was  given  in  fifteen-grain  doses — three  doses 
in  all — and  fifteen  drops  of  tincture  of  opium  were  administered 
three  times  a  day.    The  case  ended  in  recovery. 


ARSENIC  IN  CHOREA. 

Discussing  the  uses  of  arsenic,  Dr.  William  Murray,  in  the 
Lancet  for  February  25th,  makes  a  statement  that  will  some- 
what surprise  American  physicians.  He  says  that  little  stress 
has  been  laid  on  the  efficacy  of  arsenic  in  large  doses  in  chorea. 
That  use  of  the  drug  is  a  well-established  plan  of  treatment  in 
this  country.  It  is  the  common  teaching  that  arsenic  is  of  but 
little  value  until  its  physiological  effects  have  been  obtained.  1% 
is  now  the  universal  custom  to  carry  its  administration  to  that 
point,  and  even  to  restrain  its  action  upon  the  bowels  by  small 
doses  of  opium.  The  dose  should  be  regulated  according  to  the 
symptoms  and  the  tolerance  of  the  patient.  The  author  insists 
upon  giving  fifteen-drop  doses  of  Fowler's  solution  for  several 
days;  ten  drops,  he  says,  will  not  answer.  No  fixed  rule  can 
be  adopted  for  the  use  of  this  or  any  other  drug.  It  must  be 
administered  according  to  the  age  and  tolerance  of  the  patient. 
If  taken  with  food  in  the  middle  of  the  meal,  it  rarely  causes 
digestive  disturbance  even  in  very  large  doses. 


CINCHONIDINE  IN  THE  TREATMENT  OF  MALARIAL  FEVERS. 

The  Noumau  Montpellier  medical  for  March  Ist  contains  an 
article  on  The  Treatment  of  Intermittent  Fevers  with  Sulphate 
of  Cinchonidine,  by  Dr.  H.  Villard,  of  the  Montpellier  hospi- 
tals. His  conclusions  are  as  follows :  Cinchonidine  sulphate 
overcomes  attacks  of  intermittent  fever  quite  as  surely  as  the 
salts  of  quinine,  and  in  the  same  doses;  in  addition,  it  exerts 
a  very  favorable  action  upon  the  anaamia  and  visceral  engorge- 
ments of  paludism.  The  attack  yields  to  it  a  little  less  rapidly 
than  to  quinine.  He  has  usually  employed  cinchonidine  in  fif- 
teen-grain doses,  but  thinks  there  is  no  objection  to  giving 
from  eighteen  to  twenty-two  grains.  The  unpleasant  effects  of 
cinchonidine  are  less  pronounced  and  less  frequent  than  those 
of  quinine.  The  cheapness  of  cinchonidine  goes  far  to  com- 
pensate for  its  slight  inferiority  to  quinine  in  rapidity  of  action. 


BROWN-SEQUARD  INJECTIONS  IN  TRICHOPHYTOSIS. 

At  a  recent  meeting  of  the  Lyons  Society  of  the  Medical 
Sciences,  reported  in  the  llercredi  medical  for  February  22d,  M. 
Augagneur  stated  that  he  had  been  led  by  the  fact  that  the  Tri- 
chophyton tonsurans  did  not  grow  on  persons  who  had  reached 
puberty  to  the  idea  that  the  modification  of  the  tissues  incident 
to  the  evolution  of  the  genital  organs  might  be  induced  by  in- 
jections of  testicular  juice.  With  this  notion  in  mind,  he  had 
practiced  a  great  number  of  such  injections  in  his  service  at 
the  Antiquailles,  and  the  children,  for  the  most  part  puny  and 
miserable,  had  been  much  improved  in  their  general  health  ;  as 
to  their  local  disease,  it  had  been  pretty  frequently  noted  that 
there  was  a  mitigation  of  its  manifestations.  This  is  indeed  a 
roundabout  way  of  attacking  a  parasitic  skin  disease;  perhaps 
it  would  have  met  with  the  aj)proval  of  the  late  Sir  Erasmus 
Wilson. 

THE  INDUCTION  OF  LABOR  BY  INJECTING  GLYCERIN 
INTO  THE  UTERUS. 

Dr.  C.  Pei-zkk  {Arehiv  fUr  Oyndkologie,  xlii,  2;  Wiener 
Minische  Wochemchri/t,  March  23,  1893)  recommends  the  in- 
duction of  premature  labor  by  passing  a  soft  catheter  into  the 
cavity  of  the  body  of  the  uterus,  between  the  uterine  wall  and 


388 


MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Mbd.  JorE., 


the  foetal  membrancB,  and  injecting  throagh  it  about  three 
ounces  of  glycerin,  whereby  gradual  separation  of  the  mem- 
branes is  effected.  The  glycerin  is  kept  from  flowing  out  by 
causing  the  woman  to  maintain  the  knee-elbow  or  Sims's  pos- 
ture. Powerful  pains  come  on  in  froto  half  an  hour  to  an  hour 
and  a  half.  The  method  can  be  carried  out  aseptically,  and  is 
less  disturbing  to  the  parturient  organs  than  puncture  of  the 
membranes.  Air-embolism  has  not  been  observed  as  a  conse- 
quence of  its  employment. 


THE  ETIOLOGY  OF  ROTHELN. 

Opinion  in  England  etill  seems  to  be  somewhat  divided  as 
to  the  {etiology  of  rotheln.  ^Goodhart  and  others  have  ex- 
pressed a  doubt  as  to  whether  it  is  an  independent  disease. 
Dr.  Donald  Hood,  as  reported  by  the  British  Medical  Journal 
for  March  18th,  recently  read  a  paper  advocating  the  view  that 
rotheln  and  measles  were  due  to  the  same  contagium,  assuming 
different  degrees  of  force  and  intensity,  and  being  profoundly 
modified  by  the  different  states  of  "soil"  and  environment. 
This  view  was  combated  by  Sir  Andrew  Clark,  Sir  Dyce  Duck- 
worth, Dr.  Pye-Smith,  and  others.  The  evidence  adduced  by 
Dr.  Hood  certainly  seems  insufficient  to  disprove  the  opinion 
now  generally  accepted  that  rotheln  is  a  distinct  entity  and 
entirely  independent  of  measles. 


Daniel  Lewis,  of  New  York  ;  and  the  third.  The  Domain  of  the 
Knife  in  the  Treatment  of  Carcinoma,  is  by  Dr.  Nathan  Jacob- 
son,  of  Syracuse. 

HAMAMELIS  IN  PAINFUL  VARICOCELE. 
Nouveau  MontpelUer  medical  for  March  11th  contains  a  note 
by  Dr.  P.  Gilis  on  the  internal  use  of  Hamamelis  virginica  in 
cases  of  painful  varicocle.  Twenty  drops  of  the  tincture  are 
added  to  about  six  ounces  of  distilled  water,  and  the  whole  of 
this  mixture  the  patient  is  to  take,  in  tablespoonful  doses,  in 
the  course  of  twenty-four  hours.  He  is  also  to  bathe  the  scro- 
tum with  cold  water  night  and  morning  and  wear  a  suspensory. 


A  TUMOR  ATTRIBUTED  TO  A  FOREIGN  BODY. 

At  a  recent  meeting  of  the  Rouen  Society  of  Medicine,  re- 
ported in  the  Normandie  medicale  for  March  1st,  M.  Bataille 
gave  an  account  of  a  [tumor,  as  large  as  an  orange,  which  he 
had  removed  from  just  above  the  fold  of  the  groin  in  a  man 
sixty  years  old.  He  had  taken  it  for  a  sarcoma,  but,  on  cutting 
it  open,  its  substance  was  found  to  be  purely  of  inflammatory 
origin  and  appeared  to  have  formed  about  one  of  the  branches 
of  a  shell  hair-pin  that  was  found  in  it.  As  there  was  not  the 
slightest  scar  to  be  seen,  it  was  thought  probable  that  the  man 
had  swallowed  the  foreign  body,  and  that  it  had  made  its  way 
through  the  intestinal  wall  in  the  inguinal  region  and  become 
lodged  in  the  subcutaneous  tissue. 


RHIZODONTRYPY. 
This  name  has  been  given  to  the  operation  of  drilling  through 
the  alveolar  process  to  the  tip  of  the  diseased  fang  and  remov- 
ing the  necrosed  portion  in  cases  of  alveolar  abscess.  The  word 
has  recently  become  current  in  a  misspelled  form-that  of  rhi- 
zodonirovhy-^^^  we  do  not  wonder  that  the  Medical  Newt 
finds  the  etymology  of  this  spurious  form  difficult  to  under- 
stand.   

LIGATION  OF  THE  INNOMINATE  AND  CAROTIDS  FOR  SUB- 
CLAVIAN ANEURYSM. 
A  ooRRESPONDBNT  living  in  Dublin,  Ireland,  who  dates  his 
communication  March  22d,  informs  us  that  Dr.  Coppinger  s 
case  of  ligation  of  the  innominate  and  carotid  arteries  for  sub- 
clavian aneurysm  is  thus  far  (up  to  the  seventy-second  day 
after  the  operation)  successful. 


THE  PENNSYLVANIA  MEDICAL  EXAMINERS  BILL. 
We  are  glad  to  learn  that  the  prospect  is  good  of  tne  enact, 
ment  of  a  good  meaicai  practice  bill  in  Pennsylvania,  similar  to 
the  one  in  force  in  New  York. 


ITEMS,  ETC. 

Infections  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  April  \,  1893: 


CHLOROBROM. 

This  is  the  name  given  by  Professor  Charteris,  of  Glasgow, 
to  a  solution  each  ounce  of  which  contains  thirty  grains  of 
chloralamide  and  potassium  bromide.  In  the  Lancet  for  March 
18th  Dr.  John  Keay,  medical  superintendent  of  the  Mavisbank 
Asylum,  Edinburgh,  commends  its  action  as  a  hypnotic  in  melan- 
cholia and  allied  mental  conditions,  but  says  he  has  not  been 
encouraged  to  persevere  with  its  use  as  a  sedative  in  the  excite- 
ment of  mania,  general  paralysis,  or  epilepsy.  Its  action,  he 
thinks,  resembles  that  of  paraldehyde  when  given  along  with 
bromidia  or  a  bromide.  An  ounce  of  the  solution  may  be  given 
an  hour  before  bedtime.  If  there  is  much  excitement  as  much 
as  an  ounce  and  a  half  or  two  ounces  may  be  used  with  safety. 


DISEASES. 


Typhus  

Typhoid  fever  

Scarlet  fever  ■ 

Cerebro-spinal  meningitis. 

Measles   •  • 

Diphtheria  

Small-pox  


Week  ending  Mar.  !28 


Cases. 


.5 
17 
172 
13 
96 
115 
9 


Deaths. 


2 
6 

13 
9 
4 

41 
3 


Week  ending  Apr.  4. 


Cases. 


9 
16 
177 
17 
131 
104 
15 


Deaths. 


2 

6 
12 
10 

8 
47 

1 


THE  TREATMENT  OF  CANCER. 

Tbrbb  papers  of  great  value  relating  to  this  subject  were 
read  at  the  recent  meeting  of  the  Medical  Society  of  the  State 
of  New  York,  and  now  a])pear  as  consecutive  articles  in  the 
April  number  of  the  Annalu  of  Surgery.  The  first.  On  the  Value 
of  Internal  Medication  in  the  Treatment  of  Malignant  Disease, 
is  by  Dr.  Jarvis  S.  Wight,  of  Brooklyn;  the  second,  The  Use 
and  Place  of  Caustics  in  the  Treatment  of  Cancer,  is  by  Dr. 


A  Case  of  AUeged  Criminal  Abortion  ;  the  Consequences  of  a  Hasty 
Assumption.-On  December  22, 1892,  S.  J.,  a  dressmaker,  aged  about 
twenty-eight,  single,  came  to  Dr.  Adrian  Y.  Reid,  complaining  of  bear- 
ing-down pains  in  the  hypogasti  ium.  She  stated  that  her  menses  were 
some  five  weeks  overdue,  and  that  she  had  already  thrice  visited  a 
physician,  who  had  prescribed  to  bring  on  the  flow,  but  had  used  no 
instruments  upon  her.  The  nature  of  the  medicines  which  she  had  taken 
could  not  be  ascertained.  She  simply  blushed  when  asked  if  she  had 
been  "  exposed." 

The  rational  and  other  symptoms,  which  were  completely  canvassed, 
and  examination,  digital  and  with  the  specuhmi,  failed  to  show  any- 
thing inconsistent  with  her  statement  that  she  was  suffering  simply 
from  irregular  menstruation.  The  womb,  on  palpation,  was  found 
slightly  enlarged,  but  the  os  was  of  normal  outline  and  consistence  and 


April  8,  1893.J 


ITEMS. 


389 


the  mucous  membrane  of  the  vagina  of  a  rose  tint;  a  small  drop  of 
dark,  grumous  blood  was  oozing  from  the  cervix,  but  still  within  it. 
There  was  no  sign  of  sepsis.  Dr.  Reid  directed  the  discontinuance  of 
the  medicines  then  being  taken,  prescribed  an  anodyne  and  complete 
rest  for  several  days  and  the  use  of  carbolized  douches  of  warm  water 
if  the  apparently  coming  discharge  should  prove  foul  or  disagreeable, 
and  instructed  the  patient  to  call  again  if  she  had  not  recovered  by  that 
time. 

Fourteen  days  afterward,  on  January  6,  1893 — a  stormy  and  in- 
clement day — she  again  presented  herself,  slightly  paler  than  before, 
and  with  a  six  or  seven  days'  vaginal  discharge,  which  had  been  offen- 
sive from  the  begimiing.  Digital  examination  disclosed  a  decided  sep- 
tic odor,  and  there  was  a  foetid  mass,  somewhat  larger  than  a  hazel-nut, 
protruding  from  the  os.  Home  treatment  being  manifestly  necessary, 
the  patient  was  visited  there  within  two  hours.  Examination  failed  to 
disclose  any  symptoms  of  peritonitis  or  constitutional  symptoms  of  sep- 
ticaemia. The  usual  antiseptic  precautions  having  been  taken,  the 
foetid  mass  alluded  to  was  removed  by  gentle  manipulation ;  it  seemed 
to  be  part  of  an  ovum.  The  uterine  cavity  was  carefully  scraped  clean 
with  both  sharp  and  blunt  curette,  putrid  membrane  and  blood-clots 
coming  away,  and  then  washed  with  a  bichloride-of-mercury  solution  (1 
to  4,000),  and  packed  with  iodoform  gauze.  The  patient  was  put  to  bed, 
complete  rest  was  enjoined,  and  tonics  and  an  invigorating  diet  were 
prescribed.  Upon  the  6th  the  packing  was  removed.  All  trace  of 
sepsis  was  gone  and  the  general  condition  of  the  patient  decidedly  im- 
proved. On  the  Tth  the  discharge  was  of  simply  lochial  appearance. 
The  parts  were  daily  douched  with  five-per-cent.  carbolized  solution. 
This  general  treatment  was  continued  till  the  10th,  when  the  patient  was 
well  enough  to  dispense  with  further  personal  attendance,  and  she  was 
discharged  with  instructions  to  douche  twice  daily  with  carbolized  solu- 
tion, and  to  maintain  complete  rest  for  several  days.  Elixir  of  phos- 
phates of  iron,  quinine,  and  strychnine  (Wyeth's  preparation)  was  also 
prescribed. 

The  patient  lived  alone.  During  the  course  of  the  treatment  she 
was  frequently  admonished  to  procure  a  nurse,  always  promised  to  do 
so,  but  never  had  one,  except  on  one  or  two  occasions,  when  a  female 
friend  remained  a  short  while  with  her. 

On  the  14th  Dr.  Reid  was  again  called,  found  the  patient  in  bed, 
with  a  temperature  of  102°,  pulse  98,  slight  hypogastric  tenderness,  but 
no  tympanites.  She  admitted  that  she  had  violated  the  doctor's  in- 
structions, had  not  rested,  but  had  done  her  housework,  scrubbed,  and 
had  gone  into  the  hall,  all  in  her  stocking  feet.  This  was  during  the 
coldest  days  in  the  January  cold  spell. 

There  was  a  .^lightly  septic  vaginal  discharge.  The  womb  was 
gently  scraped  with  a  blunt  curette,  but  disclosed  a  smooth,  uniform 
interior,  with  no  focus  of  sepsis.  It  was  washed  with  bichloride-of- 
mercury  solution  and  packed  as  before.  An  anodyne  was  prescribed 
for  present  pain,  and  a  carminative  of  equal  parts  of  compound  tincture 
of  cardamom  seed  and  aromatic  spirit  of  ammonia  ;  in  addition,  topical 
applications  of  equal  parts  of  flaxseed  meal  and  mustard  were  ordered, 
to  be  followed  by  flaxseed-meal  poultices  with  ground  poppyheads  ; 
quinine  in  three-grain  doses  as  a  tonic,  and  turpentine  stupes  in  case  of 
tympanites.  Absolute  rest  was  directed,  and  the  patient  was  strongly 
advised  to  enter  a  hospital  at  once.  To  this  she  demurred,  and  again 
promised  to  procure  a  nurse. 

On  the  15th  the  symptoms  of  peritonitis  were  aggravated.  There 
was  tympanites,  with  increased  tenderness  over  the  whole  abdomen,  a 
temperature  of  102°,  and  pulse  of  aljout  104.  The  packing  was  re- 
moved ;  all  trace  of  sepsis  had  disappeared  from  the  uterus  ;  it  was 
washed  with  the  carbolized  solution  and  left  unpacked.  The  patient 
was  now  peremptorily  urged  to  go  to  a  hospital,  agreed  to  do  so,  and 
chose  the  Roosevelt  Hospital.  Her  choice  was  approved  of  by  the 
doctor,  and  she  promised  to  send  at  once  for  an  ambulance. 

She  did  not  keep  her  promise,  however,  for  on  the  16th  the  doctor 
was  again  summoned,  and  found  her  very  tympanitic,  and  with  a  tem- 
perature of  103°  and  pulse  of  115.  The  womb  was  foimd  still  aseptic, 
and  was  again  washed  with  the  carbolized  solution.  The  patient  was 
strongly  chided  for  not  having  kept  her  word,  and  now  promised  more 
positively  to  do  so ;  whereupon  the  doctor  wrote  and  left  with  her,  for 
delivery  to  the  hospital  authoritice,  the  following  letter : 


"  Physicians,  Roosevelt  Hospital. 

"  S.  J.,  of  —  East  Forty-fifth  Street,  is  suffering  from  peritonitis 
following  abortion — natural  I  believe — and  is  without  proper  care.  She 
is  able  to  pay  something  for  your  care,  and  at  her  desire  I  have  recom- 
mended her  to  enter  your  hospital.  I've  fomid  it  necessary  to  scrape 
the  womb  twice,  and  wash  it  out  each  morning  for  a  week.  She  has 
been  indiscreet  in  being  up  and  around  immediately  after  her  abortion, 
and  not  having  the  chills  and  other  symptoms  of  septic  peritonitis,  I 
regard  hers  as  idiopathic  or  catarrhal. 

"  Trust  you  may  send  for  her  at  once  and  give  her  your  best  care. 
"  I  am,  yours  respectfully,  A.  Y.  Reid,  M.  D. 

"  104  Lexington  Avende,  January  16,  1893. 

"  P.  S. — Besides  being  treated  antiseptically,  she  has  had  elix.  phos. 
iron,  quinine,  and  strych.,  two-  and  three-grain  pills  of  quinine,  every 
three  or  four  hours.  Morphine  to  relieve  pain,  hot  topical  applications  ; 
freely  nourished  by  beef-tea,  matzoon,  gruels,  etc." 

He  directed  that  he  be  sent  for  if  the  patient  was  not  speedily  re- 
moved.   She  was  all  this  time  perfectly  rational. 

The  letter  was  duly  received  at  Roosevelt  Hospital,  and  an  ambu- 
lance was  sent  for  her  at  once ;  but,  as  the  hospital  had  at  the  time  no 
facilities  for  the  proper  treatment  of  the  case,  the  ambulance  surgeon. 
Dr.  Stone,  notified  the  police  of  the  case,  and  the  patient  was  admitted 
to  Bellevue  Hospital  at  '7.55  p.  m.  There  she  came  under  the  personal 
charge  of  Dr.  W. 

The  policeman  who  called  the  ambulance  at  once  reported  the  fact  at 
his  precinct  station  house,  and  Joseph  O'Donohue,  an  officer  on  detec- 
tive duty,  called  at  about  9.30  on  the  same  evening  at  the  hospital,  to 
investigate  the  case.  Here,  according  to  his  testimony,  he  met  Dr.  W., 
who  "  toW  me  it  was  a  criminal  abortion,  and  he  told  me  that  if  I  ar- 
rested the  doctor  he  would  help  me  out  with  it — that  there  was  too  muck 
of  that  carried  on  now." 

The  detective  conversed  with  the  patient.  Dr.  W.  being  present.  In 
answer  to  O'Donohue's  questions,  she  declared,  in  substance,  that  one 

W  was  "  the  cause  of  her  trouble  "  ;  that  a  girl  whom  she  met  on 

Lexington  Avenue  had  recommended  her  to  Dr.  Reid,  whose  residence 
she  gave  to  O'Donohue  as  nearly  as  her  memory  served ;  and  that  he 
had  treated  her,  and  had  used  an  instrument  on  her,  which  she  did  not 
describe. 

Upon  Dr.  W.'s  statement  and  the  declarations  of  the  patient, 
O'Donohue  sought  Dr.  Reid  that  night  to  arrest  him,  but  failed  to  find 
his  address.  The  next  morning  (the  17th)  he  again  visited  the  patient, 
and  asked  her  as  to  the  truth  of  her  statement  of  the  night  before. 
She  now  declared  that  it  was  not  true.  The  officer  thereupon  left  word 
for  the  coroner  to  take  a  statement  from  the  patient,  put  under  arrest 

W  ,  above  mentioned  [not  Dr.  W.],  who  had  come  to  the  station 

house  to  learn  her  condition,  and  obtained  from  Dr.  W.,  for  production 
at  court,  a  written  certificate,  signed  by  him,  as  follows :  "  This  is  to 
certify  that  S.  J.  is  suffering  from  peritonitis,  and  is  not "  [«ic]  "  in 
condition  to  forbid  removal  from  the  hospital.  Her  condition  la  very 
critical,  the  result  apparently  of  criminal  abortion." 

Armed  with  this  certificate,  O'Donohue  and  another  detective,  in 
company  with  W.  [not  Dr.  W.],  proceeded  to  Dr.  Reid's  house,  where 
they  arrested  him  between  two  and  three  o'clock  in  the  afternoon.  On 
inquiry,  the  doctor  was  told  that  he  was  charged  with  a  criminal  abor- 
tion upon  S.  J. ;  that  she  had  made  the  charge,  and  that  he  had  a  cer- 
tificate from  the  attending  physician  to  the  same  effect.  Dr.  Reid 
thereupon  expressed  his  surprise,  and  promptly  denied  performing  any 
abortion  at  all.  He  stated  that  the  girl  came  to  him  suffering  from,  I 
think,  some  womb  trouble,  and  he  examined  her,  and  used  insti'uments  to 
scrape  her  womb,  and  he  said  that  he  would  do  the  same  to-morrow  if 
anybody  came  suffering  in  that  condition  to  him "  ;  that  she  had  pre- 
viously been  treated  by  another  physician,  and  that  he  was  a  law-abiding 
citizen  and  would  go  with  the  officer,  which  he  did.  He  was  at  once 
arraigned  in  the  Yorkville  Police  Court,  before  Justice  McMahon,  to 
lahom  he  made  a  fuller  statement  of  his  action  in  tlie  case.  In  answer  to 
a  question,  he  informed  the  justice  that  he  was  a  member  of  the  County 
Medical  Society.  The  justice  paroled  him,  directing  the  officers,  after 
the  doctor's  departure,  to  rearrest  him  in  case  of  the  girl's  death. 

Immediately  upon  his  release  Dr.  Reid  went  to  Bellevue  Hospital  to 
learn  the  ground  of  the  charge  against  him.    For  this  purpose  lie  in- 


390 


ITEMS. 


[N.  y.  Mkd.  Joitb., 


quired  of  Dr.  W.,  with  wliom  he  had  an  extended  conversation,  detail- 
ing to  him  hh  treatment  of  the  case.  Dr.  W.  said  that  he  knew  of 
nothing  thai  should  have  led  to  his  arrest,  and  that  he  [ Dr.  VF.]  hud  done 
nothing  tliat  should  have  caused  it. 

At  6.10  P.M.  that  day,  according  to  the  official  record,  the  patient 
died.  She  had  made  not  a  single  statement  receivable  as  evidence  in  a 
court  of  justice.  At  about  eight  o'clock,  without  any  additional  evi- 
dence, Dr.  Reid  was  again  arrested  at  his  house  by  the  same  officers. 
He  was  permitted  to  send  for  a  neighboring  friend  to  accompany  him 
for  the  purpose  of  bail,  and  was  then  taken  to  the  police  station,  where 
he  was  formally  charged  with  a  felony,  based  upon  the  statement  of  the 
deceased  and  the  certificate  of  Dr.  W.,  which  was  exhibited  to  him. 
Bail  was  offered  and  refused,  both  at  the  station  house  and  by  the  jus- 
tice, to  who.se  residence  the  friend  above  mentioned  had  been  imme- 
diately dispatched.  The  doctor,  after  giving  up  several  articles  from 
his  pockets,  was  taken  to  a  cell  in  the  prison.  The  night  was  very  cold. 
The  cell  contained  only  a  hard  bench,  with  no  covering.  With  much 
difficulty  permission  was  obtained  to  have  some  bedclothes  sent  from  the 
doctor's  house,  for  warmth  rather  than  sleep. 

Next  morning  (the  18th)  he  was  again  arraigned  in  the  police  court 
before  Justice  McMahon  and  informed  that  he  was  now  charged  with 
manslaughter.  After  considerable  delay,  owing  to  counsel's  absence, 
the  judge,  without  hearing  the  case,  referred  it  to  the  coroner,  saying 
that  if  it  came  back  to  him  he  would  dismiss  it.  Between  twelve  and  one 
o'clock  Dr.  Reid  was  arraigned  before  Coroner  Schultze,  who,  without 
making  investigation,  announced  his  intention  of  holding  the  doctor  at 
once  for  the  Grand  Jury  and  the  Court  of  General  Sessions,  on  the 
ground  that  "  the  case  was  Coroner  Messemer's."  Counsel  attending 
for  Dr.  Reid  asked  that  at  least,  instead  of  that  course,  the  case  be  re- 
ferred back  to  Coroner  Messemer.  The  matter  hanging  in  this  posture 
of  uncertainty.  Dr.  Reid  interposed  and  personally  made  to  the  coioner 
the  oft-repeated  statement  of  his  medical  treatment,  whereupon  bail 
was  accepted  in  the  sum  of  $2,500,  and  he  was  at  last  set  at  liberty, 
W.  [not  Dr.  W.],  arraigned  at  the  same  time,  being  held  in  custody. 

The  autopsy  on  the  body  of  the  deceased  was  made  that  same  day, 
at  about  4  p.  m.,  at  the  Morgue,  in  the  presence  of  Dr.  Frank  Ferguson, 
of  the  New  York  Hospital  and  the  New  York  Post-graduate  Medical 
School,  Dr.  Donlin  and  Dr.  O'Hare,  coroner's  physicians,  Dr.  Reid,  and 
Dr.  H.  P.  Loomis,  who  attended  at  Dr.  Reid's  desire.  The  manual 
work  of  the  autopsy  was  performed  by  Dr.  Loomis,  at  the  request  of 
Dr.  O'Hare. 

Upon  opening  the  abdominal  cavity,  the  existence  of  general  puru- 
lent peritonitis  was  at  once  apparent.  There  was  a  large  quantity  of 
pus  upon  the  surface  of  the  viscera,  which  floated  in  probably  two  gal- 
lons of  sero-purulent  fluid.  There  was  a  general  agglutination  of  the 
organs  within  the  cavity,  which  was,  however,  easily  broken  through  by 
the  hand  of  the  operator.  The  mesenteric  vessels  were  enlarged  and 
of  a  purplish  hue,  the  stomach  and  intestines,  and  particularly  the 
vermiform  appendix  and  caecum,  were  carefully  examined,  but  no  possi- 
ble channel  for  septic  infection  was  there  found.  The  connections  of 
the  womb  were  severed  close  to  the  pelvic  walls,  the  vagina  being  cut 
across  about  an  inch  below  the  cervix,  and  the  womb  and  appendages 
were  taken  in  hand  and  subjected  to  careful  scrutiny.  Externally  the 
womb,  though  slightly  enlarged,  was  of  normal  post-mortem  color.  In- 
ternally no  trace  of  sepsis  was  discovered ;  the  os  was  slightly  dilated, 
its  margins  were  perfect,  with  no  evidence  of  disease.  The  uterine  walls 
had  been  thoroughly  scraped — the  left  side  about  twice  as  deeply  as  the 
right.  The  most  careful  examination  .showed  no  sign  of  puiu  t^ire  or  lacera- 
tion in  any  part  of  the  womb  or  vagina  or  elsewhere.  The  right  Falloppian 
tube  was  somewhat  enlarged  in  caliber  and  thickened  in  its  walls,  open 
at  the  fimbriated  and  closed  at  the  uterine  extremity,  and  contained  a 
small  amount  of  pus.  The  left  tube  was  closed  at  both  ends,  and  sac- 
culated about  midway.  Upon  incision,  it  gave  forth  about  a  teaspoon- 
ful  of  pus.  The  ovaries  were  enlarged  to  about  twice  their  natural 
size,  and  upon  incision  presented  throughout  their  stroma  small  collec- 
tions of  pus.  It  was  the  opinion  of  all  present  that  there  was  no  evidence 
of  abortion..  The  deceased  had  evidently  siilfered  from  endometritis, 
salpingitis,  and  septic  peritonitis. 

The  incjuest  was  hold  on  March  tith,  before  Coroner  Messemer 
ind  the  following  jnry  :  Dr.  Paul  V.  .Mundd,  foreman ;  Dr.  A.  Palmer 


Dudley,  Dr.  H.  J.  Boldt,  Dr.  Egbert  H.  Grandin,  Dr.  H.  Marion  Sims, 
Dr.  A.  M.  Jacobus,  Dr.  J.  E.  Janvrin,  Dr.  R.  Van  Santvoord,  Dr.  Henry 
C.  Coe,  Dr.  J.  R.  Goffe,  Dr.  E.  H.  Peaslee,  and  Dr.  J.  L.  Morrill. 

As  to  all  the  facts  foregoing  there  was  practically  no  dispute.  Dr. 
W.,  who  was  present  during  the  wliale  of  the  inquest,  did  not  contradict 
any  of  the  above-mentioned  testimony  relating  to  himself,  altltough  ex- 
pressly informed  that  he  could  do  so  upon  the  stand,  and  that,  moreover. 
Dr.  Reid^s  counsel  would  cross-examine  the  witjiesses  as  Ae  desired — a 
courtesy  of  which  he  did  not  avail  himself. 

As  the  only  essential  difference  develo|)ed  upon  the  hearing  resulted 
from  Dr.  W.'s  explanation  of  the  circumstances  under  which  the  certificate 
was  made,  we  have  reserved  till  this  point  the  testimony  in  that  regard. 

Dr.  \V.  testified  that  he  found  the  patient  suffering  from  general 
peritonitis,  with  tenderness  and  extreme  pain  in  the  pelvis  and  lower 
abdomen,  and  tympanites,  with  the  uterus  slightly  enlarged,  but  very 
clean  and  free  from  pus  and  sepsis,  and  that  he  desired  to  emphasize 
that  fact ;  that  the  condition  of  the  uterus  was  "  not  such  as  would  indi- 
cate criminality,  but  the  very  best  treatment  that  .such  a  case  could  have  on 
the  part  of  a  physician  "  ;  that  he  scraped  and  curetted  the  womb  and 
packed  it  with  iodoform  gauze,  and  gave  the  patient  the  ordinary  symp. 
tomatic  treatment  of  peritonitis ;  that  he  treated  the  uterus  as  de- 
scribed, though  clean,  "  because  on  examination,  when  there  is  nothing 
found  in  the  vagina  or  the  cervix  is  closed,  if  there  are  symptoms  of 
peritonitis,  and  the  slightest  doubt  of  its  having  come  from  uterine  sep- 
sis, I  consider  it  the  very  best  treatment  to  examine  the  contents  of  the 
uterus.  I  obtained  practically  nothing  by  curetting ;  the  uterus  was 
very  clean  indeed." 

Upon  cross-examination  he  testified :  "  I  can  not  swear  that  there 
had  been  a  recent  [jregnancy ;  I  judged  so  from  the  os  being  enlarged, 
which  it  never  would  have  been  in  a  normal  condition.  Nothing  came 
away  in  the  curetting  which  induced  that  belief.  From  that  condition 
of  the  uterus  I  judged  there  had  been  an  abortion ;  I  do  not  pretend  to 
say  that  it  was  criminal ;  I  have  never  made  any  absolute  statement  as 
to  that."  Q.  "  Have  you  ever  given  a  certificate  one  way  or  the  other 
concerning  that  ?  "  A.  "  I  gave  a  statement  once  saying  that  she  was 
sick  with  peritonitis,  and  I  think  it  said  '  apparently  from  criminal 
abortion  '  or  '  from  abortion ' ;  I  don't  remember  which  ;  I  can't  say,  for 
it  was  written  very  hurriedly ;  I  gave  that  to  a  detective — O'Donohue  ; 
I  think  it  was  at  the  same  time  the  coroner  took  her  statement,  if  I  am 
not  mistaken  ;  /  gave  it  at  the  detective's  urgent  request,  and  not  of  my 
own  motion.  I  can  not  say  whether  I  characterized  it  as  a  criminal 
abortion  ;  I  have  no  reason  now  to  suppose  there  was  a  criminal  abor- 
tion committed."  [The  certificate  above  mentioned  was  then  produced 
and  identified  by  the  witness.]  "  When  I  wrote  that  certificate  it  was 
in  accordance  with  my  judgment ;  I  would  not  permit  my  judgment  to 
be  overridden  by  the  urgency  of  the  detective.  My  judgment  that  this 
was  a  criminal  abortion  was  formed  partly  from  her  condition,  partly 
from  the  stories  she  told.  The  word  '  apparently '  I  employed  to  show 
that  /  was  not  at  all  clear  that  it  was  a  criminal  case  ;  I  had  no  evi- 
dence of  it.  I  knew  my  certifimte  was  to  be  used  in  court.  I  don't  know 
lohether  I  knew  on  that  day  that  Dr.  Eeid  was  to  be  arrested.  I  think  I 
saw  Dr.  Reid  that  same  day  in  the  evening.  I  don't  know  whether  1 
said  to  him  on  that  occasion  that  I  knew  no  reason  why  he  should  be  ar- 
rested ;  I  may  have  said  it.'"  Q.  "  Did  you  say  that  you  had  done  noth- 
ing which  should  have  caused  or  led  to  his  arrest?  "  A.  "  I  remember 
having  a  conversation  with  Dr.  Reid  on  that  subject,  and  I  remember 
speaking  to  him  of  the  case.  1  did  not  know  any  man  who  was  con- 
cerned in  the  case.  The  woman  didn't  know  the  man  to  whom  she  had 
gone  at  first,  before  Dr.  Reid,  and  insomuch  as  I  gave  that  statement  con- 
cerning her  condition,  I  did  not  think  that  it  implicated  Dr.  Reid  at  all. 
There  was  no  symptom  which  the  woman  herself  gave  from  which  I  could 
say  there  was  a  criminal  abortion.  1  took  my  statement  as  to  the  crimi- 
nal abortion  frorn  the  fact  that  I  believed  that  there  had  been  an  abortion 
— that  she  7vas  umkr  arrest,  and  from  her  evidence  that  it  had  come  on 
(she  had  taken  pills,  etc.) — it  seemed  further  probable  that  her  abortion 
had  been  presumaldy  from  some  unknown  cause.  My  judgment  as  to 
the  criminnlity  was  based  largely  on  what  she  said ;  there  was  no  physical 
sign  that  induced  me  to  think  it  was  criminal ;  Twill  say  frankly  that  it 
was  entirely  what  she  or  somebody  said  to  me.  There  was  no  laceration 
of  the  OS  or  puncture  of  the  vagina,  and  no  sign  on  lite  woman's  body 


April  8,  1893.] 


ITEMS. 


391 


which  indicated  a  criminal  abortion.  It  is  my  judgment  to-day  that  there 
was  no  physical  sign  which  warranted  giving  such  a  certificate.  I 
formed  the  impression  that  she  had  been  pregnant  from  the  condition 
of  the  womb,  its  general  tenderness  and  the  tenderness  of  the  pelvis, 
and  the  other  symptoms  I  have  described.  She  did  not  say  she  had 
been  pregnant.  She  made  a  variety  of  statements  which  were  some- 
what conflicting.  She  said  at  first  she  thought  she  was  pregnant,  and 
then  she  thought  she  was  not ;  but  the  history  of  the  disease  led  me  to 
think  she  had  naturally  had  an  abortion." 

The  testimony  of  O'Donohue  touching  Dr.  W.'s  statements  and  cer. 
tificate,  in  addition  to  that  above  given,  was  as  follows  :  "  I  went  to 
Bellevue  Hospital  on  the  night  of  the  16th  of  January  to  investigate  a 
suspicious  case  from  the  sergeant  that  was  in  command  of  the  station 
house.  I  went  down  there,  and  found  that  this  S.  J.  was  assigned  to 
Ward  22  in  care  of  Dr.  W.,  and  I  asked  Dr.  W.  what  he  thought  it  was. 
He  said  that  it  was  a  criminal  abortion.  Next  day  I  told  Dr.  W.  that  it 
was  necessary  for  me  to  have  a  certificate  to  take  to  court  ;  so  Dr.  W. 
gave  me  a  certificate."  Q.  (By  Dr.  Boldt.)  "  I  should  like  to  ask  one 
more  question  with  regard  to  this  particular  certificate.  Dr.  W.  made 
a  statement  here  on  the  stand  that  he  had  been  requested  to  give  a  cer- 
tificate to  the  effect  that  the  operation  was  apparently  of  criminal  origin. 
Is  that  so  ?  ''  A.  "  No,  sir.  This  S.  J.  was  also  made  a  prisoner  on  ac- 
count of  her  performing  or  being  supposed  to  have  had  an  operation 
performed  on  her,  and  she  was  to  be  assigned  to  the  prisoner  ward,  but 
the  doctor  said  no,  that  he  would  not  allow  her  to  be  moved,  that  she 
was  in  too  dangerous  a  condition ;  and  then  I  told  him  that  it  was  neces- 
sary for  me  to  take  a  certificate  before  the  magistrate,  and  he  sat  down 
and  wrote  that  certificate.  I  did  not  urge  the  doctor  to  give  me  that 
certificate  ;  no  such  thing.  Dr.  W.  and  all  doctors  know  that  it  is  neces- 
sary to  have  a  certificate.  He  gave  that  entirely  o  f  Ids  owji  accord,  after 
my  simple  statement  that  I  wished  a  certificate  to  explain  her  absence  in 
court.  The  first  mention  of  the  word  '  criminal '  in  connection  with  the 
supposed  abortion  I  heard  from  Dr.  W.,  upon  the  first  occasion  lohen 
I  called  to  see  the  girl,  on  the  evening  of  the  16th.  I  had  that  certificate 
when  I  first  arrested  Dr.  Reid,  and  told  him  so." 

It  was,  of  course,  the  statements,  oral  and  written,  of  Dr.  W.  which 
produced  the  arrest  and  imprisonment  of  Dr.  Reid,  even  after  his  visit 
and  conversation  with  Dr.  W.  The  tone  and  substance  of  the  verdict 
show  how  the  jury  were  impressed  by  his  testimony. 

The  hearing  was  unusually  searching  for  a  coroner's  court.  Dr. 
William  S.  Stone,  of  the  Roosevelt  Hospital,  and  all  the  officers  con- 
nected with  the  case  were  examined.  The  autopsy  was  described  by  Dr. 
Reid,  Dr.  O'Hare,  and  Dr.  Ferguson,  and  Dr.  Reid  detailed  his  treatment 
of  the  deceased.  Professor  William  H.  Thomson  testified  to  the  excel- 
lent professional  reputation  of  Dr.  Reid,  and  Dr.  Horace  T.  Hanks  and 
Dr.  Joseph  H.  Gunning  to  the  entire  correctness  of  his  treatment. 

At  the  conclusion  of  the  testimony  the  assistant  district  attorney  in 
attendance  declared  "  that  the  evidence  absolutely  has  failed  to  disclose 
any  criminal  conduct  on  the  part  of  Dr.  Reid.  On  the  contrary,  it  dis- 
closes the  fact  that  his  professional  conduct  in  this  matter  was  entirely 
blameless  and  without  reproach  in  this  entire  transaction  ;  and  the  vin- 
dication that  this  jury  can  give  to  him  is  very  little  satisfaction  for  the 
injury  and  wroug  that  has  been  done  to  him." 

The  jury,  after  a  brief  charge,  retired,  and  in  a  few  minutes  returned 
with  the  following  verdict : 

"  The  jury  find  unanimously  that  S.  J.,  according  to  the  evidence 
given,  came  to  her  death  at  Bellevue  Hospital  on  January  17, 1893,  and 
that,  in  accordance  with  the  evidence  likewise,  the  cause  of  death  of 
said  S.  J.  was  general  purulent  peritonitis,  in  all  probability  following 
an  abortion.  We  further  find,  also  in  accordance  with  the  evidence, 
that  there  is  no  proof  that  such  abortion  was  otherwise  than  natural, 
and  we  absolutely  exonerate  Dr.  Adrian  Y.  Reid,  the  defendant,  from 
any  other  than  honorable  professional  connection  with  the  case.  In  ad- 
dition, we  find  that  Dr.  Reid's  treatment  was  in  accordance  with  that 
generally  pursued  in  such  cases.  In  conclusion,  this  jury  desire  to  ex- 
press their  condemnation  of  an  apparent  too  great  readiness  on  the  part 
of  some  persons  connected  with  this  case  to  incriminate,  without  suffi- 
cient evidence,  a  reputable  physician,  and  thus  subject  him  to  the  in- 
dignity of  arrest  and  criminal  prosecution." 
Dr.  Reid  and  W.  were  then  discharged. 


The  Chicago  World's  Fair. — At  a  meeting  of  the  joint  committee 
of  the  Chicago  medical  profession  on  the  world's  fair  entertainment, 
held  at  the  Sherman  House  in  November,  1892,  the  establishment  of  a 
bureau  of  information  and  service  was  delegated,  with  approval  and 
indorsement,  to  Charles  Truax,  Greene,  &  Co.,  the  committee  reserv- 
ing to  itself  the  duty  of  such  social  entertainment  of  visiting  phy- 
sicians during  the  continuance  of  the  exposition  as  might  seem  de- 
sirable. This  action  was  confirmed  at  the  final  meeting  of  the  joint 
committee,  on  Feburary  25,  1893,  and,  on  application  of  the  Practi- 
tioners' Club  and  the  South  Side  Medical  Club,  the  matter  of  social  en- 
tertainment was  delegated  to  them,  with  full  authority  to  act  in  the 
capacity  of  entertaining  bodies,  with  the  retention  of  the  chairman  and 
its  American  and  foreign  secretaries  already  appointed :  Chairman,  Dr- 
C.  Warrington  Earle ;  American  Secretaries,  Dr.  Archibald  Church, 
Dr.  G.  Henry  Cleveland,  Dr.  John  C.  Cook,  Dr.  J.  C.  Culbertson ;  Brit- 
ish, Dr.  Sanger  Brown ;  German,  Dr.  F.  C.  Hotz ;  French,  Dr.  Fernand 
Henrotin ;  Spanish,  Dr.  E.  J.  Gardiner ;  Italian,  Dr.  A.  Lagario ;  Swed- 
ish, Dr.  K.  Sandberg;  Canadian,  Dr.  R.  D.  McArthur. 

The  Report  of  the  Academy  of  Medicine's  Committee  on  the  Protec- 
tion of  the  Water  Supply  of  New  York  City. — The  committee  of  the 
Academy  of  Medicine  appointed  at  the  special  meeting  of  that  body  on 
March  9th,  presented  an  elaborate  report  to  the  academy  on  Thursday 
last,  together  with  a  large  number  of  papers,  including  copies  of  the 
various  bills,  amendments,  and  statutes  bearing  upon  the  subject  of 
water  protection. 

The  report  states  that  the  committee  were  appointed  at  a  special 
meeting  and  instructed  to  present  the  views  of  the  academy  to  the 
Legislature.    The  views  to  be  presented  are  said  to  be : 

"  What  the  city  needs  (in  the  opinion  of  the  academy)  is :  First,  a 
consistent  plan,  approved  by  sanitary  experts,  for  the  safe  disposal  of 
town  and  village  sewage  on  the  watershed,  and  legal  and  financial 
power  to  carry  such  a  plan  into  effect.  Second,  such  legislation  as 
shall  forbid,  under  compelling  penalties,  individual  pollution  of  the 
water  and  honest  and  efficient  enforcement  of  that  legislation.  Third, 
the  city  needs  the  power  and  means  to  acquire  (under  proper  safe- 
guards of  individual  rights)  such  real  estate  as  may,  in  the  minds  of 
competent  sanitary  experts  and  engineers,  be  necessary  to  protect  the 
water  after  the  sewage  problem  shall  have  been,  so  far  as  possible, 
solved  by  the  more  simple  and  effective  measures  which  science  has 
made  known." 

The  committee  presented  these  views  in  the  form  of  amendments 
to  the  "  Webster  bill,"  at  that  time  under  consideration  by  the  Senate 
committee  on  cities.  Not  the  least  attention  was  given  to  the  acade- 
my's representatives,  save  a  formal  hearing  by  the  Senate  committee, 
when  the  chairman  of  that  committee,  as  appears  from  the  steno- 
graphic report  presented  to  the  academy,  seems  to  have  acted  much 
the  same  part  as  a  lawyer  engaged  to  oppose  the  academy's  suggestions 
might  have  done.  The  Senate  committee  reported  the  original  bill 
favorably,  making  no  pretense  of  paying  the  least  attention  to  the 
academy,  and  the  Senate  promptly  passed  the  measure  the  next  day. 
The  academy  committee  at  once  telegraphed  to  the  Governor  asking  to 
be  heard  by  him  before  the  bill  should  be  enacted  by  receiving  his 
signature.  The  Governor  granted  the  request  and,  after  consideration 
signed  the  bill,  filing  at  the  same  time  a  memorandum  which  directed 
attention  to  the  faults  mentioned  by  the  committee  and  urged  the  ne- 
cessity for  legislation  which  should  be  unquestionably  sufficient  in  the 
premises.  The  committee,  immediately  after  learning  that  the  bill 
had  been  signed,  sent  it  to  Albany,  and  it  was  introduced  upon  the 
same  day  into  both  Senate  and  Assembly  by  Senator  Saxton  and 
Assemblyman  Kempner  respectively.  This  bill  was  in  accord  with 
the  committee's  instructions.  With  it  were  forwarded  alternative 
amendments  which,  though  the  committee  did  not  approve  of  them, 
itiight  be  accepted  in  case  of  emergency.  At  a  conference  with  the 
Mayor,  these  ammendraents  were  accepted  by  the  latter,  and  intro- 
duced at  the  request  of  the  Corporation  Counsel.  The  academy  bill 
was  not  withdrawn,  however. 

The  following  is  an  abstract  of  the  "  Webster  bill "  and  the 
changes  recommended  by  the  academy. 

Section  1  makes  it  lawful  for  the  Commissioner  of  Public  Works  of 


392 


ITEMS. 


[N.  Y.  Mkd.  JoiTB., 


the  City  of  New  York,  acting  for  and  in  behalf  of  the  city,  to  acquire 
or  take,  in  the  manner  subsecjuently  specified  in  the  act,  title  to,  or  to 
acquire  or  extinguish  any  interest  in,  any  real  estate  in  the  counties  of 
Westchester,  Putnam,  or  Dutchess  which  may  be  necessary  for  sanitary 
protection  of  the  water  supply. 

Section  2  defines  the  terms  "real  estate"  and  "interest  therein  "  as 
used  in  the  act. 

Section  3  directs  the  commissioner  "  from  time  to  time,  and  as  often 
as  he  deems  necessary,  and  within  three  years  after  the  passage  of  this 
act,"  to  cause  maps  and  statements  to  be  prepared  indicating  the  water 
courses,  etc.,  and  the  property  of  which  the  "use  or  condition  does  or 
may  injuriously  affect  the  sources  of  water  supply,"  and  specifying  what 
real  estate  or  interest  it  is  proposed  to  ac(iuire,  take,  or  extinguish. 
Both  maps  and  statements  may  be  modified  when  necessary.  Notice 
must  be  given  and  hearings  allowed  to  all  persons  interested  before  the 
maps  and  statements  are  finally  certified  and  approved.  The  commis- 
sioner is  empowered  to  administer  oaths  and  issue  subpoenas  in  any 
proceedings  pending. 

Section  4  gives  authority -to  enter  upon  any  land  or  water  for  the 
purpose  of  making  examinations,  surveys,  etc. 

Section  6  specifies  the  details  to  be  shown  on  the  maps.  It  also  di- 
rects that  a  certain  number  of  copies  of  maps  and  statements  shall  be 
prepared  and  distributed  in  a  certain  way. 

Sections  6  to  25  (inclusive)  prescribe  the  manner  of  acquiring  and 
making  compensation  for  property  condemned. 

Section  26  authorizes  the  commissioner  to  cause  surveys  and  maps 
to  be  prepared  without  contract,  and  to  employ  such  persons  as  may  be 
needed  to  carry  out  the  provisions  of  the  act,  to  fix  the  compensation 
for  their  services,  to  make  without  contract  any  alterations  required  for 
sanitary  reasons  in  any  property  acquired,  and  to  appoint  and  fix  com- 
pensation of  any  persons  needed  to  maintain  in  good  condition  the 
property  acquired. 

Section  27.  The  commissioner  "  is  hereby  authorized  to  take  such 
measures  as  may  be  necessary  to  preserve  from  pollution  and  defile- 
ment all  the  sources  of  water  supply,  .  .  .  and  to  that  end  to  enter  in 
and  upon,  at  any  time  within  three  years  after  the  passage  of  this  act, 
any  or  all  lands  near,  on,  adjacent  to,  or  contiguous  to  any  of  the  said 
sources  of  water  supply,  and  to  abate  and  remove  the  cause  of  any  such 
pollution  or  defilement."  The  section  then  sets  forth  the  manner  of 
determining  and  making  compensation  for  damages  resulting. 

Sections  28,  29,  and  30  authorize  the  issue  of  bonds  in  order  to  ob- 
tain the  necessary  money,  limit  the  amount  to  be  expended  to  $350,000 
per  annum  for  three  years,  direct  the  commissioner  to  make  monthly 
reports  of  money  spent  and  liabilities  incurred,  and  direct  the  comp- 
troller to  pay  the  sums  required,  proper  precautions  being  taken  to 
avoid  fraud. 

Section  31  reaflBrms  certain  limitations  already  existing  as  to  the 
use  of  the  waters  of  Lake  Mahopac  and  Lake  Gleneida. 

It  will  be  seen  that  this  act  gives  enormous  power  to  a  single  man — 
a  part  of  which  power  is  legislative ;  that  it  does  not  give  power  to 
make  and  enforce  sanitary  regulations  ;  that  it  does  not  require  the 
adoption  of  a  plan  for  sewage  disposal  devised  or  approved  by  sanitary 
experts  and  engineers ;  and  that,  although  it  gives  authority  to  abate 
nuisances,  it  does  not  forbid  the  creation  of  nuisances,  except  the  city 
buys  the  land  upon  which  they  may  be  estabUshed. 

The  instructions  which  the  committee  had  received  were  to  present 
the  academy's  views  to  the  Legislature.  The  first  thing  to  be  pro- 
vided, according  to  the  resolutions,  was  a  consistent  plan  for  the  safe 
disposal  of  town  and  village  sewage  upon  the  watershed,  approved  by 
sanitary  experts,  and  legal  and  financial  power  to  carry  out  the  plan. 
The  second  was  to  make  possible  the  promulgation  and  enforcement  of 
sanitary  rules  and  regulations.  The  third  was  to  permit  the  purchase 
of  land  if  necessary. 

All  these  requisites  were  covered  by  the  amendments  suggested 
by  the  committee  to  the  Webster  bill.  The  amendments  made  the  fol- 
lowing changes  in  the  bill : 

1.  A  commission  composed  of  the  Commissioner  of  Public  Works, 
who  was  to  be  president  of  the  commission,  a  member  of  the  city 
health  board,  a  member  of  the  State  health  board,  to  be  nominated  by 
that  body;  a  member  to  be  nominated  by  the  Chamber  of  Commerce 


of  this  city ;  a  sanitary  engineeer,  approved  by  the  American  Society 
of  Civil  Engineers  of  New  York,  was  substituted  for  the  Commissioner 
of  PubUc  Works. 

2.  The  commission  was  directed  to  take  advice  from  experts  and 
to  employ  them  to  draw  a  plan  of  action. 

3.  The  commission  was  vested  with  so  much  of  the  powers  con- 
ferred upon  a  town  or  village  health  board  as  might  be  necessary  to 
make  and  enforce  sanitary  rules  and  regulations  and  to  abate  and  [)re- 
vent  nuisances. 

4.  Sufficient  power  was  given  to  do  whatever  might  be  necessary  in 
the  premises,  to  buy  land  or  build  and  maintain  any  necessary  safe- 
guards, such  as  sewers,  etc. 

The  late  Dr.  Laurence  Johnson. — The  trustees  of  the  New  York 

Academy  of  Medicine  have  adopted  the  following : 

Resolved,  That  the  trustees  of  the  New  York  Academy  of  Medicine 
are  deeply  sensible  of  a  great  loss  through  the  death  of  their  recent  as- 
sociate, Laurence  Johnson. 

That  they  have  long  shared  with  his  professional  brethren  an  appre- 
ciation of  his  faithfulness  to  every  trust,  his  versatiUty  of  accomplish- 
ments, his  gentleness  of  spirit  and  charity  toward  others,  and  the  many 
traits  that  contributed  to  his  noble  nature. 

That  although  his  untimely  death  leaves  in  our  circle  of  associates  a 
gap  that  no  one  can  fill,  the  memory  that  will  ever  remain  among  the 
most  cherished  of  our  lives  will  inspire  us  to  emulate  his  manly  char 
acter,  professional  zeal,  and  geneious  nature,  and  so  long  as  this  memory 
lasts  will  his  influence  among  his  former  associates  continue. 

Be  it  also  Resolved,  That  these  resolutions  be  entered  upon  the  min- 
ute of  this  meeting  and  reported  to  the  academy,  and  that  a  copy 
thereof,  signed  by  the  remaining  members  of  the  board  of  trustees,  be 
sent  to  the  family  of  our  deceased  member. 

A  Prize  Essay  on  Homceopathy. — To  Dr.  William  W.  Browning,  of 

Brooklyn,  has  been  awarded  a  prize  of  $100  for  the  best  essay  on  the 
pretensions  of  modem  homceopathy,  offered  by  Dr.  George  M.  Gould, 
the  editor  of  the  Medical  News.  There  were  thirteen  competitors.  Dr. 
Browning's  essay  is  entitled  Modern  Hommopathy  ;  iU  Absurdities  and 
Inconsistencies. 

The  Manhattan  Cliaical  Association  was  organized  on  March  lYth, 

and  the  following  officers  were  elected  :  President,  Dr.  J.  P.  McGowan ; 
vice-president.  Dr.  Emilio  Echeverria ;  secretary  and  treasurer,  Dr.  Wil- 
liam Smith  Roosc. 

The  Bichmond  Academy  of  Medicine  and  Surgery. — Dr.  Stuart  Mc- 
Guire  is  announced  to  open  a  discussion  on  drainage  in  abdominal 
surgery  at  the  next  meeting,  on  Tuesday  evening,  the  11th  inst. 

Professor  Hans  Virchow  is  to  be  given  a  reception  in  Newark, 
N.  J.,  this  (Saturday)  evening  by  Dr.  Charles  J.  Kipp. 

Professor  Rudolf  Virchow. — The  British  Medical  Journal  an- 
nounces that  the  honorary  degree  of  D.  C.  L.  has  been  conferred  on 
Professor  Virchow  by  the  University  of  Oxford. 

Changes  of  Address. — Dr.  Charles  Jewett,  Brooklyn,  to  No.  330 

Clinton  Avenue ;  Dr.  C.  H.  Robinson,  Dublin,  Ireland,  to  No.  1  De 
Vesci  Place,  Kingstown,  County  Dublin ;  Dr.  R.  W.  Wilcox,  to  No.  706 
Madison  Avenue. 

The  Society  of  Medical  Jurisprudence. — At  the  next  meeting,  on 
Monday  evening,  the  10th  inst..  Dr.  Landon  Carter  Gray  vrill  read  a 
paper  entitled  A  Suggestion  for  a  New  Method  of  taking  Expert  Tes- 
timony. 

A  Handsome  Consultation  Fee. — The  Deutsche  Medizinal-Zeitung 
states,  on  the  authority  of  a  Russian  journal,  that  Professor  Sacharin, 
of  Moscow,  has  received  a  consultation  fee  of  14,000  roubles  from  a 
well-known  millionaire. 

The  Association  of  American  Medical  Editors  will  hold  its  eleventh 
annual  meeting  in  Milwaukee  on  June  5th.  Mr.  Ernest  Hart,  the  edi- 
tor of  the  British  Medical  Journal,  will  deliver  the  annual  address. 


April  8,  IH93.I 


ITEMS.— BOOK  NOTICES. 


393 


Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army,  from  March  £6  to  April  1,  1893  : 

Dk  Shon,  George  D.,  First  Lieutenant  and  Assistant  Surgeon,  Fort  D. 

A.  Russell,  Wyoming,  is  granted  leave  of  absence  for  sixteen  days, 

to  take  effect  on  or  about  April  1,  1893. 
Spencer,  William  G.,  Captain  and  Assistant  Surgeon,  is  granted  leave 

of  absence  for  two  months,  on  surgeon's  certificate  of  disability, 

with  permission  to  leave  the  Department  of  the  Platte. 
Byrne,  Charles  C,  Lieutenant-Colonel  and  Deputy  Surgeon-General, 

Medical  Director,  Headquarters  Department  of  the  Columbia,  is 

granted  leave  of  absence  for  one  month,  with  permission  to  apply 

for  an  extension  of  one  month. 

Society  Meetings  for  tho  Coming  Week : 

Monday,  April  10th :  New  York  Academy  of  Medicine  (>Section  in  Gen- 
eral Surgery) ;  New  York  Ophthalmological  Society  (private) ;  New 
York  Medico-historical  Society  (private);  New  York  Academy  of 
Sciences  (Section  in  Chemistry  and  Technology) ;  Society  of  Medical 
Jurisprudence,  New  York ;  Lenox  Medical  and  Surgical  Society 
(private) ;  Gynaicological  Society  of  Boston ;  Burlington,  Vt.,  Medi- 
cal and  Surgical  Club ;  Norwalk,  Conn.,  Medical  Society  (private) ; 
Baltimore  Medical  Association. 

Tuesday,  April  11th :  New  York  Academy  of  Medicine  (Section  in 
Genito-urinary  Surgery) ;  New  York  Medical  Union  (private) ;  Kings 
County,  N.  Y.,  Medical  Association ;  Medical  Societies  of  the  Counties 
of  Jefferson  (quarterly — Watertown),  Oneida  (quarterly — Utica),  On- 
tario (quarterly),  Rensselaer,  and  Tioga  (quarterly — Owego),  N.  Y. ; 
Richmond,  Va.,  Academy  of  Medicine  and  Surgery ;  Bergen  (annual 
— Hackensack)  and  Cumberland  (annual),  N.  J.,  County  Medical  So- 
cieties ;  Fairfield  County,  Conn.,  Medical  Association  (annual) ;  New- 
ark, N.  J.,  and  Trenton  (private),  N.  J.,  Medical  Associations ;  North- 
western Medical  Society  of  Philadelphia ;  Baltimore  Gynaecological 
and  Obstetrical  Society. 

Wednesday,  April  12th :  New  York  Surgical  Society  ;  New  York  Patho- 
logical Society  ;  Metropolitan  Medical  Society  (private) ;  American 
Microscopical  Society  of  the  City  of  New  York ;  Medical  Society  of 
the  County  of  Albany  ;  Tri  States  Medical  Association  (Port  Jervis, 
N.  Y.) ;  Pittsfield,  Mass.,  Medical  Association  (private) ;  Philadelphia 
County  Medical  Society ;  Kansas  City,  Mo.,  Ophthalmological  and 
Otological  Society. 

Thursday,  April  13th :  New  York  Academy  of  Medicine  (Section  in 
Paediatrics) ;  New  York  Laryngological  Society ;  Brooklyn  Patho- 
logical Society;  Medical  Societies  of  the  Counties  of  Cayuga  and 
Fulton  (quarterly),  N.  Y. ;  South  Boston,  Mass.,  Medical  Club  (pri- 
vate) ;  Pathological  Society  of  Philadelphia ;  New  London,  Conn., 
County  Medical  Society  (annual). 

Friday,  April  IJjih :  New  York  Academy  of  Medicine  (Section  in  Neu- 
rology) ;  Yorkville  Medical  Association  (private) ;  German  Medical 
Society  of  Brooklyn  ;  Brooklyn  Dermatological  and  Genito-urinary 
Society  (private) ;  Medical  Society  of  the  Town  of  Saugerties,  N.  Y. 

Saturday,  April  16th :  Clinical  Society  of  the  New  York  Post-graduate 
Medical  School  and  Hospital. 


Disease  in  Children.   A  Manual  for  Students  and  Practitioners. 
By  James  Cakmichael,  M.  D.,  F.  R.  C.  P.  Ed.,  Physician, 
Royal  Hospital  for  Sick  Children,  etc.    Illustrated  with 
Thirty-one  Ciiarts.    New  York:  D.  Appleton  &  Co.,  1892. 
Pp.  xvi-591.    [The  Students"  Series.]    [Price,  $3.] 
The  snbject-matter  of  this  most  admirable  treatise  is  derived 
largely  from  tlie  author's  private  and  hospital  practice,  and, 
although  the  many  authorities  he  has  had  occasion  to  consult 
in  his  busy  medical  life  are  duly  quoted,  there  is  no  evidence  of 
an  undue  desire  to  display  erudition.    The  author  assumes  that 


the  reader  is  acquainted  with  general  medicine  and  the  diseases 
afflicting  adult  life,  and  therefore  believes  it  to  be  his  duty  to 
accentuate  such  divergence  as  may  exist  in  the  anatomical  and 
physiological  characteristics  of  those  of  infancy  and  childhood 
and  to  siiow  in  what  deirree  they  may  modity  the  features  and 
the  clinical  relations  of  disease.  He  declares  the  highest  aim  of 
the  physician  to  be  the  prevention  of  disease,  and  therefore 
very  properly  begins  his  book  with  a  dissertation  on  hygiene, 
domestic  and  scholastic.  This  is  followed  by  a  chapter  on  the 
methods  of  examining  a  child.  The  study  of  pathology  is  en- 
tered upon  by  that  of  the  fevers,  to  which  succeeds  that  of  the 
disorders  of  the  general  nutrition.  We  should  have  preferred  to 
find  the  every-day  disturbances,  such  as  disorders  in  the  digestive 
or  pulmonary  tract,  the  first  in  order,  for  then  the  student's  mind 
would  have  been  impressed  with  the  necessity  of  remembering 
the  disproportion  frequently  existing  in  childhood  between 
cause  and  effect,  and  with  the  fact  that  great  disturbances  do 
not  necessarily  denote  the  existence  of  severe  disease.  This, 
however,  is  a  minor  detail  of  a  very  valuable  book  that  every 
physician  would  be  the  wiser  for  consulting. 


The  Food  Inspector's  Handbook.  By  Feanois  Vaohbr.  Lon- 
don: The  Record  Press,  1892.  Pp.  ix-140. 
This  little  work  is  a  collection  of  papers  that  appeared  in 
the  Sanitary  Record  during  1892,  and  the  experience  of  the  au- 
thor as  a  medical  officer  of  health  and  food  analyst  has  fitted 
him  to  write  authoritatively  on  the  subject  of  food  inspection. 

He  surveys  the  requisites  that  enable  an  individual  to  be- 
come an  efficient  food  inspector,  reviews  the  various  acts  that 
apply  to  the  inspection  and  regulation  of  the  sale  of  food,  and 
divides  the  consideration  of  his  subject  into  nine  headings: 
a,  Animals,  carcasses,  and  butcher's  meat;  J,  poultry  and  game ; 
c,  fish;  d,  fruit  and  vegetables;  e,  corn,  bread,  and  flour; 
/,  milk ;  g,  arrowroot  and  similar  preparations,  butter  and  its 
substitutes,  cheese,  lard,  and  eggs;  h,  tea,  coff"ee,  cocoa,  and 
sugar;  and  i,  condiments  and  spices.  In  the  chapters  devoted 
to  each  of  these  headings  the  subject  is  presented  in  a  manner 
that  permits  the  non-professional  reader  to  grasp  the  author's 
meaning.  There  are  two  chapters  devoted  to  the  diseases  of 
animals  that  render  meat  unfit  for  food. 

While  the  author  prefers  a  good  intelligent  butcher  to  Ji 
veterinary  surgeon  for  the  office  of  food  inspector,  because  a 
practical  knowledge  of  meat  is  most  essential,  it  is  difficult  to 
understand  how  such  a  man  is  to  be  fitted  for  discharging  the 
duties  of  inspector  of  other  classes  of  foodstuffs.  It  does  not 
seem  that  the  author  is  fully  justified  by  known  facts  in  mak- 
ing the  statement  that  it  is  quite  exceptional  to  find  the  Bacillus 
tvberculosis  in  the  milk  of  tuberculous  cows. 

The  author's  style  is  attractive  and  the  omission,  as  far  as 
possible,  of  technical  terms  will  make  the  work  useful  both  to 
the  professional  and  the  lay  reader. 


Traits  clinique  et  therapeutique  de  Vhysterie  d'apr^s  I'enseigne- 
ment  de  la  Salpfetriere.  Par  le  Docteur  Gillks  dk  la  Totj- 
EETTE,  ancien  chef  de  clinique  des  maladies  du  syst^me 
nerveux  a  la  SalpetriSre.  Preface  de  M.  le  Dr.  J.  M.  Char- 
cot, Professeur  de  clinique  des  maladies  du  systdme  nerveux, 
membre  de  I'Institut.  IIyst6rie  normale  on  interparoxy- 
Btique.  Avec  46  figures  dans  le  texte.  Paris:  E.  Plon 
Nourrit  et  cie. 

Profkssok  Chaeoot,  in  his  preface  to  this  work,  bestows 
the  highest  praise  upon  its  author,  extolling  him  not  only  as 
one  of  his  own  most  careful  and  faithful  students,  but  also  as 
an  original  investigator,  and  particularly  emphasizes  the  great 
importance  of  his  discovery  of  the  chemical  formula  of  hys- 


394 


BOOK  NOTICES.— MISCELLANY. 


|N.  Y.  Mbd.  JotiB., 


teria.  A  most  interesting  chapter  on  the  evolntion  of  the  con- 
ception of  hysteria,  containing  many  illustrations  derived 
chiefly  from  well-known  paintings,  is  demonstrative  of  the  un- 
changeable nature  of  this  most  protean  disease.  The  author  is, 
curiously  enough,  guilty  of  a  sad  oversight;  nowhere  in  his 
book  do  we  find  a  definition  or  description  of  hysteria,  so  that 
we  are  ourselves  forced  to  construct  our  own  image  of  it  hit  by 
bit  out  of  his  careful  study  of  the  elements  or  fragments.  Even 
this  we  are  not  able  to  complete,  for  in  the  midst  of  an  interest- 
ing disquisition  on  blood  changes,  on  page  573,  we  read  "End 
of  Vol.  I,"  the  first  intimation  we  have  received  that  we  have 
had  in  our  hands  a  work  of  more  than  one  volume.  This  fail- 
ure on  the  part  of  the  author  to  take  the  reader  into  his  confi- 
dence deprives  the  latter  of  the  pleasure  always  felt  by  him  at 
the  logical  development  of  a  disclosed  plan  or  proposition,  and 
inadequately  replaces  it  by  an  aimless,  rudderless  condition. 
The  satisfaction  he  would  have  normally  felt  in  a  clear  exposi- 
tion of  known  facts  is  thus  largely  destroyed.  The  volume 
treats  of  the  history  and  aetiology  of  hysteria,  of  the  cutane- 
ous, raucous,  and  sensory  anjesthesise  and  hyperaesthesia,  of 
the  hysterogenetic  zones,  of  hysterical  visual  troubles,  of  con- 
tracture, of  amyasthenia,  of  the  trembling,  of  the  mental  condi- 
tion, and  of  the  general  nutrition  of  the  hysterical  patient.  The 
work  is  not  indexed  with  sufficient  care,  so  that  it  has  been  sev- 
eral times  impossible,  without  a  prolonged  and  repeated  search 
of  both  index  and  text,  to  find  paragraphs  to  which  a  second 
reference  was  desirable. 


A  Treatise  on  Diseases  of  the  Nose  and  its  Accessory  Cavities^ 
By  Greville  Maodonald,  M.  D.  (Lond.),  Physician  to  the 
Hospital  for  Diseases  of  the  Throat.  Second  Edition.  Lon- 
don and  New  York:  Macmillan  &  Co.,  1892.  Pp.  xix  to 
381.    [Price,  $2.50.] 

The  author  has  adopted  a  method  of  indexing  his  work 
that  is  sure  to  commend  it  to  general  favor — table  of  contents, 
chapter-indexing,  and  marginal  notes.  The  busy  man  is  always 
grateful  when  he  is  enabled  by  any  such  device  to  find  at  a 
glance  the  division  of  the  subject  that  particularly  interests  him, 
and  when,  moreover,  he  finds,  on  consulting  the  text,  that  the 
author  has  written,  so  to  speak,  with  the  patient  before  hire, 
his  attention  and  confidence  are  entirely  gained  and  he  follows 
with  the  closest  attention  the  lessons  of  one  who  has  seen  and 
understood.  Macdonald's  style  is  admirably  adapted  to  his  sub- 
ject, which  latter  he  keeps,  without  deviation,  constantly  before 
his  eyes.    We  can  not  too  highly  recommend  the  treatise. 

A  Manual  of  Diseases  of  the  Nervous  System.  By  W.  R.  Gowers, 
M.D.,  F.  B.C.  P.,  F.  R.S.,  Consulting  Physician  to  Univer- 
sity College  Hospital,  etc.  Second  Edition,  revised  and  en- 
larged. Volume  I.  Diseases  of  the  Nerves  and  Spinal  Cord. 
With  One  Hundred  and  Eighty  Illustrations,  including  Three 
Hundred  and  Seventy  Figures.  Philadelphia:  P.  Blakiston, 
Son,  &  Co.,  1892.    Pp.  xvi  to  616. 

The  first  volume  of  Gowers's  most  excellent  and  classical 
work  has  been  increased,  as  he  himself  states,  by  additions  on 
every  page — additions  rendered  necessary  by  the  advance  in 
science  and  bearing  on  such  important  subjects  as  multiple  neu- 
ritis, brachial  neuritis,  senile  paraplegia,  muscular  dystrophy) 
etc. 

The  whole  subject  matter  has  been  so  carefully  revised  that 
in  the  entire  volume  there  is  but  one  paragraph  showing  traces 
of  interpolation  (on  bone  fracture  in  acute  atrophic  paralysis, 
p.  364).  The  illustrations,  although  plentiful  and  sufficiently 
exact  from  a  scientific  point  of  view,  are  wanting  in  artistic 
quality. 


Spectacles  and  Eyeglasses;  tbeir  Forms,  Mounting,  and  Proper 
Adjustment.  By  R.  J.  Phillips,  M.  D.,  Instructor  in  Dis- 
eases of  the  Eye,  Pliiladeli)hia  Polyclinic  and  College  for 
Graduates  in  Medicine,  etc.  Philadelphia:  P.  Blakiston, 
Son,  &  Co.,  1892.    Pp.  viii-l7  to  97. 

This  work,  as  its  author  informs  us,  is  intended  to  supple- 
ment studies  in  refraction  and  to  give  the  student  the  necessary 
knowledge  for  the  correct  placing  of  glasses  before  the  eyes. 
Before  proceeding  to  the  demonstration  of  his  subject,  the  au- 
thor reviews  the  liistory  of  the  development  of  lenses  from  the 
time  of  their  first  discovery.  The  necessary  practical  manipu- 
lations are  succinctly  described  and  illustrated  in  their  natural 
order,  thus  enabling  physicians,  in  the  absence  of  an  optician, 
to  themselves  furnish  spectacles  to  their  patients.  Wecan  heart- 
ily recommend  this  little  book  and  believe  that  it  could  render 
much  good  service  to  every  general  practitioner. 


Lectures  on  Pathology  delivered  at  the  London  Hospital  by  the 
late  TIenky  Gawen  Sutton,  M.  B.,  F.  R.  C.  P.,  Physician  and 
Lecturer  on  Pathology  at  the  London  Hospital,  etc.  Edited 
by  Maurice  Eden  Paul,  M.  D.,  and  revised  by  Samuel 
WiLKS,  M.  D.,  LL.  D.,  F.  R.  S.  Philadelphia :  P.  Blakiston, 
Son,  &  Co.,  1891.    Pp.  xviii  to  503. 

This  is  a  series  of  causeries  on  the  various  departures  from 
health  common  to  the  human  race,  delivered  by  a  man  who  has 
evidently  outlived  systems  and  methods  so  necessary  for  the  be- 
ginner in  collating  his  newly  acquired  knowledge.  Our  author 
was  apparently  as  partial  to  the  psychological  aspect  presented 
by  every  patient  as  interested  by  his  somatic  departure  from  the 
equilibrium  or  restful  condition  indicative  of  health.  He  is  con- 
stantly full  of  regret  that  the  senses,  the  instincts,  are  not  more 
frequently  consulted,  and  considers  most  medical  interference 
as  impertinent.  His  own  sympathies  have  evidently  been  broad, 
embracing  in  their  comprehensiveness  the  thoughts  and  actions 
of  many  generations.  We  find,  curiously  enough,  but  few  cita- 
tions of  medical  authorities,  while  the  poets  and  historians  are 
constantly  being  introduced  as  familiar  friends.  As  we  are 
warned  in  the  preface  by  the  compiler  of  the  lecture  notes.  Dr. 
Maurice  Eden  Paul,  the  author's  style  is  quaintly  peculiar,  one 
might  almost  add  incomprehensibly  so.  On  the  other  hand,  the 
author's  charming  personality  so  pervades  every  sentence  that 
great  regret  arises  that  his  portrait,  as  well  as  his  biography,  has 
not  been  added  to  the  work  so  that  our  half-formed  picture  of 
him  could  be  completed.  We  can  imagine  that  it  would  have 
been  difficult  to  find  a  man  with  whom  it  would  be  possible  to 
have  talked  over  as  satisfactorily  as  with  Sutton  the  manifold 
experiences  of  a  long  and  studious  life.  Yet,  by  very  reason  of 
this  ripeness  of  knowledge,  from  which  the  angles  have  long 
since  disaf)peared,  we  doubt  if  the  work,  despite  its  great  attract- 
iveness, will  be  suitable  to  its  stated  destiny — that  of  a  clinical 
text-book.  The  subject  matter  is  not  sufficiently  co-ordinated 
or  didactic  in  its  form  to  aid  the  student  materially  in  passing 
examinations,  which,  judging  from  the  text,  was  the  immediate 
object  of  the  lectures.  But,  be  this  as  it  may,  the  work  may 
be  read  by  the  experienced  practitioner  with  equal  profit  and 
pleasure. 


The  Evolution  of  Pathology. — On  the  16th  of  March  there  was  de- 
livered before  the  Royal  Society  a  notable  Croonian  lecture  by  Pro- 
fessor Rudolf  Virchow,  who  took  for  the  theme  of  his  discourse  The 
Position  of  Pathology  among  the  Biological  Studies.    The  lecture  was 


April  8,  1893.] 


MISCELLANY. 


395 


published  in  the  British  Medical  Journal  for  March  18th.  The  fol- 
lowing is  a  considerable  portion  of  it : 

"  The  downfall  of  the  old  medicine,  the  so-called  humoral  pathology, 
was  brought  about  in  the  beginning  of  the  sixteenth  century.  We  in 
Germany  are  inclined  to  attribute  to  our  nation  a  decisive  role  in  this 
memorable  struggle. 

"  It  was  a  man  of  our  race,  Andreas  Vesalius,  or  from  Wesel,  who 
transformed  anatomy  into  an  exact  science,  and  who  thus,  at  one  stroke, 
created  for  medicine  a  solid  foundation,  which  it  has  retained  ever 
since,  and,  let  us  hope,  will  never  again  lose. 

"  But  the  principal  blow  to  the  old  medicine  was  struck  by  his  some- 
what elder  contemporary  Paracelsus — that  charlatan  yet  gifted  physi- 
cian who  removed  from  among  the  beliefs  of  mankind  the  doctrine  of  the 
four  humors  which,  quasi-chemical  in  its  construction,  formed  the  basis  of 
the  old  pathology.  Strangely  enough,  he  accomplished  this  with  weap- 
ons borrowed  from  the  armory  of  the  Arabs,  the  successors  of  the 
Greeks,  and  the  chief  representatives  of  the  medisBval  humoral  pa- 
thology. From  them  also  he  borrowed  alchemy,  and  at  the  same  time 
the  fantastic  spiritualism  of  the  East,  which  found  a  clear  expression 
in  his  doctrine  of  the  archoeus,  as  the  determining  force  in  all  living 
beings. 

"  In  this  way  the  new  medicine,  at  its  very  birth,  absorbed  the 
germs  of  that  ruinous  contradiction  which,  even  up  to  this  present 
century,  has  kept  up  the  embittered  strife  of  the  schools. 

"  To  Vesalius  is  due  the  exact  tendency  which  starts  from  the  ob- 
servation of  actual  conditions,  and  which,  without  going  further,  we 
may  call  the  anatomical. 

"Paracelsus,  who  pronounced  the  anatomy  of  the  dead  body  to  be 
useless,  and  sought  for  the  basis  of  life  as  the  highest  goal  of  knowl- 
edge, demanded  'contemplation'  before  all  else;  and,  just  as  he  him- 
self arrived  in  this  way  at  the  metaphysical  construction  of  the  archcei, 
so  he  unchained  among  his  followers  a  wild  and  absolutely  fruitless 
mysticism. 

"  Nevertheless,  there  lay  hidden  in  that  '  contemplation '  of  his  a 
healthy  kernel,  which  would  not  allow  the  intellectual  activity  which  it 
had  stirred  up  to  come  to  rest.  It  was  the  idea  of  life  which  formed 
the  ultimate  problem  for  all  future  research.  Strangely  enough,  this 
idea,  which  always  existed  in  the  popular  mind  and  which  is  in  an  un- 
mistakable form  present  even  among  primitive  nations,  had  been  driven 
far  into  the  background  in  scholastic  medicine.  Ever  since  the  time  of 
Hippocrates  it  had  been  the  custom  to  use,  instead  of  life,  the  obscure 
expression  '  <|)u<r<j,'  natura  ;  but  in  vain  does  one  seek  for  a  more  exact 
definition  of  the  term.  To  Paracelsus  Nature  was  living,  and  the  basis 
of  his  life  was  that  very  archceus,  a  force  differing  from  matter  and 
separable  from  it,  or,  as  he  himself  expressed  it,  in  the  sense  of  the 
Arabs,  a  spirit,  spirilus.  In  the  compound  organism  of  man,  the  micro- 
cosmus,  each  part,  according  to  him,  had  its  own  archmis,  but  the 
whole  was  ruled  by  the  archmis  maximus,  the  spirilus  rector.  From 
this  premise  has  proceeded  the  long  succession  of  vitalistic  schools, 
which,  in  ever-changing  forms  and  with  ever-new  nomenclature,  intro- 
duced into  the  notions  of  physicians  this  idea  of  a  fundamental  princi- 
ple of  life. 

"  If  the  sagacious  Georg  Ernest  Stahl,  whose  services  to  the  devel- 
opment of  chemistry  are  now  acknowledged  everywhere,  substituted  the 
soul  for  the  spirilus  rector,  and  so  created  a  system  of  animism,  the  last 
vestiges  of  which  have  disappeared  from  the  school  of  Montpelier 
within  our  own  time  only,  so  also  in  turn  did  the  pure  vitalists  build 
upon  the  dogma  of  specific  dynamic  energies,  maintained  so  stoutly  by 
the  physicists,  that  notion  of  the  vital  force,  the  half  spiritualistic  and 
half  physical  character  of  which  has  contributed  so  much,  even  in  our 
day,  to  puzzle  and  mislead  men's  minds. 

"  The  doctrine  of  the  vital  force  found  its  strongest  support  in  the 
Naturphilosophic,  es])ecially  in  that  which,  on  German  ground,  soon  ob- 
tained universal  sovereignty. 

"  This  summary  exposition  of  mine  has  greatly  anticii)ated  the  his- 
torical progress  of  the  evolution  of  medicine.  It  is  now  time  to  pay 
proper  homage  to  the  great  investigator  who  made  the  more  exact 
method  the  ruling  one,  and  at  the  same  time  to  award  to  this  country, 
which  brought  him  forth,  its  important  share  in  determining  the  new 
direction  of  our  science. 


"  Nearly  one  hundred  years  had  passed  since  Vesalius  and  Para- 
celsus had  begun  their  work  when  William  Harvey  published  his  Ez- 
ercitatio  anatomica  de  raotu  cordis  et  sanguxnis  in  animalibus.  Here, 
for  the  first  time,  the  anatomical  examination  of  living  parts  was  car- 
ried through  in  an  exemplary  way  according  to  experimental  methods. 
All  the  objections  that  anatomy  concerned  itself  with  dead  parts  only 
were  thus  at  once  set  aside  ;  living  action  became  the  object  of  imme- 
diate observation,  and  this  was  done  on  one  of  the  most  important 
organs,  one  absolutely  necessary  to  life,  the  varying  activity  of  which 
constantly  calls  for  the  attention  of  the  practical  physician.  Not  only 
so,  however,  but  a  new  mode  of  observation — the  experimental  method 
— was  thus  brought  into  use  for  research  ;  a  method  through  which  a 
new  branch  of  medical  science,  physiology,  has  been  laboriously  built 
up. 

"  The  influence  of  this  one  wonderful  discovery  of  Harvey's  on  the 
ideas  of  men  of  his  time  and  of  his  successors  was  memorable.  Among 
the  men  of  his  time  the  last  support  of  Galenism  disappeared  with  the 
proof  of  circulation ;  among  his  successors  the  comprehension  of  the 
causation  of  local  processes  dawned  for  the  first  time.  Very  ancient 
and  highly  difficult  problems,  such  as  inflammation,  could  now  be  at- 
tacked ;  a  goodly  piece  of  life  also  became  intelligible,  since  one  of  the 
vital  organs  themselves  could  now  be  subjected  to  experiment,  and,  to 
the  astonishment  of  all,  the  action  of  this  organ  showed  itself  to  be  an 
absolutely  mechanical  one.  The  revulsion  of  thought  was  so  complete 
that  it  has  become  since  a  difficulty  hardly  to  be  overcome  to  enter  even 
in  imagination  into  the  ideas  of  the  older  physicians,  to  whom  the  circu- 
lation of  the  blood  was  unknown. 

"Nevertheless,  in  spite  of  such  striking  results,  the  craving  of  man 
for  more  complete  understanding  remained  unsatisfied.  One  saw  the 
action  of  the  living  heart,  but  how  did  it  live  ?  What  was  this  life,  the 
action  of  which  one  saw  before  one  ?  In  the  heart  itself  the  essence  of 
life  could  not  be  recognized. 

"  Harvey  turned  his  attention  to  another  object ;  he  tried  to  observe 
the  very  beginnings  of  life  in  the  incubated  egg  of  the  fowl  and  in  the 
embryos  of  mammalian  animals.  He  thereby  soon  arrived  at  the  ques- 
tion of  the  significance  of  the  egg  in  general,  and  enunciated  the  cele- 
brated dictum,  Omne  vivum  ex  ovo.  Owing  to  the  more  extensive  re- 
searches of  modern  investigators,  this  dictum,  as  is  well  known,  proved 
too  narrow  for  the  whole  animal  kingdom,  and  is  no  longer  exact  when 
applied  to  plant  life.  Its  validity  for  the  higher  animals,  on  the 
other  hand,  can  not  be  questioned,  and  it  has  formed  one  of  the  firm 
standpoints  on  which  researches  on  sexuality  and  on  the  propagation  of 
life  have  been  based.  But  Harvey,  on  account  of  the  deficiency  of  his 
optical  instruments,  was  unable  to  see  that  which  he  was  laboring  to  dis- 
cover— namely,  the  process  of  organization  as  such,  just  as  he  had  been 
imable  in  former  times  to  see  the  continuity  of  the  capillary  flow.  This 
imperfection  lasted  for  a  long  time  afterward ;  and  thus  it  happened 
that  even  Albrecht  von  Haller  and  John  Hunter  considered  the  forma- 
tion of  the  area  vasculosa  in  the  incubated  egg  of  the  fowl  as  the 
commencement  of  organization,  and,  indeed,  as  the  type  of  organization 
itself. 

"  I  will  return  to  this  point  later  on ;  but  for  the  present  I  should 
like  first  to  draw  your  attention  to  a  man  whose  importance  for  the 
further  development  of  the  doctrine  of  life  has  always  appeared  to  me 
to  have  been  uncommonly  great  and  highly  significant,  but  who  never- 
theless has  sunk  into  unmerited  oblivion,  not  only  among  posterity  in 
general,  but  also,  I  think  I  may  be  allowed  to  say,  even  in  the  memory 
of  his  countrymen.  I  mean  Francis  Glisson,  who  was  a  contemporary 
of  Harvey,  and  whose  works  appeared  almost  simultaneously  with  those 
of  his  more  celebrated  colleague ;  but  the  brilliancy  of  Harvey's  dis- 
coveries was  so  great  that  the  light  which  shone  from  Glisson's  work- 
table  almost  disappeared.  I  rejoice  that  on  so  joyful  an  occasion  I  may 
recall  the  memory  of  the  modest  investigator,  and  may  offer  him  the 
tribute  of  gratitude  which  science  has  to  award  him. 

"  When,  thii  ty-tive  years  ago,  I  published  my  little  essay  on  Irrita- 
tion and  Irritability,*  I  did  not  know  much  more  about  Glisson  than 


*  Archiv  fiir  patholoffisehe  Anatomie  und  Physiologie,  1868,  vol. 
xiv,  p.  50. 


396 


MISCELLANY. 


[N.  T.  Mbd.  Jonm., 


what  every  student  of  medicine  learns — namely,  that  there  is  in  the 
liver  a  capsula  communis  Glissonii,  and,  what  was  even  less  kno^vn, 
that  this  anatomist  had  written  a  small  work  on  Rhachitia,  which  in- 
deed was  the  first  of  its  kind.  In  my  own  paper  on  tliis  disease  *  I  had 
tried  to  demonstrate  the  circumspection  and  accuracy  which  are  notice- 
able in  this  book,  and  which  make  it  a  typical  model  for  all  collective  in- 
vestigations ;  but  even  at  that  time  I  overlooked  the  fact  that  this  was 
only  the  smallest  merit  of  this  wonderful  man.  It  was  only  in  the  fur- 
ther course  of  my  studies  on  the  history  of  the  doctrine  of  irritation 
and  irritability  that  I  made  the  discovery — an  astonishing  one  to  me — 
that  the  idea  of  irritability  did  not,  as  is  generally  thought,  originate 
with  Haller,  but  that  the  father  of  modern  physiology,  and  the  Leyden 
school,  in  which  he  had  been  brought  up,  had  borrowed  this  idea  from 
Glisson.  I  then  stumbled  on  a  series  of  almost  forgotten  publications 
of  this  original  scholar,  especially  his  Tractalus  dc  naturd  mhitlantice 
energeticcB  seu  de  vitA  natures  ejmque  trihus  primh  facultaiibus,  percep- 
tiva,  appelitiva,  et  moiiva,  which  appeared  in  London  in  1672,  and  in 
which  the  ideas  were  further  worked  out,  the  outlines  of  which  had  al- 
ready been'brought  forward  in  his  Anatomia  /te/>a<i.i,  published  in  1654. 
In  this  work  (p.  400)  the  newly-coined  word  irrUabilitan  appears,  so  far 
as  I  can  find  out,  for  the  first  time  in  literature.  It  may  be  noticed,  by 
the  way,  that  the  expression  irrilatio  is  much  older.  I  find  it  already 
in  Celsus,  but  with  an  exclusively  pathological  signification.  It  appears 
also  occasionally  in  later  writers,  and  to  this  day  it  has  not,  speaking 
accurately,  lost  this  original  signification.  It  is  otherwise  with  Glisson ; 
to  him  irritability  is  a  physiological  property,  and  irritation  merely  a 
process  of  life  dependent  on  the  natural  faculties  of  living  matter. 

"  Thus  he  was  led,  through  a  process  of  contemplation,  to  maintain 
the  existence  of  the  biarchia,  the  prindpium  vitce,  or  the  bimia,  the 
vita  mbatantialis  vel  vitx  substantia.  And,  in  order  to  allow  of  no  mis- 
understanding as  to  the  source  of  his  '  contemplation,'  he  adds  distinctly 
that  this  is  the  archceus  of  Van  Helmont — the  vis  plaslica  of  plants  and 
animals. 

"  In  the  further  course  of  his  philosophical  discussions  he  neverthe- 
less is  led  into  the  same  bypath  which  has  misled,  even  in  the  most 
recent  times,  so  many  learned  men  and  even  excellent  observers.  This 
is  the  bypath  of  unlimited  generalization.  The  human  mind  is  only  too 
prone  to  render  intelligible  what  is  unintelligible  in  particular  phenom- 
ena by  generalizing  them.  Just  as  even  in  recent  times  an  attempt  has 
been  made  to  render  consciousness  intelligible  by  representing  it  merely 
as  a  general  property  of  matter,  so  Glisson  thought  he  might  attribute 
to  the  active  principle  (prindpium  energelicum)  which,  according  to 
him,  is  contained  in  all  matter,  the  three  faculties  of  living  matter 
which  he  considered  as  fimdamental — namely,  the  faeuUas  perceptiva 
appetitiva,  et  motiva.  All  matter  was  sensitive,  was  thus  stimulated 
to  develop  impulses,  and  moved  itself  as  a  consequence  of  these  im- 
pulses. 

"  It  is  not  necessary  for  the  purpose  of  our  present  inquiry  to  carry 
these  quotations  further,  since  they  are  quite,  in  the  Paracelsian  sense, 
contemplative  in  their  nature  ;  and  especially  as,  in  their  generalization, 
they  do  not  appear  to  be  important  for  the  history  of  advancing 
knowledge. 

"  That  which  is  full  of  significance  for  us  is  concerned  with  actual 
life  only,  in  the  narrower  sense  of  analytic  science.  It  was  not  the 
prindpium  energeticum  set  up  by  Glisson  which  stimulated  his  suc- 
-cessors  again  to  take  up  the  thread  of  his  observations,  but  rather  this 
process  of  irritation  described  by  him,  and  the  fundamental  faculties  of 
living  matter  on  which  it  depended.  In  this  way  he  has  really  led  up 
to  a  more  exact  study  of  the  actions  of  life  and  the  properties  of  liv- 
ing matter. 

"  Unfortunately,  there  intervened  a  mistaken  conception,  which  led 
his  followers  again  into  a  series  of  most  serious  errors.  Glisson,  fol- 
lowing on  this  point  also  the  example  of  Van  Helmont,  was  convinced 
that  nerves  contracted  when  irritated.  He  joined  to  this  the  idea  that, 
through  the  contraction  of  the  nerves  or  even  of  the  brain,  the  fluid 
contained  in  them  was  propelled  toward  the  periphery. 

"  This  notion,  shared  by  Willis  and  many  other  physicians  of  that 


*  Arch.  f.  path.  Anat.  u.  I'hi/siol.,  1853,  vol.  v,  p.  410. 


time,  furnishes  the  reason  why  irritability  was  identified  with  contractil- 
ity. Even  the  great  master  Hermann  Boerhaave,  and  after  him  his 
pupil  Gaubius,  the  first  special  writer  on  general  pathology,  considered 
sensation  and  motion  as  common  properties  of,  at  all  events,  all  the 
solid  parts  of  the  body.  The  former  thought  it  proved  that  hardly  a 
single  particle  of  the  body  existed  which  was  not  sensitive  and  did  not 
move;  and  thus  it  became  comprehensible  how  Haller  himself  carried 
this  idea  that  irritability  had  the  same  significance  as  contractiUty  from 
his  school  days  in  Leyden  to  his  professorship  in  Gottingen.  It  was  in 
this  sense  that  he  understood  the  irritability  of  the  muscles,  and  in  the 
same  sense  he  denied  this  property  to  the  nerves. 

"  Tills  dispute  about  the  irritability  of  muscles  has  continued  far 
into  the  present  century  ;  its  long  duration  becomes  intelligible  only 
when  we  bear  in  mind  that,  without  the  most  exact  knowledge  of  its 
historical  development,  even  the  very  statement  of  the  question  is  liable 
to  be  misunderstood. 

"  As  a  matter  of  fact,  so  far  as  we  know,  the  nerves  are  not  con- 
tractile like  the  muscles ;  on  the  other  hand,  the  muscles  are  not  only 
contractile,  but  are  also  irritable.  Irritability  and  contractility  are 
not  identical,  even  when  they  occur  in  the  same  part.  The  nerve  cur- 
rent, on  the  other  hand,  can  not  be  compared  with  the  blood  stream; 
it  does  not  consist  in  the  movement  of  a  fluid,  but  is  of  electrical  na- 
ture, and  hence  there  is  no  need  for  its  production  of  a  contraction  of 
the  nerve  tubes. 

"  It  was  also  an  erroneous  conclusion  that  every  irritated  part  con- 
tracted. Instead  of  contraction,  secretion,  or,  under  certain  circum- 
stances, a  more  vigorous  nutrition  may  occur  as  the  final  result  of  irri- 
tation. Hence  we  use  a  more  comprehensive  term  in  order  to  express 
this  final  result,  and  call  all  forms  of  it  '  actions.'  While  Glisson  de- 
fined all  actio  propria  sic  dicta  as  inotus  activus,  we  distinguish  different 
kinds  according  to  the  nature  of  the  effects,  or,  expressed  otherwise, 
according  to  the  direction  of  the  activity  (nutrition,  formation,  and 
function);  but  we  agree  with  the  above  thinker  in  the  opinion  that  no 
vital  energy  is  ever  set  free  without  stimulus ;  that,  therefore,  every  ac- 
tion is  of  an  irritative  nature.  In  this  irritation,  according  to  my  idea,  con- 
sists the  prindpium  dividendi,  according  to  which  we  must  distinguish 
between  active  and  passive  processes  of  life,  and  in  this  way  we  gain 
also  a  basis  for  the  fundamental  division  of  pathological  elementary 
processes.  How  much  work  has  been  necessary  in  order  to  render  this 
conception  possible !  And  how  great,  even  now,  is  the  number  of  our 
colleagues  who  have  not  fully  accepted  it !  The  reason  for  this  diffi- 
culty is  twofold. 

"  Most  of  the  vital  actions  of  life,  whenever  they  manifest  them- 
selves by  visible  events,  are  of  a  compound  nature.  As  a  rule,  very 
various,  at  times  wholly  unlike,  parts,  each  with  its  specific  energy, 
combine  to  produce  them.  Not  infrequently  it  thereby  happens  that  in 
the  visible  sum  of  final  effects  one  part  behaves  in  an  active,  the  other 
in  a  passive  manner.  It  is  only  the  most  minute  analysis  of  the  phe- 
nomenon, tracing  it  right  back  to  the  elementary  parts,  which  allows 
the  total  result  to  be  resolved  into  its  components ;  such  an  analysis 
can  not,  for  the  most  part,  be  expressed  in  current  language,  except  at 
great  length.  No  language  in  the  world  is  rich  enough  to  possess 
special  expressions  for  each  such  combination.  Only  too  often  we  help 
ourselves  out  of  the  difiiculty  by  regarding  the  compound  phenomenon 
as  a  simple  one,  and  by  expressing  its  character  according  to  some 
chief  trait,  which  stands  out  in  a  commanding  maimer  from  the  general 
picture.    This  is  the  practical  difficulty. 

"  With  it,  however,  a  theoretical  difficulty  is  very  often  combined. 
The  human  mind,  owing  to  a  natural  impulse,  seeks  in  the  phenomena 
indications  of  their  determining  cause.  The  more  complex  the  phe- 
nomenon, the  more  busy  is  the  imagination,  in  order  to  convert  it  into 
a  simple  one,  and  to  find  a  unitarian  cause  for  it.  So  has  it  happened 
in  respect  to  life,  so  in  respect  to  disease.  The  course  of  thought  fol- 
lowed by  Glisson  is  opposed  to  such  an  explanation.  He  had  no  scru- 
ple in  dividing  the  unit  of  life  into  a  large  number  of  individual  lives. 
Although  the  knowledge  we  now  possess  of  the  arrangements  of  the 
body  was  absolutely  foreign  to  him,  yet  he  arrived  quite  logically  at  the 
vita  propria,  the  proper  elementary  life,  of  the  several  parts.  To  be 
sure,  this  expression,  so  far  as  I  can  see,  is  not  to  be  found  in  his 
works,  but  occurs  first  in  those  of  Gaubius ;  but  Glisson  says  distinct- 


April  8,  1893.] 


MISCELLANY. 


39T 


ly :  *  '  Quod  vivit  per  se  vivit  vitam  a  n\ill4  ereaturft  prater  se  ipsum 
dependeutera.    Hoc  enim  verba  vivere  per  se  sonant.' 

"  The  unitarian  efforts  of  the  following  period  relentlessly  passed 
over  the  tendency  of  which  I  have  just  spoken.  Some  returned  to  the 
old  Mosaic  dictum,  '  the  life  of  the  body  is  in  his  blood  ' ;  others  gave 
the  nervous  system,  and  the  brain  especially,  the  first  place  in  their 
consideration.  Thus  once  more  was  renewed  the  old  struggle,  which 
for  thousands  of  years  had  divided  the  schools  of  medicine  into  humo- 
ral and  solidar  pathology.  Even  when  we  ourselves  entered  on  scien- 
tific work,  hasmato-pathologists  stood  in  hostile  attitude  to  neuro-pa- 
thologists. 

"In  England,  humoral  pathology  found  a  strong  support  in  the 
great  and  legitimate  authority  of  John  Hunter.  Although  this  distin- 
guished practitioner  never  shared  the  one-sidedness  of  the  later  pa- 
thologists, but  rather  attributed  to  the  solid  parts  the  living  principle, 
the  existence  of  which  he  assumed,  nevertheless,  in  his  investigations, 
the  blood  took  precedence  over  all  other  parts  as  the  chief  vehicle  of 
life. 

"  One  must,  however,  recall  to  mind  that  Hunter  laid  special  stress 
on  the  fact  that  life  and  organization  are  not  bound  to  each  other,  since 
animal  substances  which  are  not  organized  can  possess  life.  He  started,  as 
has  already  been  noticed,  from  the  erroneous  conception  that  eggs  are 
not  organized,  and  that  it  was  not  till  after  incubation  that  the  first  act 
of  organization — namely,  the  formation  of  vessels — took  place.  He 
considered  his  '  diffuse  matter ' — materia  vitoc  diffusa — as  the  actual  car- 
rier of  life  ;  and  this  was  to  be  met  with  not  only  in  the  solid  parts,  but 
in  the  blood  also.  This  matter,  according  to  him,  existed  in  the  brain 
in  a  remarkable  degree  of  concentration,  but  its  presence  was  quite  in- 
dependent of  all  nervous  structures,  as  is  shown  by  the  example  of  the 
lower  animals  which  possess  no  nerves.  In  the  posthumous  writings  of 
Hunter,  which  Owen  has  collected,  the  very  striking  expression  '  simple 
life '  is  met  with,  a  state  most  clearly  to  be  recognized  in  plants  and  the 
lowest  animals.  This  simple  life  was,  in  Hunter's  view,  the  ultimate 
source  of  all  living  actions,  pathological  as  well  as  physiological. 

"  Hunter  was  out  and  out  a  vitalist,  but  his  materialistic  vitalism, 
so  to  speak,  differed  toto  codo  from  the  dynamic  vitalism  of  the  Ger- 
man schools.  If  living  matter  existed  independently  of  all  organiza- 
tion, such  living  matter  was  beyond  the  scope  of  anatomical  investiga- 
tion but,  on  the  other  hand,  if  it  were  present  in  non-organized  parts, 
such  as  an  egg,  it  was  in  itself  the  ultimate  source  of  the  organization 
which  subsequently  makes  its  appearance  in  these  parts.  It  must  there- 
fore, to  adopt  a  later  mode  of  expression,  be  of  a  plastic  nature.  Here 
Hunter's  notion  fell  in  with  that  of  the  plastic  lymph,  as  developed  by 
Hewson,  and  it  was  only  logical  that  Schultzenstein  applied  it  to  the 
blood  at  last,  and  designated  as  '  plasma '  the  material  of  life  present 
in  the  blood.  In  this  way  the  formative  and  nutritive  matter  neces- 
sary to  physiological  life,  as  well  as  the  plastic  exudations  occurring  in 
diseased  conditions,  could  be  attributed  to  the  same  material — a  highly 
satisfactory  result  m  appearance,  and  one  providing  a  most  convenient 
basis  for  interpretations.  The  exponents  of  this  notion  had  no  scruples 
in  going  one  step  further,  and  in  providing  this  material  of  life  with  a 
technical  name.  They  called  it '  fibrin.'  Evidently  this  did  not  quite 
correspond  with  Hunter's  ideas,  for  we  know  of  no  such  matter  either 
in  the  egg,  or  in  the  plants  or  the  lower  animals,  as  that  to  which  he 
attributed  simple  life ;  but  the  necessities  of  pathology  overcame  all 
Buch  scruples,  and  the  plastic  exudations  were  received  as  undoubted 
evidence  that  fibrin  possessed  the  power  of  becoming  organized.  They 
foi-med,  in  the  crash  doctrine  of  the  Vienna  school,  the  bright  spot  of 
this  newest  kind  of  hasmato-pathology. 

"  Wherever  fibrin  failed,  blastemata  were  brought  to  the  fore. 
Ever  since  Schwann  had  given  the  name  of  cytoblastema  to  the  organ- 
izing material  of  the  egg,  the  way  had  been  opened  for  assuming  in 
other  places  the  existence  of  material  with  this  ambiguous  name. 

"But,  of  course,  through  these  steps  the  one  simple  matter  of  life 
predicated  by  Hunter  was  replaced  by  many  '  matters  of  life,'  and  thus 
the  entire  advantage  gained  by  the  exposition  of  a  unitary  theory  of 
life  was  at  once  lost. 


•  Glisson.    Anatomia  hepatk,  Ad  lectorcm,  N.  17. 


"  Even  when,  finally,  protoplasma  was  recognized  as  cell  contents, 
and  thus  the  one  requisite  of  Hunter — namely,  that  the  material  of  life 
must  also  be  contained  in  the  individual  parts — appeared  to  be  fulfilled, 
yet  no  single  specific  material  was  thereby  arrived  at.  No  one  dreamed 
of  regarding  protoplasm  as  fibrin,  and  least  of  all  did  any  one  consider 
it  a  simple  chemical  body. 

"  By  the  conception  of  the  blastema,  however,  there  had  been  re- 
awakened a  thought  which  had  occupied  the  minds  of  man  from  the 
earliest  times.  If  a  plastic  matter  capable  of  being  organized  really 
existed  in  the  body,  then  the  organization  of  the  same  must  present  the 
first  reliable  example  of  epigenesis.  The  problem  of  the  generatio 
wquivoca,  which  had  been  fought  over  for  so  long  a  time,  now  appeared 
to  be  solved.  What  Harvey  had  taught  concerning  the  descent  from 
the  egg  was  rejected  concerning  the  descent  from  exudation.  Several 
generations  of  young  medical  men  have  been  educated  in  this  belief.  I 
myself  remember  my  '  epigenetic '  youth  with  no  little  regret,  and  I 
have  had  hard  work  to  force  my  way  through  to  the  recognition  of  the 
sober  truth. 

"  Meanwhile  the  attention  of  other  bodies  of  inquirers  had  been  di- 
rected to  the  tissues  of  the  body.  Among  these,  in  view  of  their  im- 
portance, the  nervous  tissues,  and  especially  the  mass  of  nervous  tissues 
in  the  brain  and  spinal  cord,  rank  highest. 

"  Hunter  also  had  acknowledged  the  importance  of  the  brain,  and 
hence  called  it  the  materia  viice  coacervata.  It  was  easily  seen  that  it 
contained  no  fibrin,  but  experimental  research  showed  also  that  neither 
the  brain  nor  the  spinal  cord  was  of  the  same  value  throughout  all 
its  parts.  The  more  accurate  the  experiments,  the  smaller  became 
the  region  which,  in  the  strictest  sense,  is  the  vital  part,  until  Flourens 
limited  it  to  one  single  spot,  the  knot  of  life  (nceud  vital).  Was  the 
unity  of  life  found  in  this  way  ?  By  no  means.  The  brain  is  no  more 
and  no  less  vital  than  the  heart ;  for  life  is  present  in  the  egg  long  be- 
fore the  brain  and  heart  are  formed,  and  all  plants,  together  with 
an  immense  number  of  animals,  possess  neither  the  one  nor  the 
other.  In  the  highly  compound  organism  of  man  the  brain  and  spinal 
cord  have  a  certain  determining  action  on  other  parts  necessary  to  life. 
Their  disturbance  may  immediately  be  followed  by  the  disturbance  of 
other  vital  organs,  and  sudden  death  may  ensue. 

"  But  the  collective  death  of  a  compound  animal  no  more  implies 
the  local  death  of  all  its  special  parts  than  the  local  death  of  some  of 
the  latter  is  incompatible  with  the  collective  life  of  the  animal.  As 
has  been  well  said,  at  the  death  of  a  compound  organism  there  is  a 
primum  moriens,  one  part  which  first  ceases  to  live ;  then  follow,  at 
long  intervals  sometimes,  the  other  organs,  one  after  the  other,  up  to 
the  idiimum  moriens.  Hours  and  days  may  pass  between  the  total 
death  and  the  local  death  of  the  parts.  The  fewer  nerves  a  part  con- 
tains, the  more  slowly  usually  does  it  die ;  I  therefore  consider  the  pro- 
cess of  dying  in  the  compound  organism  as  the  best  illustration  of  the 
individual  life  of  the  several  constituent  parts,  which  is  in  its  turn 
the  first  axiom  necessary  for  the  study  and  for  the  understanding  of 
life. 

"  A  long  time,  however,  elapsed  before  it  was  possible  to  return  to 
this  starting  point  and  to  obtain  a  considerable  number  of  supporters 
for  the  doctrine  of  the  vita  propria.  The  attention  of  many  observers 
was  drawn  to  a  totally  different  side  of  the  question.  In  the  last  decade 
of  the  past  century,  about  the  same  time  that  John  Hunter,  starting 
from  careful  anatomical  investigations  and  exact  observations  of  surgi- 
cal practice,  worked  out  his  idea  of  the  material  of  life,  a  new  system 
of  medicine  was  founded  in  Scotland — the  so-called  Brownian  system — 
which  was  based  on  quite  different  premises.  Brown  also  was  a  vital- 
ist ;  he  too  constructed,  not  merely  a  pathological  and  therapeutic  sys- 
tem of  vitalism,  but  a  physiological  one,  though  this  doctrine  was  dy- 
namic in  its  character. 

"  There  is  but  little  to  be  noticed  therein  of  the  material  anatomical 
foundation  of  exact  medicine.  It  is  concerned  principally  with  con- 
templations of  the  forces  of  the  living  organism.  One  can  understand 
to  some  extent  how  this  happened  if  one  keeps  in  view  the  history 
of  the  development  of  this  extraordinary  personality.  I  can  not  go 
into  this  here,  but  anyhow  the  remarkable  fact  remains  that  the  two 
contemporaries — Brown  and  Hunter — worked  near  each  other  with- 
out it  appearing  from  their  writings  that  they  were  acquainted  with 


398 


MISCELLANY. 


[N.  y.  Mkd.  Jodh., 


one  another.  Brown  struck  out  hid  own  line  and  stuck  to  it  without 
troubling  himself  about  the  rest  of  the  medical  world.  And  yet  even 
his  first  work,  Elcmenla  meduirue,  had  the  effect  of  an  earth((uake ;  the 
whole  European  continent  was  shaken  by  it,  and  even  the  physicians  of 
the  recently  opened  New  World  bent  under  the  yoke  of  revolutionary 
ideas ;  and  in  a  few  years  the  aspect  of  the  whole  field  of  medicine  was 
entirely  changed.  True,  the  triumph  was  but  short ;  the  Brownian 
system  disappeared  as  it  had  come — a  meteor  in  the  starry  heaven  of 
science.  There  would  be  no  reason  to  go  into  it  more  fully  had  not  the 
impulse  which  he  had  given  instigated  other  men,  and  been  perma- 
nently applied  by  them  to  the  true  service  of  science.  This  impulse 
was  founded  on  the  fact  that  irritability,  or,  as  Brown  called  it,  '  incita- 
bility,'  was  thus  reinstated  as  the  starting  point  of  the  theory  ;  but  along 
with  this  the  stimuli,  which  set  living  substances  in  action,  the  pot  estates 
incitanles,  were  brought  to  the  fore.  In  so  far  that  stimuli  produced  a 
state  of  irritation  (inciialio),  or,  as  Brown  called  it  later,  excitement, 
they  came  to  be  viewed,  not  only  as  the  cause  of  health  and  disease,  but 
even  of  life  itself ;  for  excitement,  so  he  said,  is  the  true  cause  of  life ; 
but  as  excitement  stands  in  a  certain  relation  to  the  strength  of  the 
stimulus,  a  state  of  good  health  was  only  possible  with  a  normal  degree 
of  stimulus,  while  an  excess  or  a  lack  of  stimulus  brought  diseased  con- 
ditions in  its  wake.  Of  course,  excitement  is  dependent  also  on  irrita- 
bility, with  a  certain  quantity  of  which,  in  the  form  of  energy,  every 
living  being  is  endowed  at  the  beginning  of  its  life. 

"  The  division  of  diseases,  according  to  the  amount  of  vital  force 
visible  in  them,  into  sthenic  and  a.sthenio,  has  never  been  abandoned 
since,  though  acknowledged,  perhaps,  in  a  less  precise  manner ;  it  has 
sometimes  been  brought  more  prominently  forward,  and  sometimes 
thrown  into  the  Ijackground.  In  Germany,  Schiinlein  was  the  one  of 
all  others  who  took  this  doctrine  as  the  foundation  of  his  opinion  on 
special  cases  of  disease  and  for  his  choice  of  treatment. 

"  But  the  application  of  the  Brownian  principles  to  physiology  has 
been  of  far  greater  importance.  If  life  itself  were  dependent  on  exter- 
nal stimuli,  the  notion  of  the  spontaneity  of  vital  actions,  a  notion  still 
in  force,  must  lose  all  significance.  Certain  stimuli  would  in  that  case 
prove  to  be  necessary  conditions  of  vital  activity,  without  which  life  could 
at  best  be  carried  on  in^a  latent  form  only.  Certainly  even  for  this  latent 
life  the  question  remained  open.  How  does  it  come  to  pass,  and  in  what 
does  it  practically  consist  ?  Brown  avoided  this  ticklish  question,  not 
without  great  skill,  by  drawing  the  whole  attention  to  active  life  and  to 
the  stimuli  which  call  forth  action.  To  speak  openly,  science  has 
since  then  deflected  little,  or  not  at  all,  from  this  guiding  notion.  Even 
now  we  can  not  say  what  latent  life  is.  We  simply  know  that  through 
external  stimuli  it  may  be  converted  into  active  life,  and  hence  irrita- 
bility is  considered  by  us  as  the  surest  sign  of  life — not,  of  course,  of  the 
general  life  of  all  matter  in  the  sense  of  Glisson,  but  of  the  real  and 
individual  life  of  special  living  organisms.  Brown  remarked,  with  rea- 
son, that  through  irritability  the  living  substance  is  differentiated  from 
the  same  substance  in  its  dead  condition,  or  from  any  other  lifeless 
matter.  Nevertheless,  neither  irritability  nor  incitability,  neither  irrita- 
tion nor  incitation,  explains  the  essence  of  the  living  substance,  and 
therefore  neither  explains  the  essence  of  life. 

"  In  Germany  the  physiologists  especially  took  up  this  question. 
Among  the  first  was  Alexander  von  Humboldt,  who  in  his  various  writ- 
ings, especially  in  his  celebrated  treatise  on  the  irritated  muscle  and 
nerve  fiber,  entered  into  the  question.  In  the  end  he  held  fast  to  the 
assumption  of  a  vital  force.  The  majority  of  pathologists  and  physi- 
cians followed  in  his  footsteps,  and  long  and  fierce  controversies  were 
necessary  before,  nearly  half  a  century  later,  the  belief  in  a  vital  force 
was  destroyed.  When  Du  Bois-Reymond  had  demonstrated  the  elec- 
trical current  in  muscle  and  nerve  in  all  its  characters,  and,  at  the  end 
of  his  work,  had  also  disclosed  the  inadmissibility  of  vital  force,  then 
the  venerable  Humboldt  formally  and  expressly  renounced  the  dream 
of  his  youth,  with  the  masterly  submission  of  the  true  naturalist  to  the 
recognized  natural  law. 

"  The  hypothesis  of  a  vital  force  of  life  had,  however,  in  regard  to 
Brown's  theory,  neither  a  positive  nor  a  negative  value.  Johannes 
Miiller  rescued  for  general  ])liysiology,  in  which  it  has  ever  since  kept 
its  place,  that  which  was  valuable  in  Brown's  system — the  doctrine  of 
the  integrating  life  stimuli." 


The  Physiology  of  the  Embryonic  Heart. — At  a  meeting  of  the 
Royal  Society  held  on  January  26th  a  preliminary  communication  by 
Mr.  J.  W.  Pickering,  assistant  demonstrator  in  biology  at  St.  Bartholo- 
mew's Medical  School,  was  presented  by  Professor  Halliburton.  The 
communication  is  published  in  the  Proceedings  of  the  Royal  Society,  No. 
319,  as  follows : 

"The  object  of  the  following  experiments  has  been  to  study  the 
effect  of  varying  conditions  on  the  heart  previous  to  the  development 
of  a  nervous  mechanism,  and  thus  to  throw  some  light  on  the  discussion 
as  to  the  relative  importance  of  the  two  factors  in  tlie  heart's  action — 
viz.,  the  contractile  tissue  and  the  nervous  elements.  The  heart  I  have 
used  is  that  of  the  chick  *  at  a  period  of  incubation  of  seventy-two 
hours  at  a  temperature  of  38°  C.  In  some  cases  the  embryos  have  been 
a  few  hours  older  or  younger.  The  embryo  is  not  removed  from  the 
egg,  but  a  window  is  cut  3  ctm.  square  through  the  shell  and  shell 
membrane,  exposing  the  albumen  and  blastoderm,  which  remain  undis- 
tui'bed ;  the  egg  and  embryo  is  fixed  in  a  small  chamber  surrounded  on 
five  sides  by  a  water-jacket.  The  uppermost  side  is  covered  with  glass, 
while  the  air  of  the  chamber  is  kept  moist  by  the  evaporation  of  water 
from  a  small  bowl  placed  inside  it.  The  temperature  of  this  chamber 
can  be  kept  constant  or  varied  at  pleasure.  My  experiments  have  fallen 
under  three  main  heads :  1.  The  results  of  varving  the  temperature.  2. 
The  introduction  of  drugs.  3.  Electrical  stimulation.  In  my  full  paper 
the  results  will  be  shown  in  tables  giving  the  number  of  heart  beats 
per  minute,  the  peculiarities  in  the  beat,  when  such  exist,  being  duly 
noted.  At  present,  however,  I  am  only  prepared  to  give  an  abstract  of 
the  results  obtained,  in  so  far  as  temperature  and  drugs  are  concerned. 
The  electrical  experiments  are  not  yet  completed. 

"  1.  Temperature. — Each  embryo  has  an  individual  rhythm  of  its 
own,  which,  if  the  conditions  are  constant,  remains  unaltered,  but  dif- 
ferent embryos,  even  of  the  same  age,  may  have  different  rhythms,  so 
that  it  is  necessary  to  determine  for  each  embryo  its  normal  rhythm 
before  variations  can  be  studied.  An  embryo's  heart,  aged  seventy- 
two  hours,  at  a  temperature  of  31°  C,  was  beating  with  a  regular 
rhythm  of  84  per  minute.  The  temperature  of  the  air  of  the  chamber 
was  rapidly  raised  to  42°  C,  when  the  rhythm  rose  to  91  per  minute. 
A  further  rise  to  50°  C.  increased  the  rhythm  to  128,  it  still  remaining 
regular.  The  temperature  was  then  rapidly  lowered  to  26°  C,  when 
the  rhythm  fell  to  114  per  minute.  A  further  fall  to  16'  C.  reduced 
the  rhythm  to  34  per  minute.  The  temperature  was  then  raised  to  46° 
C,  when  the  rhythm  rose  to  117  per  minute.  On  again  letting  the 
temperature  fall  to  25°  C,  the  rhythm  fell  to  36  per  minute. 

"  The  above  experiment,  taken  as  an  instance  from  several,  shows 
that,  other  factors  being  constant,  the  rhythm  of  the  embryonic  heart 
varies  directly  with  the  temperature  of  the  surrounding  medium. 

"Extremes  of  temperature  stop  the  heart;  thus  exposure  to  a  tem- 
perature of  10°  C.  causes  the  beats  to  become  weaker  and  slower,  and 
finally  to  stop  in  diastole.  If  the  air  of  the  incubator  be  raised  above 
50°  C,  the  beats  become  so  rapid  as  to  be  uncountable.  They  are 
feeble,  and  the  heart  is  pale,  due  to  the  passage  of  less  blood  through 
it  than  in  the  normal  state.  Violent  systolic  spasms  alternate  with 
periods  of  quiescence.  It  stops  in  an  expanded  condition  when  the 
surrounding  temperature  is  about  55°  C.  Lowering  the  temperature 
restores  the  beating,  but  the  heart  is  enfeebled.  If  the  tempera- 
ture is  raised  much  above  this  limit  the  heart  is  killed.  Mechanical 
stimulation  of  the  heart  in  standstill,  due  to  either  extreme  of  tempera- 
ture, if  applied  at  the  ventricular  end,  gives  rise  to  one  or  more  waves 
of  contraction,  commencing  from  the  auricular  end,  and  showing  the 
direct  conduction  through  the  fibers  of  the  heart.  The  heart  will  re- 
spond to  auricular  stimulation  when  irresponsive  to  ventricular  stimula- 
tion. Small  variations  of  temperature,  such  as  one  or  two  degi-ees, 
occurring  over  a  long  period  of  time,  as  in  an  hour,  do  not  aifect  the 
rhythm. 

"  2.  The  Introduction  of  Drugs. — The  drugs  employed  were  applied 
directly  to  the  heart  substance  at  the  temperature  of  the  embryo,  and 
dissolved  in  normal  saline  (0'65  per  cent,  sodium  chloride)  solution. 

"  a.  Caffeine. — An  embryo,  aged  sixty-eight  hours,  at  33°  C.  had  a 

*  Observations  are  being  carried  on  upon  the  mammalian  embryo  in 

situ. 


April  8,  1893.J 


MISCELLANY. 


399 


rhytlim  of  88  per  minute.  To  its  heart  O'OOOIS  gramme*  of  caffeine 
was  administered,  and  in  two  minutes  the  rhythm  rose  to  100  per  min- 
ute, and  remained  constant  for  two  minutes  and  a  half,  when  it  fell  to 
96  per  minute.  A  second  dose  of  0'00015  gramme  raised  the  rate  to 
102  per  minute.  The  beats  were  also  of  greater  force,  since  more  blood 
was  seen  passing  through  the  heart.  A  dose  of  0  0025  gramme  was 
fatal.  When  given  to  an  embryo,  aged  seventy-five  hours,  at  37°  C, 
beating  with  a  rhythm  of  116  per  minute,  it  reduced  the  rhythm,  after 
one  minute's  action,  to  100  per  minute.  The  beats,  however,  re- 
mained very  strong.  After  one  minute  forty-five  seconds'  action  the 
heart  stopped  in  strong  systole,  but  started  again  and  gave  a  few  power- 
ful beats.  After  the  drug  had  acted  nine  minutes  thirty  seconds  the 
heart  stopped  permanently  in  powerful  contraction.  Caffeine,  there- 
fore, acts  directly  on  the  cells  of  the  embryonic  heart. 

"  b.  Strychnine  was  given  to  a  seventy-hours'  embryo  in  a  dose  of 
0'000017  gramme,  and  depressed  the  rhythm  of  the  heart  from  112  per 
minute  to  52  per  minute.  There  was  no  spasm.  In  an  eighty-hours' 
embryo,  at  39°  C,  a  dose  of  0  00002  gramme  temporarily  increased  the 
rhythm,  both  in  force  and  number  of  beats  ;  then  the  systole  rapidly 
became  weakened  and  the  rhythm  irregular.  A  further  dose  of  0'00002 
gramme  still  more  rapidly  reduced  both  force  and  frequency  of  beating, 
till  death  in  diastole  occurred. 

"  c.  Morphine  acetate^  if  given  in  doses  of  0-0001  gramme,  is  a  pow- 
erful depressant.  With  a  dose  of  0-0002  gramme,  after  one  minute's 
action  on  an  eighty-five  hours'  embryo  at  40°  C,  irregularities  and  slow- 
ing were  obtained  ;  after  two  minutes'  action  the  beating  stopped,  but 
went  on  again,  the  waves  of  contraction  sometimes  passing  from  ven- 
tricle to  auricle,  and  at  others  in  the  normal  direction.  Periods  of  res* 
alternated  with  violent  bouts  of  rapid  beating. 

"  d.  Veratrine. — Doses  of  O'OOOl  gramme  increase  the  number  of 
beats  per  minute.  Larger  doses  may  cause,  temporarily,  an  increase  of 
rhythm,  but  soon  depress  the  heart  by  greatly  lengthening  the  systole, 
which  becomes  very  weak  while  the  diastole  is  complete.  The  heart 
stops  in  an  expanded  condition.  The  heart  of  a  seventy-two  hours' 
embryo  that  had  stopped  in  diastole,  after  a  dose  of  0-0005  gramme, 
was  restored  by  the  application  of  0  0 1  gramme  of  potassium  chloride 
almost  to  its  normal  rhythm.  This  agrees  with  Ringer's  observation  on 
the  frog's  heart. 

"  e.  Potassium  chloride,  when  applied  in  a  dose  of  0-005  gramme  to 
an  embryo  aged  seventy-two  hours,  reduced  the  normal  rhythm  of  76  per 
minute  to  60  per  minute.  A  further  dose  of  0-01  gramme  reduced  the 
rhythm  to  64  per  minute.  After  the  administration  of  a  total  amount 
of  0'07  gramme  of  the  substance,  the  heart  stopped  in  diastole. 

"  f .  Nicotine,  in  very  minute  doses,  stimulated  the  embryonic  heart ; 
■J  c.  c.  of  a  solution  containing  ^  c.  c.  of  nicotine  to  1 00  c.  c.  of  normal 
saline  was  a  stimulant ;  with  ^  c.  c.  the  frequency  and  force  of  the 
heart  diminished,  systole  becoming  almost  absent,  while  the  heart  was 
finally  paralyzed  in  diastole.  The  addition  of  0-03  gramme  of  potas- 
sium chloride  restoreii  the  heart  to  almost  its  normal  rhythm,  the  beats 
at  the  same  time  becoming  strong,  both  as  regards  systole  and  diastole. 
A  further  dose  of  nicotine  depressed  the  heart,  and  again  brought  it 
into  diastolic  stoppage,  the  systoles  having  become  weaker  and  weaker. 
There  was  no  spasm. 

"  g.  Atropine. — Doses  of  O'OOl  gramme  had,  in  a  sixty-hours'  em- 
bryo, a  slightly  depressant  effect,  and  even  after  O'OOB  gramme  had  been 
administered,  the  rhythm  of  the  heart  had  only  fallen  from  96  to  72 
per  minute.  In  a  seventy-two  hours'  embryo,  with  a  heart  beating  at 
116  per  minute,  0-012  gramme,  after  three  minutes'  action,  had  de- 
pressed the  rhythm  to  80  per  minute,  while  even  after  the  administra- 
tion of  0-275  giamme  the  rhythm  was  strongly  maintained  at  64  per 
minute. 

"  h.  Muscarine  Nitrate. — To  the  heart  of  a  seventy-two  hours'  em- 
bryo at  35°  C,  which  was  beating  with  a  rhythm  of  90  per  minute,  three 
drops  of  half-saturated  solution  of  muscarine  nitrate  were  applied  ;  the 
rhythm  remained  constant  for  two  minutes,  after  which  period  two  more 
drops  were  added,  and  the  rhythm  kept  constant  at  94  per  minute  dur- 
ing the  next  three  minutes,  after  which  period  four  more  drops  were 
added,  and  the  ensuing  rhythm  was  93  per  mmute  ;  two  drops  of  satu- 

*  All  weights  of  drugs  used  are  expressed  in  grammes. 


rated  solution  were  then  added,  which  was  so  concentrated  as  to  stain 
the  embryo  brown.  During  the  following  five  minutes  the  rhythm  was 
constant  at  84  per  minute,  each  beat  remaining  normal  in  direction  and 
force.  Two  more  drops  of  saturated  solution  caused  slight  irregulari- 
ties, but  the  rhythm  during  the  next  seven  minutes  averaged  72  beats 
per  minute.  Finally  two  more  drops  of  saturated  solution  were  added, 
and  during  the  following  seven  minutes  the  heart's  rhythm  was  75  per 
minute.  The  whole  experiment  lasted  thirty*  minutes,  and  ten  drops  of 
half-saturated  plus  nine  drops  of  saturated  solution  of  muscarine  nitrate 
were  administered.  A  control  experiment  with  the  hearts  of  two  frogs 
showed  that  the  muscarine  used  stopped  their  beats,  which  were  typic- 
ally restored  by  atropine.  In  a  similar  experiment,  witnessed  by  Pro- 
fessor Halliburton,  with  both  embryonic  and  frogs'  hearts,  the  rhythm 
of  the  former  was  maintained  at  136  per  minute,  while  the  latter  was 
stopped  and  subsequently  restored  by  atropine.  Identical  results  were 
obtained  with  a  ninety-six  hours'  embryo.  In  an  embryo  aged  seventy 
hours  at  a  temperature  of  30°  C,  which  is  subnormal  in  the  chick,  a 
rhythm  of  92  beats  was  obtained  after  the  application  of  1  c.  c  of  half- 
saturated  solution  for  the  following  nine  minutes,  after  which  1  c.  c.  of 
saturated  solution  was  applied.  This  was  fatal  to  the  heart,  almost  in- 
stantly coagulating  the  tissues.  There  were  no  typical  phenomena  of 
muscarine  poisoning,  and  the  application  of  atropine  failed  to  restore 
the  rhythm.  Probably  any  strongly  alkaloidal  body  in  such  a  concen- 
trated solution  would  produce  a  similar  effect. 

"  i.  Schmiedeberg^ s  Digitalin. — An  embryo  aged  seventy-two  hours  at 
30°  C.  had  a  heart  rhythm  of  132  per  minute.  To  it  1  c.  c.  of  normal 
saline  containing  0-000022  gramme  of  digitalin  was  applied.  During 
the  next  eleven  minutes  the  rhythm  remained  constant,  after  which 
time  1  c.  c.  containing  0-00005  gramme  was  added,  which  produced  no 
change  in  the  rhythm;  then  0  0001  gramme  was  put  in,  and  after  one 
minute's  action  the  frequency  of  the  rhythm  had  fallen  to  92  per  min- 
ute, but  both  the  systole  and  diastole  were  strong.  The  rhythm  after 
six  minutes'  action  rose  to  104  per  minute.  After  this  another  0  0001 
gramme  was  added,  and  the  rhythm  fell  after  two  minutes'  action  to  50 
per  minute.  The  systole  was  typically  perfect,  but  the  diastole  was  in- 
complete. The  whole  heart,  after  two  minutes'  more  action  of  the  drug, 
became  very  pale  and  in  a  state  of  tonic  contraction  with  very  feeble 
fluttering  diastoles,  which  faded  away,  leaving  the  heart  stopped  in  a 
contracted  condition. 

"  j.  Strophanthin  (ot  Merck's  manufacture). — A  seventy-two  hours' 
embryo  at  a  temperature  of  32°  C.  had  a  heart  rhythm  of  132  per  min- 
ute. A  dose  of  0-00006  gramme  did  not  alter  the  rhythm.  A  second 
dose  of  the  same  amount,  after  twenty  minutes'  action,  reduced  the 
rhythm  to  54  per  minute ;  both  systole  and  diastole  were  regular  and 
complete.  Five  minutes  after  this  the  diastole  became  irregular,  and 
the  systole  was  more  marked  than  in  the  normal  condition.  After  an- 
other minute  had  elapsed  the  ventricle  passed  into  a  state  of  tonic  con- 
traction with  a  few  feeble  beats,  in  which  the  diastole  was  very  weak. 
The  auricles  had  a  marked  diastole  and  a  weak  systole,  and  were  en- 
gorged with  blood.  During  the  next  five  minutes  the  auricle  had  a 
rhythm  averaging  24  beats  per  minute,  while  the  ventricle  remained  in 
tonic  contraction.  Finally,  forty-one  minutes  after  the  administration 
of  the  dose,  the  auricle  stopped  in  diastole,  the  ventiicle  remaining  in 
tonic  contraction.  The  auricles  responded  by  10  beats  to  a  mechanical 
stimulus  ;  the  beats  did  not  extend  to  the  ventricle.  Six  minutes  after 
this  the  auricle  responded  to  mechanical  stimuli,  the  wave  of  contrac- 
tion passing  either  from  the  ventricular  end  to  the  auricle  or  vice  versa, 
according  to  which  end  of  the  auricle  the  stimulus  was  applied. 

"  In  larger  doses  of  0-0002  gramme  the  rhythm  in  a  seventy-hour 
embryo  at  33°  C.  was  depressed  from  120  to  102  per  minute,  the  sys- 
tole becoming  very  strong  and  the  diastole  imperfect.  After  four  min- 
utes' action  the  rhythm  returned  to  the  normal  both  in  frequency  and 
force.  To  the  same  embryo  0  00025  gramme  was  then  added,  when, 
after  one  minute's  action,  the  auricle  dilated,  giving  small  twitch-like 
contractions,  while  the  ventricle  passed  into  tonic  contraction.  The  au- 
ricle remained  for  six  minutes  feebly  responsive  to  mechanical  stimuli. 

"k.  Nitrite  of  Amyl. — A  ninety-six  hoius'  embryo  kept  at  35°  C. 
was  subjected  to  the  influence  of  the  vapor  of  5  minims  of  nitrite  of 
amyl.  After  one  minute's  action  the  rhythm  rose  from  96  to  124,  and 
after  another  minute  fell  to  112.    After  another  minute  it  had  fallen 


400 


MISCELLANY. 


[N.  Y.  Med.  Jocb. 


to  104,  and  six  minutes  afterward  was  at  the  normal.  In  a  seventy- 
two-hour  embryo  at  a  temperature  of  47°  the  rhythm  was  124  per  min- 
ute. A  dose  of  1  c.  c.  of  solution  of  amyl  nitrite  dissolved  in  olive  oil 
(strength  being  1"5  c.  c.  of  the  drug  to  10  c.  c.  of  olive  oil)  was  given 
and  the  frequency  of  the  rhythm  fell  in  one  minute  to  112,  but  the 
beats  were  strong.  Six  minutes  afterward  another  c.  c.  of  the  solution 
was  introduced,  and  the  rhythm  fell  to  104,  but  was  strong.  Three 
minutes  later  another  c.  c.  was  put  in,  and  the  rhythm  rose  to  112,  but 
was  very  weak  and  irregular,  and  finally  before  death  the  rhythm  was 
reversed. 

"  Concliidinff  Remarks. — The  observations  here  recorded  show  that 
the  embryonic  heart  when  kept  under  favorable  conditions  reacts  in  a 
very  delicate  manner  to  all  those  classes  of  stimuli  which  influence  the 
adult  heart.  The  experiments  on  temperature  show  that  its  variations 
act  directly  on  the  cardiac  muscle,  and  thus  confirm  the  opinion  of 
Newell  Martin  *  and  others  who  have  arrived  at  the  same  conclusion 
from  experiments  on  the  adult  heart. 

"  The  action  of  caffeine,  morphine  acetate,  potassium  chloride,  vera- 
trine,  nicotine,  digitalin,  strophanthin,  and  amyl  nitrite  is  direct  on  the 
contractile  tissue  of  the  embryonic  heart.  This  greatly  favors  the  view 
that  they  act  direct  on  the  adult  cardiac  muscle.  It  will  be  noted 
that  many  of  the  actions  here  described  on  the  embryonic  heart  are 
almost  identical  to  those  observed  by  others  on  the  adult  heart.  Noto- 
riously so  is  the  antagonism  between  veratrine  and  potassium  chloride, 
where  my  observations  are  identical  with  those  of  Ringer  f  on  the  frog's 
heart.  A  similar  antagonism  exists  between  nicotine  and  potassium 
chloride.  The  remarkable  correspondence  of  my  results  with  strophan. 
thin  on  the  embryonic  heart  with  those  of  Professor  Fraser  ^  on  the 
frog's  heart  greatly  supports  the  view  of  that  observer  as  to  the  direct 
action  of  strophanthin  on  cardiac  muscle  without  the  intervention  of 
any  nervous  mechanism,  and,  further,  the  absence  of  diastolic  stoppages 
in  my  experiments  also  supports  Eraser's  view  that  that  condition  in  the 
frog's  heart  is  due  to  the  action  of  small  doses  of  strophanthin  on  the 
cardiac  nervous  mechanism  of  that  animal. 

"  The  lengthening  out  of  the  systole  in  veratrine  poisoning  corre- 
sponds to  the  same  well-known  lengthening  of  the  systole  in  the  frog's 
heart  under  veratrine.  The  reversing  of  rhythm  observed  in  morphine 
poisoning  is  similar  to  that  mentioned  by  Ludwig  *  as  occurring  in  the 
mammalian  ventricle  when  under  the  influence  of  opium,  for  then  the 
auricular  beats  follow  instead  of  precede  the  ventricular  beats,  the 
rhythm  being  reversed.    The  same  occurs  in  amyl  nitrite  poisoning. 

"  Krukenberg  |  has  stated  that  neither  atropme  nor  muscarine  affects 
the  heart  of  Ascidians. 

"  My  observations  on  the  action  of  atropine  and  muscarine,  which 
have  been  made  on  a  large  number  of  embryos,  show  that  in  the  absence 
of  a  nervous  mechanism  they  do  not  influence  the  heart.  This  will 
probably  modify  the  current  views  on  the  action  of  these  drugs,  and  my 
results  show  that  the  method  I  have  adopted  is  a  valuable  one  for  dif- 
ferentiating the  functions  of  cardiac  muscle  from  those  of  the  nerves 
which  supply  it." 

"  Aminol." — A  liquid  under  this  name  has  been  brought  out  as  a 
disinfectant,  an  antiseptic,  and  also  for  internal  use.  With  regard  to 
the  possible  therapeutic  value  of  "  aminol  "  we  pass  no  opinion  ;  such 
an  opinion  can  only  be  given  after  repeated  and  prolonged  and  com- 
parative trials  made  with  scientific  exactness  in  hospital  wards.  But 
some  idea  of  its  value,  or  the  reverse,  as  a  disinfectant  may  be  obtained 
by  a  few  simple  experiments.  Solution  D  "  aminol "  is  a  clear  fluid 
with  a  strong  fishy  smell.  It  is  alkaline,  the  alkalinity  in  one  hundred 
cubic  centimetres  being  equal  to  0-12  gramme  of  ammonia  ;  it  is  indeed 
a  solution  of  ammonia  and  amines.  Pfuhl  has  shown  that  if  any  liquid 
is  sufficiently  alkaline,  it  matters  not  whether  the  alkalinity  is  due  to 


*  Newell  Martin.  Phil.  Trans.,  1883,  p.  603. 
f  Ringer.    Practitioner,  vol.  xxx,  1883,  p.  17. 

J  Fraser.  Editibur(/h  Roy.  Soc.  Tram.,  vol.  xxxvi,  1890-'91,  Part 
ii,  p.  388  el  seq. 

*  Ludwig.  Lehrbuoh  der  Physiol,  des  Men-trhen,  Bd.  ii,  1861,  p.  38. 
I  Krukenberg,  quoted  in  Brunton's  Tezt-look  of  Pharmacology,  etc., 

third  ed.,  p.  1 14. 


potash,  soda,  ammonia,  lime,  or  magnesia ;  all  these  have  disinfectant 
actions  if  a  sufficient  and  equal  degree  of  alkalinity  is  attained.  In  this 
case  the  alkalinity  per  se  is  insufficient  to  act  as  a  disinfectant,  there- 
fore any  properties  which  it  possesses  must  be  ascribed  to  its  chemical 
composition. 

The  writer  finds  that  if  a  paste  is  made  with  "  aminol "  and  flour, 
and  the  paste  infected  with  stale  urine,  the  paste  in  a  few  days  smells 
most  offensively  and  abounds  with  organisms.  A  paste  made  with 
"  aminol,"  diluted  with  four  or  five  times  its  volume  of  water  similarly 
infected,  was  still  more  offensive  than  the  paste  made  with  pure  "  ami- 
nol," showing  that  when  used  undiluted  better  effects  were  obtained 
than  when  diluted.  "  Aminol  "  added  in  small  quantities  to  urine  did 
not  prevent  mold  and  growth  of  ferments,  but,  added  in  large  quanti- 
ties, samples  of  urine  did  not  decompose  so  much  as  control  samples. 

It  is  therefore  the  writer's  opinion  that  "  aminol "  possesses  feeble 
antiseptic  powers,  but  that  in  no  true  sense  is  it  disinfectant. — Brit. 
Med.  Jour. 


To  Contributors  and  Correspondents. —  The  atterition  of  all  who  purpose 

favoring  m  tiith  cotnnauiicatiorvi  is  respectfully  called  to  t/ie  follow- 
ing : 

Authors  of  articles  intended  for  publication  under  the  /lead  of  "  original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti- 
cles, we  ahoays  do  so  with  the  understanding  that  the  following  cotuli- 
tions  are  to  be  observed :  (i)  when  a  manuscript  is  sent  to  this  jour- 
nal, a  similar  manuscript  or  any  abstract  thereof  mtist  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  ;  (2)  accepted  article* 
are  .'subject  to  the  customary  rules  of  editorial  revision,  and  will  Ije 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
coiuiitions  which  an  author  tcishcs  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  tlie  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  uiio  any  correspondence  coticeming  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  riumber  the  answer  to  his  note 
is  to  be  looked  for.  All  conimunications  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. 

Sicretarics  of  medical  societies  will  confer  a  favor  by  keeping  us  in- 
formed of  the  dates  of  their  societies''  regular  meetings.  Brief  notiji- 
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 
.lending  them  desires  to  bring  to  our  notice  .should  be  marked.  Mem- 
bers of  the  p}-ofcssion  who  send  us  information  of  matters  of  interest 
to  our  readers  icill  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  intaidcd  for  the  editor  should  be  addressed  to  him 
in  care  of  the  puldishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad- 
dressed to  the  publishers. 

Contributors  who  wish  to  order  REPRINTS  o  f  their  articles  should  do 
so  on  a  blank  ]>rcpared  for  that  purpose,  which  will  be  tent  to  them 
by  the  publishers  on  receipt  of  a  request  to  that  effect.  The  order 
tlioald  be  sent  to  tlie  publishers,  and  kot  to  the  editor. 


THE  JSTEW  YORK  MEDICAL  JOURISrAL,  Apbil  15,  1893. 


(friginal  €ommmimitonB. 


A  PLEA  FOR 

METHODICAL  EXAMINATION  OF  PREGNANT  WOMEN 
IN  PRIVATE  PRACTICE, 

AND  INCIDENTALLY  FOR 
THE  RELEGATION  OF  MIDWIVES  TO  THE  FIELD  OF  NURSING.* 

Bt  J.  MILTON  MABBOTT,  M.  D. 

The  latter  part  of  the  title  of  my  paper  may  mislead 
some  to  suppose  that  its  chief  purpose  is  the  promotion  of 
improvement  in  obstetrical  practice  among  the  poor.  Per- 
mit me  at  the  beginning  to  correct  such  an  impression  by 
saying  that  the  first  part  of  my  subject  is  as  important  as 
the  latter,  and  it  would  be  difficult  to  decide  which  class  of 
the  community  is  most  in  need  of  improvement  in  regard 
to  the  matter  to  which  I  first  invite  your  attention. 

Some  of  the  members  of  our  society  who  are  interested 
in  other  specialties,  and  who,  in  private  practice  at  least, 
have  done  little  or  no  obstetrical  work,  have  perhaps,  and 
probably,  never  paused  to  consider  whether  or  not  the  same 
careful  and  thorough  examinations  are  regularly  made  in 
private  practice  which  they  know  to  form  part  of  the 
routine  in  the  modern  clinic  and  hospital.  If  such  consid- 
erations have  presented  themselves  to  mind  at  all,  it  has 
probably  been  assumed  that  private  patients  are  treated  at 
least  as  well  as  patients  in  the  hospital,  and  it  may  have 
been  further  assumed  that  the  so-called  "  better  class  "  of 
private  patients,  who  can  afford  to  pay  well  for  attendance, 
would,  if  there  were  any  difference  or  distinction  between 
classes,  be  likely  to  receive  the  most  attention.  You  are 
disposed  to  assume  that  among  this  class  of  patients,  where 
misfortune  to  the  mother  connected  with  the  birth  of  her 
child  means  so  much  to  the  community  and  so  much,  let 
me  add,  to  the  accoucheur,  that  the  latter,  from  mere  policy 
if  not  from  conscience  and  a  sense  of  duty,  will  certainly 
do  all  in  his  power  to  assure  the  advantage  and  safety  of 
his  patients.  But  the  facts  in  the  case  do  not  support  such 
inferences,  and  those  of  you  who  are  familiar  with  private 
obstetrical  work  will  support  me  in  the  statement  that 
many  reputable  physicians  make  no  pretense  of  examining 
their  patients  under  ordinary  circumstances  prior  to  receiv- 
ing the  call  to  attend  them  at  the  onset  of  labor.  The  in- 
dividual cases  in  which  the  examination  for  which  I  plead 
in  this  paper  would  be  the  means  of  leading  to  the  adoption 
of  measures  which  are  capable  of  simplifying  labor,  saving 
a  child's  life,  or  averting  calamity  to  the  mother,  form  so 
small  a  part  of  the  grand  total  that  practitioners  have  re- 
mained indifferent  and  "  taken  chances  "  on  the  result. 

At  the  present  day  I  trust  there  is  no  necessity  of  ex- 
tending my  plea  to  include  institutions  for  lying-in  women. 
But,  strange  as  it  may  seem,  as  recently  as  some  five  years 
ago,  when  I  became  house  physician  of  the  Nursery  and 
Child's  Hospital,  where  some  of  the  women  are  admitted 
as  early  as  the  sixth  or  seventh  month  of  pregnancy,  no 
examination  was  regularly  made  previous  to  labor,  except 

*  Read  before  the  Hospital  Graduates'  Club,  February  23,  1893. 


in  cases  in  which  the  staff  had  reason  to  suspect  unnatural 
conditions  as  indicated  by  the  history  or  appearance  of  the 
patient.  I  took  the  liberty  to  introduce  the  practice  of  ex- 
amining every  patient  shortly  after  admission,  and  my  ac- 
tion received  the  approval  of  the  attending  staff.  But  I 
was  informed  that  such  practice  had  been  previously  insti- 
tuted in  the  hospital  and  had  been  discontinued  in  defer- 
ence to  the  wishes  of  some  of  the  managers,  who  had  raised 
the  objection  that  the  ordeal  was  too  trying  to  the  modesty 
and  sensitiveness  of  the  women,  and  opposed  to  the  promo- 
tion of  the  aims  of  the  institution,  which  was  endeavoring 
to  secure  to  those  whom  it  sheltered  all  the  comforts  and 
consideration  with  which  they  would  be  treated  in  their 
homes.  "  And  surely,"  some  lady  is  reported  to  have  said, 
"  you  doctors  can  not  claim  that  such  examinations  in  all 
cases  are  necessary  for  the  welfare  of  the  women  or  babies ; 
otherwise  why  do  not  our  family  physicians  insist  upon 
them  in  private  practice  ?  "  The  attending  physician  who 
furnished  part  of  the  foregoing  history  thought  it  would 
not  be  at  all  surprising  if  the  managers  should  again  re- 
quest the  discontinuance  of  the  practice.  Be  it  said  to 
their  credit  that  this  time  they  interposed  no  obstruction, 
and  the  further  experience  of  the  hospital  with  breech 
labors,  for  example,  became  materially  diminished. 

It  seems  to  me  a  false  modesty  and  supersensitiveness 
on  the  part  of  the  patient,  and  an  unpardonable  amount  of 
indifference  on  the  part  of  the  doctor,  which  permits  the 
willing  neglect,  in  any  case,  of  means  which  some  time  may 
save  a  life.  We  may  save  but  one  life  in  five  hundred 
cases ;  it  may  never  fall  to  our  individual  lot  to  save  a  life. 
But  if  we  meet  with  a  single  case  in  which  we  might  have 
saved  a  life  and  did  not,  can  we  hold  ourselves  blameless  f 
The  medical  profession,  I  fear,  has  sometimes  attached  too 
little  importance  to  the  life  of  the  child.  May  we  assume 
that  the  recent  renewed  interest  in  Caesarean  and  allied 
operations  is  the  sign  of  a  better  conscience  ?  Such  opera- 
tions are  sometimes  undertaken  with  a  view  to  saving  the 
child  even  at  the  expense  of  great  risk  to  the  life  of  the 
mother.  Some  of  us  are  not  fully  persuaded  that  subjec- 
tion of  the  mother  to  additional  risk  is  ever  justifiable,  and 
would  select  a  Csesarean  operation  only  when  it  offered  the 
mother  at  least  as  good  hope  of  recovery  as  an}'^  other  feasi- 
ble procedure.  But  methodical  examinations  during  preg- 
nancy may  be  urged  in  the  interests  of  mother  and  child 
alike.  There  is  no  conflict  between  the  two.  Such  exami- 
nations should  become  as  much  a  part  of  routine  practice 
as  analysis  of  the  urine.  And  who  in  these  days  will  neg- 
lect urinary  analysis  in  any  instance  of  pregnancy,  though 
happily  negative  in  an  overwhelming  majority  of  cases  ? 

The  practice  under  consideration  comprises  abdominal 
palpation  and  auscultation,  digital  exploration  per  vaginam 
(and  rarely  per  rectum),  and  external  and  conjoined  manipu- 
lation by  one  or  more  persons.  Methods  need  not  be  here 
described ;  some  of  the  text-books  contain  excellent  disser- 
tations upon  this  subject.  My  purpose  is  simply  to  urge 
the  adoption  of  the  practice  in  all  possible  cases — primi- 
gravidoE  and  multigravidce  alike — soon  after  they  come  under 
professional  care,  and  certainly  without  unnecessary  delay 


402 


MABBOTT:   METHODICAL  EXAMINATION  OF  PREGNANT  WOMEN.   [N.  Y.  Med.  Jodb., 


if  the  woman  has  passed  the  eighth  month  of  pregnancy. 
If  the  first  examination  lias  been  made  much  earlier  than 
the  period  indicated,  I  should  consider  it  advisable  to  re- 
peat it  at  some  time  during  the  last  month  of  gestation, 
since  it  is  not  rare  for  fcetal  positions  to  change  during  the 
earlier  part  of  pregnancy.  And  in  cases  in  which  an  un- 
favorable presentation  is  met  with  and  rectified,  a  subse- 
quent examination  near  the  time  of  expected  delivery  will 
appeal  to  all  as  rational  practice.  The  desired  correction 
may  even  be  left  until  some  time  near  the  full  period  of 
gestation  in  the  hope  that  it  may  occur  spontaneously  in 
the  mean  time.  I  have  notes  of  a  case  of  spontaneous  sub- 
stitution of  the  head  for  the  breech  occurring  between  the 
thirty-fourth  and  thirty-sixth  weeks.  But  it  should  not  be 
forgotten  that  external  version  is  sometimes  more  difficult 
later  in  pregnancy,  and  labor  may  supervene  earlier  than 
you  expect. 

Unless  the  conditions  are  especially  favorable  to  exam- 
ination, some  experience  is  necessary  before  an  observer 
acquires  the  requisite  skill  for  diagnosis  of  foetal  positions 
in  utero  with  much  confidence.  The  practical  observer  will 
occasionally  fail.  Pronounced  obesity,  muscular  tension 
of  the  uterine  or  abdominal  walls,  marked  hydramuion, 
small  proportions  of  the  foetus,  multiple  pregnancy,  and 
other  rarer  conditions  may  interfere  with  recognition  of 
such  positions  or  nullify  our  capacity  to  improve  them. 

(The  writer  may  hope  to  be  pardoned  for  reminding 
you  parenthetically  of  his  so-called  "trousers  case,"  in 
which  the  woman  gave  birth  to  "  a  pair  of  breeches."  For 
the  benefit  of  one  of  our  members,  whose  special  interest 
in  obstetrical  matters  is  well  known,  I  would  further  state 
that  the  "  breeches  "  had  become  soiled  in  some  way  and 
Lad  to  be  washed.  The  "  way  "  in  which  the  soiling  had 
occurred  was  the  via  naturalis,  so  it  was  unavoidable.  But 
it  was  none  the  less  a  pity,  for  they  were  very  nicely 
creased."  They  had  just  been  "  pressed  "  by  the  mother 
with  a  good  deal  of  "  labor  "  ;  in  fact,  she  had  taken  con- 
siderable "  pains  "  with  them. 

It  is  not  always  especially  difficult  to  diagnosticate  the 
presence  and  positions  of  twins.  To  modify  the  latter  is 
quite  another  matter,  and  I  offer  no  apology  except  for  the 
pleasantry.) 

The  most  common  utility  of  the  practice  recommended 
consists  in  the  conversion  of  podalic  or  pelvic  into  cephalic 
presentations  in  single  pregnancies.  The  time  of  election 
is  prior  to  labor,  preferably  toward  the  end  of  the  eighth 
raionth,  to  secure  the  advantage  of  the  presence  of  abundant 
amniotic  fluid  with  unruptured  membranes,  and  the  absence 
of  the  contractions  of  parturition.  Under  these  condi- 
tions it  is  not  usually  difficult  to  push  up  the  breech  and 
bring  down  the  head  by  a  procedure  requiring  no  anajsthet- 
ic  and  involving  but  slight  discomfort  to  the  mother,  while 
it  improves  the  prognosis  of  labor  both  for  herself  and  for 
the  child.  And  while  infant  mortality  in  breech  labors  is 
conceded,  cceteris  paribus,  to  be  much  higher  than  in  vertex 
cases,  additional  danger  to  the  cervix  and  perinajum  being 
also  involved  on  account  of  the  necessity  for  rapid  delivery 
of  the  after-coming  head,  what  right  have  obstetricians  to 
neglect  a  means  so  simple  and  devoid  of  danger  ?  Some  one 


may  raise  the  hypothetical  objection  that  the  practice  recom- 
mended might  occasionally  result  in  a  face  or  brow  pres- 
entation, which  would  be  more  unfavorable  than  a  breech. 
So  far  as  I  know,  no  one  has  yet  raised  such  an  objection  or 
met  with  such  a  case.  Attitudes  resulting  in  face  and  brow 
presentations  are  not  generally  assumed  by  the  foetus  until 
shortly  before  or  during  the  first  stage  of  labor.  Such  an 
unfavorable  occurrence  in  breech  cases  subjected  to  version 
should  certainly  be  no  more  common  than  among  head 
presentations  in  general.  In  the  rare  cases  in  which  it 
might  be  directly  produced  by  version  it  would  probably  be 
recognizable  and  remediable  ;  and,  furthermore,  it  is  offset 
by  the  possibility  of  recognizing  and  counteracting  condi- 
tions favoring  spontaneous  face  and  brow  presentations 
which,  without  the  examination,  would  have  gone  undis- 
covered and  unremedied. 

The  recognition  and  correction  of  breech  cases  are  not 
the  only  field  of  utility  of  examinations  during  pregnancy. 
The  discovery  of  an  anteverted  or  retroverted  uterus  sus- 
ceptible of  replacement,  a  uterine  fibroma  or  carcinoma,  an 
ovarian  cystoma,  or  an  ectopic  gestation  may  reward  early 
investigation. 

Face  and  brow  cases  (as  just  indicated),  occipito-poste- 
rior  positions  of  the  head,  oblique  positions  and  unusual 
size  of  the  foetus,  deformities  of  the  pelvis,  tumors,  and 
other  causes  of  dystocia  or  of  danger,  may  be  unexpectedly 
encountered.  Some  of  the  latter  are  as  remediable,  per- 
haps, at  the  commencement  of  labor  as  earlier.  Even  in 
such  cases  may  not  a  previous  examination  make  us  better 
prepared  to  render  the  required  assistance  ?  In  other  cases 
when  we  are  called  after  the  advent  of  labor  it  is  too  late, 
and  we  can  only  contemplate  what  might  have  been. 

I  have  regretfully  in  mind  a  case  that  occurred  in  my 
practice  last  summer  in  which  no  examination  was  made, 
and  in  regard  to  which  I  can  not  refrain  from  raising  the 
question,  "  Might  not  such  an  examination  have  averted  a 
calamity  ? "  The  case  has  been  published  in  part  by  Dr. 
Dawbarn  in  hi^-  article  on  Arterial  Saline  Infusion  in  the 
Medical  Record,  November  12,  1892.  It  may  not  be  deemed 
improper  for  me  to  acknowledge  in  this  place  my  sense  of 
obligation  to  Dr.  Dawbarn  and  to  Dr.  Burkelman  and  Dr. 
L.  F.  Bishop,  who  also  rendered  much  appreciated  assist- 
ance in  the  case. 

The  woman  was  an  out  patient  of  the  New  York  Lying-in 
Asylum.  My  impression  is  that  she  first  applied  to  me  out  of 
ofBce  hoars  and  when  I  was  otherwise  engaged,  so  that  it  was 
not  convenient  for  me  to  examine  her  then,  and,  after  taking 
her  history  in  brief,  I  directed  her  to  return  in  a  day  or  two  for 
examination,  and  to  bring  a  specimen  of  urine.  She  was 
thirty-five  years  old  and  had  already  borne  eight  children  and 
had  two  miscarriages  in  the  ten  years  of  her  married  life.  She 
was  within  about  three  weeks  of  the  expected  date  of  con- 
finement. She  gave  no  history  of  haemorrliage,  though  I  after- 
ward elicited  a  doubtful  acknowledgment  that  there  had  been 
a  slight  show  of  blood  once  or  twice  in  the  course  of  her  preg- 
nancy, which  had  made  very  little  impression  on  her  memory, 
and  to  which  she  had  attached  no  importance.  She  did  not  re- 
turn for  examination.  Twelve  days  after  application  her  husband 
came  for  me,  informing  me  that  she  had  been  losing  blood  in  large 
amount  for  the  last  two  days  and  was  beginning  to  have  pains. 


April  15,  1893.1        MABBOTT:  METHODICAL  EXAMINATION  OF  PREGNANT  WOMEN. 


403 


I  responded  immediately  and  found  upon  examination  a  central 
placenta  prie via.  Active  labor  pains  were  present,  but  the  os  uteri 
was  dilated  only  sufficiently  to  admit  two  fingers.  Barnes's  dila- 
tors controlled  lisemorrhage  and  assisted  dilatation,  and  as  soon 
as  the  latter  was  sufficient  I  delivered  a  living  child  by  podalic 
version.  I  have  since  learned  that  the  child  survived  only  a  few 
days.  It  was  doubtless  much  weakened  by  the  hsemorrbage. 
There  was  very  little  loss  of  blood  after  my  arrival  until  about 
three  quarters  of  an  hour  after  the  delivery  of  the  placenta, 
which,  it  need  hardly  be  said,  had  immediately  followed  the 
child.  Then  there  supervened  a  sudden  haemorrhage  of  consid- 
erable amount,  and  by  the  time  it  had  been  controlled  the 
woman  was  so  exsanguinated  that  I  sought  the  assistance  of 
Dr.  Dawbarn  (who  had  previously  proffered  such  assistance  in 
case  I  should  ever  require  it),  and  we  resorted  to  arterial  and 
subcutaneous  saline  infusion. 

Our  patient  remained  alive  for  six  days.  Had  I  been 
permitted  to  examine  her  during  the  latter  part  of  preg- 
nancy, might  I  not  have  discovered  or  suspected  placenta 
prcevia,  warned  her  in  regard  to  hissmorrhage,  watched  her 
more  closely,  and  then,  being  permitted  to  treat  her  before 
the  exhausting  drain  of  two  days'  htemorrhage  before  de- 
livery, might  we  not  have  averted  the  post  partum  haimor- 
rhage,  which  was  probably  largely  due  to  exhausted  uterine 
tone  ?  Or,  if  the  same  amount  of  post-partum  haemorrhage 
had  occurred  unpreceded  by  the  two  days'  haemorrhage 
which  had  so  greatly  diminished  the  haematopoietic  powers 
I  of  the  system  and  her  capacity  for  convalescence,  might  she 
not  have  made  a  good  recovery  ?  It  seemed  as  if  she  only 
just  fell  short  as  it  was. 

During  our  first  interview  every  pregnant  woman  should 
be  warned  to  notify  the  physician  immediately  in  the  ad- 
vent of  haemorrhage  whether  an  examination  has  been 
made  or  not.  But  ordinarily  we  prefer  to  pass  lightly  over 
such  a  subject,  unwilling  to  add  to  the  already  too  great 
anxiety  associated  with  child-bearing.  An  examination  in 
every  case  will  give  us  greater  confidence  to  assure  our  pa- 
tients that  the  warning  is  only  a  matter  of  routine  when  we 
find  apparently  normal  conditions.  And  the  assurance  that 
"  everything  is  as  it  should  be  "  alone  repays  most  women  for 
the  annoyance  of  submitting  to  the  examination,  whereas, 
if  we  find  suspicious  conditions,  we  shall  feel  justified  in 
adopting  treatment,  summoning  consultation,  or  at  least 
giving  greater  weight  to  our  warning  (to  the  husband  or 
some  responsible  attendant,  if  not  to  the  patient  directly), 
and  our  management  of  the  case  will  certainly  be  more  in- 
telligent. Such  a  case  as  the  one  related,  therefore,  im- 
presses upon  my  mind  another  reason  for  the  invariable 
practice  recommended. 

And  I  am  not  forgetting  the  views  of  those  gentlemen 
who  feel  disposed  to  decry  vaginal  examination  on  account 
i  of  the  danger  of  sepsis.    Let  us  practice  aseptic  and  anti- 
septic midwifery. 

And  now,  for  a  twofold  reason,  I  come  to  the  second 
j  part  of  my  subject.  I  am  becoming  more  and  more  per- 
suaded that  midwives  should  not  be  permitted  to  assume 
the  entire  charge  and  responsibility  of  cases  of  childbirth, 
j  The  midwife  most  assuredly  can  not  be  expected  to  make 
^  intelligent  examinations  during  pregnancy.  And,  second- 
'  ly,  the  average  widwife  seems  to  possess  so  little  re- 


gard for  ordinary  cleanliness,  not  to  mention  asepsis  and 
antisepsis,  that  she  ought  certainly  not  to  be  permitted  to 
introduce  her  fingers  into  the  vagina  during  labor  on  her 
own  responsibility.  In  my  hospital  experience  1  admitted 
to  the  institution  far  too  many  infants  whose  mothers  had 
been  attended  in  confinement  by  midwives  and  had  died  of 
septicaemia  and  from  other  preventable  causes. 

The  midwife,  however,  not  only  works  for  small  com- 
pensation, but  offers  her  services  in  the  general  capacity  of 
accoucheuse,  nurse,  housekeeper,  cook,  and  domestic  ;  and 
it  is  largely  on  this  account,  as  well  as  from  national  and 
hereditary  prejudices,  that  she  retains  her  hold  on  certain 
classes  of  the  community.  Let  these  people  still  employ 
the  midwife,  if  sufficiently  competent,  to  act  in  the  capacity 
of  nurse  and  as  many  of  the  other  capacities  as  desired, 
with  the  exception  of  the  first-mentioned.  And  let  every 
midwife  so  employed  be  required  to  insist  upon  having  her 
patient  engage  professional  attendance  as  well.  If  the 
family  is  very  poor  and  can  not  afford  to  pay  regular  fees 
for  such  additional  attendance,  there  are  enough  young 
doctors  nearly  everywhere  competent  and  willing  to  attend 
poor  women  in  their  homes  for  the  sake  of  charity  and  the 
experience  which  increases  their  own  efficiency  and  reputa- 
tion, content  with  whatever  fees  they  can  afford  to  pay,  or 
no  fee  if  they  really  can  afford  none.  If  the  people  or  the 
midwife  do  not  know  of  such  doctors  in  private  practice, 
they  should  be  informed  that  there  are  institutions — nota- 
bly the  New  York  Lying-in  Asylum  *  and  the  Midwifery 
Dispensary  (Society  of  the  New  York  Lying-in  Hospital)  f 
—  which  supply,  upon  application,  the  services  of  physicians 
and  advanced  students  under  competent  and  responsible 
supervision,  expecting  the  recipients  of  their  services  to  pay 
for  them  if  they  can  afford  to  do  so,  but  furnishing  them 
gratuitously  to  the  poor.  Care  should  be  thus  exercised 
not  to  make  this  a  further  abuse  of  medical  charity,  or  a 
means  of  further  pauperizing  the  poor,  but  a  means  of  im- 
proving their  condition  and  affording  needed  relief. 

The  better  midwives  may  be  able  to  secure  a  regular 
medical  education  and  diploma  ;  but  if  not,  let  them,  for 
the  sake  of  humanity,  be  content  to  be  good  nurses,  and 
there  are  few  more  worthy  vocations.  Let  them  continue 
to  receive  the  same  compensation  as  now,  and  let  them  con- 
tinue laboring  among  the  same  classes  of  the  community, 
for  it  is  there  that  they  are  most  needed.  But,  as  with  other 
nurses,  let  their  work  be  under  the  direction  and  supervision 
of  the  medical  profession.  Reproduction  may  be  looked 
upon  by  the  optimist  as  a  natural  function  which  may  be 
left  to  Nature.  Fortunately,  this  is  very  frequently  the  case, 
but  difficult  and  unnatural  labors  are  sufficiently  numerous, 
and  maternal  and  infantile  deaths  resulting  therefrom  are 
sufficiently  common  (to  say  nothing  of  preventable  suffering 
and  invalidism),  to  warrant  the  profession  and  the  people  in 
demanding  that  the  practice  of  midwifery  should  not  be  left 
in  incompetent  hands.  It  is  as  important  as  the  practice  of 
medicine,  and  if  our  legislators  were  child-bearing  members 
of  the  community,  would  it  not  be  similarly  regulated  by 
law  ?    The  milder  measures  recently  advocated  before  the 

*  139  Second  Avenue.  f  314  Broome  Street. 


MARLOW:  HETEROPHORIA  AND  ITS  TREATMENT. 


[N.  Y.  Mro.  JouB., 


State  society  are  to  my  mind  sadly  inadequate,  though  a 
step  in  the  right  direction. 

I  trust  that  I  have  not  overdrawn  the  importance  of 
either  portion  of  my  theme.  May  v?e  soon  see  the  day 
when  every  pregnant  woman,  rich  and  poor,  will  be  under 
the  care  of  a  qualified  physician  and  when  methodical  ex- 
amination of  pregnant  women  will  become  as  general  in  pri- 
vate as  in  institution  practice  ;  as  general  as  the  inspection 
of  a  sore  throat  before  treatment.  By  modern  obstetrical 
practice  the  suffering  and  mortality  incident  to  childbirth 
have  been  greatly  reduced.  That  they  are  capable  of  still 
further  reduction  along  the  lines  traversed  in  this  paper  is 
to  my  mind  a  statement  not  open  to  question.  I  under- 
stand that  statistics  are  in  course  of  preparation  designed 
to  compare  the  results  of  the  practice  of  midwives  with 
those  of  physicians  in  private  practice  and  maternity  hospi- 
tals in  New  York  city.  Such  statistics  when  published  will 
doubtless  be  of  great  interest.  Let  us  hope  they  will  exert 
a  large  influence  upon  the  medical,  legal,  and  popular  mind 
to  the  end  that  the  midwife  may  be  speedily  relegated  to 
her  legitimate  field  of  nursing.  Let  the  medical  profession 
rise  to  the  full  sense  of  its  own  responsibility  and  insist 
upon  the  right  to  extend  to  private  practice  among  all 
classes  all  the  possible  benefits  of  modern  advancement  in 
the  science  and  art  of  midwifery. 

19  Fifth  Avenue. 


SOME  REMARKS  ON 

HETEROPHORIA  AND  ITS  TREATMENT. 
Bv  F.  W.  MARLOW,  M.  D.,  M.  R.  C.  S.  E., 

PROFESSOR  OF  OPHTHALMOLOGY 
IN  THE  MEDICAL  DEPARTMENT  OF  8TRACDSE  UNIYERSITT  ; 
■BUBER  OF  THE  OPHTHALMOLOGICAL  SOCIBTT  OP  THE  UNITED  KINGDOM  ; 
FORMERLY  CLINICAL  ASSISTANT 
AT  THE  ROYAL  LONDON  OPHTHALMIC  HOSPITAL  (MOORFIELDS), 
AND  OPHTHALMIC  ASSISTANT  AT  ST.  THOMAS'S  HOSPITAL,  LONDON,  ETC. 

Two  papers  recently  published  have  presented  the  ex- 
tremes of  current  opinion  relating  to  the  effect  of  faulty 
ocular  equilibrium  and  its  correction,  chiefly  by  tenotomy, 
on  asthenopia,  and  various  functional  neuroses. 

That  of  Dr.  A.  L.  Ranney  {N.  Y.  Med.  Journal,  June, 
1892)  presents  the  optimistic  view  and  criticises  the  work 
and  ideas  of  those  who  differ  with  him  as  being  behind  the 
times,  and  refers  to  their  "  manifest  ignorance  of  the  later 
methods  of  examination,"  their  prejudice,  and  bigotry. 

It  is  to  be  regretted  that  Dr.  Ranney's  paper  does  not 
contain  details  of  the  actual  changes  in  equilibrium  brought 
about  by  tenotomy,  that  he  quotes  so  freely  from  the  ex- 
travagant statements  of  patients  instead  of  giving  the  sober 
estimate  of  a  well-balanced  scientific  mind,  such  as  is  essen- 
tial to  the  proper  appreciation  of  these  cases. 

It  is  also  to  be  regretted  that  reprints  of  papers  by  Dr. 
Ranney  should  find  their  way  into  the  hands  of  Dr.  Ran- 
ney's patients.  With  minds  well  prepared  for  miracles,  it 
is  not  remarkable  that  testimony  should  later  be  forthcom- 
ing of  their  performance. 

So  far  my  criticism  is  in  line  with  that  of  the  author  of 
the  second  paper.  Dr.  A.  E.  Davis  {N.  Y.  Med.  Journal, 
October  8,  1892),  who  takes  an  extremely  pessimistic  view 
of  the  treatment  of  heterophoria,  especially  by  partial  te- 


notomy, apparently  thinking  that  no  change  in  the  position 
of  rest  can  be  brought  about  by  partial  tenotomy,  and  that 
the  benefit  admitted  by  patients  is  derived  from  the  correc- 
tion of  refractive  error,  which  commonly  accompanies  mus- 
cular treatment,  or  is  due  to  suggestion,  or  to  anything  rather 
than  partial  tenotomy  or  prisms.  In  other  words,  Dr.  Davis 
is  a  disciple  of  Dr.  Roosa  in  this  matter. 

If  Dr.  Ranney's  paper  does  not  go  far  to  place  the  cor- 
rection of  heterophoria  on  a  scientific  basis  and  to  rate  the 
practice  of  graduated  tenotomy  at  its  true  value,  Dr.  Davis's 
can  not  be  said  to  greatly  advance  or  strengthen  his  side 
of  the  question.  It  is  extravagant  in  language  and  contains 
evidence  of  careless  thinking.  If  forcible  in  statement  it  is 
weak  in  argument,  where  the  latter  can  be  detected.  Dr. 
Davis  brings  forward  absolutely  no  facts  of  his  own  ;  he 
has  apparently  had  no  experience  in  the  correction  of  het- 
erophoria by  prisms,  much  less  by  tenotomy,  graduated  or 
otherwise,  or,  if  he  has  had  any  experience  in  the  latter 
method,  he  has  had  one  hundred  per  cent,  of  failures — he 
gives  us  his  own  word  for  it.* 

Much  as  this  is  to  be  regretted  from  the  standpoint  of 
the  doctor  and  his  patients,  it  is  insufficient  to  prove  the  in- 
efficacy  of  incomplete  tenotomies  for  changing  the  position 
of  rest,  and  the  non-dependence  of  asthenopia,  headaches, 
and  other  functional  nervous  disturbances  on  latent  devia- 
tions of  the  visual  axes. 

Dr.  Ranney  has  stated  the  condition  of  equilibrium  after 
operation  in  one  case  only,  and  it  happens  to  have  been  pre- 
cisely the  same  as  before.  Dr.  Davis  seizes  upon  this  soli- 
tary case  as  evidence  that  graduated  tenotomy  has  no  effect 
whatever  in  any  case.  It  does  not  seem  to  occur  to  him 
that  although  the  manifest  error  was  the  same  before  and 
after  operation,  the  latent  error  may  have  been  much  dimin- 
ished. 

"  I  am  of  opinion,"  he  writes,  "  that  the  same  nil  effect 
of  graduated  tenotomies  would  have  been  shown  in  the  other 
cases  had  the  final  condition  of  the  muscles  been  reported." 

Evidently,  however,  his  argumentative  method  does  not 
leave  his  conscience  quite  easy,  for  he  adds  : 

"  To  judge  all  the  cases  by  one  seems  unjust,  but  we  do 
this  from  necessity,  as  in  only  one  case  did  he  give  a  full 
report,  and  we  measure  the  others  by  that." 

The  generalization  would  be  unjust  even  if  the  explana- 
tion of  the  facts  assumed  by  the  writer  were  the  only  one 
possible,  but  it  appears  still  more  so  when  we  consider  that 
there  is  at  least  one  other  admissible — that  of  Dr.  G.  T.  Ste- 
vens. As  in  hypermetropia,  when  the  manifest  error  is  cor- 
rected, the  latent  gradually  becomes  manifest,  so  in  hetero- 
phoria, part  only  of  which  is  usually  manifest  at  first,  the 
correction  of  a  portion  or  the  whole  of  the  manifest  part  by 
prisms  or  tenotomy  is  followed  by  the  manifestation  of  a 
further  part  of  the  latent  error.  I  have  several  times  seen 
a  tenotomy  which  fully  or  slightly  overcorrected  a  devia- 
tion at  the  time  of  operation,  followed  within  a  few  days 

*  "  When  a  method  has  been  tried,  as  has  been  the  case  with  gradu- 
ated tenotomies,  and  found  wanting  nine  hundred  and  ninety-nine  times 
in  a  thousand,  or  ratlier  a  thousand  times  in  a  thousand  cases,  then  it  is 
time  to  give  it  up  "  [loc.  cit.).  Dr.  Davis  brings  forward  no  evidence  to 
support  tiiis  sweeping  statement. 


April  15,  1893.] 


MARLOW:  HETEROPHORIA  AND  ITS  TREATMENT. 


405 


(and  before  contraction  of  the  cicatrix  could  have  taken 
place)  by  a  manifest  error  equal,  or  nearly  equal,  to  the  origi- 
ual  error.  I  find  it  hard  to  escape  the  conclusion  that  Dr. 
Stevens's  explanation  is  the  correct  one. 

It  is  on  this  case  and  on  his  own  inferred  explanation 
of  its  facts  that  Dr.  Davis's  argument  to  prove  the  "ab- 
surdity of  such  a  procedure  as  partial  tenotomy  "  largely 
depends.  If  Dr.  Davis  had  had  any  personal  experience 
with  these  operations,  he  would  not  have  been  inclined 
to  build  so  large  a  superstructure  on  such  small  premises. 
And  I  may  add  that  I  doubt  if  Dr.  Davis  would  have 
written  this  paper  at  all,  so  far  as  it  refers  to  graduated 
tenotomies. 

Because  Dr.  Davis,  in  common  with  many  others,  can 
not  accept  the  wonders  worked  by  Dr.  Ranney  by  means  of 
tenotomy  and  prisms,  have  these  agents  therefore  no  place 
in  ocular  therapeutics  ? 

One  of  the  most  remarkable  statements  in  the  paper  is 
the  following :  "  That  heterophoria  is  of  little  importance 
is  evidenced  from  the  fact  that  it  so  often  occurs."  Fre- 
quency of  occurrence,  then.  Dr.  Davis  considers,  is  evi- 
dence of  unimportance.  The  importance  of  an  abnormal 
condition,  in  other  words,  is  in  inverse  ratio  to  frequency. 
Without  consuming  space  to  show  where  this  most  extraor- 
dinary law  would  lead  us,  let  us  see  the  absurdity  into  which 
it  conducts  its  propounder.  Ametropia  is  decidedly  of  more 
frequent  occurrence  than  heterophoria,  and  therefore  (ac- 
cording to  Davis's  law)  of  decidedly  less  importance.  But 
the  whole  burden  of  Dr.  Davis's  paper  is  that  ametropia  is 
altogether  responsible  for  asthenopia,  etc.,  and  that  hetero- 
phoria has  little  if  anything  to  do  with  it ;  so  that  we  find  in 
the  paper  conclusive  evidence  that  Dr.  Davis  considers  ame- 
tropia both  of  greater  importance,  and  yet,  if  possible,  of 
less  importance,  than  heterophoria,  which  he  considers  to 
be  of  no  importance  at  all  ! 

The  theory  of  the  disbelievers  in  muscular  asthenopia 
as  enunciated  by  Roosa  is  that  in  cases  of  asthenopia — 
using  the  term  in  its  widest  sense — the  refractive  error  is  the 
all-in-all.*  Correct  that  and  the  muscular  system  will  right 
itself.  Thus,  in  a  case  of  hypermetropia  with  esophoria, 
the  latter  will  disappear  after  the  correction  of  the  former ; 
and  in  the  almost  equally  common  cases  of  hypermetropia 
with  exophoria  the  deviation  will  cease  after  the  correction 
of  the  refraction.  Similarly  with  hyperphoria ;  that  is  to 
say,  relaxation  of  the  accommodation  may  be  followed  by 
either  increase  or  diminution  of  convergence  or  by  change 
in  the  relative  tension  of  the  vertical  muscles  in  either  di- 
rection as  a  direct  consequence  of  such  relaxation,  and  this 
claim  is  made  as  that  of  a  disciple  of  Donders  ! 

I  happen  to  have  seen  this  day  three  cases  illustrative 
of  the  relation  of  hypermetropic  astigmatism  with  various 
forms  of  heterophoria.  All  are  the  subjects  of  asthenopia 
and  headaches.    I  report  very  briefly  the  degrees  of  ame- 

*  "  Insufficiency  of  the  ocular  muscles  is  usually  if  not  always  a 
•consequence  of  organic  conditions  in  the  eyeball — that  is  to  say,  of 
myopia,  hypermetropia,  and  astigmatism.  Working  exactly  on  the 
lines  of  Donders's  discoveries,  muscular  asthenopia  should  be  expurgated 
from  ophthalmic  momenclature."  (Roosa,  OplUhalmic  Review,  vol.  ix, 
p.  262.) 


tropia  and  heterophoria  after  complete  abolition  of  accom- 
modation by  homatropine. 

Case  I. — Refractive  error  corrected  by  -(-0-25  D.  cyl.  180' 
in  each ;  esophoria  =  pr.  8° ;  externi  =  4°.* 

Cask  II. — R-  accepts  4-0'5  D.  cyl. ;  L.  accepts  -(-0'75  D.  cyl. ; 
exophoria  =  pr.  24°. 

Case  III.— R. -1-1-25  s.  C-f-0-5  c.  ;  L.-H1-5  8.  C  +  0-25c.;  bj- 
perphoria  =  pr.  7°. 

(In  Cases  II  and  III  there  is  occasional,  but  only  occa- 
sional, diplopia.)  Though  not  devoid  of  faith  and  hope,  I 
neither  believe  nor  expect  that  the  correction  of  the  amef- 
tropia  will  remove  the  heterophoria  in  all  these  cases. 
Moreover,  it  has  not  been  my  good  fortune  to  become  ac- 
quainted, through  personal  experience  or  the  literature  of 
the  subject,  with  any  facts  which  would  make  this  result  ap- 
pear probable.  Dr.  Roosa  and  Dr.  Davis  will  hardly  deny 
that  the  existence  of  such  errors  is  an  effective  bar  to  the 
easy  performance  of  the  visual  function. 

As  one  of  the  "  exceptional  few "  (?)  who  have  for 
some  years  past  corrected,  in  selected  cases,  heterophoria 
by  prisms  or  tenotomy,  I  feel  somewhat  bound  to  give  the 
results  of  my  experience  so  far  as  it  relates  to  the  questions 
brought  up  in  this  controversy. 

These  questions  are  : 

1.  Can  an  incomplete  tenotomy  change  the  position  of 
rest  ? 

2.  Is  heterophoria  simply  a  consequence  of  ametropia 
and  does  it  disappear  on  the  correction  of  the  latter  ? 

3.  Are  the  asthenopic  symptoms  removed  by  the  re- 
fractive correction,  or  is  relief  due  to  treatment  directed 
toward  the  muscular  errors  ?  j 

As  a  working  theory  I  assume — in  common,  doubtless, 
with  many  others — that  the  refraction  and  accommodation 
and  muscular  equilibrium  are  of  normal  (or  of  most  desira- 
ble) type  when  images  of  an  observed  distant  object  are 
clearly  and  simultaneously  focused  on  each  yellow  spot,  the 
ciliary  and  external  muscles  being  completely  at  rest.  I  am 
well  aware  that  this  assumption  is  not  universally  accepted, 
but  I  have  found  it  to  accord  better  with  the  facts  observed 
in  my  own  experience  than  any  other.  Therefore  at  present 
I  act  in  accordance  with  it.  These,  however,  are  the  con- 
ditions which  permit  of  minimum  innervation  for  distant 
vision,  and  this  I  presume  is  the  state  in  which  most 
ophthalmologists  attempt  to  place  their  patients'  ciliary 
muscles  in  cases  of  asthenopia.  Why  should  the  attempt 
be  limited  to  the  ciliary  muscles  ? 

There  is  reason  to  think  that  latent  convergence  or 
esophoria  is  sometimes  due  to  hypermetropia  (accommoda- 
tive esophoria),  but  I  believe  esophoria  of  this  type  to  be 
the  exception  rather  than  the  rule.  Usually  paralysis  of  ac- 
commodation and  the  correction  of  the  refractive  error 
have  no  influence  in  diminishing  the  degree  of  esophoria, 
and  many  times  I  have  seen  it  increase  under  these  condi- 

*  Throughout  this  paper  the  amount  of  deviation  is  expressed  in 
terms  of  prisms  designated  by  tlieir  refracting  angles.  Thus,  esoplioria 
=  8°  means  that  the  latent  convergence  is  corrected  by  a  prism  with 
a  refracting  angle  of  8°,  representing  an  actual  deviating  tendency  of 
about  4°.  The  power  of  abduction,  etc.,  are  expressed  in  tlie  same 
manner. 


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[N.  T.  Med.  Jocb., 


tions,  and  in  at  least  one  case  a  transient  manifest  squint 
has  developed. 

In  myopia,  exophoria  may  possibly  occur  as  a  result  of 
the  altered  relations  between  accommodation  and  conver- 
gence (accommodative  exophoria),  but  I  do  not  recall  any 
case  in  which  it  has  disappeared  on  the  correction  of  the 
myopia  with  glasses.  After  all,  a  convergent  position  of 
rest  is  at  least  as  common,  if  not  more  common,  than  di- 
vergence in  myopia. 

If  we  disregard  these  exceptional  cases  (accommodative 
esophoria  and  exophoria),  I  believe  it  to  be  true  that  the 
form  of  heterophoria  is  in  no  way  dependent  on  the  kind 
of  refraction  in  the  vast  majority  of  cases,  that  the  two  con- 
ditions are  separate,  and  that  a  separate  factor  in  the  treat- 
ment is  necessary  for  each  of  them. 

I  have  two  or  three  times  observed  the  refraction  pass 
from  hypermetropia  to  myopia  while  the  heterophoria  has 
remained  the  same,  which  would  scarcely  be  the  case  if 
the  heterophoria  were  caused  by  the  refractive  condition. 
So  far  from  this  being  so,  I  think  it  highly  probable  that 
the  onset  of  myopia  was  due  to  tension  of  the  external  mus- 
cles caused  by  heterophoria. 

The  following  cases  are  related  to  show — 

1.  That  incomplete  tenotomy  can  alter  the  position  of 
rest. 

2.  That  correction  of  refractive  error  fails  to  remove 
heterophoria  in  many  cases,  and  that  in  others  the  glasses 
can  not  be  worn  until  after  the  heterophoria  is  corrected  by 
prisms  or  tenotomy. 

3.  That  symptoms  unrelieved  or  aggravated  by  refrac- 
tive correction  are  relieved  by  muscular  treatment,  and 
that  cases  in  which  no  refractive  error  is  present  are  re- 
lieved by  correction  of  heterophoria. 

Cases  I,  II,  III,  IV,  V,  VI,  VIII,  IX,  and  X  illustrate 
the  effect  of  partial  tenotomies  in  changing  the  position 
of  rest. 

Cases  II,  III,  VIII,  IX,  X,  and  XI  show  that  at  any 
rate  in  some  cases  correction  of  refractive  error  fails  to  re- 
move heterophoria. 

In  Cases  II,  VI,  VII,  and  VIII  correction  only  of  the 
refractive  error  greatly  aggravated  the  symptoms,  which 
were  later  greatly  relieved  by  prisms  or  tenotomies. 

I,  IV,  and  V  are  cases  of  emraetropia  with  heterophoria 
— great,  in  two  cases  complete,  relief  being  afforded  by 
graduated  tenotomies. 

Case  I. — January,  1889.  Ch.  A.  B.,  aged  thirty-eight;  great 
BuEFerer  from  sick  headache;  occasional  double  vision.  Ex- 
amination of  eyes  showed  right  hyperphoria  2° ;  exterui  =  15°; 
exophoria  12°  to  15°;  interni  =12°;  R.  V.  f,  hypermetropia 
0-25  D.  barely;  L.  V.  |-,  with  +0-15  c.  90°  =  |. 

Partial  tenotomy  was  done  on  the  right  superior  rectus, 
leaving  right  hyperphoria  =1°  (according  to  the  patient,  three 
quarters  of  the  defect  being  removed),  and  on  the  left  externns, 
leaving  exophoria  =  1  °,  and  afterward  on  the  left  inferior  rectus, 
leaving  a  low  degree  of  left  hyperphoria. 

Three  years  and  a  half  later  condition  of  muscles  is:  Left 
hyperphoria  —  pr.  f°  about;  exophoria  =  5°  to  6°.  Patient  re- 
ports no  attacks  of  diplopia;  headache  greatly  diminished  in 
intensity  and  frequency. 

Case  reported  to  show  effect  of  partial  tenotomy.    No  one 


who  has  ever,  intentionally  or  otherwise,  divided  a  whole  supe- 
rior or  inferior  rectus  muscle  will  suspect  its  having  been  done 
in  this  case.  The  effect  of  dividing  the  whole  tendon  is  at  least 
pr.  12°. 

Case  II. — Miss  M.  M.  W.,  aged  seventeen  years.  Symp- 
toms: Aching  and  itching  of  eyelids  after  reading;  can  only 
read  a  few  minutes  with  comfort;  frontal  headache. 

January,  1892. — Refraction  after  ^homatropine,  R.  -(-  0"25  c. 
5°,  V.  =^-;  L. -1-0-25  c.  175°,  ;V.  =  f  -  ;  low  degree  of 
esophoria.    Ordered  +  0*25  c.  each ;  constant  wear. 

Six  weeks'  faithful  trial  showed  that  she  could  not  get  ac- 
customed to  glasses.  She  was  more  uncomfortable  with  than 
without  them. 

February  29th. — Refraction  precisely  as  above ;  esophoria 
=  pr.  4°  ;  ordered  pr.  1°  each,  bases  out. 

March  11th. — Two  degrees,  bases  out. 
^19th. — Esophoria  =  10°  to  [11°,  but  the  prisms,  although 
more  comfortable  than  the  cylinders,  gave  her  little  relief. 

25th. — Partial  tenotomy  of  right  internus,  leaving  esophoria 
2°  to  3°. 

;^7fA.— Esophoria  =  6°. 

April  1st. — Esophoria  8° ;  partial  tenotomy  of  left  internns, 
leaving  esophoria  less  than  1°. 
2d. — Esophoria  =  4°. 

From  this  time  she  was  able  to  wear  her  cylindrical  glasses 
with  benefit,  although  her  eyes  still  tired  more  easily  than  they 
should  have  done.  After  being  fairly  comfortable  during  the 
summer,  she  came  back  on  September  15th  with  some  return 
of  symptoms. 

Examination  showed  esophoria  =  3°. 

Case  III. — Mrs.  M.,  aged  about  fifty-six,  a  myope,  was  pre- 
scribed for  about  1880  by  Dr.  Thomson,  of  Philadelphia,  who 
ordered  —14  D.  for  right  eye,  —11  D.  for  left  for  distance, 
and  weaker  glasses  for  reading,  and  expressed  the  opinion  that 
the  muscular  trouble  which  he  detected  would  disappear  with 
the  use  of  the  glasses.    (Patient's  statement.) 

In  March,  1890,  I  found  4°  to  5°  of  left  hyperphoria,  and  12° 
to  15°  of  exophoria.  There  was  also  some  uncorrected  astig- 
matism in  the  right  eye. 

Her  most  marked  symptoms  were  headache  and  blurring, 
and  reading  required  too  much  effort. 

The  astigmatism  was  corrected,  but  in  January,  1892,  the 
heterophoria  remained  the  same,  and  was  then  corrected  by 
partial  tenotomies  of  right  inferior  and  both  external  recti  mus- 
cles, with  considerable  relief  to  symptoms.  e^iUM 

Case  reported  to  show  (1)  the  failure  of  refractive  cor- 
rection to  remove  heterophoria  (even  in  twelve  years)  ;  (2) 
the  ability  of  partial  tenotomy  to  alter  position  of  rest ; 
and  (3)  the  improvement  in  symptoms  afforded  by  correc- 
tion of  heterophoria. 

Case  IV. — I.  H.  B.,  aged  twenty-three,  student  of  divinity. 
January  20,'1892.  Since  influenza,  two  years  ago,  has  been  sub- 
ject to  very  severe  headaches,  occurring  once  in  two  or  three 
months.  Blurring  for  reading  and  distance.  Can  only  read 
twenty  minutes,  sometimes  not  at  all,  without  aching  of  eyes. 
Omitting  preliminary  examination,  refraction  after  complete 
paralysis  of  accommodation  by  horaatropine  was  R.  V.,  |,  slight- 
ly improved  with  — 0  25  c.  90°  ;  L.  V.,  f ,  slightly  improved  with 
4-0-25  c.  120°.  Exophoria  =  7°.  R.  hyperphoria  ^°  barely. 
Ordered  1°  prism  each,  bases  in. 

February  1st. — Prisms  have  given  great  relief ;  can  read  for 
some  hours. 

2d. — Partial  tenotomy  of  right  externus,  leaving  orthophoria 
or  low  esophoria. 


April  15,  1893.] 


MAELOW:  HETEROPHORIA  AND  ITS  TREATMENT. 


407 


J^th. — Very  low  esophoria. 

6th. — Exophoria  =  1°.  Can  read  as  long  as  he  wants  to 
without  discomfort. 

April  28th. — Pei'fectly  comfortable  until  now.  No  head- 
aches or  asthenopia.    Exophoria  =  3°  barely. 

October  11th. — Some  return  of  asthenopia  since  returning  to 
studies  after  summer  vacation. 

Phorometer  shows  no  deviation,  but  divergence  can  be  seen 
on  covering  and  uncovering  each  eye  alternately ;  =  4°  by  paral- 
lax test. 

I5th. — Prisms,  1°  each,  have  given  him  complete  relief. 

Case  V. — November  9,  1891.  Mr.  B.  E.,  aged  twenty-one, 
had  to  stop  study  a  year  ago  on  account  of  weak  eyes;  can  not 
sit  in  a  room  with  bright  light ;  eyes  smart,  burn,  and  water ; 
bright  sunlight  annoys;  can  not  read  more  than  ten  or  fifteen 
minutes  in  daylight. 

Condition  of  eyes:  R.  V.,  |— ,  -f  0-25  c.  150°,  slight  im- 
provement. L.V.,  f  em.  After  paralyzing  accommodation  with 
homatropine,  refraction  remained  the  same.  Right  hyperpho- 
ria, 1°.  No  lateral  deviation.  1°  prism,  base  down,  before 
right  eye  was  prescribed  for  constant  use. 

December  11th. — -Reports  that  he  has  read  three  hours  and  a 
half  without  tiring ;  has  at  no  time  tired  his  eyes  by  reading ; 
is  quite  comfortable  with  glasses.  Right  hyperphoria  =  1^°. 
Prism  2°,  base  up,  before  right,  produces  diplopia;  down,  per- 
mits single  vision. 

March,  11,  1892. — Eyes  have  begun  to  trouble  again ;  can 
only  read  a  short  time.  Right  hyperphoria  =  2°  -f .  Ordered 
1°,  base  up,  before  left. 

April  5th. — As  the  additional  glass  has  given  only  partial 
relief,  and  as  there  is  no  refractive  error  necessitating  the  use 
of  glasses,  tenotomy  was  advised.  On  same  day  right  superior 
rectus  partially  divided,  leaving  right  hyperphoria  <1°. 

23d, — Much  more  comfortable  since  operation,  but  right  hy- 
perphoria =  1°H-.  Tenotomy  (partial)  of  left  inferior  rectus, 
leaving  right  hyperphoria  very  low  degree,  about 

May  5th. — Eyes  perfectly  comfortable  so  far  ;  has  read  three 
hours  continuously.    Right  hyperphoria,  about 

The  patient  has  remained  comfortable  up  to  date  of  writ- 
ing. This  case  illustrates  the  effect  of  partial  tenotomy 
on  the  position  of  rest  and  upon  symptoms.  The  normal 
equilibrium  has  been  restored  about  as  completely  as  pos- 
sible, and  the  symptoms  simultaneously  disappeared. 

Cask  VI. — Miss  M.  V.  O.,  aged  nineteen.  For  two  months 
eyes  painful  on  use ;  blurring;  supra  orbital  pain  almost  daily; 
sometimes  has  to  give  up  work  and  go  to  bed ;  eyes  ache  on 
waking. 

May  15,  1891.— R.,  +  0-5  sph.,  -f-  0-5  c.  20°  =f ;  L.,  -f-  0-5 
.8.,  -1-  0-25  c.  180°  =  |.    Esophoria,  6°. 

After  homatropine,  R.  chose  -f  1  sph.,  +  0*25  c.  20°.  Eso- 
phoria, 12°  or  more.  L.  chose  -I-  1-25  s.,  -f-  0  25  c.  180°.  Con- 
vergence easily  seen  by  covering  one  eye.  Was  ordered,  R.  -f- 
0-75  sph.,  -f-  0-25  c. ;  L.  +  I  s.,  +  0-25  c.  180°. 

June  15th. — Glasses  make  eyes  and  head  ache ;  seems  to  get 
worse  from  day  to  day ;  comes  with  smoked  glasses  on  account 
of  photophobia;  can  not  read  at  all.  Esophoria  =21°.  Or- 
dered prisms  3°,  bases  out. 

July  9th. — Much  more  comfortable  until  last  three  days. 
Esophoria  —  20°.    Ordered  5°  each. 

16th. — No  headache,  and  eyes  perfectly  comfortable  since 
wearing  5°  prisms. 

She  was,  however,  unable  to  wear  the  5°  prisms  for  long, 
and  partial  tenotomies  of  both  interni  were  done,  giving  relief 
to  symptoms,  but  leaving  a  low  degree  of  esophoria. 


January  23,  1893. — Complains  of  some  blurring  recently, 
but  has  been  fi'ee  from  headache  except  when  reading  without 
glasses.    Esophoria  =  pr.  2°. 

Reported  to  show  failure  of  refractive  correction  to  re- 
lieve symptoms,  or  rather  aggravation  of  symptoms,  by  at- 
tempt to  correct  refraction  in  presence  of  heterophoria, 
and  the  relief  afforded  by  prisms  and  later  by  tenotomy. 

Case  Vil. — Miss  M.,  aged  nineteen,  university  student,  for 
past  three  years  has  suflFered  from  frontal  and  temporal  head- 
ache, and  for  one  year  from  occipital  headache  also,  neuralgic 
in  character  and  occasionally  accompanied  by  vomiting.  Head- 
ache specially  apt  to  be  brought  on  by  reading.  Suffers  also 
from  vertigo. 

November  2,  1889. — First  examination  showed  low  myopic 
astigmatism.  After  use  of  atropine  for  two  days,  examination 
showed  H.  —  2-25  sph.,  0*25  cyl.  in  each,  and  esophoria  =  prism 
of  8°  ;  +  r25  sph.,  -(-  0'25  c,  orderd  for  each  eye. 

These  glasses  could  not  be  worn,  although  given  a  prolonged 
and  faithful  trial.  They  increased  her  headache  and  made  her 
very  dizzy.  She  consulted  me  again  on  February  1st,  when  I 
found  esophoria  =  pr.  7°  to  8°,  and  prescribed  for  temporary 
use  a  prism  of  2°,  base  out,  before  each  eye. 

On  February  5th  she  reports  that  she  has  been  much  freer 
from  headache,  and  shows  esophoria  =  10°. 

February  8th. — Esophoria  =  12°  pr.  Ordered  R.  3°,  bases 
out;  L.  4°,  bases  out. 

IJfth. — Esophoria  =  12°  pr.    Sees  double  without  glasses. 

22d. — Head  much  freer  from  pain ;  only  one  headache  dur 
ing  week.  Right  accepts  -|-  0-25  or  5  c.  70° ;  left,  -|-  0-25  or  5 
c.  110°. 

With  these  glasses  she  has  esophoria,  15°.  Ordered  -f-  0-5  s., 
-(-  0'25  c,  4°  prism,  bases  out,  for  each. 

October  17,  1891. — Has  worn  glasses  last  prescribed  until 
present  time  with  comfort.  Since  returning  to  studies  has  a 
return  of  headaches. 

Homatropine  used  to  full  effect. 

R.  -f  1-5  s.,  -1-0-5  cyl.;  left,  ditto.  With  full  correction, 
esophoria  =  pr.  12°,  images  being  separated  two  to  three  feet 
at  twenty  feet.    Tenotomy  advised. 

This  case  is  reported  to  illustrate  (1)  the  aggravation  of 
symptoms  produced  by  the  partial  correction  of  hyperme- 
tropic astigmatism  in  the  presence  of  heterophoria ;  (2)  the 
relief  to  symptoms  afforded  by  the  correction  of  hetero- 
phoria in  the  presence  of  a  marked  degree  of  ametropia. 
It  is  also  worthy  of  note  that  the  constant  use  of  prisms 
correcting  a  large  part  of  the  manifest  esophoria  for  two 
years  has  not  resulted  in  any  increase  in  the  amount  of 
esophoria. 

I  am  not  familiar  with  any  evidence  tending  to  prove 
the  truth  of  Dr.  Davis's  assertion  that  heterophoria  can  be 
produced  in  any  case  by  the  use  of  prisms.  A  transient 
spasm  of  certain  muscles  may  be  brought  about,  but  not 
true  heteroplioria. 

Case  VIII.— March  28,  1890,  Miss  M.  E.  H.,  aged  twenty- 
five.  One  year  ago  the  eyes  ''gave  out";  failure  attributed  to 
exposure  to  bright  light  and  heat  in  Kansas;  now  imable  to 
use  eyes;  pain  in  eyes  and  brows  on  looking  steadily  at  any- 
thing, etc.;  seems  to  have  been  subject  to  headache  and  paiu 
in  the  eyes  on  waking  in  the  morning  for  some  time  previous. 
Dr.  Fryer,  in  Kansas  City,  six  months  ago  prescribed  R.  -f 
0-25  cyl.  60°;  L.  -H  0-25  c.  130°  and  a  year's  rest,  but  eyes 


408 


MA  BLOW:  EETEROPHORIA  AND  ITS  TREATMENT. 


(N.  Y.  Mkd.  Joub., 


have  been  no  better;  and,  although  glasses  make  things  very 
clear,  they  intensify  the  discomfort  and  make  her  nervous. 

Examination  showed  the  refractive  error  to  be  exactly  cor- 
rected by  Dr.  Fryer's  glasses :  Exophoria  =  6°  prism  ;  externi 
=  12°  prism  at  least;  interni  =  <  20°  prism.  Ordered  for 
temporary  use  R.  prism  1°,  L.  prism  2°. 

April  3d. — Exophoria  =  8°  to  9°  prism  ;  R.  glass  changed 
to  prism  3°. 

8th. — Exophoria  =  8°  to  9°  pri.sm. 

Exophoria  —  9",  but  not  10°. 

May  2!fth. — Has  worn  glasses  (prism  =  5°)  constantly.  Has 
had  no  headaches,  and  on  her  best  days  has  been  able  to  read 
continuously  for  an  hour.  Exophoria  =  10°  prism,  externi  = 
15°  or  16°  prism.  Ordered  +  0  25  c.  3°  prism,  base  in,  for 
•each  eye. 

July  18th. — She  returns,  having  been  comfortable  until 
within  a  few  days,  complaining  of  aching  and  pressure  in  eyes. 
Exophoria  =  8°  or  9°  prism  ;  externi  >  15° ;  interni  <  15°. 

21st. — Partial  tenotomy  of  righ  t  exlernus,  leaving  no  lateral 
■deviation. 

29th. — Orthophoria  or  low  esophoria.  Externi  =  7°  prism, 
interni  =  29°. 

50<A.— Interni  =  34*.  No  pain  in  eyes  on  waking  (says  it 
is  the  first  time  in  three  years  that  this  has  happened). 

August  1st. — Externi  =  9°.  Now  wears  Dr.  Fryer's  glasses 
with  comfort. 

Case  IX. — Mrs.  K.  II.,  aged  thirty-five,  consulted  me  in 
May,  1889,  for  chronic  middle-ear  disease,  and  her  eyes  were 
incidentally  examined  on  account  of  a  complaint  of  severe  head- 
ache; repeated  examination  showed  hypermetropic  astigmatism 
in  each  =  0'5  D;  axis  at  90°.  R.  hyperphoria  varying  on  dififer- 
<ent  days  from  3°  to  5°,  and  esophoria  3°. 

She  was  ordered  -f  0*5  c.  90°  each  for  constant  wear,  with 
which  she  could  use  her  eyes  more,  but  did  not  have  less  head- 
ache. In  June,  1891,  she  returned  on  account  of  increasing  dif- 
ficulty in  using  her  eyes  and  very  severe  headaches,  intoler- 
ance of  light,  etc.,  and  showing  R.  hyperphoria  =  4°  or  5° 
prism  ;  esophoria  =  4°  or  5°.  Prisms  =  3°,  divided  equally 
l)etween  the  two  eyes,  were  added  to  the  cylinders,  the  axes  of 
■which  were  slightly  changed  in  direction.  These  glasses  gave 
her  considerably  more  relief  than  the  former,  still  she  returned 
in  July,  1892,  with  increasing  headache  and  difficulty  in  using 
the  eyes;  on  removing  her  glasses  she  can  not  keep  her  eyes 
open ;  the  palpebral  fissure  narrows  to  a  slit-like  opening. 
Says  the  distress  caused  by  opening  the  eyes  without  glasses  is 
inexpressible ;  never  opens  eyes  in  the  morning  until  she  has 
glasses  on.    Hyperphoria  still  =  4°  to  5°. 

July  19th. — Tenotomy  of  right  superior  rectus,  leaving  mar- 
ginal fibers  uncut.    R.  hyperphoria  1°  to  2°  left. 

20th. — No  hyperphoria ;  can  open  eyes  without  glasses  with 
■complete  comfort. 

September  I5th. — R.  hyperphoria  2°  to  3° ;  partial  tenotomy 
«f  left  inferior  rectus,  leaving  images  level. 

16th. — R.  hyperphoria  low  degree. 

Nonemher  1st. — Has  used  her  eyes  a  good  deal  more,  and  had 
■only  one  severe  headache  since  last  operation.  R.  hyperphoria 
=  1^°  prisms  (phorometer) ;  partial  tenotomy  of  left  inferior 
rectus. 

2d. — L.  hyperphoria  =  1°. 

Si. — No  hyperphoria;  read  four  columns  of  magazine  last 
night  without  discomfort  or  headache. 

This  case  (IX)  is  incomplete,  but  is  quoted  to  show  (1) 
the  failure  of  refractive  correction  to  effect  any  change  in 
She  heterophoria ;  (2)  the  immediate  relief  to  symptoms 


afforded  by  prisms  and  tenotomies;  (3)  the  effect  of  par- 
tial tenotomy  in  changing  the  position  of  rest ;  (4)  the 
failure  of  the  prolonged  use  of  prisms  to  increase  the  hete- 
rophoria. 

Case  X. — January,  1892,  Miss  K.  C.  R.,  aged  thirty-five. 
Vision  defective  until  prescribed  glasses  in  1887,  which  seem  to 
be  a  very  accurate  correction  of  refractive  error.  ,R.  -t-  1  s. 
0-38° ;  L.  -I-  1  s.  —  60  c.  115°.  Symptoms  complained  of 
now  are  headache,  asthenopia,  and  a  great  facility  in  seeing 
double. 

Examination  showed  exophoria  =  prisms  6°.  After  tem- 
porizing with  prisms,  etc.,  partial  tenotomies  of  both  externi 
were  done,  giving  almost  complete  relief  to  symptoms,  and  mak- 
ing it  impossible  for  her  to  see  double  in  distance  at  will,  as  was 
previously  the  case. 

January  IJf,  1893. — Examination  shows  esophoria  =  <  1° 
prism.    Has  been  comfortable  up  to  the  present  time. 

Case  XI. — May,  1888.  P.  B.,  boy,  aged  eleven.  Refraction 
after  atropine:  R.  +  0  5  s.,  -f  0-5  c.  120°;  L.  +  0-25  s.,  +  0-5 
c.  75°.    Equilibrium  not  noted. 

May,  — Complains  of  not  seeing  clearly  in  distance. 
Homatropine.  R.  —  0-5  c.  30°,  L.  —  0'5  c.  165°;  R.  hyper- 
phoria 4°,  exophoria  5°.  Ordered  R.  —  0-5  c.  1°  prism,  base 
down ;  L.  —  0*5  c.  1°  prism,  base  up. 

May,  1892.—  Got  on  well  until  Christmas,  when  he  broke  his 
glasses;  after  repair  they  were  uncomfortable  for  a  time,  but 
finally  settled  down.  Now  for  a  few  days  headache  and  eye- 
ache  have  returned.  Examination  of  glasses  shows  prisms  to 
have  been  reversed.  Refraction  as  above.  R.  hyperphoria  ^* 
only!  Prismatic  effect  of  glasses  removed  by  placing  both  with 
bases  in  same  direction. 

Four  days  later  he  returned,  stating  that  at  first  he  was  com- 
fortable, but  headache  and  eyeache  have  now  come  back.  Ex- 
amination shows  R.  hyperphoria  4^°! 

To  illustrate :  1.  Persistence  of  heterophoria  in  spite  of  re- 
fractive correction. 

2.  Temporary  change  of  equilibrium  due  to  prolonged  exer- 
cise with  prisms. 

3.  Incidentally,  onset  of  myopia  in  heterophoria. 

These  cases  and  many  similar  ones  have  set  at  rest  for- 
ever, for  me,  the  doubts  which  I  entertained  some  years 
ago  as  to  the  effect  of  incomplete  tenotomies  upon  the  posi- 
tion of  rest. 

When  I  began  to  perform  these  tenotomies  I  followed 
closely  the  method  of  Stevens,  making  a  minute  opening  in 
the  conjunctiva,  dilating  it  with  forceps  and  picking  up 
and  cutting  through  the  middle  fibers  of  tendon  with  scis- 
sors, enlarging  the  incision  in  tendon  by  hook  and  scissors. 

I  found  two  disadvantages  attending  this  method :  In 
the  first  place,  the  tendon  was  not  seen ;  one  could  not  see 
how  much  was  divided  and  how  much  undivided.  In  the 
second  place,  if  haemorrhage  occurred,  the  clot  formed  a 
subconjunctival  swelling  immediately  over  the  portion  of 
the  tendon  to  be  operated  upon,  thus  further  interfering 
with  the  performance  of  the  operation,  and  also  extending 
so  as  to  cover  the  whole  eyeball  in  some  cases. 

To  avoid  these  disadvantages,  I  make  an  incision  over 
the  insertion  of  the  tendon,  in  the  direction  of  the  muscle, 
long  enough  to  enable  the  tendon  to  be  seen,  and  the  size 
of  the  incision  allows  the  blood  to  escape  externally  instead 
of  subconjunctivally.    The  operation  is  essentially  that  de- 


April  15,  1893.]  SULLIVAN:   CLINICAL  OBSERVATIONS  ON  APPENDICITIS. 


409 


scribed  by  Landolt,  done  with  the  delicate  instruments  of 
Stevens.  If  the  conjunctival  wound  gapes,  I  use  a  suture. 
The  effect  is  tested  after  each  portion  of  the  tendon  is 
divided.* 

If,  in  order  not  to  expose  "  our  ignorance  and  stupidi- 
ty "  (Davis),  we  eschew  prisms  and  partial  tenotomy,  upon 
what  therapeutic  measures  can  we  fall  back  ? 

"  The  correction  of  the  refractive  errors,"  say  Dr.  Roosa 
and  Dr.  Davis. 

But  in  many  cases  there  is  no  refractive  error ;  in  others 
such  error  is  an  infinitesimal  quantity  compared  with  the 
degree  of  heterophoria  present;  in  others,  again,  the  re- 
fractive correction  can  not  be  worn  while  the  heterophoria 
remains  uncorrected ;  and  finally,  in  cases  in  which  the  re- 
fractive correction  can  be  and  is  worn,  the  heterophoria 
persists  and  gives  rise  to  symptoms. 

To  these  large  classes  of  cases  neither  Dr.  Roosa  nor 
Dr.  Davis  makes  any  reference,  and  consequently  no  sugges- 
tion as  to  treatment. 

To  conclude,  the  experience  I  have  had  in  the  treatment 
of  latent  deviations  of  the  visual  axes  up  to  the  present 
time  seems  to  point  to  the  following  generalizations  : 

1.  That  the  kind  of  deviation  has  very  rarely  any  rela- 
tion to  the  kind  of  refractive  error. 

2.  That  heterophoria  is  only  exceptionally  influenced 
by  the  correction  of  the  refractive  error. 

3.  That  in  many  cases  the  symptoms  can  be  relieved 
by  prisms  alone,  or  in  combination  with  the  refractive  cor- 
rection. 

4.  That  in  some  cases  of  undoubted  heterophoria 
prisms  are  rejected  altogether,  and  that  in  some  of  these 
cases  correction  by  tenotomy  or  tenotomies  gives  the  desired 
relief. 

5.  That  the  position  of  rest  can  be  changed  by  a  strictly 
partial  tenotomy. 

6.  That  the  ophthalmologist  who  ignores  the  condition 
of  muscular  equilibrium  in  a  case  of  asthenopia  (in  the 
widest  sense  of  the  term)  does  not  do  his  whole  duty  to 
his  patient. 

401  Montgomery  Street,  Syracuse,  N.  Y. 


German  Jubilees. — We  learn  from  the  Wiemr  Hiniscke  Woch- 
enschrift  that  Professor  Karl  Schweigger,  of  Berlin,  recently  cele- 
brated the  twenty-fifth  anniversary  of  bis  accession  to  a  professor- 
ship ;  Professor  Oskar  Liebreich,  of  Berlin,  the  completion  of  twenty- 
five  years  since  he  became  a  Decent ;  and  Professor  Karl  Ewald  Haase, 
of  Hannover,  the  sixtieth  year  of  his  doctorate. 


*  There  are  a  number  of  cases  in  which  division  of  the  middle  por- 
tion of  the  tendon  does  not  produce  a  sufficient  effect,  and  a  complete 
tenotomy  would  almost  surely  cause  a  considerable  over-correction.  In 
such  cases  a  partial  tenotomy  may  be  done  in  the  usual  manner,  leaving 
only  the  marginal  fibers  attached  to  the  sclera,  and  after  sufficient  time 
for  the  middle  portion  of  the  tendon  to  become  adherent  in  its  now 
position  has  elapsed,  the  marginal  fibers  can  also  be  completely  divided, 
leaving  now  the  middle  fibers  only  attached.  In  this  way  the  whole 
insertion  of  the  tendon  can  be  set  back,  with  but  little  danger  of  over- 
correction, or  of  altering  the  relation  of  the  muscle  to  the  eyeball.  If 
the  effect  is  still  insufficient,  the  whole  yoceeding,  or  as  much  of  it  as 
is  necessary,  may  be  repeated. 


CLINICAL  OBSERVATIONS  ON  APPENDICITIS, 

WITH  REPORT  OF  CASES 
ILLUSTRATING  DIFFERENT  FORMS  OF  THE  DISEASE.* 

By  J.  D.  SULLIVAN,  M.  D., 

BBOOKLTN. 

Emulating  the  example  of  my  distinguished  predeces- 
sors, I  will  make  a  free  interpretation  of  the  provision  in 
the  by-laws  of  this  association  which  states  that  "  at  the 
February  meeting  each  year  the  nine-o'clock  hour  shall  be 
devoted  to  an  address  by  the  president  of  the  preceding 
year  upon  the  progress  made  during  the  year  in  that 
branch  of  medical  art  or  science  in  which  he  may  have 
been  specially  interested,"  and  trust  that  I  shall  comply 
with  the  spirit  of  that  by-law  by  presenting  a  paper  which 
will  embrace  some  of  my  individual  observations  on  appen- 
dicitis during  the  year. 

It  is  now  quite  universally  admitted  that  we  are  in- 
debted to  the  achievements  of  modern  surgery  for  our  pres- 
ent knowledge  of  the  pathology  and  the  treatment  of  dis- 
eases originating  in  the  vermiform  appendix,  and  that  the 
progress  made  in  that  special  branch  of  medical  science 
within  the  last  six  years  has  been  the  means  of  saving  hun- 
dreds of  our  fellow-creatures  from  an  untimely  death.  Al- 
though the  various  forms  of  appendicular  inflammations  have 
been  repeatedly  described  and  demonstrated,  and  the  appro- 
priate treatment  of  each  form  intelligently  discussed  and 
applied,  I  still  think  that  we  have  yet  much  to  learn  before 
we  can  ultimately  claim  proficiency  in  dealing  with  them. 

Believing  that  clinical  knowledge  is  more  instructive 
and  practical  than  rehearsing  the  experiences  and  teachings 
of  others,  and  that  the  careful  study  of  a  comparatively 
few  cases  will  afford  a  more  definite  knowledge  of  the 
pathological  conditions  of  the  appendix  and  the  indications 
for  treatment  than  an  indefinite  amount  of  theory  based  on 
the  casual  observation  of  a  very  large  number,  I  have  selected 
the  following  cases  for  the  purpose  of  illustrating  the  views 
now  entertained  on  this  subject,  and  crave  your  indulgence 
if  I  occupy  your  time  unprofitably  by  dwelling  too  minutely 
on  the  minor  details  of  each  case  : 

Case  L — Miss  J.  B.,  a  well-developed  young  lady,  aged 
twenty-two  years,  enjoyed  good  health  up  to  March,  1888. 
One  day  while  at  school  she  was  taken  with  a  severe  pain  in 
the  lower  portion  of  her  abdomen,  which  continued  for  several 
days  and  obliged  her  to  remain  in  bed  for  three  weeks.  Dur- 
ing that  time  she  was  treated  by  a  homoeopathic  physician,  who 
said  she  had  "inflammation  of  tlie  bowels."  For  several 
weeks  after  that  there  was  tenderness  in  the  right  inguinal  re- 
gion, and  for  the  following  two  years  she  continued  to  have 
occasional  attacks  of  a  similar  character,  and  always  accom- 
panied by  derangement  of  her  digestive  organs.  On  October 
25, 1891,  I  was  called  to  attend  her.  Her  temperature  was  100°, 
pulse  about  116,  bowels  constipated,  and  she  complained  of 
pain  in  the  right  side  of  her  abdomen. 

Pressure  at  a  point  two  inches  and  a  half  from  the  right 
anterior  superior  spine  of  the  ilium  in  the  direction  of  the  um- 
bilicus, known  as  "  McBurney's  point,"  elicited  acute  pain.  No 
tumor  could  be  found.    Absolute  rest  in  the  recumbent  posi- 


*  Read  before  the  Kings  County,  N.  Y.,  Medical  Association,  Febru- 
ary 14,  1893. 


I 


410 


SULLIVAN:   CLINICAL  OBSERVATIONS  ON  APPENDICITIS.         [N.  Y.  Mko.  Jocb., 


tion,  hot  foracDtations  to  the  abdomen,  gentle  laxatives,  and 
fluid  diet  were  prescribed.  The  pain  gradually  subsided  and 
there  were  no  indications  for  further  treatment.  Although  she 
did  not  appear  sick  after  the  first  few  days,  her  temperature  re- 
mained at  about  100°,  and  there  was  tenderness  on  pressure 
over  the  cificum  for  a  period  of  two  weeks. 

On  June  24,  1892,  I  was  again  summoned  to  see  her,  and 
she  presented  all  the  symptoms  of  her  former  attacks  excepting 
that  the  pain  was  more  severe.  On  this  occasion  I  ordered  the 
application  of  a  mercurial  ointment,  diluted  with  six  parts  of 
stramonium  ointment,  to  the  seat  of  psiin,  instead  of  the  hot 
fomentations.  She  recovered  from  this  attack  in  about  one 
week.  Since  then  she  has  had  two  light  attacks,  but  by  rest- 
ing in  bed  and  applying  the  mercurial  ointment  the  pain  ceased 
within  a  few  days. 

A  few  weeks  ago  she  called  at  my  office  and  I  made  an  ex- 
amination of  her  abdomen.  There  is  no  evidence  of  a  tumor  or 
induration,  but  there  is  a  marked  tenderness  on  pressure  in  the 
location  known  as  the  McBurney  point.  She  informs  me  that 
any  very  active  exercise,  as  dancing  or  going  rapidly  up  or 
down  stairs,  will  cause  a  moderate  degree  of  pain  in  the  right 
inguinal  region,  extending  over  the  abdomen  and  down  the 
right  thigh.  She  now  realizes  the  nature  of  her  trouble,  and 
knows  that  while  her  digestive  organs  are  in  good  condition 
she  is  not  so  liable  to  a  recurrence  of  these  attacks. 

This  is  evidently  one  of  the  cases  which  is  called 
catarrhal  appendicitis,  in  which  we  may  assume  that  sup- 
puration has  not  yet  occurred,  or,  if  it  has,  the  pus  was 
either  absorbed  or  discharged  into  the  bowel.  There  must 
have  been  more  or  less  local  peritonitis  accompanying  the 
several  attacks,  but  the  inflammation  was  probably  of  a 
plastic  type  and  did  not  extend  beyond  the  immediate 
vicinity  of  the  appendix.  The  great  contrast  between  this 
case  and  the  next  is  worthy  of  special  attention. 

Case  II. — Miss  M.  C,  a  healthy  young  lady,  aged  twenty- 
three,  on  May  23,  1892,  was  quite  suddenly  seized  with  acute 
abdominal  pain,  which  was  continuous  and  severe  throughout 
that  night.  The  next  day  I  was  called  and  found  her  sitting 
up  in  the  parlor.  She  did  not  complain  of  being  very  sick,  but 
simply  wanted  something  to  relieve  the  "  cramps  in  her  bow- 
els." Her  temperature  was  101°,  pulse  120,  bowels  free,  and 
her  general  appearance  was  fairly  good. 

An  examination  of  the  abdomen  revealed  a  point  of  extreme 
tenderness  in  the  right  inguinal  region,  about  two  inches  and  a 
half  from  the  anterior  superior  spine  of  the  ilium  in  the  direc- 
tion of  the  umbilicus. 

No  tumor  was  perceptible.  I  was  quite  positive  in  my 
diagnosis  of  appendicitis,  but  unable  to  determine  the  charac- 
ter of  the  inflammatory  process.  It  required  considerable  per- 
suasion to  make  her  realize  the  importance  of  remaining  in  bed 
and  complying  with  my  instructions.  Hot  fomentations  were 
applied  to  the  abdomen  and  small  doses  of  sulphate  of  mag- 
nesia prescribed.  A  few  moderate  doses  of  opium  were  or- 
dered to  be  taken  only  when  the  pain  was  severe.  On  the 
following  day  she  appeared  quite  well  and  comfortable,  but  her 
pulse  continued  at  120  and  her  temperature  had  risen  to  102°. 
Bowels  had  moved  freely.  There  was  slight  dullness  on  per- 
cussion and  acute  pain  on  pressure  at  the  typical  point,  extend- 
ing toward  the  median  line  of  the  abdomen.  On  May  2(3th,  the 
third  day  of  the  disease,  the  general  symptoms  were  about  the 
same  and  the  local  induration  was  more  distinct  and  painful. 
On  the  fourth  day  the  pulse  was  more  rapid,  the  tempera- 
ture had  risen  to  103°,  and  the  tumor  was  well  defined.  The 
patient  presented  an  expression  of  anxiety,  and  while  the  pain 


continued  in  a  moderate  degree  it  did  not  increase  in  propor- 
tion to  the  other  symptoms.  I  was  now  certain  that  an  abscess 
had  formed,  and  recommended  an  operation,  but,  at  the  earnest 
solicitation  of  the  patient  and  her  friends,  I  consented  to  wait 
another  day. 

By  the  fifth  day  her  temperature  had  fallen  to  102°,  pulse 
130,  soft  and  weak,  and  lier  general  appearance  indicated  great 
depression.  It  was  evident  that  the  patient  was  passing  into 
a  state  of  collapse,  and  that  an  operation  offered  the  only  hope 
of  saving  her  life.  She  was  carefully  removed  to  St.  Mary's 
Hospital,  and,  assisted  by  the  house  staff,  I  made  the  usual  ab- 
dominal incision  directly  over  the  tumor.  "When  the  abdomen 
was  opened  the  small  intestines  presented  'an  intensely  con- 
gested appearance  and  were  adherent  to  the  caput  coli.  While 
separating  the  adhesions  I  opened  into  an  abscess  cavity  con- 
taining about  three  drachms  of  very  offensive  pus.  This  was 
carefully  taken  up  on  sponges,  and  the  appendix,  which  was 
black  and  in  a  gangrenous  condition,  perforated  at  its  base, 
was  found  on  the  inner  side  of  the  caput  coli.  While  attempt- 
ing to  ligate  the  appendix  at  the  proximal  side  of  the  perfora- 
tion the  ligature  cut  through  the  necrotic  tissue,  and  the  dead, 
offending  organ  was  removed.  Another  attempt  was  made  to 
close  the  appendicular  opening,  but  the  tissues  were  so  necrotic 
and  friable  that  they  would  not  hold  a  ligature  or  suture. 

After  all  the  inflammatory  products  were  removed,  a  square 
piece  of  iodoform  gauze  was  laid  over  the  wound,  its  center  de- 
pressed to  the  bottom  of  the  abscess  cavity,  and  the  pocket 
thus  formed  was  packed  with  several  strips  of  the  same  kind  of 
gauze.  By  this  means  the  intestines  were  walled  off  and  the 
packing  could  be  removed  without  disturbing  the  abdominal 
contents.  A  few  sutures  were  placed  in  the  upper  angle  of  the 
wound  and  the  usual  dressings  applied.  On  the  following  day 
the  patient  was  bright  and  comparatively  comfortable  and  her 
convalescence  was  uninterrupted  thereafter. 

The  dressings  were  changed  on  the  third  day,  and  the 
wound  was  found  in  a  very  favorable  condition.  I  was  agree- 
ably surprised  to  find  the  former  site  of  the  appendix  covered 
over  with  a  healthy  exudation,  and  that  there  was  no  opening 
into  the  bowel.  Within  a  week  the  abscess  cavity  was  covered 
with  healthy  granulations,  and  the  reparative  process  continued 
undisturbed  until  the  wound  was  completely  healed.  The  pa- 
tient left  the  hospital  July  21st,  and  has  remained  in  perfect 
health  since. 

If  you  will  permit  me  to  take  you  over  another  phase 
in  the  history  of  this  case  you  will  readily  understand  how 
easy  and  apparently  reasonable  it  would  be  to  allow  the  pa- 
tient to  pass  into  a  hopeless  condition  before  resorting  to 
any  efficient  treatment  for  her  relief.  When  I  first  saw 
this  lady  she  did  not  appear  to  be  afflicted  with  any  serious 
ailment,  and  as  I  was  in  a  hurry  to  keep  another  engage- 
ment, it  would  seem  quite  natural  to  prescribe  for  her 
"  colic  "  on  general  principles ;  but  the  danger  of  possible 
appendicitis  flashed  through  my  mind  and  I  insisted  upon 
a  physical  examination  of  the  abdomen.  By  the  second 
day  the  few  doses  of  opium  had  given  her  a  sense  of  false 
security,  and  she  appeared  so  well  that  her  relatives  were 
willing  to  dispense  with  any  further  professional  attendance. 

Experience  had  taught  me  that  in  these  cases  subjective 
symptoms  were  not  to  be  trusted,  and  that  the  omission  of 
proper  attention,  even  for  a  day,  might  prove  disastrous. 
It  is  well  known  that  septic  peritonitis  may  exist  without 
much  pain  or  elevation  of  temperature.  The  conditions 
found  in  this  case,  when  the  abdomen  was  opened,  showed 


April  15,  1893.] 


SULLIVAN:   CLINICAL  OBSERVATION'S  ON  APPENDICITIS. 


411 


tliat  tlie  gangrenous  appendix  was  inciting  a  septic  perito- 
nitis, and  demonstrated  the  fact  that  the  operation  could 
have  been  done  to  a  better  advantage  a  day  or  two  sooner, 
and  that  in  all  probability  a  further  delay  of  twenty-four 
liours  would  have  allowed  the  disease  to  progress  to  a  fatal 
issue.  To  me  this  was  a  very  instructive  case,  for  it 
brought  to  ray  recollection  the  demise  of  several  useful 
members  of  society  whose  deaths  occurred  under  a  similar 
train  of  symptoms,  because  the  true  pathological  conditions 
were  not  clearly  comprehended  at  the  proper  time. 

Case  III. — Mr.  J.  C,  aged  forty-six  years;  occupation,  a 
furrier.  A  robust  man  who  had  enjoyed  good  health  up  to 
September  14.  1892,  when  he  began  to  have  pain  in  the  lower 
portion  of  his  abdomen.  While  the  pain  was  persistent  and 
annoying,  it  was  not  very  severe,  and  he  continued  at  his  em- 
ployment as  nsnal  for  the  next  three  days.  During  that  time 
his  bowels  were  regular  and  his  general  health  fairly  good.  On 
September  17th  the  pain  suddenly  became  so  severe  that,  to 
use  his  own  expression,  "  it  doubled  him  up  "  for  some  hours. 

This  pain  was  accompanied  by  nausea  and  was  followed  by 
a  chill  and  fever. 

Dr.  J.  R.  Kevin,  of  this  city,  was  called  to  attend  him,  and 
promptly  made  the  diagnosis  of  appendicitis.  After  three  days' 
observation  and  treatment.  Dr.  Kevin  considered  the  case  a 
proper  one  for  surgical  interference  and  he  was  sent  to  St. 
Mary's  Hospital.  He  arrived  there  September  20th  at  8  p.  m. 
I  saw  him  at  9.30  that  evening,  and  upon  examination  found  a 
well-marked  tumor  in  the  right  inguinal  region  which  was  quite 
hard  and  not  very  painful  on  gentle  manipulation.  After  the 
usual  preparation  an  incision  was  made  through  the  abdominal 
wall,  over  the  tumor,  and  a  hard  mass,  composed  of  omentum 
and  inflammatory  products,  was  exposed.  While  separating  the 
adhesions  around  the  tumor  an  abscess  cavity  was  opened 
which  contained  about  half  an  ounce  of  pus,  which  was  re- 
moved with  sponges.  The  mass  was  found  to  contain  the  rup- 
tured vermiform  appendix,  which  was  given  off  at  an  acute 
angle  from  the  outer  side  of  the  ascending  colon  at  about  an 
inch  above  its  lower  extremity.  The  appendix  was  ligated  near 
the  colon,  severed,  and  the  stump  cauterized  with  pure  carbolic 
acid.  That  portion  of  the  omentum  which  was  involved  in  the 
tumor  was  ligated  in  sections  with  catgut  and  cut  off,  and  the 
entire  mass  was  detached  with  the  fingers  from  its  surroundings 
and  removed.  The  space  was  carefully  cleansed  and  packed 
with  iodoform  gauze.  About  one  third  of  the  wound  was 
closed  with  silkworm  gut  and  the  usual  toilet  made. 

The  next  day  the  patient  was  comfortable  and  in  a  good 
condition  ;  pulse,  90 ;  temperature,  100°. 

In  a  few  days  his  pulse  and  temperature  became  normal 
and  continued  so  throughout  his  convalescence.  His  bowels 
were  moved  on  the  second  day  and  acted  well  thereafter.  On 
the  third  day  the  dressings  were  removed  and  the  wound 
cleansed  and  repacked  with  iodoform  gauze,  and  subsequently 
they  were  changed  every  other  day. 

By  the  end  of  the  third  week  the  wound  was  closed,  with 
the  exception  of  a  small  sinus  which  led  down  to  the  stump  of 
the  appendix. 

At  about  the  fifth  week  small  particles  of  faeces  began  to 
escape  from  the  sinus,  and  a  probe  could  be  carried  directly 
through  it  into  the  colon.  This  fistulous  tract  was  repeatedly 
cauterized  with  nitrate  of  silver,  and  various  stimulating  appli- 
cations— such  as  peroxide  of  hydrogen,  balsam  of  Peru,  naph- 
thalin,  etc. — were  applied  at  different  times,  but  traces  of  fajcal 
matter  appeared  at  irregular  intervals  for  a  period  of  four 
weeks  more.    Then  for  three  weeks  the  sinus  remained  as  a 


very  small  fistula  from  which  only  a  little  clear  mucous  escaped. 
This  mucus  evidently  came  from  the  mucus  follicles  in  the 
stump  of  the  appendix,  and  demonstrated  the  fact  that  the 
mucous  membrane  in  the  stump  was  the  cause  of  the  delay  in 
the  healing  of  the  w  ound  and  shows  one  of  the  evil  results  of 
leaving  any  portion  of  the  appendicular  tissue  ren)aining.  The 
delay  was  very  annoving,  as  the  patient  was  in  perfect  health 
in  all  other  respects. 

Comparing  the  symptoms  presented  in  this  case  before 
the  operation  with  the  pathological  conditions  found  after 
opening  the  abdomen,  I  deem  it  proper  to  term  it  one  of 
acute  ulcerative  appendicitis  in  which  the  plastic  inflamma- 
tion protected  the  patient  from  general  peritonitis.  It  is 
fair  to  assume  that  the  mild  pain  which  simply  annoyed 
tlie  patient  for  the  first  three  days  of  the  attack  was  caused 
by  the  ulcerative  process,  and  that  a  perforation  of  the  ap- 
pendix occurred  on  the  third  day  when  the  violent  pain  was 
felt.  Then  a  localized  peritonitis  was  excited,  but  its  ex- 
tension was  limited  by  the  formation  of  an  abscess  wall 
composed  of  omentum  and  loops  of  small  intestine,  which 
were  firmly  bound  together  by  the  plastic  exudation.  This 
pathological  condition  illustrates  the  absolute  necessity  of 
surgical  interference  in  this  class  of  cases. 

Case  IV. — Mr.  S.  H.,  a  spare  young  man,  aged  twenty-one 
years,  occupation  bookbinder,  walked  into  my  office,  October 
14,  1892,  and  gave  the  following  history  of  his  ailment:  Ten 
days  before,  while  lifting  a  package  of  paste  board  on  to  a  table, 
he  was  seized  with  an  acute  pain  in  the  right  lower  portion  of 
his  abdomen,  which  obliged  him  to  quit  work  and  go  home. 
Thinking  that  it  was  only  a  trifling  disturbance  in  his  bowels, 
he  refused  to  have  a  physician  called,  but  took  a  cathartic  and 
remained  in  bed  for  the  next  three  days,  suffering  only  a  mod- 
erate degree  of  pain.  After  the  third  day,  while  the  pain  in 
the  right  loin  was  quite  constant  it  was  not  very  severe,  and  he 
walked  about  more  or  less  daily,  and  slept  fairly  well  at 
night.  As  he  came  into  my  office  I  observed  that  he  leaned 
forward  and  to  the  right  side,  stepping  very  carefully  with  the 
right  leg.  His  pulse  was  120,  soft  and  compressible,  and  his 
temperature  101 '4°. 

On  inspection,  there  was  a  well-marked  fullness  in  the  right 
iliac  region.  Pressure  with  one  finger  at  the  McBurney  point 
did  not  elicit  any  special  tenderness,  but  from  a  point  an  inch 
and  a  half  in  front  of  the  anterior  superior  spine  of  the  ilium, 
and  extending  upward  and  backward  just  above  its  crest  to  the 
right  quadratus-lumborum  muscle,  the  tissues  were  tense,  firm, 
and  very  painful.  My'diagnosis  was  that  the  tumor  was  a  para- 
typhlitic  abscess,  which  was  burrowing  toward  the  right.  I 
advised  him  to  submit  to  an  operation  on  the  following  day,  to 
which,  after  consultation  with  his  parents,  he  consented.  He 
slept  well  that  night  without  an  anodyne,  and  at  ten  o'clock  the 
next  morning  his  pulse  was  112  and  his  temperature  100°. 
Notwithstanding  this  apparent  improvement  in  his  condition, 
he  was  then  sent  to  St.  Mary's  Hospital,  and,  after  the  usual 
preparation,  an  incision  about  four  inches  and  a  half  long  was 
made  about  an  inch  outside  the  linea  semilunaris  and  the  peri- 
toneal cavity  deliberately  opened.  The  intestines  were  held 
aside  and  protected  with  pads  of  sterilized  gauze,  and  it  was 
then  seen  that  the  tumor,  commencing  at  the  outer  surface  of 
the  caput  coli,  extended  outward,  upward,  and  backward  to  the 
lumbar  muscles.  While  separating  the  tumor  from  the  abdomi- 
nal wall  on  the  right  of  the  wound,  a  quantity  of  fcrtid  i)U8  and 
a  faecal  concretion  came  into  view. 

The  abscess  cavity  was  cleaned  out,  and  the  appendix. 


412 


SULLIVAN:   CLINICAL  OBSERVATIONS  ON  APPENDICITIS.         [N.  Y.  Mhd.  Jouh., 


curved  like  the  letter  S,  was  found  at  the  bottom  completely 
invested  with  a  false  membrane  of  organized  lymph,  and  pre- 
senting an  opening  at  its  extremity  whence  the  fascal  concretion 
escaped.  The  false  membrane  was  peeled  off,  and  the  appendix 
ligated  near  the  cajcum  and  removed.  The  stump  was  cauter- 
ized, the  wound  partially  closed,  the  abscess  cavity  packed  with 
iodoform  gauze,  and  the  usual  dressings  applied. 

On  the  following  day  the  patient  was  bright  and  comforta- 
ble. His  pulse  and  temperature  were  nearly  normal,  and  con- 
tinued so  throughout  his  convalescence.  The  wound  was  dressed 
on  the  third  day,  and  every  second  or  third  day  thereafter.  On 
the  tenth  day  the  ligature  which  was  placed  on  the  appendix 
came  away,  and  the  wound  was  closing  rapidly  by  healthy 
granulations.  About  this  time  the  patient  stated  that  he  could 
occasionally  feel  air  or  gas  escaping  from  the  wound.  An  ex- 
amination revealed  a  small  opening  in  the  stump  of  the  appen- 
dix, through  which  a  probe  passed  into  the  caput  coli.  This 
proved  to  be  the  appendicular  canal  through  which  the  intes- 
tinal gases  were  escaping.  Then  the  impossibility  of  effecting 
a  permanent  closure  of  the  appendix  with  any  kind  of  a 
ligature  was  forcibly  impressed  upon  my  mind.  As  it  is  im- 
possible to  make  mucous  surfaces  grow  together  by  holding 
them  in  apposition,  it  is  but  reasonable  to  expect  that  when 
the  portion  of  th&^edicle  outside  the  ligature  sloughed  away, 
or  the  ligature'  became  absorbed,  the  lumen  of  the  remaining 
portion  would  still  be  patent.  This  subject  will  presently  be 
referred  to  again.  An  effort  was  made  to  destroy  the  mucous 
membrane  in  the  pedicle  by  cauterizing  it  with  nitrate  of  silver, 
but  the  result  was  not  very  satisfactory  ;  the  canal  remained  open 
for  a  period  of  nine  weeks  after  the  operation,  when  it  became 
obliterated  by  the  surrounding  granulations,  and  the  wound 
finally  closed  a  week  later. 

During  the  interval  from  the  third  to  the  seventh  week  after 
the  operation  small  quantities  of  fsecal  matter  passed  out  of  the 
appendicular  orifice  at  various  times,  as  it  did  in  the  preceding 
case,  showing  that  it  is  quite  a  common  occurrence  for  faeces 
to  pass  from  the  colon  into  the  appendix.  I  will  here  present 
for  your  inspection  the  last  patient  spoken  of  and  his  appendix, 
with  the  fajcal  concretion  that  caused  its  perforation.  You  will 
observe  that  the  appendix  is  about  four  inches  and  a  half  in 
length,  and  presents  a  ragged  perforation  at  its  extremity.  The 
faecal  concretion  is  half  an  inch  long  and  a  quarter  of  an  inch 
in  diameter.  This  case  represents  a  not  uncommon  feature  of 
appendicular  inflammations,  in  which  the  abscess  develops  at 
a  considerable  distance  from  the  normal  site  of  the  appendix, 
and  which  in  itself  would  be  misleading  if  we  did  not  bear  in 
mind  the  great  variety  of  irregularities  connected  with  this  dis- 
ease. When  I  first  saw  this  patient  he  stated  that  the  pain  was 
in  his  right  side,  and  the  tumor  was  virtually  in  the  right  loin, 
with  little  or  no  tenderness  over  the  abdomen  or  atMcBurney's 
point. 

The  appendix  was  found  adherent  to  the  lateral  abdominal 
wall  with  its  extremity  upward.  The  plastic  inflammation  which 
accompanied  and  followed  its  perforation  protected  the  perito- 
neal cavity  from  septic  invasion  and  limited  the  suppuration  to 
a  small  portion  of  the  parietal  peritonaeum. 

It  may  be  considered  imprudence  on  my  part  to  advise 
an  operation  on  a  patient  who  had  not  yet  received  any  treat- 
ment whatsoever,  who  was  sufficiently  well  to  walk  to  my 
office,  and  whose  symptoms  were  apparently  so  mild  in  char- 
acter. Why  not  try  milder  treatment  first  and  watch  its 
progress  ?  The  inflammation  and  swelling  may  subside  and 
the  dangers  of  an  operation  be  avoided.  I  admit  that  up  to 
the  last  few  years  such  a  course  would  seem  proper  for  me 


to  pursue,  but,  in  the  light  of  our  present  knowledge,  I  would 
feel  guilty  of  neglect  of  duty  if  by  delay  I  failed  to  give  the 
patient  the  benefit  of  my  best  judgment  in  the  case.  Con- 
sidering the  history,  symptoms,  and  palpable  signs,  I  be- 
lieve there  was  more  danger  in  delay  than  in  a  prompt  and 
radical  operation.  One  of  the  possible  results  of  delay  in 
this  class  of  cases  is  illustrated  by  the  following  case  : 

Case  V. — On  January  22d  of  this  year  I  was  called  by  Dr. 
Alexander  Koch  to  see  Mrs.  S.,  aged  thirty-seven  years,  who 
was  then  in  the  fourth  month  of  pregnancy  and  had  enjoyed 
good  health  up  to  about  two  months  before.  At  that  time  she 
began  to  have  pain  in  the  right  iliac  fossa  and  above  the  crest 
of  the  ilium,  which  was  accompanied  by  considerable  nauseaand 
occasionally  vomiting.  The  pain  was  quite  constant  but  not 
severe  in  character,  and,  as  she  presumed  it  was  due  to  her  preg- 
nant condition,  she  paid  no  attention  to  it,  but  continued  to  per- 
form her  household  duties  for  the  following  five  weeks.  During 
that  time  her  bowels  were  very  nmch  constipated  and  required 
large  doses  of  cathartic  medicines  to  produce  any  movement,  and 
every  movement  was  attended  with  a  feeling  of  weakness,  nau- 
sea, and  sometimes  vomiting. 

Since  the  second  week  of  the  attack  she  could  lie  on  her  right 
side  with  comparative  comfort,  but  turning  over  on  her  left  side 
would  cause  a  dragging,  painful  sensation  across  her  abdomen 
which  compelled  her  to  leave  that  position.  This  is  a  symptom 
which  I  have  frequently  observed  in  cases  of  appendicitis,  but, 
so  far  as  I  know,  has  not  yet  been  mentioned  by  any  other  writer 
on  the  subject.  It  is  probably  produced  by  the  gravitation  of 
the  intestines  from  the  right  toward  the  left  side,  thereby  mak- 
ing traction  at  the  point  of  inflammation,  thus  producing  the 
symptom  alluded  to.  About  the  fifth  week  she  noticed  a  swell- 
ing in  the  right  iliac  fossa  which  gradually  increased  and  ex- 
tended backward  along  the  crest  of  the  ilium.  Shortly  after  this 
a  lameness  in  her  right  hip,  as  she  termed  it,  supervened,  and 
she  was  obliged  to  keep  her  right  thigh  partially  flexed  and  lean 
forward  while  standing  or  walking.  She  allowed  a  period  of 
seven  weeks  to  elapse  before  calling  the  attention  of  a  physician 
to  her  trouble,  and  then  only  permitted  him  to  prescribe  for  her 
without  making  an  examination.  Two  days  before  calling  me 
Dr.  Koch  examined  her  and  found  a  swelling  which  I  will  pres- 
ently describe,  and  informed  her  husband  that  her  aifliction  was 
of  a  serious  nature. 

On  my  arrival  I  found  her  sitting  up  and  noticed  that  she 
presented  a  sallow,  muddy  complexion,  and  that  in  walking  to 
the  bed  she  leaned  forward  and  limped  as  if  the  right  limb  were 
shorter  than  the  left.  Dr.  Koch  informed  me  that  her  tempera- 
ture was  98°  in  the  morning  and  100-4°  in  the  afternoon.  Pulse 
was  104,  soft  and  weak.  An  examination  revealed  the  presence 
of  a  tumor  in  the  right  side  occupying  the  space  between  the 
lower  border  of  the  ribs  and  the  crest  of  the  ilium,  extending 
downward  and  forward  to  its  anterior  superior  spine  and  to  the 
outer  margin  of  the  right  rectus  abdominis  and  backward  to  the 
quadratus  lumborum  muscle.  The  tissues  covering  this  tumor 
were  very  tense  and  light  pressure  elicited  acute  pain.  Guided 
as  much  by  exclusion  as  by  direct  information,  I  ventured  the 
opinion  that  this  tumor  was  a  paratyphlitic  abscess,  but,  as  I  was 
not  positive  of  my  diagnosis,  I  requested  Dr.  J.  D.  Rushmore  to 
see  the  case  with  us. 

Dr.  Rushmore  responded  promptly,  and,  after  an  examination 
of  the  case,  stated  that  he  was  inclined  to  treat  the  disease  as  an 
abscess,  but  indisposed  to  express  an  opinion  in  regard  to  its 
astiology. 

An  exploring  needle  was  inserted  just  above  the  crest  of  the 
ilium  about  an  inch  in  front  of  the  quadratus  lumborum  muscle, 


April  15,  1893.J  SULLIVAN:    CLINICAL  OBSERVATIONS  ON  APPENDICITIS. 


413 


and,  as  the  appearance  of  pus  confirmed  the  diagnosis,  a  scalpel 
was  introduced  along  the  needle  into  the  abscess  cavity  and  a 
quart  or  more  of  foetid  pus  evacuated. 

The  opening  was  enlarged  longitudinally  to  about  an  inch 
and  a  half  in  length,  and  subsequently  the  abscess  cavity  was 
irrigated  with  a  warm  solution  of  chloride  of  sodium,  a  drachm 
to  the  pint,  and  a  drainage-tube  left  in  the  wound.  The  next 
day  the  patient  was  bright  and  comfortable  and  very  grateful 
for  the  relief  which  she  experienced.  The  abscess  cavity  was 
then  curetted  and  considerable  necrotic  tissue  removed.  On 
introducing  the  forefinger  through  the  wound,  several  pockets 
were  found  posteriorily,  but  the  greater  portion  of  the  abscess 
cavity  was  in  the  right  iliac  fossa,  between  the  caput  coli  and 
the  ilium,  and  its  inner  wall  was  felt  extending  upward  along 
the  ascending  colon.  The  cavity  was  daily  irrigated  and  loosely 
packed  with  iodoform  gauze,  and  it  soon  presented  a  healthy 
granulating  surface.  The  general  health  of  the  patient  im- 
proved rapidly  and  her  complexion  became  clear  and  ruddy. 
The  posterior  portion  of  the  abscess  cavity  closed  within  a 
week,  that  portion  in  the  iliac  fossa  rapidly  filled  up  with 
healthy  granulations,  and  the  wound  healed  by  the  end  of  the 
third  week.  Although  it  is  only  twenty-three  days  since  the 
opening  was  made,  the  patient,  is  restored  to  the  enjoyment  of 
good  health  in  every  respect. 

While  we  have  not  been  able  to  demonstrate  that  this 
is  a  case  of  appendicitis,  I  have  no  doubt  now  about  the 
propriety  of  reporting  it  as  a  paratyphlitic  abscess  with  an 
aetiology  quite  similar  to  the  preceding  case.  It  is  a  good 
illustration  of  how  generous  and  conservative  Dame  Nature 
can  act  in  constructing  an  abscess  wall  which  not  only  pre- 
served the  life  of  this  woman,  but  that  of  the  foetus  in  utero. 
A  description  of  the  various  forms  of  appendicitis  would  be 
incomplete  if  that  variety  in  which  septic  peritonitis  rapidly 
follows  the  onset  of  the  attack  were  omitted. 

Within  the  last  year  I  have  witnessed  two  cases  of  that 
class,  but  am  not  in  possession  of  the  history  or  symptoms 
of  either  case,  and  only  know  that  the  abdomen  was  opened 
within  a  few  days  after  the  prominent  symptoms  were 
recognized,  and  that  a  large  quantity  of  pus  was  found  in 
the  general  peritoneal  cavity  in  each  case. 

The  vermiform  appendix  was  diseased  in  both  cases, 
but  whether  the  septic  peritonitis  resulted  directly  from  a 
perforation  of  the  appendix  or  the  rupture  of  a  perityphlitic 
or  paratyphlitic  abscess  1  am  unable  to  say.  I  simply 
mention  these  facts  as  an  illustration  of  the  insidious 
character  of  this  most  serious  form  of  the  diease. 

As  this  paper  has  already  exceeded  the  limits  of  my 
original  intentions,  I  will  refrain  from  any  further  remarks 
on  the  medical  treatment  of  this  multiform  disease  and  re- 
fer to  only  one  point  in  the  technique  of  the  operation  of 
appendicectomy,  if  I  may  be  permitted  to  apply  the  term, 
which  Dr.  Rushmore  suggested  for  the  operation  at  one  of 
our  meetings  in  1891. 

It  is  worthy  of  reflection  that  the  recovery  in  Cases  III 
and  IV,  reported  in  this  paper,  was  very  much  delayed  by 
the  failure  of  the  ligatures  to  effect  a  permanent  occlusion 
of  the  canal  in  the  stump  of  the  appendix.  This  is  ex- 
plained by  considering  the  anatomy  of  the  tissues  entering 
into  the  structure  of  the  appendix  and  its  pathological  sur- 
roundings at  the  time  of  the  operation. 

We  know  that  a  ligatured  stump  will  not  become  en- 


capsulated in  an  open  wound  attended  with  more  or  less 
suppuration ;  consequently  the  ligature  must  either  become 
absorbed  or  slough  away,  and,  as  the  mucous  surfaces  of 
the  canal  can  not  unite,  its  closure  can  only  be  effected  by 
the  slow  and  uncertain  process  of  granulation  from  and 
about  its  extremity.  For  these  reasons  I  do  not  deem  it 
good  surgery  to  apply  a  ligature  of  any  kind  to  the  vermi- 
form appendix,  although  it  has  been  extensively  practiced 
by  the  eminent  surgeons  who  have  been  pioneers  in  this 
special  line  of  surgical  work,  and  is  described  as  the  proper 
treatment  in  a  recent  publication — An  American  Text-book- 
of  Surgery.  I  consider  it  better  practice  to  operate  in 
accordance  with  the  method  adopted  by  Dr.  Robert  T. 
Morris  and  described  by  him  in  the  New  York  Medical 
Journal  of  October  15,  1892,  and  in  the  Medical  Record  of 
January  14,  1893. 

The  points  which  I  desire  to  emphasize  in  this  opera- 
tion may  be  briefly  outlined  as  follows : 

Cut  off  the  appendix  quite  close  to  the  caecum,  ligate 
or  suture  the  protruding  collar  of  mucous  membrane,  invert 
the  remaining  portion  of  the  stump  so  that  the  peritoneal 
surfaces  come  together,  scarify  the  peritoneal  margins  to 
secure  their  firm  adhesion,  and  close  the  opening  with  cat- 
gut, using  the  Lembert  suture. 

By  this  method,  where  the  tissues  are  sound  and  it  is 
possible  to  pursue  this  plan,  a  much  more  rapid  closure  of 
the  wound  may  be  obtained,  and  there  will  be  no  diverticu- 
lum remaining  to  invite  further  trouble. 


The  Eleventh  International  Medical  Congress  and  the  Steamship 
Companies, — The  American  National  Committee  make.s  the  following 
announcement : 

"  The  North  German  Lloyd,  2  Bowling  Green,  N.  Y.,  offers  a  reduc- 
tion of  twenty-five  per  cent,  to  the  medical  men  going  to  and  coming 
from  the  Eleventh  International  Medical  Congress,  on  the  steamer  Werra,, 
which  is  to  sail  from  New  York  on  August  5th  and  September  9th,  and 
on  the  steamer  Fulda,  on  August  19th.  Both  these  steamers  sail  ta 
Genoa.  The  same  reduction  will  be  made  for  the  return  trips  in  Octo- 
ber and  November,  on  the  same  steamers,  and  for  the  company's  Satur- 
day, off  Bremen  (Sunday,  off  Southampton),  steamers. 

"  The  Hamburg-American  Packet  Co.,  37  Broadway,  N.  Y.,  125  La 
Salle  Street,  Chicago,  offers  a  reduction  of  twenty-five  per  cent.,  both 
out  and  return,  for  all  its  steamers  during  the  year  1893. 

"  The  Compagnie  G6nerale  Transatlantique,  3  Bowling  Green,  N.  Y.,. 
offers  the  rates  which  are  allowed  French  officers — that  is,  $63.50  for 
an  $80  accommodation  and  $91.50  for  a  $120  accommodation. 

"  Five  other  lines  decline  to  make  any  satisfactory  arrangements." 

The  Medico-legal  Society. — The  programme  for  the  meeting  of 
Wednesday  evening,  the  ISth  inst.,  in  Brooklyn,  included  a  paper  enti- 
tled A  Case  of  Traumatic  Psychosis  foUowmg  Fractured  Skull — the 
Medico-legal  Aspects,  and  a  discussion  of  the  question  How  can  we  Pre- 
vent Cholera  ?  to  be  opened  by  Dr.  George  M.  Sternberg,  of  the  army. 

The  New  York  Post-graduate  Clinical  Society. — The  programme 
for  the  meeting  of  Saturday  evening,  the  8th  inst.,  included  a  paper  by 
Dr.  H.  H.  Whitehouse  on  The  Association  of  Several  Skin  Affections 
ujjon  the  Same  Individual — Points  in  Diagnosis  and  Treatment ;  and  a 
report  of  a  case  of  haematosalpinx,  by  Dr.  A.  C.  Stanard. 

The  New  York  Neurological  Society. — At  the  meeting  of  April  4th 
officers  for  the  ensuing  year  were  re-elected  as  follows :  President,  Dr. 
M.  Allen  Starr ;  vice-president,  Dr.  Bernard  Sachs ;  secretary,  Dr.  E.  D. 
Fisher. 

The  Medical  Society  of  London.— The  Britusk  Medical  Journal  an- 
nounces the  election  of  Dr.  Robert  Barnes  to  honorary  membership. 


414 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jodb., 


THB 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

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


NEW  YORK,  SATURDAY,  APRIL  15,  1893. 


SO-CALLED  HYPODERMIC  TRANSFUSION. 

Professor  Luton,  director  of  the  Reims  School  of  Medi- 
cine, writes  in  the  Gazette  des  hopitaux  for  February  2d  con- 
cerning the  virtues  of  a  certain  artificial  serum  devised  by  him, 
usually  composed  of  a  hundred  parts  of  distilled  water,  five  of 
crystallized  sodium  phosphate,  and  ten  of  sodium  sulphate, 
boiled  together  and  filtered.  He  insists  that  the  sodium  phos- 
phate, the  sine  qua  non  of  any  artificial  serum,  shall  be  the  sal 
tnirahile  [perlatum]  of  the  old  chemists,  having  the  formula 
(2N"aO  +  HO)P06-t-24HO  [according,  apparently,  to  the  old 
notation].  The  sulphate  is  added  chiefly  to  bring  the  solution 
to  the  desired  density.  The  subcutaneous  use  of  this  solution 
is  termed,  quite  irrationally,  "hypodermic  transfusion,"  or,  as 
a  paragraphist  contributing  to  the  Revue  generale  de  medecine, 
de  chirurgie  et  d'' obstetrique  puts  it,  "nervous  transfusion." 
The  excuse  for  calling  this  procedure  transfusion  is  found  in 
the  alleged  similarity  of  the  results  to  those  of  transfusion  of 
blood.  Five  grammes  (about  a  drachm  and  a  quarter)  are  to 
be  injected  at  once,  and  only  once  a  month  is  it  necessary  to 
administer  an  injection. 

The  immediate  effects  of  such  an  injection  of  the  artificial 
serum  are  said  not  to  be  pronounced,  especially  if  the  liquid  is 
warmed  a  little  or  mixed  with  glycerin.  As  the  result  of  its 
absorption,  however,  there  is  a  general  feeling  of  warmth,  to- 
gether with  moderate  functional  excitement.  Sometimes  there 
is  a  little  headache,  but  at  the  same  time  the  subject  is  con- 
scious of  a  heightened  capacity  for  work  and  thought.  The 
first  moments  of  excitement  passed,  the  consecutive  effects  de- 
'Pelop,  according  to  the  nature  of  the  case,  and  persist  for  a 
number  of  days,  to  the  patient's  great  advantage.  It  is  not  to 
any  special  disease  that  the  remedy  is  applicable,  but  rather  as 
an  auxiliary  in  a  multitude  of  morbid  or  semi-morbid  condi- 
tions: organic  weaknesses,  senile  enfeeblement,  tabetic  affec- 
tions, retarded  development  in  infancy,  athrepsia,  chronic  dys- 
pepsia, etc.  A  few  representative  cases  are  cited  in  brief,  and 
the  author  declares  that  he  is  using  the  injections  constantly  in 
his  hosj)ital  and  private  practice  with  the  happiest  results.  To 
many  an  enfeebled  person,  to  many  an  old  man  plunged  into 
senile  debility,  he  says,  their  use  has  brought  back  vigor  and  a 
renewal  of  life. 

There  are,  however,  some  special  states  in  which  the  use  of 
the  injections  has  proved  of  decided  advantage.  Of  these,  chol- 
era is  an  example.  Moreover,  the  serum  is  a  useful  vehicle  for 
the  subcutaneous  administration  of  various  medicaments,  espe- 
cially acetate  of  copper,  which  the  author  uses  largely  in  tuber- 
culous affections,  and  almost  exclusively  in  the  form  of  a  solu- 


tion of  one  part  of  the  copper  salt  in  five  parts  of  the  artificial 
serum. 

The  similarity  of  the  effects  alleged  for  the  Brown-S6quard 
organic  liquids  and  those  of  this  artificial  serum  is  set  forth,  and 
the  advantages  of  the  latter  are  insisted  on;  the  greater  facility 
of  its  production  and  the  absence  of  danger  in  its  employment. 
Finally,  the  author  says :  A  monthly  injection  of  five  grammes 
[about  a  drachm  and  a  (juarter]  of  the  artificial  serum  of  the 
composition  mentioned  may  maintain  a  feeble  invalid  in  a  state 
of  nervous  energy  suflScient  to  enable  him  to  earn  his  living. 


(EDEMA  LABIORUM  PUERPERALE. 

Pkofkssoe  Schauta,  of  the  University  of  Vienna,  recently 
delivered  a  clinical  lecture  concerning  that  complication  of  the 
puerperal  state  which  is  designated  by  him  cedema  labiornm 
eclampsia  consequente.  The  lecture  is  reported  in  the  Medical 
Press  and  Circular  for  January  4th.  The  patient  shown  was  a 
primipara  of  twenty-six  years,  who  had  had  extensive  oedema 
lasting  for  about  half  of  the  eighth  month  of  pregnancy  and 
who  had  had  five  eclamptic  seizures,  all  of  them  post  partum. 
She  had  been  treated  by  free  puncturing  of  the  labia  during  the 
first  four  days  that  she  was  under  observation  at  the  hospital. 

Schauta's  experience  is  that  the  irritation  caused  by  the 
slow  escape  of  the  liquid  and  its  constant  flow  over  the  geni- 
tals are  all  that  is  necessary  to  induce  labor  in  a  very  short 
time.  In  both  hospital  and  private  practice  he  has  met  the  in- 
dication for  premature  childbirth  in  this  way,  if  cedema  was 
present.  He  has  seen  no  case  in  which  any  other  procedure 
was  required.  If  there  is  no  desire  to  bring  on  early  labor  the 
puncturing  of  the  cedematous  parts  must  not  be  resorted  to, 
but  the  reduction  of  the  swelling  must  be  attempted  by  means 
of  warm  baths  and  compresses. 

In  this  case  of  Schauta's  an  examination  of  the  urine  had 
shown  it  to  be  albuminous,  with  a  large  proportion  of  granular 
casts.  This  condition  persisted  after  the  birth  of  the  child, 
which  occurred  on  the  second  day  after  the  first  puncturing 
was  done.  It  began  to  subside  on  the  fifth  day  after  the 
woman's  admission,  and  on  the  fifteenth  neither  albumin  nor 
casts  were  found.  The  patient  appeared  in  good  health,  but 
was  not  allowed  to  leave  the  hospital  until  a  longer  treatment 
by  baths  had  been  employed  and  all  trace  of  oedema  had  disap- 
peared. 

Regarding  the  aetiology  of  post-partum  eclampsia,  Schauta 
has  nothing  new  to  offer.  The  question,  he  says,  is  still  shroud- 
ed in  much  doubt.  According  to  him,  it  is  not  sufiicient  to  say 
that  in  all  cases  that  have  been  fatal  renal  lesions  have  been 
present,  for  the  reason  that  these  lesions  may  be  secondary  to 
some  complication  of  pregnancy  which,  especially  in  primiparse, 
may  induce  the  renal  disease.  In  this  case  Schauta  followed 
out  the  hint  given  by  Blanc,  of  Paris,  that  puerperal  eclampsia 
was  due  to  a  micro-organism,  and  caused  a  careful  examination 
to  be  made  of  the  blood  and  other  fluids,  but  the  results  were 
of  a  negative  character.  The  fact  that  Gerbes,  of  Halle,  has 
been  able  to  isolate  a  micro-organism  from  the  blood  of  an 


April  15,  1893.] 


MINOR  PARAGRAPHS. 


415 


eclamptic  patient,  and  from  cultures  and  inoculations  of  lower 
animals  to  induce  in  the  latter  convulsions  resembling  those  of 
puerperal  eclampsia,  is  a  strong  bit  of  testimony,  but  without 
confirmation  can  not  be  received  as  proof  that  the  micro-organ- 
ism is  the  sole  cause.  The  convulsions  observed  in  these  ani- 
mals were  similar  to  those  that  affect  many  quadrupeds  from  a 
variety  of  causes,  and  may  not  have  been  solely  due  to  the  in- 
oculated micro-organisms. 


M.INOR    PA  RA  GRA  PES. 

THE  TREATMENT  OF  INFANTILE  CONVULSIONS. 

The  Deutsche  Medizinal-Zeitung  for  March  13th  gives  an 
Abstract  of  an  article  by  Dr.  Descroizilles,  published  in  the 
Archivio  italiano  di  pediatria,  the  substance  of  which  is  as 
follows :  The  child  should  be  placed  in  a  cool,  airy  chamber, 
And  its  clothing  removed  at  once.  The  physician  should  then 
satisfy  himself  as  to  the  existence  of  visceral  irritation,  as  from 
intestinal  worms,  and  lay  the  child  on  a  rather  hard  bed.  Cold 
frictions  may  then  be  applied,  or  the  child  may  be  given  an 
ordinary  tepid  bath  or  one  with  mustard  added.  The  frictions 
may  be  applied  to  the  whole  body.  In  addition,  cold  douches 
may  be  applied  to  the  head  or  a  protracted  forcible  stream  of 
water  directed  upon  the  fontanelle.  In  convulsions  occurring 
■during  a  feverish  attack  the  cold  bath  can  not  be  highly  recom- 
mended. If  intestinal  irritation  is  present,  vomiting  should  be 
induced  by  tickling  the  uvula  or  by  means  of  an  emetic;  if 
there  is  tympanites,  a  laxative  should  be  given,  such  as  calomel 
or  castor  oil ;  in  case  of  worms,  an  anthelminthic  should  be 
given.  If  there  is  cerebral  congestion,  a  few  leeches  may  be 
applied  over  the  mastoid  process,  sometimes  also  to  the  lower 
part  of  the  thigh  ;  even  venesection  may  be  employed  in  suck- 
lings of  a  strong  constitution.  At  the  same  time  warm,  stimu- 
lating applications  should  be  made  to  the  lower  limbs  or' com- 
pression of  the  carotid  resorted  to.  Chloroform  given  by  in- 
halation is  only  temporary  in  its  action,  and  repeated  recourse 
to  it  is  dangerous.  If  the  tendency  to  convulsions  ])ersists,  zinc 
■oxide  and  hyoscyamus  may  be  given,  but  better  results  follow 
the  use  of  sodium  bromide  with  from  seven  to  fifteen  grains  of 
chloral  hydrate  in  young  children,  or  from  a  drachm  to  a 
drachm  and  a  half  in  those  verging  on  puberty.  These  large 
doses  of  chloral  are  to  be  used  with  the  greatest  circumspec- 
tion. When  the  attack  is  over,  the  child  must  be  kept  abso- 
lutely quiet  for  a  considerable  length  of  time,  tonics  should  be 
■employed,  and  the  diet  should  be  strictly  regulated.  From  time 
to  time  small  doses  of  chloral  hydrate,  valerian,  and  zinc  oxide 
are  to  be  given. 


THE  NORTH  CAROLINA  STATE  BOARD  OF  HEALTH. 

The  March  number  of  the  Bulletin  of  this  important  organi- 
zation reports  that  a  new  bill  has  been  passed  by  the  Legisla- 
ture which  will  materially  alfect  the  future  operations  of  the 
board.  The  sanitary  functions  and  powers  of  the  board  will 
probably  be  amplified  in  order  that  it  may  protect  the  State 
against  cholera,  but  the  hold  of  the  State  Medical  Society  ap- 
pears to  have  been  weakened.  For  many  years  that  society  has 
been  represented  by  six  of  the  nine  members,  and  these  six 
were  each  elected  to  hold  office  for  six  years.  The  Governor 
had  the  right  to  appoint  three  commissioners,  whose  tenure  of 
office  was  two  yeavs.  Hereafter,  if  the  recently  proposed  act 
becomes  operative,  the  medical  society  will  be  entitled  to  only 
four  members  of  the  board,  while  the  Governor  will  nominate 
five,  and  all  members,  however  constituted,  will  serve  for  two 


years  only.  The  Bulletin  offers  no  comment  on  the  probable 
future  influence  of  tliis  kind  of  legislation,  but  it  quietly  re- 
marks that  "  in  other  respects  it  was  passed  essentially  as  intro- 
duced, and  we  feel  that  the  cause  of  preventive  medicine  in 
North  Carolina  has  been  greatly  strengthened  and  advanced." 
The  query  naturally  arises  in  medical  minds,  how  any  great 
advance  can  follow  the  transfer  of  the  management  of  the 
board  away  from  the  State  society  to  the  best  Governor  the 
State  can  possibly  put  into  office — and  the  bert  men  do  not 
always  get  there.  If  the  law  has,  in  fact,  been  mischievously 
conceived,  the  medical  profession  will  probably  be  strong  enough 
to  effect  its  amendment  at  the  next  session  of  the  Legislatfj^re. 
Every  registered  physician  of  the  State  is  to  be  supplied  with  a 
copy  of  the  new  law. 

PARATHYREOID  GLANDS  IN  UA"^.  -.g^ 

At  a  meeting  of  the  Paris  Medical  Society  of  the  Hospit^^ 
held  on  March  17th,  reported  in  the  Union  medicale  for  March 
21st,  Dr.  Chantemesse  and  Dr.  Marie  described  some  little 
glandular  organs  found  in  the  neighborhood  of  the  thyreoid 
gland  in  man,  and  confirmed  Sandstrom's  description  of  para- 
thyreoid  glands.  They  form  two  groups,  one  of  which,  the 
more  important,  is  situated  at  the  level  of  the  point  of  penetra- 
tion of  the  inferior  thyreoid  artery.  This  group  consists  of 
two  or  three  glandules,  none  of  them  larger  than  a  lentil,  round, 
ovoid,  or  kidney-shaped.  The  other  group,  generally  less  volu- 
minous, is  at  the  level  of  the  point  of  penetration  of  the  supe- 
rior thyreoid  artery.  These  little  glands  are  free  or  surrounded 
with  connective  tissue  and  provided  with  a  minute  vascular 
pedicle.  Their  structure  is  very  different  from  that  of  lym- 
phatic ganglia.  They  are  divided  into  lobules  by  a  connective- 
tissue  stroma,  and  are  traversed  by  numerous  capillary  vessels. 
The  lobules  are  formed  of  little  cells  sometimes  disposed  irregu- 
larly, sometimes  arranged  in  a  circle,  the  periphery  of  which  is 
bordered  with  little  cubical  cells  and  the  center  filled  with 
irregularly  disposed  elements.  Occasionally  true  tubes  of  epi- 
thelial cells  may  be  made  out,  and  at  the  periphery  of  the 
glands  there  are  often  to  be  seen  little  rounded  masses,  the 
central  part  of  which  contains  a  material  having  a  colloid  ap- 
pearance. Stress  was  laid  on  the  fact  that  these  glandules  were 
situated  externally  to  the  capsule  of  the  thyreoid  gland,  and  it 
was  urged  that  they  be  left  in  cases  of  thyreoidectomy,  for 
they  were  capable  of  a  compensatory  function  analogous  to  that 
of  the  pituitary  gland. 


VESICAL  TENESMUS  CAUSED  BY  FARADIZATION. 

In  the  March  number  of  the  Annales  de  la  Polielinique  de 
Bordeaux  Dr.  G.  Liaras  relates  the  case  of  a  boy,  seven  years 
old,  who,  having  been  brought  to  Dr.  Loumean's  clinic  on  ac- 
count of  "  essential "  incontinence  of  urine,  was  subjected  to 
treatment  by  what  the  author  calls  Guyon's  method  of  faradiza- 
tion. An  olive-tipped  electrode,  with  the  bulb  as  large  as  a 
No.  10  sound,  was  inserted  into  the  urethra  as  far  as  the  mem- 
branous portion.  This  was  connected  with  the  negative  pole. 
The  positive  electrode  was  applied  to  the  hypogastrium,  and  a 
feeble  current  was  allowed  to  pass  for  two  minutes.  After  the 
second  application,  four  days  later,  the  patient  was  unable  to 
urinate  for  four  hours.  The  retention  was  painful  and  the 
pains  extended  into  the  penis.  The  trouble  yielded  to  very  hot 
poultices  applied  to  the  belly.  Urination  and  defecation  then 
took  place  simultaneously,  and  the  remark  is  made  that  the 
current  had  caused  both  vesical  and  rectal  tenesmus.  Seven 
subsequent  applications,  each  of  three  minutes'  duration,  were 
well  borne,  and  at  the  end  of  two  months  after  the  last  one 
there  had  been  no  recurrence  of  incontinence. 


416 


MINOR  PARAORAPHS. 


[N.  Y.  Med.  Jodh., 


ALLEGED  REMUNERATION  FOR  A  PUBLIC  MEDICAL 
SERVICE. 

A  pnYsioiAN  livin;,'  in  Maison-Laffitte,  France,  having,  at 
the  request  of  the  police,  viewed  the  body  of  a  foundling  and 
made  a  report  in  writing  to  the  proper  official,  received  as  his 
remuneration  an  order  for  three  francs  payable  only  on  his 
presenting  himself  in  person  at  some  time  within  specified 
hours  at  an  office  in  Saint-Germain.  He  spent  three  hours  in 
making  the  journey  to  Saint-Germain  and  back,  besides  1  fr. 
40  for  omnibus  fare.  Estimating  the  value  of  his  lost  time  at 
Y  fr.  50,  he  counted  his  entire  outlay  as  8  fr.  90.  Hardly  had 
he  reached  home  when  he  received  a  communication  from  the 
disbursing  office  informing  him  that  an  irregularity  had  been 
discovered  in  the  money  order,  which  was  inclosed,  and  asking 
him  to  return  the  three  franca  that  had  been  paid  to  him,  send 
the  order  to  Versailles  for  correction,  and  again  present  it  for 
payment.  The  Province  medicale,  which  tells  the  story,  says 
that  the  doctor  is  tranquilly  staying  at  home  awaiting  arrest, 
and  adds  that  if  that  takes  place  the  farce  will  be  complete. 


BROWN-SEQUARD'S   LIQUID  AS  A  REMEDY  FOR  CHOREA. 

At  a  recent  meeting  of  the  National  Society  of  Medicine  of 
Lyons  a  paper  was  read  on  the  treatment  of  chorea  and  of  in- 
continence of  urine  with  the  Brown-S6quard  liquid.  In  the 
discussion,  reported  in  Lyon  medical  for  March  2r)th,  Dr.  Teis- 
sier declared  that  he  had  observed  convincing  instances  of  the 
happy  effects  of  injections  of  spermine  in  choreics.  He  cited 
the  case  of  a  young  girl  whose  chorea  had  lasted  for  seven 
months,  but  was  cured  by  three  injections.  He  then  went  on 
to  say  that  he  had  used  the  Brown-S6quard  injections  five  hun- 
dred times ;  that  it  was  important  to  use  a  good  preparation, 
such  as  that  made  at  the  College  of  France,  which  was  not  pro- 
ductive of  pain,  although  it  was  very  active;  that  all  antiseptic 
precautions  were  necessary ;  and,  above  all,  that  large  doses 
should  be  reached.  He  added  the  startling  statement  that 
Brown-S6quard  estimated  that  one  might  inject  a  tenth  of  the 
weight  of  the  body  without  danger;  at  least,  that  is  what  the 
report  makes  him  appear  to  have  said,  but  it  is  probably  a 
printer's  error. 

CHOLERA  AND  FRUIT. 

The  Imperial  Health  Office  at  Berlin  has  issued  a  notice  to 
the  effect  that  a  bacteriological  research  has  been  made  to  show 
what  dangers  of  cholera,  if  any,  inhere  in  the  importation  of 
fruits  from  the  Mediterranean.  It  has  been  demonstrated  that 
the  cholera  spirillum  is  destroyed  in  a  few  hours  after  being  in 
contact  with  the  cut  surface  of  a  lemon  or  that  of  an  orange. 
The  spirilla  retain  their  activity  for  a  longer  time,  however,  on 
the  uninjured  exterior  of  these  fruits,  but  even  there  they  do 
not  survive  twenty-four  hours.  This  shortened  vitality  of  the 
micro-organisms  is  believed  to  be  due  to  the  effect  of  the 
high  acidity  proper  to  the  fruits  named.  There  will  be  no  re- 
strictions placed  upon  the  sale  of  those  fruits  even  if  they  are 
brought  from  places  where  cholera  has  been  prevalent.  There 
is  no  authentic  account  of  a  single  case  of  cholera  having  been 
conveyed  by  means  of  either  oranges  or  lemons. 


THE  USE  OF  THE  BROMIDES  IN  LARGE  DOSES. 

In  the  March  number  of  the  Revue  de  medecine  there  is  an 
article  by  Dr.  F6r6,  of  the  Bic^tre,  which  concludes  with  en- 
joining the  utmost  watchfulness  of  patients  who  are  under 
treatment  by  means  of  the  bromides  in  large  doses.  They 
should  be  examined  frequently  in  a  state  of  nudity,  both  to 


ascertain  if  they  have  any  cutaneous  lesions  and  to  weigh  them. 
When  the  skin  shows  the  effects  of  bromine,  or  when  there  is  a 
loss  of  weight  that  is  not  of  the  most  fleeting  character,  the 
state  of  the  digestive  tract  should  be  watched  over  with  the 
greatest  care,  especially  if  the  patient  is  physically  or  morally 
depressed,  and  most  of  all  if  the  temperature  is  notably  low. 
There  must  now  be  no  temporizing;  the  use  of  the  drug 
should  be  stopped  at  once,  and  its  elimination  by  the  intestines 
hastened  with  ])urgatives,  and  that  by  the  skin  with  subcuta- 
neous injections  of  pilocarpine. 


THE  TREATMENT  OF  PARALYSIS  AGITANS. 

In  athorajieutical  i)eriscope  prepared  by  Dr.  Henry  Huchard, 
published  in  the  Revue  generale  de  cUniqve  et  de  therapeutique 
for  March  29th,  Dr.  Mendel,  of  Berlin,  is  cited  as  having  pro- 
duced notable  abatement  of  the  tremor  of  paralysis  agitans  by 
the  use  of  subcutaneous  injections  of  from  two  to  three  deci- 
milligrammes  of  duboisine  three  times  a  day.  In  so  short  a  time 
as  fifteen  minutes  after  an  injection  the  trembling  of  the  hands 
may  be  so  moderated  as  to  enable  the  patient  to  write  more 
legibly.  Dr.  Grasset  and  Dr.  Sacaze  are  mentioned  in  the  same 
summary  as  having  published  in  the  Semaine  medicale  an  ac- 
count of  notable  amelioration  of  the  symptoms  and  improve- 
ment of  the  patient's  general  condition  as  the  result  of  the  ad- 
ministration of  sodium  borate,  beginning  with  four  grains  four 
times  a  day,  and  gradually  increasing  the  doses  to  two  or  three 
times  as  much. 


A  DIPLOMA  DEALER  SENT  TO  JAIL. 

On  April  7th  an  aged  dealer  in  fraudulent  medical  diplomas, 
named  Alfred  Booth,  was  sentenced  to  six  months'  imprison- 
ment in  the  penitentiary.  He  pleaded  guilty  to  a  charge  of  sell- 
ing for  fifty  dollars  a  signed  and  sealed  diploma,  a  crime  that 
might  have  been  made  the  basis  of  prosecution  for  felony ; 
but  the  accused  was  permitted  to  plead  to  a  lesser  crime — that 
of  misdemeanor.  Under  this  procedure  the  judge  passed  sen- 
fence,  omitting  to  impose  a  fine  and  imposing  the  utmost  limit 
of  imprisonment,  six  months.  The  judge  remarked  that  this 
kind  of  punishment  was  more  deterrent  than  that  by  fines,  and 
that  he  thought  that  the  diploma-selling  gentry  would  give  New 
York  a  wide  berth  for  some  time  to  come. 


THE  RHOPALOCEPHALUS  CARCINOMATOSUS. 

Undke  this  name  Dr.  A.  Korotnew  describes  in  Vratch, 
1893,  No.  2,  a  parasitic  organism  observed  by  him  within  the 
cells  of  a  cancer  of  the  lip.  According  to  a  summary  given  in 
the  Centralhlntt  fur  Chirurgie  for  April  1st,  it  is  very  much 
like  one  briefly  described  by  Ssawtschenko  in  the  last-named 
journal,  and  tnay  be  identical  with  it.  It  is  referred  to  the 
Gregarina,  and  Korotnew  attributes  the  formation  of  pearls  to 
its  presence.  At  least  the  adult  forms  have  been  found  solely 
in  the  center  of  such  a  formation,  and  have  been  absent  from 
it  only  when  there  has  been  granular  degeneration  of  the  cells 
forming  the  pearls,  an  occurrence  that  seems  to  be  destructive 
to  the  parasite. 


THE  PROGNOSIS  OF  ALCOHOLIC  PARALYSIS. 

In  the  Gazette  des  hopitaux  for  March  2d  Dr.  S.  Arnaud  re- 
lates the  case  of  a  woman,  twenty-seven  years  old,  who  had  an 
attack  of  delirium  tremens  with  complete  paralysis  of  the  limbs, 
especially  of  the  extensors,  hyperaesthesia,  muscular  atrophy, 
and  the  reaction  of  degeneration.  After  the  delirium  there  was 
loss  of  memory.    She  ultimately  recovered  completely  from  the 


April  15,  1893.] 


MINOE  PARAGRAPHS.— ITEMS. 


417 


paralysis.  The  author,  whose  article  is  summarized  in  the  Ga- 
zetie  liebdomadairedemedecine  et  de  chirurgie  for  April  Ist,  then 
reviews  the  various  forms  of  alcoholic  paralysis,  and  shows  that 
they  generally  end  favorably. 


CAFFEINE-IODOL. 

In  the  April  number  of  the  American  Journal  of  Pharmacy 
Mr.  Frank  X.  Moerk  gives  au  abstract  of  an  article  by  Konte- 
schweller,  in  the  Pharmaceutische  Centralhalle,  concerning  a 
crystalline  addition  product  obtained  by  mixing  alcoholic  solu- 
tions of  caffeine  and  iodol  in  molecular  proportion.  This  caf- 
feine-iodol  contains  74*6  per  cent,  of  iodol  and  25'4  per  cent,  of 
caffeine,  and  is  described  as  light-gray,  odorless,  tasteless,  and 
nearly  if  not  quite  insoluble  in  most  solvents.  The  compound 
is  permanent,  and  is  therefore  considered  worth  trying  as  a  sub- 
stitute for  iodol,  which,  on  prolonged  keeping,  liberates  iodine 
and  thus  has  an  injurious  effect. 


OIL  OF  AMBER. 

In  the  British  Medical  Journal  for  April  1st  Dr.  William 
Murrell  speaks  of  this  substance  as  of  value  in  flatulent  dyspep- 
sia and  in  hysteria  accompanied  by  globus,  and  cites  Wood  as 
stating  that  in  hiccough  it  is  probably  the  most  elBcient  remedy 
except  musk.  It  is  given  in  doses  of  from  ten  to  twenty  drops. 
As  to  its  external  use,  it  enters  into  the  composition  of  two  old- 
fashioned  remedies,  Roche's  embrocation  and  Haarlem  oil,  fric- 
tions of  the  spine  and  chest  with  which  are  reputed  very  effica- 
cious in  whooping-cough  and  in  coughs.  A  good  liniment,  says 
Murrell,  is  made  by  mixing  equal  parts  of  oil  of  amber,  spirit  of 
camphor,  and  spirit  of  hartshorn. 


THE  HOUSE  STAFF  OF  THE  NEW  YORK  HOSPITAL. 

The  One  hundred  and  twenty-second  Annual  Report  of  the 
State  of  the  New  York  Hospital  and  Bloomingdale  Asylum,  for 
the  year  1892,  recently  published,  contains  an  addendum  of  un- 
usual interest  in  the  form  of  a  list  of  the  house  physicians  and 
house  surgeons  for  the  last  hundred  years,  specifying  the  term  of 
service  of  each.  The  preparation  of  this  list  evidently  entailed  a 
great  deal  of  labor  upon  the  compiler,  Mr.  Henry  W.  Crane,  the 
secretary  of  the  board  of  governors,  to  whom  great  credit  is  due 
for  its  accuracy. 


ITEMS,  ETC. 

Infectious  Biseases  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  April  11,  1893  ; 


DISEASES. 

Week  ending  Apr.  4 

Week  ending  Apr.  11. 

Cases. 

Deaths. 

Cases. 

Deaths. 

5 

2 

13 

4 

\n 

H 

15 

4 

172 

13 

220 

19 

Cerebro-spinal  meningitis.  . . . 

13 

9 

10 

7 

96 

4 

117 

7 

115 

41 

132 

35 

9 

3 

9 

2 

Columbia  College  General  Catalogue. — At  a  meeting  of  the  trus- 
tees of  Columbia  College,  held  on  the  6th  of  March,  the  pul)lication  of 
a  new  general  catalogue  of  officers  and  alumni  was  authorized,  and  a 
committee,  consisting  of  Professor  J.  Howard  Van  Amringe  and  Mr. 
John  B.  Pine,  clerk  of  the  board,  was  appointed  to  prepare  the  same. 
The  new  edition,  which  is  to  be  issued  in  1894,  will  be  the  eleventh 
since  the  foundation  of  the  college,  and  will  be  also  the  most  elaborate 


and  comprehensive.  The  dead  and  living  alumni  of  the  college  now 
number  considerably  more  than  eleven  thousand.  In  previous  cata- 
logues all  alumni  have  been  divided  into  schools  and  arranged  by  classes, 
with  an  alphabetical  conspectus.  Only  the  degrees  of  the  graduates 
were  added  to  the  names.  It  is  the  intention  of  the  present  commit- 
tee, for  the  first  time,  to  supplement  the  names  of  living  alumni  with 
their  addresses  and  with  such  further  information  as  may  properly  en- 
ter into  a  work  of  this  description,  including  the  professions  of  the 
men,  their  degrees,  the  colleges  where  they  were  granted,  their  titles, 
judicial,  military,  clerical,  or  political,  etc.  While  the  committee  is  in 
possession  of  the  present  addresses  of  a  great  number  of  the  alumni, 
the  list  of  graduates  whose  whereabouts  are  unknown  is  still  appalling- 
ly long.  To  locate  these  men  will  be  a  difficult  and  troublesome  task, 
which  can  only  be  accomplished  by  patient  and  persistent  effort  on  the 
part  of  the  committee,  entailing  a  great  amount  of  clerical  work,  cor- 
respondence, etc.,  and  by  the  cordial  co-operation  of  the  alumni  them- 
selves. It  is  this  co-operation  which  is  most  earnestly  desired  by  the 
committee,  and  they  appeal  to  every  alumnus  of  the  college,  no  matter 
of  which  school,  to  assist  them  with  whatever  pertinent  information 
may  be  in  his  possession.  It  will  at  least  be  possible  for  every  gradu- 
ate of  Columbia  who  reads  this  to  forward  to  the  committee  his  own 
name,  class,  and  present  address,  with  such  other  facts  regarding  him- 
self as  he  deems  material.  The  list  of  the  missing  among  the  gradu- 
ates in  medicine  is,  notwithstanding  the  excellent  catalogue  of  the  Col- 
lege of  Physicians  and  Surgeons,  published  in  1891,  especially  lengthy. 
Physicians  holding  diplomas  from  the  medical  school  are  most  urgently 
requested  to  respond.  Alumni  who  may  be  so  far  interested  in  the 
progress  of  this  important  undertaking  as  to  go  beyond  the  data  con- 
cerning themselves  will  confer  a  special  obligation  upon  the  committee 
if  they  will  inform  them  (1)  of  any  living  graduate  known  to  be  now 
residing  or  practicing  his  profession  outside  of  the  United  States,  with 
his  address  and  class,  when  known ;  (2)  of  the  death  of  any  graduate 
occurring  within  the  past  live  or  six  years,  date  and  place,  when  known  ; 
(3)  of  recent  changes  of  address  among  alumni ;  (4)  of  anything  else 
suggested  by  the  foregoing  description  of  the  committee's  intentions. 
The  work,  when  completed,  will  be  circulated  generally  among  the 
alumni,  and  it  is  hoped  that  it  will  exert  an  important  and  sensible  in- 
fluence in  bringing  them  into  closer  union,  besides  serving  many  useful 
purposes  that  need  not  be  here  detailed.  All  correspondence  may  be 
addressed  to  the  Committee  on  the  General  Catalogue,  Columbia  Col- 
lege, New  York  city. 

Politics  and  Asylum  Appointments. — The  American  Journal  of  In- 
sanity for  April  contains  the  following  timely  editorial  article,  entitled 
Are  Asylum  Physicians  Party  Pensioners  ?  :  "  The  notion  that  public 
officers  are  the  pensioners  of  a  party,  not  the  servants  of  the  whole 
people,  seems  to  die  hard.  The  prospect  appears  to  be  that  the  officers 
of  all  the  hospitals  for  the  insane  of  the  State  of  Illinois  will  be  turned 
out  to  make  room  for  members  of  the  political  party  which,  after  an 
outing  of  thirty-five  years,  has  once  more  gained  the  upper  hand.  It  is 
true  that  the  present  Governor,  in  his  canvass,  made  charges  of  ex- 
travagance and  mismanagement  against  those  institutions,  but  we  pre- 
sume that  no  one  will  seriously  maintain  that  a  lack  of  confidence  in 
their  management  is  the  only,  or  even  the  principal  reason  for  so  sweep- 
ing a  change.  It  is  also  true  that,  so  far  as  one  wrong  can  justify  an- 
other, the  course  of  the  Republican  party,  during  the  long  period  of  its 
dominance  in  the  State,  has  afforded  an  excuse  for  such  a  couree.  Only 
Republicans  have  been  appointed  on  the  board  of  trustees,  and  we 
understand  that  the  officers  of  the  hospitals  have  been  regularly  as- 
vSessed  a  portion  of  their  salaries  for  the  campaign  funds.  It  is  not 
long  since  the  superintendent  of  the  hospital  at  Anna  was  driven  out  of 
office  with  little  or  no  pretense  of  concealment  of  the  fact  that  the 
ground  of  his  dismissal  was  his  lukewarmness  in  partisanship,  and  from 
all  that  we  can  learn,  his  successor  has  not  erred  in  that  direction,  al- 
though his  attainments  as  an  alienist  have  not,  we  believe,  even  yet, 
earned  him  any  very  wide  celebrity. 

"  We  do  not  suppose  that  if  a  member  of  Governor  Altgeld's  family 
were  to  become  insane,  and  he  were  looking  for  a  suitable  private  hos- 
pital, it  would  ever  occur  to  him  to  inquire  into  the  physician's  views 
on  the  tariff.    We  have  no  doubt  that  multitudes  of  those  who  will  ap- 


418 


ITEMS.— LETTERS 


TO  THE  EDITOR. 


[N.  Y.  Med.  Jour.. 


plaud  his  action  in  this  matter,  or  take  it  as  a  matter  of  course,  employ, 
by  choice,  physicians  of  a  diiforent  political  faith  from  their  own  in 
their  families,  and  would  laugh  at  the  idea  that  a  man's  political  views 
have  anything  to  do  with  his  professional  competency.  It  is  the  view 
that  the  salaries  of  these  offices  are  not,  piimarily,  the  reasonable  com- 
pensation for  honest  and  faithful  discharge  of  their  duties,  but  the  re- 
ward of  activity  in  an  entirely  different  field,  that  allows  people  to  view 
with  approval  or  indifference  such  changes,  entirely  without  regard  to 
the  merits  either  of  those  who  are  turned  out  or  those  who  are  put  in. 

"  The  pernicious  effect  of  such  a  policy  is  so  plain  that  we  should 
feel  as  if  we  were  insulting  the  intelligence  of  our  readers  by  arguing 
the  question.  Men  whose  aspirations  are  for  professional  eminence  and 
usefulness  will  hesitate  about  accepting  positions  in  which  such  quali- 
ties count  for  nothing.  Even  if  competent  men  are  secured,  they  are 
sure,  in  a  State  in  which  parties  are  pretty  evenly  balanced,  under  such 
a  system,  to  be  turned  out  before  they  have  acquired  tlie  experience 
that  will  enable  them  to  do  their  best  work.  The  inevitable  tendency, 
under  such  conditions,  is  to  the  filling  of  the  offices  by  men  whose  only 
object  is  to  make  money  out  of  them,  and  who,  knowing  that  the  time 
is  short,  will  '  make  hay  while  the  sun  shines.' 

"  We  have  no  doubt  that,  in  time,  the  mischief  of  treating  the  funds 
provided  for  the  relief  of  the  unfortunate  as  plunder  will  become  so 
plain  that  it  will  be  no  longer  possible  in  a  government  like  o>irs.  But 
we  fear  that  a  good  many  object  lessons  will  be  needed  first,  and  in  the 
mean  time  the  insane  must  suffer.  We  shall  be  as  much  surprised  as 
gratified  if  the  medical  profession  of  Illinois,  without  distinction  of 
party,  shall  denounce  the  iniquity  as  it  deserves.  In  the  mean  time, 
we  believe  it  is  the  right  and  the  duty  of  the  American  Medico-psy- 
chological Association  to  scan  critically  the  qualifications  of  the  men 
who  profit  by  the  misfortunes  of  its  honored  members,  should  they 
apply  for  admission." 

The  .Joiirwd  also  quotes  the  following  letter  from  Dr.  D.  Hack  Tuke 
to  the  editor  of  the  British  Medical  Journal,  April : 

"  The  American  papers  report  a  proceeding  on  the  part  of  the  Gov- 
ernor of  Illinois  which  ought  to  be  stigmatized  in  the  manner  it  de- 
serves by  every  medical  journal.  The  old  country  has  many  faults.  It 
may  learn  many  things  from  America.  There  is  one  offense,  however, 
of  which  it  is  not  guilty — that  of  making  changes  in  the  appointments 
held  by  medical  men  at  the  head  of  public  institutions  on  a  change  of 
government ;  yet  this  has  just  been  done  in  the  State  of  Illinois. 

"  Dr.  Dewey,  the  medical  superintendent  of  the  Kankakee  Asylum, 
is  to  be  deposed  from  an  office  which  he  has  held  with  so  much  credit 
to  himself  and  advantage  to  the  patients  for  many  years.  I  speak  from 
personal  knowledge  when  I  say  that  this  physician  is  an  honorable  man, 
free  from  reproach,  and  devoted  to  the  institution  which  he  has  made  a 
great  success  under  the  exceptional  difficulties  which  a  new  departure  from 
the  old  lines  has  necessitated — the  experiment,  namely,  of  providing  a 
number  of  separate  buildings  for  the  patients  in  addition  to  the  central 
asylum.  It  has  demonstrated  how  much  good  may  be  done  in  this  di- 
rection, and  has  exercised  a  great  influence  upon  the  construction  and 
arrangement  of  similar  institutions,  in  carrying  out  the  intentions  of 
Mr.  Frederick  Wines  and  others  in  regard  to  segregation  as  opposed  to 
herding  thousands  of  patients  together  in  one  monster  building. 

"  Dr.  Dewey  has  solved  a  difficult  problem,  but  now  that  the  tide  of 
political  feeling  has  taken  a  certain  turn,  it  has  swept  him  away,  re- 
gardless of  his  admirable  work,  and  he  is  to  be  superseded  by  another 
man.  That  his  successor  may  be  a  good  physician  and  capable  of  fill- 
ing this  responsible  post  I  do  not  for  a  moment  call  in  question,  but 
the  gross  injustice  done  to  a  worthy  medical  officer,  on  purely  political 
grounds,  remains  unaltered,  and  is  a  serious  reflection  on  the  system 
which  permits  it." 

Changes  of  Address. — Dr.  Edward  C.  Mann  (sanitarium),  to  Flat- 
bush,  Brooklyn  ;  Dr.  B.  Sachs,  to  No.  21  East  Sixty-fifth  Street. 

The  Death  of  Dr.  William  P.  Sejrmour,  of  Troy,  N.  Y.,  is  announced 
as  having  taken  place  on  P'riday,  the  7tli  inst.  Tlie  deceased  was  a 
graduate  of  the  medical  department  of  the  University  of  Pennsylvania, 
of  the  class  of  1848.  He  was  eminent  as  an  obstetrician  and  gynajcolo- 
gist  and  esteemed  in  the  profession  for,  the  ardor  with  which,  on  occa- 


sion, he  advocated  what  he  looked  upon  as  for  the  honor  and  glory  of 
physicians  as  a  class.  He  was  one  of  the  original  members  of  the  Xew 
York  State  Medical  Association. 

Society  Meetings  for  the  Coming  Week : 

Monday,  April  17th :  New  York  County  Medical  Association  ;  New 
York  Academy  of  Medicine  (Section  in  Ophthalmology  and  Otology) ; 
Hartford,  Conn.,  Medical  Society;  Chicago  Medical  Society. 

Tuesday,  April  18th:  New  York  Academy  of  Medicine  (Section  in 
General  Medicine) ;  New  York  Obstetrical  Society  (private) ;  Medi- 
cal Societies  of  the  Counties  of  Kings  and  Westchester,  N.  Y. ; 
Ogdensburgh,  N.  Y.,  Medical  Association  ;  Passaic,  N.  J.,  County 
Medical  Society  (annual) ;  Baltimore  Academy  of  Medicine. 

Wednesday,  April  19th :  Medical  Association  of  Georgia  (first  day — 
Americus);  New  York  Academy  of  Medicine  (Section  in  Public 
Health  and  Hygiene) ;  Northwestern  Medical  and  Surgical  Society 
of  New  York  (private) ;  Medico-legal  Society  ;  Harlem  Medical  As- 
sociation of  the  City  of  New  York ;  New  Jersey  Academy  of  Medi- 
cine (Newark);  Philadelphia  County  Medical  Society;  Windham, 
Conn.,  County  Medical  Society  (annual — Plainfield) ;  Middlesex, 
Mass.,  South  District  Medical  Society  (annual — Waltham). 

Thursday,  April  SOth :  Medical  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  ^Ist :  Medical  Association  of  Georgia  (third  day) ;  New 
York  Academy  of  Medicine  (Section  in  Orthopaedic  Surgery) ;  Balti- 
more Clinical  Society ;  Chicago  Gynaicological  Society. 

Saturday,  April  22d :  New  York  Medical  and  Surgical  Society  (pri- 
vate) ;  Worcester,  Mass.,  North  District  Medical  Society  (annual — 
Fitchburg). 


f  ttttrs  to  tbc  ^bitor. 


CHLOROFORM  ANAESTHESIA  AS  AN  AID  IN  THE 
DIAGNOSIS  OF  LARYNGEAL  OBSTRUCTION. 

29  East  Thirty-first  Street,  March  IJ^,  1893. 

To  the  Editor  of  tJie  New  YorTc  Medical  Journal  : 

SiE :  Reading  the  "minor  paragraph"  in  the  Journal  of 
March  4th,  Varieties  of  Obstructed  Respiration,  has  led  me  to 
call  your  attention  to  a  suggestion  which  I  made  in  the  January 
meeting  of  the  New  York  Clinical  Society.  The  suggestion  was 
this :  In  cases  of  laryngeal  dyspnaa,  where  there  is  doubt  as  to 
whether  the  dyspnoea  is  due  to  mechanical  obstruction  or  to 
spasm,  it  is  a  simple  matter  to  give  a  child  enough  chloroform 
to  relieve  the  spasm,  if  it  exists ;  in  cases  of  simple  croup  this 
procedure  is  sufficient  to  relieve  the  symptoms  of  obstruction 
and  to  satisfy  one  that  no  mechanical  obstruction  exists — at 
least  not  enough  to  demand  operative  interference. 

In  a  case  of  membranous  laryngitis  recently  under  my  care 
in  St.  Mary's  Free  Hospital  for  Children,  the  anaesthetization 
produced  by  a  small  amount  of  chloroform  relieved  the  dysp- 
noea, which  was  present,  suflBciently  to  satisfy  me  that  no  opera- 
tion was  urgent ;  the  next  day  the  same  procedure  did  not  re- 
lieve the  dyspnaia  and  an  O'Dwyer  tube  was  introduced,  which 
gave  relief.  As  bearing  on  this  question  I  append  a  paragraph 
cut  from  the  March  number  of  the  Medical  World  : 

"  Dr.  Betz  reports  the  case  of  a  child,  aged  eighteen  months, 
that  presented  the  typical  symptom  of  laryngeal  croup.  The 
case  appeared  so  liopeless  that  tracheotomy  was,  although  pro- 
posed, rejected.  Three  drops  of  a  mixture  of  ether  sulph.  three 
parts,  acetic  ether  one  part,  menthol  O'l  part,  were  ordered  to 
be  inhaled  every  quarter  of  an  hour,  just  as  chloroform  is  in- 
haled. It  was  hoped  that  the  cold  from  the  evaporating  mix- 
ture would  contract  the  surface  blood-vessels  of  the  larynx,  and 


April  15,  1893.] 


PROCEEDINGS  OF  SOCIETIES. 


419 


thus  reduce  the  cedema  present.  The  child  was  seen  again  in 
two  hours,  and  the  condition  had  somewhat  improved.  The 
etherization  to  be  continued,  three  to  four  drops  every  half- 
hour.  After  six  hours  the  condition  was  unmistakably  better 
— so  much  so,  in  fact,  that  the  etherization  could  be  dispensed 
with.  A  piece  of  intestine  filled  with  ice  was  placed  around 
the  child's  neck.  After  this,  pregress  was  so  rapid  that  in 
twenty-four  hours  the  child  was  out  of  danger. — Archives  of 
Gynacologyy  George  Montague  Swift,  M.  D. 


PHILADELPHIA  COUNTY  MEDICAL  SOCIETY. 

Meeting  of  March  8,  1893. 

Hypodermic  Medication  in  SypMlis.— Dr.  L.  Wolff  read 
a  paper  of  which  the  following  is  the  substance  : 

Among  the  therapeutic  methods  which  are  largely  employed 
on  the  continent  of  Europe,  but  have  found  very  few  adherents 
in  this  country  is,  no  doubt,  the  hypodermic  treatment  of  syphi- 
lis. Although  proposed  and  practiced  in  the  early  part  of  1860, 
it  was  some  time  before  it  was  extensively  employed,  even 
abroad.  This  was,  no  doubt,  largely  due  to  the  fact  that  it  was 
little  understood,  that,  from  timidity,  the  doses  employed  were 
by  far  too  small,  and  results,  therefore,  not  brilliant,  as  well  as 
from  fear  of  the  formation  of  abscesses  and  the  necessary 
amount  of  pain  accompanying  such  medication.  The  pain  ac- 
companying it  is  to-day  still  an  argument  against  its  employ- 
ment that  is  not  to  be  overcome.  If  we,  however,  consider  that 
in  the  principal  medical  centers  of  continental  Europe  little  or 
almost  no  mercury  is  given  internally  any  more,  even  the  pain 
accompanying  and  following  the  injections  must  be  outweighed 
by  the  results.  While  the  first  experiments  on  hypodermic  medi- 
cation in  syphilis  were  made  with  solutions  of  corrosive  subli- 
mate, the  insoluble  mercurials  were  soon  substituted  by  Sca- 
renzio  and  others.  Therefore  we  may  divide  the  mercurials 
into  those  preparations  which  are  soluble  and  those  which  are 
insoluble.  It  was  found  that  if  insoluble  mercurials  were  intro- 
duced beneath  the  skin  they  were  rapidly  absorbed,  that  they 
were  soon  found  in  the  urine,  and  also  often  produced  the  un- 
toward effects  of  mercury,  besides  their  characteristic  inhibiting 
and  curative  influence  over  the  lesions  of  syphilis. 

In  a  former  paper  on  this  subject  {Therapeutic  Gazette,  No- 
vember, 1889)  1  dwelt  on  the  history  of  this  method  of  medica- 
tion, and  gave  also  a  synopsis  of  the  literature  on  the  subject. 
I  shall  therefore  in  this  paper  consider  principally  my  experi- 
ence with  this  treatment  and  with  the  various  agents  so  em- 
ployed. During  my  student  days  I  had  the  opportunity  of 
watching  and  practicing  this  method,  and  I  have  continued  to 
employ  it  to  this  day  in  a  large  and  varied  practice  which  has 
brought,  perhaps,  to  me  an  unusual  number  of  cases  of  early  and 
secondary  syphilis.  Though  I  have  again  and  again  abandoned 
it,  owing  to  the  pain  it  occasioned,  I  have  always  had  to  revert 
to  it  in  order  to  satisfy  my  patients,  who,  if  they  had  been 
treated  hypodermically  once,  and  were  then  treated  with  mer- 
curials taken  by  the  mouth,  would  gladly  stand  the  pain  of  the 
injections  rather  than  the  slow  results  and  the  digestive  derange- 
ment caused  by  the  older  methods  of  medication. 

I  usually  begin  the  injections  of  corrosive  sublimate  in  the 
interscapular  region  on  one  side  and  about  two  inches  from  the 
posterior  vertebral  processes,  and  continue  down  the  back  in 
the  costal  interspaces — the  injections  being  about  an  inch  or  an 


inch  and  a  half  apart.  The  effect  of  the  injections  on  still  open 
primary  sores,  on  indurated  glands,  on  macular  syphilides,  and 
on  pharyngeal  ulcerations  may  be  said  to  be  almost  magical.  It 
is  noticeable  that  within  a  few  days,  and  usually  within  a  week 
or  ten  days,  all  these  signs  have  disappeared.  The  same  benefi- 
cent results  may  also  be  said  to  take  place  in  specific  iritis  and 
chorioiditis,  and  it  is  especially  in  these  two  affections  that  I 
consider  the  hypodermic  administration  of  corrosive  sublimate, 
in  the  doses  and  manner  mentioned,  of  the  greatest  value. 
Papular  eruptions  do  not  show  the  same  tendency  to  disappear 
rapidly  under  the  hypodermic  treatment,  but  have  usually  faded 
within  a  few  weeks.  The  effect  on  luetic  fever  and  nocturnal 
pains  is  so  marked  that  with  the  first  or  second  injection  the 
patient  notices  a  marked  improvement.  I  never  use  less  than 
a  one-fourth-grain  injection  at  one  time  and  generally  employ 
a  one-per-cent.  solution  in  distilled  water,  filling  a  syringe  of 
twenty-five  minims'  capacity.  These  injections  are  continued 
daily,  and  during  the  first  week  or  two  patients  stand  the  treat- 
ment fairly  well.  There  is  rarely,  during  this  period,  any  evi- 
dence of  soreness  of  the  mouth  or  gums,  nor  is  there  any  intes- 
tinal trouble  noticeable.  After  the  entire  back,  on  both  sides, 
has  been  gone  over  with  injections,  many  of  which  have  left 
quite  sensitive  indurations,  their  repetition  in  or  near  the  old 
places  proves  quite  painful,  and  it  is  only  then  that  real  com- 
plaints from  patients  are  heard.  Usually  after  eighteen  or 
twenty  injections  tumefaction  of  the  gums  becomes  marked, 
and  gingivitis  is  often  noticed.  The  daily  injections  are  then 
intermitted,  and  are  made  at  intervals  of  two,  three,  or  four 
days,  the  untoward  symptoms  rapidly  disappearing  during  such 
intervals.  The  total  number  of  injections  usually  made  in  any 
one  treatment  is  about  twenty-five,  but  I  have  continued  them 
to  the  number  of  thirty  or  thirty-five,  when  marked  pigmenta- 
tion of  the  local  lesions  supervened.  A  good  rule  may  be  to 
carry  on  supermedication  for  about  two  weeks  after  the  total 
disappearance  of  all  symptoms.  It  is,  of  course,  understood 
that  during  this  time  the  patient  is  to  be  supported  by  a  liberal 
diet,  by  milk  punches,  and,  when  the  digestion  is  impaired,  by 
tonics  and  quinine.  The  mouth  should  be  kept  scrupulously 
clean,  the  teeth  being  cleansed  after  each  meal  and  at  bedtime 
with  a  soft  brush  dipped  in  a  solution  of  one  drachm  of  potas- 
sium chlorate  to  six  ounces  of  water,  and  containing  also  a 
drop  of  carbolic  acid  to  each  fluidounce.  While  warm  full 
baths  or  steam  and  hot-air  baths  are  adjuvants  to  the  treat- 
ment, the  cold  bath  should  be  interdicted,  as  well  as  exposure 
to  cold  and  deprivations.  I  may  safely  say  that  I  have  made 
thousands  of  these  injections,  and  have  yet  to  record  a  case 
where  they  have  been  followed  by  abscess  or  sloughing.  All 
of  my  patients  so  treated  were  ambulant,  and  I  do  not  remem- 
ber that  any  of  them  have  lost  a  day  from  their  usual  voca- 
tions. 

The  immediate  effects  of  the  injections  of  corrosive  subli- 
mate have  been  so  uniformly  good  that  I  need  to  consider  now 
only  the  remote  effects  on  the  progress  of  the  disease  and  its 
liability  to  relapses.  The  permanency  of  a  remedy  in  syphilis 
is  one  of  the  features  of  the  greatest  importance,  and  l)ere  I 
must  say  that,  rapid  as  is  the  beneficial  effect  of  this  method  of 
medicafion,  there  is  a  corresponding  large  number  of  relapses. 
Of  the  cases  that  I  have  so  treated,  and  of  which  I  have  been 
able  to  keep  a  record,  I  can  safely  state  that  in  about  sixty  per 
cent,  no  further  symptoms  developed.  I  have  notes  on  a  num- 
ber of  ])atients  so  treated  who  subsequently  married  and  raised 
aj)parently  healthy  offspring.  Of  the  remaining  forty  per 
cent.,  however,  I  can  not  say  that  they  have  done  so  well,  and 
many  of  thom,  after  receiving  two,  three,  and  oven  four  courses 
of  treatment  by  injections,  had  to  submit  to  treatment  by  sys- 
tematic inunction  before  the  tendency  to  relapse  was  overcome. 


420 


PROCEEDINGS 


OF  SOCIETIES. 


[N.  Y.  Med.  Jotra., 


It  is  this  tendency  to  relapses  which  has  caused  me  to 
abandon  hypodermic  injections  after  a  second  failure  as  to  per- 
manency of  cure.  It  made  me  investigate  the  many  other  mer- 
curials suitable  for  hypodermic  medication.  It  has  been  ex- 
perimentally proved  by  Vajda,  of  Vienna  ( Ueber  den  EinfusH 
des  Quechsilbers  anf  den  syphilitischen  Process),  that  the  iodides 
inhibit  the  elimination  of  mercury  by  the  kidneys,  and  that  the 
slov?er  the  elimination  the  greater  the  safety  from  relapses. 
For  this  reason  it  has  been  my  practice  to  give  five  to  ten  grains 
of  potassium  iodide  three  times  daily,  after  the  injection  treat- 
ment, for  months;  but  oven  this  plan  has  not  always  prevented 
frequent  relapses.  Acting  on  this  indication,  and  at  the  sug- 
gestion of  my  friend  Dr.  Thomas  H.  Fenton,  I  have  tried  in- 
jections of  iodo-liydrargyrate  of  potassium,  a  compound  of 
iodine  and  mercury,  but  I  have  found  these  injections  no  less 
painful,  and  their  permanency  of  effect  has  not  been  greater  in 
my  hands  that  with  the  corrosive-sublimate  treatment.  In 
resi)ect  to  permanency,  it  is  said  that  injections  of  the  insoluble 
mercurials  are  of  greater  benefit  than  those  of  the  soluble  ones. 
This  might  be  inferred  from  the  fact  that  their  conversion  into 
a  soluble  compound  beneath  the  skin  is  a  slower  process,  and 
while  thus  a  mild  continued  mercurialization  is  produced,  the 
injections  need  not  be  repeated  so  often.  The  insoluble  mercu- 
rials have,  however,  the  disadvantage  of  not  being  always  asep- 
tic or  of  being  readily  rendered  so.  It  is  true  that  with  the 
introduction  of  vaseline  oil  as  a  vehicle  for  their  hypodermic 
administration  they  can  be  rendered  both  less  septic  and  less 
painful. 

At  the  head  of  the  insoluble  preparations,  so  far  as  effi- 
ciency is  concerned,  calomel  must  figure.  I  give  below  the 
formula  for  its  use,  as  well  as  the  formulae  for  other  of  the  in- 
soluble mercurials,  according  to  Professor  Edward  Lang  in  his 
Ordinations-  hormeln : 

R  Calomel,       )  --  a  k 

'  '       }  aa  4'5  grammes. 

vaseline  oil,  i 

Lanolin   4  " 

Each  c.  c.  contains  0'371  gramme  of  mercury,  0"1  c.  c. 
to  be  injected  not  oftener  than  two  or  three  times  the  first 
week. 

The  precipitated  mercuric  oxide  (hydrarg.  oxid.  flav.)  comes 
next : 

5  Yellow  oxide  of  mercury   4  grammes. 

Vaseline  oil   4*5  " 

Lanolin   3  5 

Each  c.  c.  contains  0'391  gramme  of  mercury.  To  be  used 
like  the  calomel  injection. 

The  salicylate  of  mercury  is  lauded  very  highly,  and  is  pre- 
pared for  injection  as  follows : 

5  Salicylate  of  mercury   7  grammes. 

Vaseline  oil   4  " 

Lanolin   2  " 

Each  c.  c.  contains  0'391  gramme  of  mercury. 
The  latest  preparation,  and  at  the  present  time  the  one  gen- 
erally employed  in  the  hospitals  of  Paris,  even  by  the  veteran 
Fournier,  is  the  mercurous  oxide,  which  is  really  a  mercurous- 
merouric  oxide,  but  better  known  as  the  black  oxide  of  mer- 
cury.   It  is  used  as  in  the  following  formula: 

5  Black  oxide  of  mercury   4-7  grammes. 

Vaseline  oil   6  2  " 

Lanolin   3-1  " 

Each  c.  c.  containing  0'39  gramme  of  mercury,  and  the 
mixture  is  to  be  used  like  the  other  preparations. 

I  might  go  on  and  mention  in  the  same  manner  the  thymol- 
acetate,  the  diphenylate,  and  the  sozoiodolate  of  mercury  and 
other  forms  of  the  drug,  but,  as  those  named  are  the  prepara- 
tions generally  used,  I  will  omit  the  others. 


It  will  appear  from  the  foregoing  that,  after  all,  the  virtues 
of  the  preparations  quoted  consist  in  the  amount  of  mercury 
they  contain  and  in  the  slowness  of  its  conversion  beneath  the 
skin.  The  more  rapidly  it  is  converted,  the  sooner  the  lesions 
disappear ;  the  more  mercury  is  introduced  with  safety  to  the 
general  health,  the  greater  the  curative  effect  on  syphilis;  but 
the  slower  and  more  persistent  the  conversion,  the  greater  the 
permanency  of  the  remedial  action  and  the  likelihood  of  a  total 
extinction  of  the  syphilitic  poison.  It  may  be  said  against  these 
insoluble  mercurials,  and  with  some  force,  that  their  advantage 
over  the  soluble  preparations  is  only  by  their  slower  action,  while 
the  marked  local  reaction  which  they  produce  is  (juite  as  great  as 
with  the  soluble  mercurials.  Such  is  really  the  case,  and  the 
desideratum,  therefore,  seems  to  be  to  employ  a  preparation  that 
will  produce  the  least  reaction  and  that  will  be  slowly  con- 
verted, while  least  in  its  tendency  to  produce  untoward  effects. 
Professor  Edward  Lang,  of  Vienna,  some  years  ago  experi- 
mented on  the  direct  introduction  of  metallic  mercury  in  mi- 
nute subdivision  as  being  nearest  to  the  ideal  method  of  inunc- 
tions, which  yet  hold  the  highest  place  in  permanency  in  the 
treatment  of  syphilis.  He  found  that  they  were  readily  borne, 
that  they  produced  little  or  no  local  reaction,  and,  on  account  of 
the  slow  conversion  of  the  mercury,  that  they  needed  repetition 
only  at  long  intervals.  He  maintained  that  the  introduction  of 
the  metallic  mercury  hypodermically  exercised  an  influence  over 
the  syphilitic  jjrocess  which  was  in  direct  proportion  to  its  con- 
version, which  could  be  studied  by  its  excretion  through  the 
kidneys.  This  appealed  to  me  as  one  of  the  methods  most 
likely  to  prove  more  permanently  efficacious  than  any  of  the 
others,  and  I  introduced  it  into  my  private  practice  as  well  as 
into  the  wards  of  the  German  Hospital  under  my  control. 

To  fully  describe  this  method  I  must  mention  the  manner 
of  the  preparation  for  hypodermic  use,  as  given  by  Professor 
Lang  in  his  Ordinations- Formeln.  This  consists  in  first  mak- 
ing an  ointment  of  mercury  with  lanolin  as  follows: 

Anhydric  lanolin,  fifteen  grammes;  dissolve  in  a  sufficient 
quantity  of  chloroform,  fifty  grammes,  and  evaporate  the  chloro- 
form by  continued  stirring  until  the  weight  is  thirty  grammes; 
then  add  pure  metallic  mercury,  thirty  grammes,  and  continue 
stirring  until  all  the  chloroform  is  evaporated  and  the  mercury 
is  perfectly  extinguished.  This  can  be  recognized  if,  by  spread- 
ing with  a  spatula  on  paper,  no  mercury  globules  are  visible  by 
means  of  a  magnifying  glass. 

This  is  his  strong  lanolin  mercurial  ointment,  and  it  forms 
the  basis  for  his  oleum  cinereum,  or  gray  oil.  Of  the  latter  he 
has  two  preparations,  according  to  the  dilutions,  the  fifty-per- 
cent, and  the  thirty-per-cent.  oil.  The  formula  for  the  former 
is  as  follows: 

5  Strong  lanolin  mercurial  ointment   9  grammes. 

Olive,  almond,  or  vaseline  oil   3  " 

Mix  well. 

Five  one-hundredths  of  a  cubic  centimetre  is  the  average  dose 
for  injections,  but  if  it  is  desirable  to  inject  double  the  quantity 
it  is  best  done  in  two  different  places.  To  produce  a  very  ac- 
tive effect  it  is  advisable  to  inject  twice  a  week  0"05  c.  c.  of  this 
strong  oil  until  all  symptoms  have  disappeared.  After  that, 
and  to  prevent  relapses,  0'05  c.  c.  should  be  injected  about  once 
a  week  or  once  in  two  weeks  for  some  time  afterward.  All 
injections  should  be  made  beneath  the  skin  in  the  back,  about 
an  inch  from  the  median  line,  the  semisolid  mixture  being  pre- 
viously warmed  by  immersion  in  hot  water  until  it  becomes 
fluid.  Lang  also  makes  use  of  injections  of  0-05  o.  c,  two  to 
four  times  during  the  first  week,  and  subsequently  every  week, 
and  later  every  two  weeks,  the  same  amount.  He  also  recom- 
mends a  milder  gray  oil,  made  as  follows  from  the  strong  lano- 
lin mercurial  ointment: 


April  15,  1893.J 


PROGEEDINOS 


OF  SOCIETIES. 


421 


5  Strong  lanolin  mercurial  ointment.  . .  4'5  grammes. 
Oil  of  sweet  almonds  (or  olive  or 

vaseline  oil)   5-5       "  M. 

Each  cubic  centimetre  of  this  contains  0-366  gramme  of 
mercury.  This  is  termed  the  thirtj-per-cent.  gray  oil.  Of  this 
oil  one  tenth  cubic  centimetre  is  the  average  injection  made  in 
two  places  on  the  back. 

These  formulae,  complicated  as  they  may  seem,  can  easily 
be  worked  out,  and  when  once  the  lanolin  mercurial  ointment  is 
made  the  dilution  takes  very  little  time,  as  but  small  quantities 
are  required;  half  an  ounce  will  last  for  weeks,  and,  if  neces- 
sary, should  be  made  fresh  every  month  or  two,  although  these 
oils  really  keep  for  a  much  longer  period. 

The  syringe  for  injections  should  be  accurately  gauged  and 
subdivided  into  O'l  c.  c.  and  tenth  parts  thereof.  The  syringes 
as  made  by  Reiner,  also  Leiter,  of  Vienna,  are  used  for  that 
purpose,  the  total  capacity  of  each  being  half  a  cubic  centi- 
metre. They  have  been  accurately  gauged,  and  a  certificate  of 
accuracy  accompanies  each.  While  it  might  be  well  to  disinfect 
the  needles  and  syringe  before  using,  by  syringing  them  with  a 
four-per-cent.  carbolic-acid  water,  I  have  found  that  there  is 
but  little  danger  in  private  practice  even  if  this  precaution  is 
not  observed.  The  gluteal  regions  are  said  not  to  be  very  suit- 
able for  these  injections. 

In  the  use  of  the  gray  oil  it  has  been  my  practi'^e  to  inject 
0"1  c.  c.  every  week  for  the  first  four  to  six  weeks.  Usually 
macular  eruptions  fade  after  the  second  or  third  injection, 
papular  ones  after  the  fourth  or  fifth.  Examination  of  the 
urine  showed  the  presence  of  mercury  within  the  first  week, 
and  its  presence  was  noted  for  a  month  and  more  after  all  in- 
jections had  been  stopped.  The  injections  of  smaller  quanti- 
ties (O'l  c.  c.  of  the  thirty-per-cent.  oil)  in  different  parts  of 
the  back  are  of  greater  advantage  than  the  injection  of  double 
the  amount  in  one  place,  the  urine  showing  the  mercury  sooner 
in  the  first  case  than  in  the  second.  The  only  precaution  to  be 
observed  in  the  employment  of  the  gray  oil  is  not  to  use  too 
much.  It  is  a  frequent  temptation  when  the  curative  process  is 
slow  to  increase  the  amount  injected  or  to  repeat  it  oftener. 
This  is  to  be  avoided,  as  the  mercury  is  only  slowly  converted 
and  accumulates  to  the  point,  when  it  manifests  its  potency 
over  the  syphilitic  i)rocess.  Another  precaution  to  be  observed 
is  to  pay  careful  attention  to  the  teeth  and  mouth.  As  the  de- 
velopment of  absorbable  mercurial  compounds  is  progressive, 
the  injections  should  be  discontinued  or  made  smaller  even 
upon  the  slightest  effect  noticed  on  the  gums.  This  medication 
is  a  most  effective  and  potent  one,  and  I  can  readily  see  how, 
by  a  lack  of  precaution,  severe  salivation  might  ensue.  Let  no 
one  suppose  that,  as  there  is  little  reaction  immediately  upon 
the  injection,  it  might  be  pushed  without  hesitation.  Litera- 
ture records  several  cases  where  an  uncalled-for  free  use  of  this 
remedy  has  caused  not  only  bad  but  also  fatal  results.  In  my 
experience  such  has  not  been  the  case,  although  I  have  em- 
ployed it  with  uniformly  happy  results  in  a  large  number  of 
cases. 

To  sum  up  the  indications  for  the  hypodermic  medication 
of  syphilis,  I  should  say  that  in  cases  where  the  symptoms  re- 
quired urgency  of  treatment  I  would  employ  the  injection  of  a 
quarter  of  a  grain  of  corrosive  sublimate,  at  first  daily  and  sub- 
sequently every  other  day,  until  about  twenty-five  injections 
had  been  given.  If,  after  this,  all  the  symptoms  had  not  en- 
tirely subsided  (as  shown  by  entire  absence  of  all  pigmentation) 
I  should  resort  to  injections  of  the  thirty-per-cent.  gray  oil, 
O'l  0.  c.  in  one  or  two  places  in  the  back  once  a  week,  until 
six  to  eight  injections  have  been  made.  If,  after  a  shorter  or 
longer  period  without  medication,  further  manifestations  of 
syphilis  should  appear,  the  same  series  of  injections  with  gray 


oil  should  be  made  and  thus  continued  until,  after  long  lapses 
between  treatment,  no  further  return  of  the  lesions  appeared. 
The  injections  of  corrosive  sublimate,  as  described,  have  the 
advantage  of  more  rapid  action,  and  will  often  suffice.  I 
should  always  recommend  their  use  at  first  as  preferable  to  oth- 
ers, but  when  relapses  occur  the  injections  of  gray  oil  are  less 
painful  and  promise  greater  immunity  from  subsequent  relapses. 

Dr.  J.  William  White  said  there  were  some  points  in  the 
paper  that  had  attracted  his  attention,  although  he  would  men- 
tion them  chiefly  to  disagree.  The  reader  had  stated  in  one 
of  the  opening  paragraphs  of  his  paper  that  in  the  principal 
medical  centers  of  Europe  little  or  no  mercury  was  given  by  the 
mouth,  the  inference  being  that  in  this  respect  we  were  behind 
the  times.  As  a  matter  of  fact,  if  we  looked  over  the  present 
treatment  of  syphilis  in  the  hands  of  the  most  distinguished 
men  of  the  profession  who  had  made  syphilis  a  specialty,  we 
should  see  that  the  reverse  of  this  statement  was  true,  and  that 
comparatively  little  mercury  was  given  hypodermically.  In 
Germany  some  of  the  best  men  had  pronounced  against  it  as  the 
method  of  choice,  although  there  it  prevailed  to  a  great  extent. 
In  France,  even  the  veteran  Fournier  had  pronounced  against 
the  routine  use  of  the  hypodermic  method.  In  Great  Britain, 
Jonathan  Hutchinson  found  no  reason  in  his  experience  for  the 
use  of  this  method.  In  this  country,  Taylor  and  Keyes,  of  New 
York,  Bryson,  of  St.  Louis,  and  specialists  in  all  parts  of  the 
country  were  reserving  the  employment  of  this  method  for  rare 
cases.  The  speaker  would  therefore  take  issue  with  the  state- 
ment that  in  the  principal  medical  centers  of  Europe  this  was 
the  method  of  choice. 

Another  point  that  had  attracted  his  attention  was  the  ex- 
traordinary quality  that  the  author's  patients  seemed  to  possess 
of  preferring  this  method  of  treatment.  This  was  absolutely 
the  reverse  of  the  experience  of  everybody  else  who  had  put 
himself  on  record.  Fournier  had  called  attention  to  the  fact 
that  while  one  might  cause  a  rapid  disappearance  of  the  disease, 
one  also  caused  a  rapid  disappearance  of  the  patient.  Every 
French  syphilographer  who  had  recently  written  had  empha- 
sized this  point,  with  the  exception  of  two  or  three  enthusiasts 
who  were  still  carrying  on  experiments  in  this  direction. 

The  remarks  in  regard  to  the  effect  of  the  treatment  on  open 
sores  would  seem  to  indicate  that  Dr.  Wolff  began  the  treat- 
ment very  early.  If  the  rule  not  to  begin  treatment  until  con- 
stitutional symptoms  were  manifested  was  adopted,  it  might 
change  his  percentages.  His  statistics  were  open  to  the  impu- 
tation that  the  cases  were  not  all  cases  of  syphilis,  on  account 
of  the  fact  that  there  was  a  considerable  proportion  of  "  sores  " 
which  it  was  impossible  to  diagnosticate  unless  constitutional 
symptoms  were  waited  for. 

Dr.  Wolff  gave  twenty-five  to  thirty  injections,  and  then 
stopped  the  treatment.  Tliat  seemed  the  most  defective  feat- 
ure in  the  method.  It  had  been  alleged  that  the  disease  was 
cured  by  thirty-five  injections,  each  of  a  quarter  of  a  grain  of 
corrosive  sublimate,  the  treatment  lasting  a  little  over  a  month, 
a  little  less  than  nine  grains  of  mercury  being  given.  If  this 
was  true,  we  had  to  suppose  that  there  was  some  virtue  about 
mercury  given  in  this  way  which  it  did  not  possess  when  ad- 
ministered in  other  ways.  The  evidence  was  steadily  accumu- 
lating that  it  did  not  produce  permanent  cures  and  that  it  was 
attended  by  a  larger  number  of  relapses  than  other  methods, 
and  the  contention  that  thirty  or  forty  injections  of  a  soluble 
preparation  of  mercury  or  five  or  six  of  an  insoluble  prepara- 
tion would  produce  a  cure  of  syphilis  was  without  foundation. 
Dr.  Wolff  had  spoken  of  the  liability  to  relapse,  and  the  speaker 
could  readily  understand  this  if  he  stopped  nt  the  end  of  thirty- 
five  injections.  If  he  had  had  only  forty  per  cent,  of  relapses 
he  had  been  fortunate. 


422 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mei>.  Jot«., 


As  to  the  insoluble  preparations,  calomel,  which  Dr.  WolfiF 
had  placed  first,  was  first  in  order  of  time,  as  it  had  been  intro 
duced  in  1864,  and  revived  seven  to  ten  years  ago  by  Smirnoff, 
a  Russian  physician,  and  had,  until  a  few  years  ago,  kept  its 
place.  It  had,  however,  been  supplanted  by  the  yellow  oxide, 
which  was  now  used  more  than  any  other  insoluble  preparation. 
The  objection  to  this  plan  was  that  it  was  only  another  way  of 
giving  a  soluble  salt.  The  insoluble  salt  was  slowly  converted 
into  a  soluble  form,  and,  so  far  as  the  speaker  understood  the 
matter,  this  became  one  of  the  most  inaccurate  methods  of  giv- 
ing mercury.  One  of  the  claims  put  forward  for  this  method 
was  that  it  insured  scientific  accuracy.  Anything  more  unsci- 
entific, as  regarded  precision  of  dose,  than  to  throw  under  the 
skin  an  emulsion  of  metallic  mercury  in  lanolin  or  a  quantity  of 
calomel  or  yellow  oxide,  and  allow  it  to  remain  there,  subject 
to  the  vicissitudes  of  different  degrees  of  inflammatory  action 
attended  with  different  degrees  of  absorption,  would  be  hard  to 
imagine. 

As  to  the  freedom  from  harmful  consequences,  as  a  matter 
of  fact  there  were  in  some  patients,  as  a  direct  result  of  this 
treatment,  a  violent  stomatitis,  dangerous  salivation,  entero- 
colitis with  bloody  stools,  and,  where  vaseline  or  fatty  prepara- 
tions were  used,  pulmonary  embolism.  There  were  on  record 
fatal  cases  from  these  sources.  Occasionally  the  metallic  mer- 
cury remained  under  the  skin  inert  for  a  time,  and  then  sud- 
denly became  absorbed  in  large  quantities,  with  the  development 
of  violent  symptoms. 

These  objections  were  founded  upon  the  observations  of  men 
who  were  advocates  of  the  method,  who  had  had  the  frankness 
to  record  their  unfavorable  cases,  and  who  could  not  be  dis- 
puted. Autopsies  in  cases  where  the  insoluble  salts  had  been 
administered  experimentally  in  other  diseases  showed  that  there 
was  great  variability  in  the  rapidity  of  absorption. 

The  pain  was  severe  and  belonged  to  the  use  of  every  mer- 
curial salt  administered  in  this  way.  Lang's  statement  in  regard 
to  the  absence  of  pain  and  other  symptoms  after  the  adminis- 
tration of  the  gray  oil  was  contradicted  by  other  observers.  In 
the  best  hands  there  had  been  a  certain  percentage  of  abscesses, 
and,  although  the  introduction  of  antiseptic  methods  had  re- 
duced their  number,  they  were  occasionally  inevitable.  Far 
more  frequent  were  painful  nodosities  about  the  seat  of  the  in- 
jection.- 

The  conditions  under  which  the  method  should  be  employed 
were  extremely  limited.  The  speaker  believed  that  it  should  be 
held  in  reserve  for  cases  where  other  methods  had  failed.  Given 
a  patient  whose  gastro-intestinal  tract  reacted  to  mercury  in 
such  a  way  that  the  various  preparations  became  irritants,  and 
in  whom  the  use  of  inunctions  produced  a  violent  dermatitis  or 
mercurial  erythema,  such  a  case  would  suggest  a  trial  of  the  hy- 
podermic method.  In  grave  emergencies,  such  as  the  serious 
eye  troubles  of  the  secondary  stage,  it  might  even  be  regarded 
upon  an  equal  basis  with  inunctions.  There  was  no  evidence 
to  show  that  it  was  of  greater  value.  If  one  wanted  to  produce 
rapid  mercurialization,  the  administration  of  small  doses  of  the 
protiodide,  calomel,  or  mercury  and  clialk,  supplemented  by  the 
simultaneous  inunction  of  mercurial  ointment,  would  almost 
equal  in  rapidity  of  action  the  use  of  the  soluble  salts  of  mer- 
cury. Probably  every  one  would  admit  that  in  the  presence  of 
threatened  grave  complications  the  hypodermic  method  might 
be  suggested.  In  old  syphilis  mercury  did  not  take  the  place  of 
iodide  of  potassium.  If  there  was  a  gummatous  meningitis,  or 
an  infiltrating  gumma  of  the  brain,  or  a  periostitis  in  the  late 
stages  of  syphilis,  or  if  there  were  any  of  the  tertiary  phenomena^ 
while  mercury  hypodermically  might  be  useful,  it  should  be  re- 
garded only  as  a  valuable  adjuvant,  but  secondary  to  the  use  of 
the  iodide  of  potassium. 


Dr.  RicnAED  A.  Cleeman  had  used  the  hypodermic  method, 
and  thought  that  Dr.  White  was  a  little  severe.  He  had  had 
several  patients  who  preferred  it  very  much  to  mercury  by  the 
mouth.  He  had  used  more  than  thirty-five  consecutive  injec- 
tions, and  had  given  as  much  as  a  third  of  a  grain  at  a  time, 
giving  two  injections  of  a  sixth  of  a  grain  each.  He  had  never 
seen  abscess,  but  he  had  seen  the  painful  nodosities,  and  once 
had  had  to  stop  because  the  parts  were  so  painful  that  the  pa- 
tient was  not  willing  to  continue  the  treatment.  After  the  no- 
dosities disa[)peared  he  came  back  and  the  treatment  was  re- 
sumed. 

He  had  found,  contrary  to  what  had  been  said  in  the  books, 
that  a  small  quantity  of  corrosive  sublimate  would  not  remove 
the  symptoms,  particularly  in  cases  of  tuberculous  skin  disease 
in  the  form  complicated  with  ulceration.  One  had  to  use  many 
injections  before  any  effect  on  the  ulceration  was  produced. 
Finally,  the  ulcerations  disappeared  as  a  rule.  The  great 
advantage  of  the  use  of  injections  was  that  it  overcame 
the  great  tediousness  of  the  ordinary  treatment  and  the  lia- 
bility of  the  production  of  digestive  disturbances.  In  a  case 
he  had  in  mind  a  man  was  in  splendid  general  health  while 
the  hypodermic  method  was  used,  but  when  mercury  was  used 
by  the  mouth  he  suffered  from  diarrhoea  and  troubles  with  the 
stomach. 

He  had  not  used  injections  in  the  primary  stage  of  syphilis, 
but  in  one  case  he  had  used  them  immediately  on  the  appear- 
ance of  the  secondary  symptoms.  After  the  use  of  twelve  in" 
jections  the  symptoms  disappeared,  but  they  reappeared  in  the 
course  of  a  month  in  a  rather  unusual  form — that  of  thickening 
of  the  nails.  He  was  now  using  injections  in  this  case.  The 
general  health  was  excellent,  although  the  patient  had  been 
much  run  down  before.  The  pain,  while  it  was  sometimes  se- 
vere, was  not  unbearable. 

Dr.  J.  A.  Cantkell  thought  that  the  hypodermic  treatment 
of  syphilis  would  cure  in  most  of  the  cases.  He  had  seen  forty 
or  fifty  cases  where  the  treatment  had  been  continued  up  to 
thirty  or  thirty-five  injections,  and  where  the  patients  had  not 
come  back  for  the  treatment  of  the  disease.  He  had  seen  one 
of  these  cases  seven  years  after  the  treatment,  and  there  had 
been  no  return  of  the  disease.  He  had,  however,  seen  cases 
where  the  injections  had  been  continued  until  as  many  as  sixty 
or  even  a  hundred  and  twenty  had  been  given  without  benefit. 
Fournier  had,  he  believed,  within  a  month  injected  for  macular 
syphiloderm.  Sometimes  the  injections  were  not  absorbed  for 
-a  week  or  ten  days,  and  often  left  decided  ulceration.  In  the 
cases  in  which  he  had  seen  the  method  employed  he  thought 
that  it  would  have  been  better  to  use  internal  treatment,  and  if 
the  cases  did  not  do  well  the  hypodermic  method  might  have 
been  tried. 

Dr.  Edwin  Rosenthal  had  used  hypodermic  injections  of 
corrosive  sublimate  quite  a  number  of  times.  He  thought  that 
Dr.  White  had  been  too  severe  in  his  denunciation  of  this 
method  of  treating  syphilis.  Practical  experience  had  demon- 
strated its  utility  and  the  many  advantages  it  h;id  over  other 
methods.  The  inunction  method,  for  instance,  was  the  dirtiest 
that  could  be  employed,  and  would  drive  away  more  patients 
than  the  hypodermic  method  would.  One  of  the  points  in  favor 
of  the  latter  method  was  that  the  patient  had  nothing  to  do 
with  the  treatment,  but  ate  and  drank  while  undergoing  a  cure. 
The  injections  were  cleanly  and  devoid  of  all  risk  when  judi- 
ciously made;  at  first  they  were  made  daily,  and  atterw'ard 
every  second  or  third  day. 

He  had  given  the  injections  in  the  primary  disease,  in  a  case 
of  chancre  of  the  tongue,  in  which  the  lymphatic  glands  in  the 
cervical  region  were  very  much  enlarged,  and  where  the  inter- 
nal administration  of  remedies  could  not  be  borne  by  the  pa- 


April  15,  1893.] 


PROCEEDINGS 


OF  SOCIETIES. 


423 


tient  and  prompt  treatment  was  indicated,  with  very  good  re- 
sults. This  patient  was  still  under  treatment,  but  there  had 
been  no  appearance  of  an  eruption. 

Speaking  of  the  large  dose  given  at  a  single  injection  and  its 
good  results,  he  wished  to  recoi'd  another  point,  and  that  was: 
In  infantile  syphilis  the  dose  of  -^^^  or  grain  of  corrosive 
sublimate,  as  recommended  by  Dr.  Jacobi  {Journal  of  Pmli- 
atrics),  was  too  small.  He  had  seen  a  vast  number  of  cases  of 
infantile  syphilis,  and  had  lost  quite  a  number  of  patients  until 
he  had  increased  the  dose ;  and  he  now  never  began  with  less 
than  grain  of  corrosive  sublimate,  and  gradually  increased 
the  dose. 

Dr.  Charles  Wirgman -thought  that  a  point  to  be  borne  in 
mind,  both  in  private  and  in  hospital  practice,  was  that  as  soon 
as  the  lesions  disappeared  the  patient  ceased  to  return  for 
treatment.  No  matter  how  eloquent  one  might  be  in  regard  to 
the  necessity  of  continuing  treatment,  they  disappeared.  If  it 
could  be  demonstrated  by  a  more  extensive  use  of  this  method 

!  that  thirty-five,  seventy-five,  or  even  one  hundred  and  seventy- 
five  injections  would  take  the  place  of  two  or  three  years'  treat- 
ment, that  would  be  a  great  boon  to  humanity,  and  the  question 

j     was  worthy  of  serious  consideration  and  further  trial. 

J          Dr.  S.  SoLis-OoHEN  thought  the  discussion  pointed  to  the 

I     fact  that  it  would  be  well  to  elicit  further  testimony  as  to  the 

j  time  when  a  syphilitic  patient  could  be  considered  "cured." 
His  own  experience  had  been  so  largely  with  late  lesions,  oc- 
curring in  patients  who  had  been  treated  by  many  different 
methods,  and  in  whose  cases  quite  a  number  of  years  had 
elapsed  since  the  primary  infection,  tliat  he  was  compelled  to 
consider  it  at  least  premature,  because  symptoms  might  have 
disappeared  for  a  time,  to  say  that  the  treatment  had  cured  the 
disease.  The  patient  must,  it  seemed  to  him,  be  kept  under  ob- 
servation for  a  prolonged  period  before  we  could  record  even  a 

I  probable  cure  or  recovery ;  and  this  was  the  fatal  defect  of  all 
methods  which  limited  themselves  to  a  comparatively  brief  pe- 
riod during  the  time  of  early  symptoms.  His  personal  use  of 
hypodermic  injections  of  mercury  in  syphilis  had  been  limited 
to  the  employment  of  coi-rosive  sublimate  for  rapid  effect  in 
early  or  late  cases,  so  that  he  was  unable  to  discuss  the  other 
methods,  except  from  a  theoretical  standpoint ;  and  therein  he 
was  entirely  in  accord  with  Dr.  White.  In  the  extreme  cases 
of  late  lesions  he  sometimes  met  with  he  resorted  preferably 
to  inunction,  associated  with  or  followed  quickly  by  the  inter- 
nal use  of  potassium  iodide  in  ascending  doses;  and,  acting 
upon  a  suggestion  of  Bartholow's,  he  sometimes  conjoined  with 
this  the  steam  bath  and  the  hypodermic  use  of  pilocarpine  to 
hasten  elimination.    It  was  dangerous  to  push  the  action  of 

'  tissue  destructives  unless  we  provided  for  rapid  elimination- 
Hence  the  advantage,  too,  of  giving  large  draughts  of  water  or 
milk  with  potassium  iodide. 

Dr.  Joseph  Hearn  had  used  the  hy]>odermic  method  in  only 
one  case,  where  the  stomach  was  irritable.  Under  treatment 
with  eighth-of-a-grain  doses  the  patient  had  improved.  He 
thought  it  a  metliod  which  should  be  held  in  reserve.  There 
were  patients  who  could  not  bear  the  iodides.  He  had  been 
taught  that  the  iodides  did  not  cure  syphilis,  but  rather  its  con- 

!  sequences.  Only  mercury  cured  syjjliilis.  If  he  was  in  a  hurry 
he  used  inunctions,  but  if  there  was  no  urgency  he  used  internal 
treatment.  He  could  not  say  how  many  of  his  cases  were  cured. 
He  believed  that  the  disease  could  be  put  in  abeyance  so  that 
the  patient  would  live  for  any  length  of  time. 

He  would  like  to  ask  if  the  administration  of  mercury  dur- 

1     ing  the  primary  stage  would  mask  the  secondary  symptoms  so 

I     that  one  could  not  recognize  them. 

Dr.  James  Mitoiiell  thought  there  were  cases  of  syphi- 
lis where  the  disease  appeared  to  have  taken  a  mild  form. 


He  had  used  all  forms  of  treatment  with  the  exception  of  the 
hypodermic.  His  experience  of  late  years  had  been  principally 
with  the  secondary  and  tertiary  affections,  particularly  of  the 
eye.  He  found  that  sometimes  the  patients  denied  anything 
like  infection.  When  we  came  to  a  study  of  the  treatment  of 
any  disease,  we  must  take  into  consideration  the  fact  that 
all  diseases  varied  in  their  intensity  in  different  individuals. 
This  was  the  reason  that  we  had  different  results  with  the 
same  treatment,  and  why  one  method  of  treatment  would  fail 
while  another  would  effect  a  cure. 

Dr.  John  B.  Deaver's  experience  with  the  hypodermic  ad- 
ministration of  mercury  had  been  comparatively  limited.  He  had 
not  used  it  sufficiently  to  say  much  in  its  favor.  Of  course,  one 
of  the  objections  was  the  decided  pain  which  it  caused.  Painful 
indurations  had  been  marked  in  some  cases  and  had  been  some 
time  in  disappearing.  He  had,  however,  seen  most  excellent 
results  obtained  in  ulcerative  conditions  of  the  pharynx  and 
soft  palate,  where  the  internal  administration  of  mercury  did 
not  suffice,  largely,  perhaps,  because  it  excited  irritation  of  the 
digestive  tract,  and  where  inunction  had  also  failed. 

One  of  the  weakest  arguments  against  the  use  of  injections 
was  that  a  cure  was  produced  in  so  short  a  time.  He  believed 
that  many  of  the  cases  of  early  relapse  were  due  to  the  fact 
that  the  physician  had  been  led  to  believe  that  he  had  cured 
the  case.  From  his  observation  he  thought  that  treatment 
should  be  prolonged  for  four  years,  or  at  least  three  years. 
He  had  had  sufficient  satisfaction  with  the  ordinary  treatment 
not  to  resort  to  the  hypodermic  metliod,  except  in  special 
cases. 

Dr.  White,  in  reply  to  the  question  of  Dr.  Hearn,  would  say 
that  he  believed  that  the  prompt  administration  of  mercury  in 
primary  syphilis  would  prevent  the  appearance  of  the  second- 
ary symptoms. 

He  knew  of  no  test  that  could  be  applied  to  the  individual 
which  would  demonstrate  the  presence  or  absence  of  active 
syphilis.  He  believed  that  ninety  to  ninety-five  per  cent,  ot 
the  cases  could  be  cured,  but  it  was  impossible  to  say  at  the  be- 
ginning which  of  the  cases  would  not  be  cured.  As  a  matter 
of  fact,  syphilis  was  inclined  to  be  a  self-limited  disease.  Nothing 
but  the  experience  of  years  would  demonstrate  the  possible 
cure.  The  point  had  already  been  made  in  regard  to  relapses,  and 
he  thought  that  figures  were  accumulating  that  were  distinctly 
against  the  method,  and  would  show  that  the  proportion  of  re- 
lapses with  the  hypodermic  method  was  greater  than  under  the 
classical  methods  which  we  had  been  using. 

Dr.  Drake  had  recently  returned  from  Europe.  For  six 
months  he  had  been  Kaposi's  assistant.  In  most  of  his  cases 
he  used  the  hypodermic  method,  the  injection  being  made  in 
the  gluteal  region  once  a  week.  Neumann,  of  Vienna,  used 
salicylate  of  mercury  hypodermically.  He  also  used  internal 
treatment  in  some  cases.  Lang,  of  Vienna,  was  at  the  present 
time  experimenting  with  the  gray  oil.  Lukasiewicz  also  used 
injections  of  a  five-per-cent.  corrosive- sublimate  solution,  a 
gramme  every  week. 

In  Berlin,  the  dermatologists  and  syphilographers,  Joseph 
and  Lassar,  used  hypodermic  injections  in  most  of  their  cases. 
In  some  they  used  inunction. 

In  Paris,  Fournier  was  using  hypodermic  injections  at  the 
time  that  he  had  left.  In  some  cases  there,  after  the  first  injec- 
tion, the  eruption  had  entirely  disappeared.  Of  course,  it  was 
a  little  painful,  but  it  did  not  occasion  the  patients  mucii  trouble, 
and  they  gladly  submitted  to  the  treatment,  and  preferred  the 
hyjjodermic  injections. 

Dr.  Wolff  repeated  that  he  had  made  thousands  of  injec- 
tions, and  the  patients  with  whom  he  had  exchanged  the  hypo- 
dermic method  for  the  administration  of  protiodide  by  the 


424 


BOOK  NOTICES. 


[N.  Y.  Mbd.  Jodb., 


mouth,  had  asked  to  have  the  former  method  resumed.  They 
did  not  seem  to  mind  tlie  pain  very  much. 

In  regard  to  the  administration  of  the  remedy  before  the 
diagnosis  was  established,  he  would  state  that  the  injections 
wore  not  made  until  the  macular  eruptions  and  other  character- 
istic symptoms  had  manifested  themselves.  He  never  treated 
constitutionally  for  the  primary  sore  alone. 

As  to  the  results,  he  had  stated  that  he  had  found  no  return 
of  the  symptoms  in  sixty  per  cent,  of  the  cases.  He  did  not 
know  whether  or  not  these  gentlemen  could  tell  syphilis  when 
there  were  no  symptoms.  Syphilis  was  only  present,  in  his  opin- 
ion, when  there  were  symptoms.  The  duration  of  the  treatment 
had  been,  on  an  average,  for  twenty-five  injections,  and  he  was 
not  the  only  one  who  had  made  that  statement.  Many  thou- 
sands of  cases  had  been  treated  at  the  Charit6  in  Berlin. 

Kaposi  had  led  the  discussion  on  the  therapeutics  for  syphilis 
at  the  Congress  fur  innere  Medicin  in  Wiesbaden  in  1887,  and 
it  was  generally  accepted  for  the  principal  methods  of  treatment 
and  the  relative  permanency  of  their  results,  as  followed  :  the 
inunction  method,  most  permanent;  the  calomel-injection  treat- 
ment next,  and  the  hy]jodermic  injection  of  corrosive  sublimate, 
as  third.  It  was  stated  elsewhere  that  the  permanent  results  of 
the  first  were  seventy-five  per  cent. ;  the  second,  seventy  per 
cent. ;  tlie  latter,  sixty-five  per  cent.  Tlie  speaker's  results  had 
not  been  so  good,  although  he  had  injected  larger  doses  and  for 
a  longer  time. 

In  regard  to  the  time  of  cure.  This  might  be  said  to  be  ob- 
tained when  there  was  no  return  of  symptoms.  There  was  no 
such  thing  as  saying  that  syphilis  would  be  extinct  after  two  or 
after  four  years.  He  had  seen  it  return  after  twenty  years,  in 
spite  of  treatment.  There  was  extinction  only  when  there  was 
no  return  of  symptoms.  To  limit  it  to  any  one  time  was  almost 
out  of  the  question,  because  the  time  of  cure  for  syphilis  could 
not  be  predicted. 

He  had  given  his  paper  as  the  result  of  personal  experience. 
If  mistakes  had  been  made,  they  had  been  the  result  of  misin- 
terpretation and  lack  of  a  suflBcient  number  of  cases,  rather  than 
of  a  want  of  truthful  statement. 


S^rok  Notices. 


A  Manual  of  Bacteriology.  By  Geoegk  M.  Sternberg,  M.  D., 
Deputy  Surgeon-General,  tJ.  S.  Army,  etc.  New  York : 
William  Wood  &  Co.,  1893. 

The  subject  of  bacteriology  has  made  such  rapid  progress  in 
the  last  four  years,  and  its  literature  is  so  voluminous  and,  in 
many  instances,  so  vague,  that  it  has  been  almost  impossible 
for  one  not  wholly  devoting  his  time  to  it  to  keep  himself  in- 
formed with  regard  to  what  was  positively  known  and  what 
was  only  surmised.  The  object  of  the  author  in  the  present 
work  has  been  to  go  over  the  whole  ground  and  arrange  our 
present  knowledge  in  a  form  suitable  for  the  use  of  students. 
No  commendation  is  too  high  for  the  manner  in  which  he  has 
accomplished  his  task.  So  far  as  we  can  find,  not  a  single  one 
of  the  various  forms  of  bacteria  known  to  science  has  failed  to 
receive  his  attention.  To  review  his  book,  therefore,  would  be 
to  review  the  whole  subject  of  bacteriology.  The  important 
pathogenic  bacteria  and  the  technology  of  the  subject  are  de- 
scribed in  large  type,  thus  separating  them  from  the  unimpor- 
tant and  non-pathogenic  varieties,  which  are  described  in 
smaller  type.  This  arrangement  will  save  the  student  much 
unnecessary  reading,  and  will  at  the  same  time  suggest  to  him 
fields  for  study  which  have  not  been  thoroughly  explored. 


The  plates  and  illustrations  are  largely  borrowed  from  the 
original  memoirs  in  which  the  particular  varieties  were  de- 
scribed, and  the  artistic  part  of  the  work  has  been  most  credit- 
ably performed.  The  book  is  the  most  com])lete  treatise  yet 
published  upon  this  subject,  and  one  which  the  student  of  bac- 
teriology can  ill  afford  to  be  without. 


The  Principles  of  Bacteriology.  A  Practical  Manual  for  Stu- 
dents and  Physicians.  By  A.  C.  Abbott,  M.  D.,  First  Assist- 
ant, Laboratory  of  Hygiene,  University  of  Pennsylvania. 
With  Illustrations.  Philadelphia:  Lea  Brothers  &  Co., 
1892.    Pp.  263. 

The  author,  keeping  before  him  constantly  the  object  of  his 
book,  the  needs  of  the  student  and  practitioner  of  medicine, 
who,  being  otherwise  engaged,  can  devote  but  a  portion  of 
their  time  to  bacteriological  research,  has  restricted  himself  to 
a  clear  exposition  of  such  fundamental  features  as  are  essential 
to  the  understanding  of  the  subject.  His  historical  data  are 
derived  from  Loffler's  Vorlesungen  uber  die  geschichtlichen 
Entwickelung  der  Lehre  von  den  Baeterien,  and  are  presented 
in  a  sufficiently  detailed  manner  for  his  present  purpose.  The 
author's  constant  efi'ort  is  to  develop  independent  thought  in 
the  student,  and  experiments  are  constantly  suggested  with  a 
view  of  diminishing  the  frequency  of  the  oft-heard  query 
"  What  shall  I  do  next?  "  There  is  no  attempt  at  a  display  of 
erudition,  and  yet  our  author's  discriminating  use  of  his  mate- 
rial, his  clear  exposition,  his  very  simplicity,  show  his  control 
of  his  subject  and  merit  our  highest  praise. 

What  bacteria  are.  how  they  grow,  how  classified,  how  iso- 
lated, how  intensified,  how  cultivated,  are  all  questions  an- 
swered in  their  due  order. 

The  treatise  closes  with  a  detailed  examination  of  the  vari- 
ous pathological  excreta  from  the  human  subject,  afi^ected  by 
the  usual  diseases,  bringing  him  the  most  frequently  under  the 
physician's  care,  and  of  the  induced  pathological,  macroscopical 
and  microscopical,  variations  succeeding  inoculation  experi- 
ments. 


The  Year  Booh  of  Treatment  forgl893.    A  Critical  Review  for 
Practitioners  of  Medicine  and  Surgery.    By  Various  Con- 
tributors.   Philadelphia:  Lea  Brothers  &  Co.,  1893. 
This  publication  is  so  well  known,  and  during  the  past  eight 
years  has  established  for  itself  so  high  a  reputation  for  accuracy 
and  value,  that  extended  criticism  is  scarcely  called  for.  The 
surest  proof  that  this  value  exists  is  the  favorable  reception 
which  has  been  and  still  continues  to  be  given  to  it  by  the  pro- 
fession at  large.    Certain  changes,  including  the  addition  of  a 
separate  article  on  Public  Health  and  Hygiene,  have  been  made 
in  this  year's  edition,  all  of  which  add  yet  more  to  its  value. 
The  arrangement  of  the  volume  and  its  indexing  are,  as  usual, 
excellent. 

The  Medical  Annual  and  Practitioner^ s  Index:  A  Work  of 
Eeference  for  Medical  Practitioners.  By  Various  Authors. 
1893.  Eleventh  Year.  Bristol :  John  Wright  &  Co.  New- 
York  :  E.  B.  Treat.    Pp.  lx-590. 

In  presenting  the  volume  for  1893  (eleventh  year)  the  pub- 
lishers, in  their  preface,  make  the  following  statement:  "The 
design  we  keep  before  us  is  to  bring  the  practitioner  into  direct 
communication  with  those  who  are  advancing  the  science  of 
medicine  in  any  particular  direction,  so  that  practical  informa- 
tion, the  result  of  personal  experience,  may  have  a  larger  share 
in  the  composition  of  the  work  than  would  be  the  case  if  we 
contented  ourselves  with  a  simple  collection  of  abstracts  from 
the  various  medical  journals."    It  would  be  difficnlt,  we  think. 


April  15,  1893.] 


BOOK  NOTICES. 


425 


if  not  impossible,  to  more  perfectly  attain  a  given  object  than 
has  been  done  in  this  year's  annual;  and  certainly  such  a  great 
amoant  of  valuable  matter  could  scarcely  be  better  sifted,  con- 
densed, and  arranged  for  quick  and  easy  reference. 

While  the  list  of  contributors  guarantees  the  general  excel- 
lence of  the  volume,  we  regard  the  portions  of  the  book  deal- 
ing with  therapeutics,  digestion,  and  the  heart  as  of  special  in- 
terest and  value. 

On  cholera,  a  subject  which  perhaps  more  than  any  other  at 
present  demands  our  attention,  there  are  six  contributions  of 
the  greatest  interest  and  value,  and  we  can  not  too  heartily  in- 
dorse the  wise  policy  of  the  publishers,  which  has  given  us  the 
opinions  of  several  men  of  eminence  on  this  most  important 
matter  and  saved  us  from  the  necessarily  prejudiced  opinion  of 
a  single  writer. 

The  arrangement,  the  paragraphing,  and  the  indexing  of  the 
book  are  excellent,  but  it  is  much  to  be  regretted  that  so  much 
space  should  have  been  devoted  to  advertisements. 

BOOKS,  ETC.,  RECEIVED. 

A  Text-book  of  the  Theory  and  Practice  of  Medicine.  By 
American  Teachers.  Edited  by  William  Pepper,  M.  D.,  LL.  jD., 
Provost  and  Professor  of  the  Theory  and  Practice  of  Medicine 
and  of  Clinical  Medicine  in  the  University  of  Pennsylvania.  In 
Two  Volumes.  Illustrated.  Vol.  I.  Philadelphia:  W.  B. 
Saunders,  1893.    Pp.  xii-909. 

A  Manual  of  Operative  Veterinary  Surgery.  By  A.  Liau- 
tard,  M.  D.,  V.  M.,  Principal  and  Professor  of  Anatomy,  Sur- 
gery, Sanitary  Medicine,  and  Jurisprudence  in  the  American 
Veterinary  College,  etc.  With  nearly  600  Illustrations.  New 
York:  Sabiston  &  Murray,  1893.    Pp.  xvi-786. 

Handbook  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Throat,  Nose,  and  Nasopharynx.  By  Carl  Seller,  M.  D.,  In- 
structor in  Laryngology  and  Lecturer  on  Diseases  of  the  Upper 
Air  Passages  in  the  University  of  Pennsylvania,  etc.  Fourth 
Edition,  thoroughly  revised  and  greatly  enlarged.  Illustrated 
with  Two  Lithographic  Plates  containing  Ten  Figures  and  One 
Hundred  and  Seven  Wood  Engravings.  Philadelphia:  Lea 
Brothers  &  Co.,  1893.    Pp.  xl-13  to  411. 

The  Medical  Annual  and  Practitioner's  Index  :  A  Work  of 
Reference  for  Medical  Practitioners.  By  Various  Authors. 
1893.  Eleventh  Year.  Bristol:  John  Wright  &  Co.;  New 
York :  E.  B.  Treat.    Pp.  lx-590. 

The  Disease  of  Inebriety  from  Alcohol,  Opium,  and  other 
Narcotic  Drugs;  its  JEtiology,  Pathology,  Treatment,  and  Medi- 
co-legal Relations.  Arranged  and  compiled  by  the  American 
Association  for  the  Study  and  Cure  of  Inebriety.  New  York : 
E.  B.  Treat,  1893.    Pp.  xiv-17  to  400.    [Price,  $2.75.] 

Report  of  a  Case  of  Right-angled  Deformity  of  the  Knee, 
resulting  from  Tubercular  Arthritis.  By  James  F.  E.  Colgan, 
M.  D.,  Philadelphia.    [Reprinted  from  the  Therapeutic  Gazette.] 

Hydrotherapy  in  the  Treatment  of  Nervous  and  Mental  Dis- 
eases. By  Frederick  Peterson,  M.  D.  [Reprinted  from  the 
American  Journal  of  the  Medical  Sciences.] 

Traumatic  Synovitis  of  Knee  Joint  with  Haemorrhage  into 
Joint  Cavity;  Four  Ounces  of  Blood  encapsuled  Sixteen  Months. 
By  F.  C.  Schaefer,  M.  D.,  Chicago.  [Reprinted  from  the  Chi- 
cago Clinical  Review.] 

Brain  Surgery.  Injury  received  Five  Years  ago  followed 
Three  Years  later  by  Convulsions  and  Paralysis.  Blood  Clot 
found  under  the  Dura  Mater  and  removed.  Patient  improving. 
By  F.  C.  Schaefer,  M.  D.  [Reprinted  from  the  Chicago  Clini- 
cal Review.] 

Bloodless  Amputation  at  the  Hip  Joint  by  a  New  Method. 
By  Nicholas  Senn,  M.  D.  [Reprinted  from  the  Chicago  Clini- 
cal Revie^c] 


Gastric  Ulcer  in  a  Child  Two  and  a  Half  Years  Old.  By 
James  F.  E.  Colgan,  M.  D.    [Reprinted  from  the  Medical  News.] 

Skin  Grafting  upon  the  Cranium.  By  F.  C.  Schaefer,  M.  D. 
[Reprinted  from  the  Chicago  Medical  Recorder.] 

Notes  on  some  Interesting  Cases  at  the  New  York  Mothers' 
Home  Maternity  Hospital.  By  T.  J.  McGillicuddy,  M.  D.  [Re- 
printed from  the  Journal  of  the  American  Medical  Association.] 

A  Consideration  of  the  Knee-jerk  Symptom.  By  R.  M. 
Phelps,  M.  D.,  Rochester,  Minn.  [Reprinted  from  the  North- 
western Lancet.] 

Trional  and  Tetronal.  Clinical  Observations  on  their  Ac- 
tion as  Hypnotics  and  Sedatives  for  the  Insane.  By  W.  Mabon, 
M.  D.,  Utica,  N.  Y.  [Reprinted  from  the  American  Journal  of 
Insanity.] 

A  Case  of  Hsemorrhagic  Iritis,  with  Remarks.  By  Dr. 
Charles  Zimmermann,  of  Milwaukee,  Wis.  [Reprinted  from 
the  Archives  of  Ophthalmology.] 

A  Topical  Treatment  of  Bronchitis.  By  Edwin  J.  Knh, 
M.  D.    [Reprinted  from  the  Chicago  Medical  Recorder.] 

Fourth  Biennial  Report  of  the  North  Carolina  Board  of 
Health,  1891-1892. 

Human  Anatomy.  A  Complete  Systematic  Treatise  by 
Various  Authors,  including  a  Special  Section  on  Surgical  and 
Topographical  Anatomy.  Edited  by  Henry  Morris,  M.  A.  and 
M.  B.  Lond.,  Surgeon  to  and  Lecturer  on  Surgery,  formerly 
Lecturer  on  Anatomy  at  the  Middlesex  Hospital,  etc.  Illus- 
trated by  791  Woodcuts,  214  of  which  are  printed  in  Colors  from 
Drawings  made  expressly  for  this  Work  by  Special  Artists. 
Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1893.  Pp.  xxxiii-17  to 
1286.    [Price,  $7.50.] 

Diseases  of  the  Skin.  A  Manual  for  Students  and  Practi- 
tioners. By  Charles  C.  Ransom,  M.  D.,  Assistant  Dermatologist, 
Vanderbilt  Clinic,  New  York.  Series  edited  by  Bern  B.  Gal- 
laudet,  M.  D.,  Demonstrator  of  Anatomy,  College  of  Physicians 
and  Surgeons,  New  York.  Philadelphia :  Lea  Brothers  &  Co., 
1893.    Pp.  6-17  to  201.    [The  Students'  Quiz  Series.] 

New  York  State  Reformatory  at  Elmira.  Seventeenth 
Year  Book,  containing  the  Annual  Report  of  the  Board  of 
Managers.    For  the  year  ending  September  30,  1892. 

Fixation  after  Excision  of  the  Knee.  By  H.  Augustus 
Wilson,  M.  D.,  Philadelphia.  [Reprinted  from  the  American 
Journal  of  the  Medical  Sciences.] 

Congenital  Induration  or  Tumor  of  the  Stern o-Mastoid.  By 
Justin  Herold,  M.  D.,  New  York.  [Reprinted  from  the  Inter- 
national Medical  Magazine.] 

The  Prevention  of  Hernia  after  Incision  of  the  Abdominal 
Walls.  By  George  M.  Edebohls,  M.  D.  [Reprinted  from  the 
New  York  Journal  of  Oyncecology  and  Obstetrics.] 

A  New  Method  of  Artiticial  Respiration  in  Asphyxia  of  the 
New-born,  with  Cases.  By  W.  E.  Forest,  M.  D.,  New  York. 
[Reprinted  from  the  Medical  Record.] 

Some  of  the  Effects  of  "Withdrawal."  By  L.  Bolton 
Bangs,  M.  D.,  New  York. .  [Reprinted  from  the  Southern 
Clinic] 

Blood  in  the  Urine.  How  to  discover  its  Source  and  what 
to  do  for  it.  By  L.  Bolton  Bangs,  M.  D.,  New  York.  [Re- 
printed from  the  Medical  Record.] 

Care  and  Treatment  of  the  Nipple  in  the  Gravid  and  Puer- 
peral States.  By  S.  Marx,  M.  D.,  New  York.  [Reprinted  from 
the  Medical  Record.] 

Hypnotism  as  a  Therapeutic  Agent.  By  William  Lee  How- 
ard, M.  1).,  of  Baltimore,  Md. 

Tumor  of  the  Cortex  producing  Hemiplegia,  with  Loss  of 
Tactile,  Pain,  and  Muscular  Sense.  By  Frank  S.  Madden,  M.  D., 
Plattsburgh,  N.  Y.  [Reprinted  from  thQ  Journal  of  Nervous  and 
Mental  Disease.] 


426 


NE  W  IN  VENTIONS.-  MISOELLA  NY. 


[N.  Y.  Med.  Joub.^ 


Nuevo  Concepto  de  la  Histologia  de  los  Centres  Nerviosos. 
Por  el  Dr.  D.  Santiago  Ramon  y  Cajal.  [Piiblicadas  en  la  Re- 
vista  de  Giencias  Aledican  de  Barcelona.] 

01iol6ra  et  fi^vre  typlioide.  Par  M.  L.  Galliard.  [Extrait 
des  Bulletins  et  memoires  de  la  Societe  medicale  des  hopilaux 
de  Paris.] 


Ilcto  Infamtions,  etc. 


A   SHIELD  TO  PROTECT  THE  CLINICAL  THERMOMETER. 

By  Herbert  U.  Williams,  M.  D., 
bttfpalo,  n.  t. 

This  device  is  intended  to  protect  tlie  tliernioineter  while  it 
is  being  held  in  the  nioutli  so  that  it  may  not  be  bitten.  It 
consists  of  a  tube  of  German  silver,  an  inch  and  a  sixteenth 
(twenty-seven  millimetres)  in  length,  having  a  narrow  opening 
in  front.  It  sliould  cla.sp  the  thermometer  with  moderate  press- 
ure, and  should  slip  off  easily.  It  may  be  made  to  fit  thermome- 
ters of  various  calibers  within  narrow  limits.  However,  the 
tubes  of  thermometers  vary  so  much  that  it  has  been  found 
necessary  to  make  the  instrument  in  three  sizes.  The  metal  is 
of  such  thinness  that  the  shield  will  go  into  the  case  with  the 
thermometer.  When  not  in  use  it  may  be  put  on  the  end  oppo- 
site the  bulb,  where  it  is  out  of  the  way.    When  it  is  to  be 


STODDART  BROS 
BUFFALO,  N.Y. 


used,  the  shield  should  be  placed  over  the  lower  end  of  the  stem 
of  the  thermometer,  a  quarter  to  half  an  inch  above  the  bulb. 
The  working  of  the  thermometer  is  not  interfered  with,  while 
the  metal  prevents  the  glass  beneath  from  being  bitten.  It  may 
be  removed  to  be  cleaned  or  boiled. 

It  may  be  applied  to  the  lens-front  thermometer  by  broad- 
ening the  opening  in  the  shield  so  that  the  blades  embrace  the 
lens.  In  this  case  the  thermometer  should  be  held  in  the  mouth 
sideways,  in  order  that  the  teeth  may  not  bite  the  lens  through 
the  broadened  opening. 

The  shield  was  designed  particularly  for  taking  the  tempera- 
tures of  children.  It  allows  us  to  do  tliat  in  the  mouth  in  many 
cases  where  we  should  otherwise  have  to  use  the  axilla.  It  is 
not  so  useful  for  very  young  children  as  for  those  old  enough 
to  act  intelligently,  yet  whom  we  are  afraid  to  trust  with  unpro- 
tected thermometers  in  their  mouths. 

The  shield  was  made  for  me  by  Stoddart  Brothers,  of  Buffalo. 

186  Allen  Street. 


The  Section  in  Neurology  and  Medical  Jurisprudence  of  the  Ameri- 
can Medical  Association  is  ovideiitly  in  gixnl  hands  this  year,  with  Dr. 
Charles  K.  Mills,  of  Philailelpliia,  as  chainnan,  and  Dr.  James  (i.  Kier- 
nan,  of  Chicago,  as  secietaiy.  This  is  shown  by  the  following  prelimi- 
nary programme :  Anorexia  Nervosa,  by  Dr.  William  Osier,  of  Balti- 
more ;  Evidences  of  Paranoia  gleaned  from  the  United  States  Patent 
Office,  by  Dr.  Irving  C.  Rosse,  of  Washington ;  Acromegaly,  by  Dr. 


Harold  N.  Meyer,  of  Chicago ;  On  the  Weight  of  the  Brain,  by  Dr. 
Henry  H.  Donaldson,  of  ("hicago ;  Paretic  Dementia  in  Women,  by  Dr. 
Harriet  C.  B.  Alexander,  of  Chicago;  Suggestions  on  the  Treatment  of 
Sclerosis  of  the  Spinal  Cord,  by  Dr.  Daniel  R.  Brower,  of  Chicago ; 
Occupation  Neuroses  affecting  the  Muscles  of  the  Neck,  and  Syringo- 
myelia, by  Dr.  Ai'chibald  Church,  of  Chicago ;  Malpractice  in  Insane 
Hospitals,  by  Dr.  James  (J.  Kiernan,  of  Chicago;  llcniiparaplegia ;  Re- 
port of  a  Case  completely  recovered  after  One  Year's  Duration,  and 
Aural  Vertigo  (Mdnifere's  Disease),  by  Dr.  L.  Harrison  Mettler,  of  Chi- 
cago ;  Race  Degeneracy  and  the  Jaws,  by  Dr.  E.  S.  Talbot,  of  Chicago ; 
Remarks  on  the  Therapeutical  Use  of  Static  Electricity,  by  Dr.  G.  F. 
Lydston,  of  Chicago;  Thoughts  on  the  Causation  of  Insanity,  by  Dr.  T. 
H.  McRride,  of  Milwaukee;  Recent  Discoveries  and  Observations  bear- 
ing on  the  Subject  of  Poisoning  from  Exposure  to  Arsenical  Wall 
Papers,  by  Dr.  .lames  J.  Putnam,  of  Boston  ;  American  Inebriate  Asy- 
lums,  by  Dr.  Thomas  D.  Crothers,  of  Hartford ;  Transverse  Myelitis,  by 
Dr.  E.  D.  Fisher,  of  New  York ;  What  should  constitute  Legal  Re- 
sponsibility, in  the  Medical  Sense,  in  Insanity  ?  by  Dr.  Landon  Carter 
Gray,  of  New  York  ;  On  the  Proper  Method  of  determining  whether 
an  Alleged  Lunatic  shall  be  declared  Legally  Insane  or  Not,  by  Dr. 
Gra;me  M.  Hammond,  of  New  York ;  The  Care  of  Epileptics,  by  Dr- 
Frederick  Peterson,  of  New  York ;  Syphilis  of  the  Cord  simulating 
Tabes,  by  Dr.  Bernard  Sachs,  of  New  York ;  Some  Medico-lcRal  Ex- 
periences in  Railway  Cases,  by  Dr.  Thomas  G.  Morton,  of  Philadelphia  ; 
Some  Points  in  the  Weir  Mitchell  Rest  Treatment,  by  Dr.  Wharton 
Sinkler,  of  Philadelphia;  A  Study  of  the  (Jliomatous  Process  in  the 
Spinal  Cord,  illu.strated  by  Microscopical  Sections,  by  Dr.  James  Heu- 
drie  Lloyd,  of  Philadelphia  ;  The  Syniptomatology  of  Cerebellar  Tumor, 
by  Dr.  Francis  X.  Dercuni,  of  Philadelphia ;  A  Study  of  the  Ocular 
Symptoms  in  Friedreich's  Disease,  by  Dr.  Charles  A.  Oliver,  of  Phila- 
delphia; Has  the  So-called  Suspension  Treatment  of  Diseases  of  the 
Spinal  Cord  proved  an  Addition  to  our  Therapeutics  ?  by  Dr.  Hobart 
A.  Hare,  of  Philadelphia ;  Notes  on  the  Treatment  of  Exophthalmic 
Goitre,  and  Insanity  in  Childhood,  by  Dr.  J.  Madison  Taylor,  of  Phila- 
delphia ;  A  Contribution  to  the  Study  of  Friedreich's  Ataxia,  by  Dr. 
Charles  W.  Burr,  of  Philadelphia ;  The  Diagnosis  of  Lead  Convulsions, 
by  Dr.  D.  D.  Stewart,  of  Philadelphia ;  A  Consideration  of  the  Different 
Trigeminal  Operations  for  the  Relief  of  Pain,  by  Dr.  .John  B.  Deaver,  of 
Philadelphia ;  Experiences  of  a  Chemist  with  Delusional  Insanity,  by 
Dr.  Henry  Leffmann,  of  Philadelphia ;  Hemianopsia  and  Certain  Symp- 
tom-Groups in  Subcortical  Lesions,  by  Dr.  Charles  K.  Mills  and  Dr.  (t. 
E.  de  Schweinitz,  of  Philadelphia ;  Paranoia  in  some  of  its  Medico- 
legal Aspects,  by  Dr.  Charles  K.  Mills,  of  Philadelphia;  The  Early 
Recognition  and  liational  Treatment  of  Moral  Imbecility,  by  Dr.  Isaac  N. 
Kerlin,  of  Elwym,  Pa. ;  A  Case  of  Subcortical  Cyst  of  the  Lower  Part 
of  the  Ascending  Parietal  Convolution ;  Operation — Recovery,  by  Dr. 
Theodore  Diller,  of  Pittsburgh,  Pa. ;  Insanity  of  the  Aged,  by  Dr. 
Frank  T.  Norbury,  of  Jacksonville,  111. ;  Gynaecology  in  the  Insane,  by 
Dr.  Annette  McFarland,  of  Jacksonville,  111. ;  Dyspepsia  as  a  Nervous 
Disease ;  or  Indigestion  in  its  Nervous  Aspects  and  Relations,  by  Dr. 
C.  H.  Hughes,  of  St.  Louis ;  A  Case  of  Syphilis  of  the  Pia  simulating 
Tumor  of  the  Brain ;  Monospasm  and  Monoparesis  ;  Operation  ;  Death 
on  the  Third  Day,  by  Dr.  J.  T.  Eskridge,  of  Denver,  Col. ;  The  Inade- 
quacy of  the  Morbid  Anatomical  Changes  found  post  mortem  to  Ex- 
plain the  Manifestations  of  Insanity,  by  Dr.  H.  A.  Tomlinson,  of  St. 
Peter,  Minn. ;  Degrees  of  Responsibility  as  found  in  the  Insane,  by  Dr. 
R.  M.  Phelp.s,  of  Rochester,  Minn. ;  Surgery  in  the  Insane,  by  Dr.  C.  B. 
Burr,  of  Pontiac,  Mich. ;  and  The  Special  Influence  of  Alcohol  on  the 
Body,  by  Dr.  T.  L.  Wright,  of  Bellefontaine,  0. 

Best  in  Cardiac  Disease. — At  a  meeting  of  the  Brighton  and  Sussex 
Medical  Society,  reported  in  the  British  Alcdicaljournal  lor  Ma,rch  25th, 
Dr.  Lauder  Brunton  read  a  paper  on  this  subject.  "  He  sketched  the 
condition  of  the  circulation  in  a  bad  case  of  mitral  disease,  and  showed 
that  it  closely  approximated  to  the  condition  after  death,  where  the 
arteries  were  empty  and  the  veins  overfull.  He  demonstrated,  by  means 
of  a  partially  stopped  syringe,  that  the  mere  loudness  of  a  murmur  did 
not  necessarily  mean  great  incompetence  of  the  valve.  In  mitral  dis- 
ease there  were  three  causes  of  regurgitation — thickening  and  contrac- 
tion of  the  valves,  dilatation  of  the  auriculo-ventricular  opening,  and 


April  15,  1893.] 


MISCELLANY. 


427 


inco-orilinated  action  of  the  iiiusfuli  papillares.  Tliis  last  he  had  first 
observed  in  dogs  poisoned  by  digitalis.  The  second  cause  occurred  as 
the  result  of  overstrain  in  young  and  quiclily-growing  persons,  in  chlo- 
rosis, in  enfeebled  hearts  after  acute  disease,  in  fatty  heart,  and  in  the 
hvpertrophied  heart  of  aortic  or  clironic  renal  disease.  Cases  of  dila- 
tation from  overstrain  in  boys  and  in  chlorotic  girls  were  narrated. 
These  were  treated  by  carefully  regulated  exercise,  or  'comparative 
rest,'  as  opposed  to  '  absolute '  rest.  Massage  was  a  valuable  adjunct 
to  tliis  treatment.  He  thought  the  cases  of  weak  heart  action  after  in- 
fluenza were  due  to  a  short  and  sharp  febrile  attack  weakening  the 
heart,  but  not  lasting  long  enough  to  enfeeble  the  limb  muscles  and 
prevent  active  exercise.  The.se  cases,  and  some  of  fatty  heart  and 
early  atheroma  of  the  aorta.  Dr.  Brunton  thought  better  treated  by 
gi'aduated  exercise  on  Oertel's  plan  than  by  absolute  rest.  In  many 
persons  over  middle  age,  befoi-e  any  signs  of  heart  failure  appeared,  a 
slight  murmur  over  the  aorta,  just  above  the  valves,  might  often  be 
heard.  Such  cases  improved  under  ten-grain  doses  of  iodide  of  potassium, 
with  graduated  exercise  and  attention  to  general  hygiene.  Passing  on 
to  consider  absolute  rest  in  advanced  cases  of  mitral  disease.  Dr.  Brun- 
ton again  described  the  condition  of  the  circulation,  and  showed  that 
the  albuminuria  was  du,e  chiefly  to  the  venous  engorgement  of  the  kid- 
ney, causing  actual  pressure  upon  the  incompletely  filled  artery  of  the 
glomerulus  and  the  tubules,  thus  causing  a  real  mechanical  impediment 
to  the  urinary  secretion.  This  was  still  further  increased  by  pressure 
on  the  ureter  when  the  abdomen  was  distended  with  fluid.  By  tapping 
the  abdomen  or  giving  purges,  and  administering  digitalis  and  other 
cardiac  tonics,  this  impediment  could  be  greatly  overcome.  When  such 
means  failed,  absolute  rest — which  meant  that  the  patient  was  not  al- 
lowed to  move  a  muscle  for  any  purpose,  and  was  kept  in  bed  on  a  hair 
mattress — often  did  great  good.  In  such  cases  Dr.  Brunton  advised  a 
purely  milk  diet,  which  gave  sufl5cient  nourishment  without  overloading 
the  system,  and  the  lactose  acted  as  a  diuretic.  The  milk  diet  was  con- 
joined with  daily  massage.  Dr.  Brunton  showed  how  massage  emptied 
the  lymph  spaces  around  the  muscles  and  increased  the  flow  of  blood 
to  the  tissues,  thus  aiding  the  elimination  of  waste  products,  and  help- 
ing to  bring  fresh  nourishment  to  the  tissues.  The  process  he  likened 
to  raking  out  the  ashes  of  a  fire  and  adding  more  fuel  to  it.  Massage 
took  the  place  of  exercise  and  helped  to  clear  away  oedema,  and  it 
also  greatly  relieved  the  sense  of  fidgetiness  and  unrest.  By  the  com- 
bined use  of  absolute  rest,  cardiac  tonics,  milk  diet,  and  massage, 
many  patients,  who  had  apparently  only  a  few  days  to  live,  might  be 
restored."  • 

The  late  Dr.  George  C.  Shattuck,  of  Boston. — The  Boston  Medical 
and  Sur(/ical  Journal  prints  the  following  obituary  notice  of  the  late 
Dr.  Shattuck : 

"Dr.  George  C.  Shattuck  was  born  in  Boston  in  1813,  and  died 
at  his  home  in  Boston,  March  22,  1893.  His  father  and  grandfather 
were  both  physicians  of  large  practice  and  wide  experience,  the  former 
in  Boston,  the  latter  in  Worcester  County.  His  mother  was  Eliza 
Cheever  Davis,  a  descendant  of  old  Boston  merchants,  and  daughter  of 
the  first  speaker  of  a  Massachusetts  House  of  Representatives  under 
the  Constitution  of  the  United  States.  He  went  to  the  Boston  Latin 
School,  and  subsequently  to  the  famous  Round  Hill  School,  established 
at  Noithampton,  Mass.,  by  Messrs.  George  Bancroft  and  Joseph  G. 
Cogswell.  He  graduated  from  Harvard  College  in  1831,  having  among 
his  classmates  Wendell  Phillips  and  J.  Lothrop  Motley.  After  a  year 
spent  at  the  Harvard  Law  School,  in  obedience  to  his  father's  wishes, 
he  entered  the  Harvard  Medical  School,  froni  which  he  graduated  in 
1835,  taking  some  additional  courses  at  Bowdoin,  and  with  his  fatlier's 
personal  friend,  Professor  Lincoln,  at  Burlington,  Vt.  He  then  spent 
three  years  in  Europe,  principally  in  Paris  and  London,  where  he  came 
under  the  influence  and  made  the  acquaintance  of  the  principal  clinical 
teachers  of  that  day. 

"  In  common  with  his  friends  Bowditch,  Gerhard,  Still6,  and  Met- 
calfe, he  was  much  influenced  l)y  the  metliods,  the  teaching,  and  ttie 
personality  of  Louis,  with  whom  he  kept  up  liis  intimacy  until  the  lat- 
ter's  death,  forty  years  later.  He  translated  into  English  Louis's  work 
on  yellow  fever.  At  Louis's  instigation,  he  crossed  over  to  London  and 
spent  some  time  in  the  London  Fever  Hospital,  acquiring  data  for  the 


accurate  differentiation  of  typhus  and  typhoid  fevers,  a  question  which 
was  still  occupying  Louis's  attention,  although  his  book,  in  which  he 
introduced  the  name  '  typhoid,' appeared  in  1829.  Dr.  Shattuck's  ex- 
perience with  typhus  in  London,  and  his  friend  Dr.  Stille's  experience 
with  it  in  Philadelphia,  under  Gerhard,  before  gomg  to  Paris,  gave 
them  materials  for  papers  before  the  Paris  Society  for  Medical  Obser- 
vation, in  1838.  These  papers  were  of  signal  service  in  establishing 
the  distinctions  between  typhus  and  typhoid  fevers  which  Louis  had 
suggested,  but  which  the  infrequency  of  typhus  fever  in  Paris  had 
given  French  physicians  in  general  little  opportunity  to  verify. 

"  On  returning  to  Boston,  Dr.  Shattuck  immediately  entered  upon 
the  practice  of  his  profession,  for  which  he  always  had  a  genuine  en- 
thusiasm, with  his  father.  In  1840  lie  married  Miss  Brune,  daughter  of 
F.  W.  Brune,  of  Baltimore.  He  was  appointed  visiting  phy.sician  to  the 
Massachusetts  General  Hospital  in  1849,  upon  the  resignation  of  Dr. 
Oliver  Wendell  Holmes.  He  served  in  this  capacity  for  thirty-six  years, 
and  upon  liis  resignation,  in  1885,  was  appointed  to  the  Board  of  Con- 
sultation. In  1855  he  was  appointed  Professor  of  Clinical  Medicine  in 
the  Harvard  Medical  School,  and  in  1859  was  transferred  to  the  chair 
of  Theory  and  Practice.  This  professorship  he  held  until  1874.  He 
was  during  many  years  dean  of  the  medical  school,  at  a  time  when  the 
school  property  and  policy  were  entirely  controlled  by  the  faculty,  and 
when,  but  for  the  name,  it  was,  to  all  intents  and  purposes,  a  private 
undertaking.  As  professor  and  as  dean,  Dr.  Shattuck's  disinterested 
unselfishness  in  seeking  to  promote  what  he  considered  the  interests 
of  the  school  and  of  the  students,  without  regard  to  the  effect  upon  his 
own  position  or  preferences,  was  a  marked  characteristic.  Several  of 
the  school's  best  teachers  would  have  been  lost  to  it  without  his  per- 
sistent advocacy  of  their  appointment ;  and  in  more  than  one  instance 
place  was  made  in  his  own  department  for  those  who  could  not  be  pro- 
vided for  in  other  departments.  His  advocacy  of  an  extension  of  teach- 
ing, outside  of  the  regular  school  lectures,  to  younger  men  in  quiz 
classes  and  otherwise,  was  practical  as  well  as  theoretical.  Practical, 
inasmuch  as  he  gave  for  this  purpose  the  use  of  the  large  and  con- 
venient room  in  his  office  building.  Had  he  been  supported  in  these 
efforts,  the  school  might  have  had  an  earlier  development  in  this  im- 
portant direction.  He  introduced  the  clinical  conference,  which  has 
since  proved  a  valuable  feature  in  the  various  departments  of  the 
school. 

"  Among  Dr.  Shattuck's  colleagues  at  the  Harvard  Medical  School 
were  Dr.  0.  W.  Holmes,  Dr.  H.  I.  Bowditch,  Di'.  H.  J.  Bigelow,  Dr.  D. 
Humphreys  Storer,  Dr.  E.  H.  Clarke,  Dr.  D.  W.  Cheever,  and  Dr.  J.  C. 
White. 

"  In  1866  he  delivered  the  annual  address  before  the  Massachusetts 
Medical  Society,  on  The  Medical  Profession  and  Society.  In  1872  and 
1873  he  was  president  of  the  society.  For  many  years  he  was  chairman 
of  its  committee  on  publications.  He  was  a  member  of  the  American 
Academy  of  Arts  and  Sciences,  vice-president  of  the  American  Statistical 
Association,  an  honorary  fellow  of  the  Philadelphia  College  of  Pliysi- 
cians,  a  member  of  the  Paris  Society  for  Medical  Observation,  and  of 
the  leading  medical  societies  of  Boston. 

"  Dr.  Shattuck  had,  as  has  been  said,  a  real  enthusiasm  for  the  prac- 
tice of  his  profession,  but  his  activity  was  much  interfered  with  at  a 
critical  period  by  a  loss  of  health  and  consequent  enforced  rest  and  ab- 
sence. His  interests,  however,  were  varied,  and  were  not  confined  solely 
to  medicine.  Ecclesiastical  and  educational  questions  occupied  much 
of  his  time  and  thought.  He  was  very  conversant  with  forms  of  relig- 
ious belief  and  questions  of  church  government,  both  at  home  and 
abroad,  in  tlie  past  and  at  present.  His  own  church,  the  Protestant 
Episcopal,  and  its  services,  were  very  dear  to  him.  He  knew  and  had 
thouglit  nmch  about  schools  and  colleges,  and  always  had  a  keen  inter- 
est, which  he  may  be  said  to  have  inherited  from  his  father,  in  the  train- 
ing of  young  men.  His  interest  in  religion  and  education  led  hiiu  to 
found  St.  Paul's  School,  at  Concord,  N.  II.,  and  to  assist  in  establishing 
a  similar  institution  at  Farit)ault,  Minn.  For  a  number  of  years  he  de- 
livered annual  lectures  on  physiology  and  hygiene  to  the  students  at 
Trinity  College,  Hartford,  Conn.,  and  at  St.  James's  College,  Maryland. 

"  Dr.  Shattuck  was  a  man  of  excellent  judgment  and  discrimination, 
of  a  very  liberal  training,  of  wide  acquaintance  with  the  world  and  with 
human  nature,  of  a  firm  purpose  but  a  tender  heart,  of  a  rare  unselfish- 


428 


MISCELLANY. 


[N.  Y.  Med.  Joto. 


ness,  a  constant  courtesy  and  thoughtfulness  for  others.  Of  deeply  re- 
ligious instincts  and  beliefs,  he  still  had  an  invariable  charity  for  all 
men  and  all  differences  of  opinion  and  belief.  He  had,  moreover,  a  keen 
sense  of  humor,  and  was  a  delightful  companion  whether  at  home  or 
abroad.  In  a  word,  he  combined  many  characteristics  not  often  united 
in  one  person.  He  had  a  genius  for  friendship,  and  the  old  friends  for 
him  were  always  the  same.  He  was  a  man  who  looked  at  this  world 
and  beyond  it  to  the  next  in  a  truly  broad  and  catholic  spirit.  He  was 
not  too  good  for  this  world  or  the  work  of  this  world  ;  but  if  he  was 
not  good  enough  for  a  better  one,  there  will  be  few  who  find  place  in 
such." 

The  Fan-American  Medical  Congress. — The  organization  of  the 
Section  in  Diseases  of  Children  is  completed,  and  we  learn  that  the  ar- 
rangement of  the  programme  is  well  advanced.  The  sessions  will  un- 
doubtedly prove  of  great  value.  American  physicians  desiring  to  read 
papers  are  asked  to  communicate  at  once  with  the  English-speaking 
secretary,  who  will  be  pleased  to  furnish  all  needed  information.  The 
officers  are  as  follows :  Executive  president :  Dr.  John  M.  Keating, 
Colorado  Springs,  Colorado.  Secretaries :  Dr.  F.  M.  Crandall  (English- 
speaking),  No.  113  West  Ninety-fifth  Street,  New  York;  Dr.  Damaso 
Laine  (Spanish-speaking),  Media,  Pa.  Honorary  presidents :  Dr.  S.  S. 
Adams,  Washington ;  Dr.  A.  D.  Blaekader,  Montreal ;  Dr.  Samuel  C. 
Busey,  Washington ;  Dr.  Charles  Warrington  Earle,  Chicago ;  Dr.  F. 
Forchheimer,  Cincinnati ;  Dr.  L.  Emmet  Holt,  New  York  ;  Dr.  A.  V. 
Meigs,  Philadelphia ;  Dr.  W.  P.  Northrup,  New  York ;  Dr.  J.  O'Dwyer, 
New  York ;  Dr.  C.  1.  Putnam,  Boston ;  Dr.  T.  M.  Rotch,  Boston ;  Dr.  J. 
Lewis  Smith,  New  York  ;  Dr.  Louis  Starr,  Philadelphia ;  Dr.  J.  E.  Win- 
ters, New  York ;  Dr.  Jesus  Valenzuela,  Mexico,  Mexico  ;  Dr.  L  N.  Love, 
St.  Louis.  Advisory  council:  Dr.  William  D.  Booker,  Baltimore  ;  Dr. 
Augustus  Caill6,  New  York ;  Dr.  Henry  D.  Chapin,  New  York ;  Dr.  J. 
P.  Crozier  Griffith,  Philadelphia;  Dr.  M.  P.  Hatfield,  Chicago;  Dr. 
Thomas  S.  Latimer,  Baltimore ;  Dr.  J.  H.  Ripley,  New  York ;  Dr. 
August  Seibert,  New  York  ;  Dr.  Charles  W.  Townsend,  Boston ;  Dr. 
Jerome  Walker,  Brooklyn ;  Dr.  William  Perry  Watson,  Jersey  City. 

The  Section  in  Pathology  has  been  organized  as  follows :  Honorary 
presidents:  Dr.  Antonio  J.  Amadeo,  Maunabo,  Puerto  Rico;  Dr.  Fran- 
cis Delafield,  New  York ;  Dr.  George  Duffield,  Detroit ;  Dr.  John 
Guit^ras,  Philadelphia;  Dr.  F.  S.  Johnson,  Chicago;  Dr.  Morris  Long- 
Btreth,  Philadelphia ;  Dr.  Alfred  L.  Loomis,  New  York ;  Dr.  L.  D. 
Mignault,  Montreal ;  Dr.  T.  Francisco  Puelma,  Santiago,  Chili ;  Dr.  Jos6 
M.  Quiroga,  Lima,  Peru  ;  Deputy  Surgeon-General  George  M.  Sternberg, 
U.  S.  Army ;  Dr.  Clark  Stewart,  Minneapolis,  Minn. ;  Dr.  Joshua  M. 
Van  Cott,  Brooklyn,  N.  Y. ;  Dr.  Joaquin  Vertiz,  City  of  Mexico ;  Dr. 
William  H.  Welch,  Baltimore ;  Dr.  J.  J.  Comilliac,  St.  Pierre,  Marti- 
nique ;  Dr.  W.  T.  Councilman,  Boston,  Mass  ;  Dr.  Juan  Landeta,  Havana, 
Cuba ;  Dr.  John  H.  Musser,  Philadelphia, ;  Dr.  E.  0.  Shakespear, 
Philadelphia.  Executive  president:  Dr.  John  Guit6ras,  4914  Sansom 
Street,  Philadelphia.  Secretaries :  Dr.  David  Inglis  (English-speak- 
ing), 21  State  Street,  Detroit,  Mich.  ;  Dr.  Louis  F.  Criado  (Spanish- 
speaking),  14*7  Fort  Greene  Place,  Brooklyn ;  Dr.  Wernicke  (Victoria 
1194),  Buenos  Aires,  Argentine  Republic;  Dr.  Enrique  Hertzog,  La  Paz, 
Bolivia ;  Dr.  Leopoldo  Mendes  Costa,  Rio  de  Jauerio,  U.  S.  of  Brazil ; 
Dr.  John  Caren,  Toronto,  Canada ;  Dr.  Raimundo  de  Castro  (Salud  esq. 
i  Gervasio),  Havana,  Cuba;  Dr.  NicolAs  Osorio  (Calle  13  niim.  181), 
Bogota,  Colombia ;  Dr.  J.  Carreau,  Point  k  Pitre,  Guadeloupe,  F.  W.  I. ; 
Dr.  Samuel  Gonzalez,  Guatemala  City,  Guatemala ;  Dr.  F.  L.  Miner 
Honolulu,  Hawaii ;  Dr.  Rafael  Fiallos,  Tegucigalpa,  Honduras ;  Dr. 
Francisco  Hurtado  (Leon  9),  Mexico,  Mexico ;  Dr.  J.  Martinez,  Granada, 
Nicaragua ;  Dr.  David  Matto  (Facultad  de  Mediciua),  Lima,  Peru ;  Dr. 
Alfredo  Vidal  y  Fuentes  (Sierra  8),  Montevideo,  Uruguay ;  Dr.  M.  M. 
Ponte,  Caracas,  Venezuela. 

The  City  Board  of  Health. — Dr.  Joseph  P.  Bryant  has  resigned  his 
office  of  commissioner,  and  been  succeeded  by  Dr.  Cyrus  Edson ;  Dr. 
Charles  F.  Roberts  has  been  made  sanitary  superintendent,  in  place  of  Dr. 
Ed.son ;  Dr.  Frank  H.  Dillingham  has  been  appointed  assistant  sanitary 
superintendent,  in  place  of  the  late  Dr.  E.  H.  Janes ;  and  Dr.  Alvah  H. 
Doty  has  succeeded  Dr.  Roberts  as  chief  inspector  in  the  bureau  of 
contagious  diseases. 


The  late  Dr.  William  E.  Ballon. — At  a  stated  meeting  of  the  So- 
ciety of  the  Alumni  of  Bellcvue  Hospital,  held  at  the  Hotel  Brunswick, 
Wednesday,  April  5th,  the  following  resolutions  were  adopted  : 

WherecK,  In  the  death  of  Dr.  William  R.  Ballou  the  Society  of  the 
Alumni  of  Bellevue  Hospital  has  lost  a  fellow-member  who  gave  prom- 
ise of  an  eminent  professional  career,  and  one  who,  by  his  geniality, 
endeared  himself  to  all, 

Resolved,  That  we  express  the  great  loss  sustained  by  this  society, 
the  profession,  and  the  community,  and  extend  to  his  bereaved  family 
our  heartfelt  sympathy  in  their  affliction. 

Resolved,  That  these  resolutions  be  spread  upon  the  minutes  of  this 
society  and  a  copy  be  sent  to  his  family  and  to  the  medical  journals  of 
this  city. 

/  JoifN  F.  Erdman,  ^ 
[Signed.]  I  W.  N.  Hubbard,  |-  Committee. 

(  H.  S.  HOCGHTON,  ) 


To  Contributors  and  Correspondents. — The  attention  of  all  who  pur/me 

favoring  us  with  comnumicationa  is  respectfully  called  to  tfie  foUoie- 
ing: 

Authors  of  articles  intended  for  publication  under  the  /lead  of  '■^original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti- 
cles, we  always  do  so  with  the  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,  uidess  we  are  specially  notifed 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (S)  accepted  arttclen 
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^  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  inedical  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  addrus,  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  thii  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  confdential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi- 
vidual practitioners. 

Secretaries  of  medical  societies  viill  confer  a  favor  by  keeping  us  in- 
formed of  the  dates  of  their  societies'  regular  meetings.  Brief  notif- 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet- 
ings will  be  itiserted  lohen  tlicy  are  received  in  time. 

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

All  commimtcations  iiitendcd  for  the  editor  shoicld  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. 

Contributors  who  wish  to  order  REPRINTS  of  their  articles  should  do 
so  on  a  b<,ank  prepared  for  thai  purpose,  which  wid  be  sent  to  t/iem 
by  the  pubh.shi  rs  on  receipt  of  a  reqitest  to  that  effect.  The  order 
should  be  sent  to  the  ptiblis/ters,  and  NOT  to  tlie  editor. 


THE  JN^EW  YORK  MEDICAL  JOURNAL,  Apbil  22,  1893. 


(irrginal  Communicatbns. 


CAR  DINE; 

THE  EXTRACT  OF  THE  HEART. 

ITS  PREPARATION 
AND  PHYSIOLOGICAL  AND  THERAPEUTICAL  EFFECTS. 

lir  WILLIAM  A.  HAMMOND,  M.  D., 

HUKQEON-GENKIIAL,  V.  8.  AJIMT  (rKTIBKD  LIST). 

In  continuation  of  the  article  on  Certain  Organic  Ex- 
tracts, etc.,  which  appeared  in  tlie  JVew  York  Medical  Jour- 
nal for  January  28,  1893,  I  have  to  submit  the  following 
remarks  on  the  subject  of  cardine,  which,  as  the  name  im- 
ports, is  the  extract  of  the  heart,  and  in  this  instance  of  the 
heart  of  the  ox.  I  have  experimented  with  the  heart  of  the 
sheep,  the  dog,  and  the  common  fowl,  but  that  of  the  ox  has 
afforded  the  most  decided  physiological  effects,  and  is  there- 
fore to  be  preferred.  So  far  as  I  am  aware,  no  such  prepa- 
ration as  the  one  I  am  about  to  describe  has  yet  been  used 
in  medicine,  nor  has  the  organ,  to  my  knowledge,  been  em- 
ployed for  the  treatment  of  the  disorders  of  the  heart  un- 
less, perhaps,  by  the  German  physician  of  some  forty  years 
ago  to  whom  I  alluded  in  my  previous  communication  as 
having  proposed  to  cure  diseases  of  the  various  organs  of 
the  body  by  causing  the  subjects  of  them  to  eat  the  cor- 
responding organs  of  animals.  As  I  then  stated,  my 
reference  is  entirely  from  memory  of  what  I  had  read 
in  medical  journals  at  aboift  the  time  of  the  publication 
of  his  essay. 

Cardine,  as  used  by  me,  is  prepared  as  follows  :  One 
thousand  grammes  of  the  finely  minced  fresh  heart  of  the 
ox,  previously  well  washed  in  a  saturated  solution  of  boric 
acid,  are  submitted  to  the  action  of  a  menstruum  consisting 
of  twelve  hundred  grammes  of  glycerin,  one  thousand 
grammes  of  a  saturated  solution  at  60°  F.  of  boric  acid,  and 
eight  hundred  grammes  of  alcohol.  These  proportions  are 
the  result  of  a  large  number  of  experiments  and  are  those, 
I  think,  which  are  most  efficacious  in  extracting  from  the 
heart  its  peculiar  principle. 

The  mixture  is  made  in  a  strong  porcelain,  glass,  or  glazed 
earthenware  jar  provided  with  a  closely  fitting  cover,  and 
every  day  for  a  period  of  at  least  eight  months — and  I  am 
disposed  to  think  that  a  year  is  preferable — the  mixture  is 
stirred  and  the  heart  substance  subjected  to  strong  pressure 
with  a  boxwood  masher,  such  as  is  used  in  the  preparation 
of  certain  vegetables  for  the  table.  If  a  much  less  period 
than  eight  months  is  given  to  the  process  of  maceration  the 
product  is  inefficient,  and  indeed,  as  1  have  said,  it  is  bet- 
ter to  let  the  extraction  go  on  for  a  much  longer  period. 

Experiments  that  I  have  made  with  the  freshly  expressed 
juice  of  the  heart,  either  pure  or  in  combination  with  gly- 
cerin or  alcohol  in  various  proportions,  show  that  it  is  abso- 
lutely without  physiological  or  therapeutical  influence  other 
than  that  of  the  transitory  stimulating  effect  of  the  alcohol 
when  the  proportion  of  this  substance  is  great. 

At  the  end  of  the  period  of  maceration  the  supernatant 
liquid  is  poured  into  the  upper  receptacle  of  a  porous  stone 


filter  and  allowed  to  percolate  through  iuto  the  lower  vessel. 
The  finely  comminuted  heart  substance  remaining  is  sub- 
jected to  very  strong  pressure  in  a  metallic  press  and  the 
resultant  juice  also  poured  into  the  filter.  The  filtration  is 
a  very  slow  process,  the  solution  of  the  heart  being  even 
more  refractory  than  that  of  the  brain  and  other  nervous 
structures,  and  several  weeks  are  required  for  the  comple- 
tion of  the  process.  Percolation  through  filtering  paper  will 
not  answer. 

As  thus  prepared,  the  solution  of  cardine  is  a  clear, 
transparent  liquid  of  a  pale  straw-color,  with  the  specific 
gravity  of  I'OVO.  Under  the  microscope  it  exhibits  no 
morphological  constituents ;  it  does  not  change,  so  far  as  I 
am  aware,  under  any  ordinary  circumstances,  and  no  bacte- 
ria possess  sufficient  vitality  to  exist  in  it.  It  is  perhaps 
better,  however,  that  it  should  be  kept  in  a  cool  place  in 
well-stoppered  phials. 

I  have  said  that  it  is  unchangeable  under  ordinary  cir- 
cumstances, but  occasionally  when  the  phials  containing  it 
have  been  subjected  to  extreme  variations  of  temperature 
and  to  agitation,  about  two  per  cent,  of  them  will  exhibit  a 
slight  flocculent  precipitate  which  is  albuminous  in  charac- 
ter. When  this  occurs,  filtration  through  Swedish  filtering 
paper  or  through  a  funnel,  the  throat  of  which  is  closed 
with  absorbent  cotton,  suffices  for  its  removal.  The  re- 
maining liquid,  under  these  circumstances,  loses  none  of  its 
properties. 

Of  course  the  most  rigid  antiseptic  precautions  must  be 
taken  in  the  preparation  of  this  and  all  the  other  animal 
extracts  which  I  have  used.  It  must  be  borne  in  mind, 
however,  that  as  the  extract  is  to  be  injected  into  the  blood, 
the  substances  employed  for  the  prevention  of  septicism 
must  be  such  as  are  not  deleterious  to  the  human  system 
or  which  of  themselves  have  any  marked  or  positive  physio- 
logical effect.  Carbolic  acid  and  corrosive  sublimate, 
therefore,  are  out  of  the  question.  Heat  and  boric  acid  I 
have  found  to  be  entirely  efficacious,  and  the  latter,  form- 
ing as  it  does  one  of  the  constituents  of  the  mixture,  is 
especially  eligible. 

A  great  many  experiments  were  required  in  regard  to 
the  dose  of  cardine  to  be  hypodermically  administered,  and 
it  is  therefore  necessary  to  insist  upon  a  due  observance  of 
the  proportions  of  the  various  substances  entering  into  its 
composition  being  strictly  adhered  to.  Regard  must  also 
be  paid  to  the  period  of  time  during  which  maceration  is 
continued.  Thus  action  for  a  month  or  two  produces  a 
liquid  v/hicli  contains  such  a  small  amount  of  the  essential 
principle  that  it  is  almost,  if  not  entirely,  inert.  Macera- 
tion for  six  months  results  in  a  product  the  effects  of  which 
are  perceptible,  but  of  which  the  dose  must  be  fifteen  or 
twenty  minims,  and  even  then  the  physiological  and  thera- 
peutical influence  is  feeble.  After  eight  months,  however, 
the  aclion  is  much  more  decided,  and  five  minims  hypo- 
dermically injected  is  a  good  average  dose  for  an  adult, 
some  persons  requiring  a  minim  or  two  more,  while  with 
others  a  minim  or  two  less  suflices.  I  have  arranged  tlu» 
dose  after  many  experiments  upon  healthy  men  and  women 
of  average  size,  and  have  accordingly  fixed  upon  five  miaims 


430 


HAMMOND:   GAR  DINE. 


[N.  Y.  Med.  Jonp., 


as  the  proper  dose  of  oardine  after  a  maceration  of  from 
eight  to  ten  months. 

I  can  not  too  strongly  insist  upon  proper  filtration  of 
cardine,  as  well  as  of  all  the  other  animal  extracts  obtained 
by  my  j^rocess.  It  is  absolutely  essential  that  no  morpho- 
logical matter  should  be  present  in  the  liquid  used  for 
hypodermic  injection.  If  this  precaution  is  not  observed, 
abscesses,  and  even  more  serious  disturbance,  will  most  cer- 
tainly follow.  After  proper  preparation  cardine  is,  as  I 
have  said,  absolutely  fatal  to  bacterial  life.  At  the  time  of 
injection  it  is  well,  though  not  essential,  to  add  to  the  quan- 
tity used  a  like  amount  of  sterilized  distilled  water.  I  say 
sterilized,  for,  although  I  am  sure  that  bacteria  will  not  live 
in  pure  cardine,  they  may  be  able  to  live  in  it  when  it  is 
diluted  with  water. 

The  physiological  effects  of  cardine,  in  their  order  of 
occurrence,  as  nearly  as  I  can  arrange  them,  are  as  follows : 
1.  Within   ten   minutes   the   pulse   becomes  fuller, 
stronger,  and  sometimes  more  frequent.    The  sphygmo- 
g  rap  h  shows  this  very  clearly.    The  accompanying  tracing 
(!''   ig.  1)  is  that  obtained  from  a  man,  thirty  years  of  age,  in 


Fig.  1. 


ood  health.  The  pulse  at  the  time  was  beating  76  \n  a 
minute. 

Fig.  2  shows  a  sphygmographic  tracing  taken  from  the 
same  person  ten  minutes  after  receiving  a  hypodermic  in- 


Fio. 


jection  of  five  minims  of  cardine.  It  is  scarcely  necessary 
to  comment  on  the  differences  which  exist.  The  influence 
in  increasing  the  force  and  frequency  of  the  pulsations  is 
remarkable,  and  it  is  still  more  remarkable  that  a  tracing 
(Fig.  3)  taken  eight  hours  subsequent   to  the  injection 


Fm.  3. 

shows  that  the  effect  upon  the  heart  was  still  present  in  a 
scarcely  diminished  degree. 

2.  These  tracings  show  what  is  also  evident  from  a 
digital  examination  of  the  pulse — that  the  arterial  tension  is 
.augmented. 

3.  Increasing,  as  cardine  does,  the  heart  pressure,  the 
•effect  upon  the  kidneys  follows  as  a  logical  consequence. 
Many  observations,  made  as  far  as  possible  under  exactly 
.similar  conditions,  establish  the  fact  that  the  amount  of 
urine  daily  excreted  is  increased  by  from  ten  to  eighteen 
ounces. 

4.  The  number  of  red  corpuscles  in  the  blood  is  in- 
I  Teased  by  the  use  of  cardine. 

Thus  I  found  that  in  a  woman  in  good  general  health 


and  development  the  number  of  red  corpuscles,  as  deter- 
mined by  the  haimocytometer,  was  four  million  three  hun- 
dred thousand  to  the  cubic  millimetre.  After  two  hypo- 
dermic injections  of  cardine  daily  for  five  successive  days 
the  number  of  red  corpuscles  had  increased  to  four  million 
eight  hundred  and  twenty  thousand.  By  means  of  the 
hajmometer  similar  results  were  obtained,  the  degree  of 
coloration  being  83°  before  the  injection  of  the  cardine, 
while  after  the  use  of  this  substance,  continued  as  in  the 
previously  mentioned  experiment,  it  rose  to  96°. 

Many  experiments  of  like  character  have  led  to  similar 
conclusions.  Indeed,  I  know  of  no  fact  more  definitely 
established  than  this  of  the  effect  of  cardine  upon  the 
composition  of  the  blood. 

My  object  in  the  present  communication  is  mainly  to 
show  the  physiological  effects  of  cardine,  leaving  to  the  in- 
telligent physician  the  office  of  drawing  his  own  deductions 
as  to  its  therapeuticul  uses.  It  is  clearly  a  heart  tonic  of 
great  power,  a  diuretic  of  notable  value,  and  an  agent 
capable  of  exercising  a  marked  effect  over  the  composition 
of  the  blood. 

In  cases  of  cardiac  weakness,  from  whatever  cause 
it  may  arise,  cardine  is  of  inestimable  value.    It  ap- 
pears to  me,  from  the  few  cases  in  which  I  have 
employed  it  in  this  connection,  to  be  useful  in  fatty 
degeneration  of  the  heart,  improving  the  nutrition  of 
the  organ  not  only  by  its  action  on  the  blood,  to  which  I 
have  made  reference,  but  by  its  effects  on  the  nervous  or- 
ganization of  the  cardiac  tissue. 

In  one  patient  under  my  charge — a  gentleman  from  North 
Carolina  in  whom  the  pulse  was,  while  he  was  in  a  state  of 
rest,  only  40  in  a  minute,  and  in  whom  the  heart  impulse  was 
exceedingly  weak,  and  in  whom  also  there  was  an  anasarcons 
condition  of  the  feet  and  legs — cardine,  in  five-minim  doses  ad- 
ministered hypodermically  twice  daily,  hegan  at  once  to  exer- 
cise a  beneScial  effect.  The  pulse  rose  to  64  and  occasionally  to  70 
in  a  minute.  The  heart-beat  was  increased  in  force,  the  amount 
of  urine  augmented,  the  dropsy  of  the  extremities  disappeared, 
and  many  symptoms  of  gastric  and  intestinal  dyspepsia  from 
which  he  suffered  were  entirely  dissipated,  and  this  after  about  a 
month's  treatment.  Six  weeks  have  elapsed  and  this  good  con- 
dition continues  in  every  respect.  That  it  will  remain  as  at 
present  without  further  treatment  is  perhaps  scarcely  to  be 
hoped  for,  but  I  think  this  result  is  quite  within  the  range  of 
possibility ;  and  should  the  symptoms  recur,  I  have  no  doubt 
that  cardine  will  prove  equally  effectual  as  in  the  first  instance. 

In  another  case  of  a  gentleman  in  whom,  from  the  excessive 
use  of  tobacco,  the  heart  rhythm  was  intermittent  and  other- 
wise irregular,  this  condition  disappeared  after  a  treatment  of 
only  four  days'  duration,  and  the  patient  has  now  a  heart  ap- 
parently as  sound  as  it  ever  was. 

But  I  have  employed  cardine  more  frequently  in  those 
cases  of  nervous  prostration  attended  with  anaemia  and 
sometimes  chlorosis.  In  such  patients  its  action  is  so  prompt 
and  effectual  as  to  excite  surprise  in  all  who  have  witnessed 
the  change.  In  all  these  cases  I  have  verified  the  great  im- 
provement in  the  appearance  and  apparent  condition  of  the 
patients  by  the  use  of  the  hsemocytometer  and  haemometer. 
In  mild  cases  a  week  or  ten  days'  treatment  has  been  sufii- 
cient,  but  never  more  than  four  or  five  weeks. 


April  22,  1893.] 


HAMMOND:  CARBINE. 


431 


A  distinguished  physician  from  the  Dominion  of  Canada 
consulted  me  in  January  last  for  great  cardiac  irritability,  the 
result  of  overwork,  both  professional  and  political.  I  treated 
him  for  two  or  three  days  with  hypodermic  injections  of  cardine, 
and  the  result  was  in  the  highest  degree  gratifying.  The  attacks 
of  vertigo  from  which  he  had  suffered,  and  which  were  clearly 
the  result  of  weak  heart,  entirely  disappeared.  He  returned 
home  and  entered  at  once  with  energy  into  an  exciting  politi- 
cal campaign,  from  which  he  emerged  successfully  after  making 
over  one  hundred  speeches.  He  writes  me  that  he  endured  this 
tremendous  exertion  without  discomfort,  and  that  the  cardiiie 
worked  wonders  with  him. 

In  a  similar  case,  that  of  a  prominent  physician  of  Indiana, 
the  heart-beat  was  feeble  and  irregular,  and  there  was  constant 
vertigo  while  walking,  or  even  while  in  a  standing  position.  In 
this  case  the  relief  was  equally  prompt.  He  remained  under 
my  care  only  three  days,  being  summoned  home  by  telegram  by 
sickness  in  his  family,  after  making  arrangements  to  procure  a 
sufficiency  of  cardine  for  home  use,  and  I  advised  him  to  con- 
tinue it  for  at  least  a  month.  He  arrived  home  before  the  car- 
dine reached  him,  and,  feeling  the  need  of  it,  he  at  once  tele- 
graphed for  it  to  be  sent  to  him  as  soon  as  possible.  He  in- 
formed me  that  the  effect  upon  him  was  so  decided  that,  whei'eas 
formerly  he  was  loath  to  walk  even  a  few  steps  for  fear  of  being 
overpowered  by  dizziness,  a  single  injection  enabled  him  to 
walk  as  much  as  he  pleased  for  four  or  five  hours  afterward. 

Of  course,  it  is  too  soon  to  fix  definitely  the  therapeu- 
tical value  of  cardine,  or,  in  fact,  of  any  other  of  the  ani- 
mal extracts  made  by  my  process.  There  is  danger  that 
over-enthusiastic  and  inexperienced  or  ignorant  persons  will 
claim  too  much  for  them.  Already  I  see  that  they  are 
spoken  of  in  various  quarters  as  "  elixirs  of  life,"  and  that 
absurd  stories  are  told  of  their  power.  No  one  person  can 
be  expected  to  determine  the  value  of  these  extracts.  That 
must  be  done  by  large  numbers  working  toward  the  same 
end  and  for  long  periods.  I  do  not  even  pretend  to  assert 
that  there  may  not  be  some  better  method  of  extracting 
the  active  principle  of  the  several  organs  of  the  body  which 
I  have  subjected  to  experiments.  I  only  say  that  I  have 
labored  more  than  three  years  in  the  attempt  to  find  the 
best  method  and  that  my  experience  should  go  for  some- 
thing, and  I  feel  called  upon  to  warn  the  profession  against 
the  crude  experiments  of  sciolists,  who  rush  in  with  heavy 
foot  where  angels  should  tread  lightly.  I  have  heard  of 
one  of  these  experimenters  who  makes  a  mixture  of  brain 
substance,  glycerin,  and  phosphate  of  sodium,  and  who  injects 
this  milky-looking  compound  into  the  blood.  Of  course,  in- 
flammation ensues,  abscesses  will  probably  follow,  and  even 
worse  consequences  are  to  be  feared.  Glycerin  of  itself  is 
not  a  preservative  of  the  nervous  tissue,  except  for  a  very 
short  time,  whereas  1  know  that  the  mixture  I  use  will  keep 
it  for  at  least  a  year  and,  I  presume,  indefinitely. 

As  to  the  essential  characteristics  of  cardine,  while  I 
am  not  able  to  give  it  a  place  in  the  nomenclature  of  or- 
ganic chemistry,  I  am  sure,  from  a  consideration  of  the 
process  by  which  it  is  obtained,  that  it  is  a  substance  de- 
rived from  the  heart.  There  is  no  escape  from  this  conclu- 
sion. As  to  how  it  acts,  I  can  at  present  only  call  attention 
to  the  theory  that  1  proposed  in  my  first  paper  on  the  sub- 
ject, and  that  is  briefly  : 

That  all  the  organs  of  the  body  possess  the  power,  when 


in  a  state  of  health,  of  secreting  from  the  blood  the  peculiar 
substance  that  they  require  for  their  nutrition,  and  that 
they  take  this  substance  and  no  other,  never  making  a  mis- 
take in  the  matter.  The  brain  separates  brain  substance  : 
the  heart,  heart  substance,  and  so  on.  If  through  disease  or 
from  derangement  of  function  they  lose  this  power,  or  if  the 
peculiar  pabulum  they  require  be  not  in  the  blood  in  sufK- 
cient  quantity,  their  functions  cease  to  be  normal.  General 
debility,  producing  a  diminution  of  nerve  force,  may  cause 
the  loss  of  this  power,  or  it  may  result  from  local  disturb- 
ance either  of  structure  or  function,  or  some  profound 
shock  to  the  organism  may  so  interfere  with  hsematosis  that 
the  blood  no  longer  contains  the  material  which  the  organ 
needs.  In  either  case,  if  we  supply  to  the  blood  the  peculiar 
principle  which  a  diseased  or  disordered  organ  requires,  we 
do  that  which  Nature,  unassisted,  can  not  or  does  not  do. 

Cardine,  therefore,  if  this  theory  of  its  action  be  cor- 
rect, nourishes  the  heart.  It  is  the  substance  which  an  ill- 
conditioned  heart  must  have  for  its  well-being.  It  is  al- 
ready in  a  fit  form  for  assimilation,  and  it  acts  with  a 
promptitude,  a  certainty,  and  a  degree  of  permanence  of 
which  no  other  heart  tonic  within  my  knowledge  is  capable. 

It  follows  also  that  in  all  weak  conditions  of  the  sys- 
tem, and  especially  in  those  in  which  the  blood  is  below 
the  normal  standard,  cardine  must  prove  to  be  of  inestima- 
ble value.  And  in  other  and  more  serious  affections,  such 
as  those  in  which  depurative  organs  of  the  body,  especially 
the  kidneys,  fall  below  the  healthy  standard  of  fuuctiona- 
tion,  cardine,  increasing  as  it  does  the  heart  pressure,  ma\ 
augment  the  bodily  comfort  and  materially  prolong  life. 

Cardine  is  not  an  annihilator  of  the  influence  of  old  age, 
but  my  experience  convinces  me  that  it  lessens  the  effects  of 
this  factor  of  deterioration  so  far,  at  least,  as  the  heart  is 
concerned.  This  organ,  as  is  well  known,  is  one  of  the  flrst 
to  fail  in  physiological  power,  and  this  is  shown  not  only 
by  the  examination  of  the  pulse  and  of  the  heart  itself,  but 
by  the  accumulation  of  fluid,  especially  in  the  lower  ex- 
tremities, owing  to  a  diminution  of  the  heart  pressure. 
Cardine,  taken  in  conjunction  with  cerebrine,  assuredly 
counteracts  this  influence,  for,  owing  to  the  increase  of  the 
cardiac  pressure,  the  passive  anasarcous  condition  disap- 
pears, and  the  other  indications  of  heart  weakness  are 
either  greatly  mitigated  or  altogether  abolished.  How 
long  this  power  will  remain  in  any  particular  case  I  am 
not  at  present  able  to  say,  but  I  know  that  a  daily  hypo- 
dermic injection  continued  for  six  months  does  not  yet 
reveal  any  sensible  loss  in  its  influence. 


The  New  York  Academy  of  Medicine. — Dr.  J.  West  Hoo.sevelt  was 
announced  to  read  a  i)a|)er  entitled  A  Consideration  of  the  Causes  of 
Acquired  Immunity  from  Infectious  Diseases  at  the  meeting  of  Thursday 
evening,  the  20th  inst.,  and  Dr.  Daniel  Lewis  to  read  one  entitled  Notes 
of  a  Case  of  Uterine  Cancer — Remarks  on  Diagnosis  and  Treatment. 

At  the  next  meeting  of  the  Section  in  Laryngology  and  Rhinology, 
on  Wednesday  evening,  the  26th  inst..  Dr.  II.  Iloyle  Butts  w  ill  read  a 
paper  on  A  New  Method  of  controlling  Tonsillar  Hicniorrhagc. 

At  the  next  meetin<;  of  the  Section  in  Obstetrics  and  (iyn;ecol()gy. 
on  Thursday  evening,  the  27th  inst.,  the  subject  of  The  Anatomy  and 
the  Practical  Significance  of  shortening  the  Round  Ligaments  in  Dis. 
placements  of  the  Uterus  will  i)e  treated  of  by  Dr.  James  E.  Kelly  Dr. 
V.  W.  .lolmson,  of  Boston,  and  Dr.  (Jeorge  Edobohls. 


432 


BATES:  SELF-INFEOTIOh  FROM  THE  INTESTINAL  TRACT.         [N.  Y.  Mkd.  Jodk., 


SELF-INFECTION 
FROM  THE  INTESTINAL  TRACT* 
By  H.  ELLIOTT  BATES,  M.  D., 

POUGHKEEPSIE,  N.  T. 

Self-infection  may  be  defined  as  that  condition  of  self- 
poisoning  which  results  from  the  entrance  into  the  circula- 
tion of  toxic  material  developed  de  novo  within  the  human 
body. 

Pettenkofer's  division  of  pathogenic  bacteria  into  endo- 
genous and  ectogenous  varieties  proves  to  have  been  based 
upon  insufficient  evidence,  inasmuch  as  tuberculosis  and 
syphilis,  by  him  cited  as  examples  of  endogenous  processes, 
are  now  known  to  be  ectogenous  in  origin ;  consequently 
self-infection,  in  the  sense  in  which  the  word  was  originally 
used — viz.,  by  pathogenic  germs  originating  within  the  body 
— is  no  longer  recognized,  and  the  endogenous  origin  of  in- 
fective diseases  is  denied. 

But  a  careful  consideration  of  the  processes  by  which 
digestion — with  its  complicated  chemical  reactions  and  favor- 
able conditions  for  fermentation,  decomposition,  and  putre- 
faction— is  accomplished,  and  of  the  modification  of  these 
processes  produced  by  disease  (not  only  of  the  alimentary 
tract,  but  of  remote  organs  and  tissues  of  the  body),  sug- 
gests the  question,  "  Is  there  not  in  certain  physiological 
processes,  independent  of  bacteriological  influence,  a  source 
of  auto-infection  the  results  of  which  are  made  manifest 
by  divers  clinical  phenomena  unexplainable  by  any  other 
logical  hypothesis  ?  " 

Panum,  Bergmann,  Vulpian,  and  others  have  shown  by 
experiment  that  septic  poisoning  can  be  produced  by  prod- 
ucts of  organic  decomposition  without  the  presence  of  liv- 
ing organisms. 

By  the  aid  of  organic  chemistry  Selmi  and  other  ob- 
servers have  called  attention  to  the  existence  in  decompos- 
ing animal  matter  of  complex  chemical  compounds  which 
resemble  in  their  toxic  properties  the  poisonous  vegetable 
alkaloids.  These  compounds  are  described  as  ptomaines. 
That  bacteria  exist  in  the  intestinal  canal  and  that  toxic 
material  is  produced  in  the  course  of  digestion  can  not  be 
denied. 

The  antiseptic  properties  of  the  digestive  secretions  and 
the  elaborating  power  of  the  liver,  kidneys,  and  skin  are 
Nature's  provision  for  the  proper  control  and  limitation  of 
toxic  production  and  absorption. 

Failure  of  one  or  both  of  these  functions  opens  the  way 
for  the  development  of  a  pathological  condition  the  nature 
and  results  of  which  it  is  the  object  of  this  paper  to  con- 
sider. 

Fermentation,  decomposition,  and  putrefaction  furnish 
gases,  waste  products,  ptomaines,  and  toxines ;  moreover,  this 
production  is  a  part  of  normal  digestion. 

Of  the  gases,  oxygen  and  nitrogen  reach  the  alimentary 
canal  in  the  air  swallowed  with  the  food. 

Nascent  hydrogen,  marsh  gas,  carbonic  acid,  sulphuret- 
ed  hydrogen,  and  phosphureted  hydrogen  are  formed  by 


*  Read  before  the  Medical  Society  of  the  County  of  Dutchess,  N.  Y., 
jMiiary  11,  imi. 


butyric  acid  and  other  fermentation,  by  the  decomposition 
of  cellulose  and  organic  material. 

Oxygen  and  nascent  hydrogen  unite  and  form  water 
which  is  absorbed  ;  carbonic  acid  is  absorbed  and  eliminated 
by  the  lungs  ;  nitrogen,  marsh  gas,  and  phosphureted  hy- 
drogen excite  peristalsis  aqd  escape  per  anum  ;  but  sulphu- 
reted  hydrogen,  with  a  coefficient  of  absorption  one  hundred 
times  higher  than  that  of  oxygen,  diffuses  into  the  blood 
rapidly  and  produces  toxic  symptoms  if  present  in  any 
amount.  In  the  intestine,  besides  the  changes  produced  by 
the  digestive  secretions  and  their  ferments,  putrefactive 
processes  always  occur  and  probably  aid  in  digestion. 

The  bacteria  which  set  up  this  process  gain  entrance 
with  the  food.  After  the  action  of  the  unorganized  fer- 
ments has  converted  proteid  material  into  albuminates,  al- 
bumoses,  and  peptones,  the  organized  ferments — viz.,  bac- 
teria— act  upon  the  proteid  products,  producing  indol, 
scatol,  phenol,  excretin,  stercorin,  cresol,  volatile  and  fatty 
acids,  altered  bile  constituents,  amines,  and  amido-acids — 
viz.,  leucin,  tyrosin,  asparaginic,  phenylacetic,  phenylpro- 
pionic,  hydrosulphuric  acids ;  and  the  oxyacids,  hydropara- 
cumaric  and  parahydroxyphenylacetic* 

There  are  also  mucous  epithelium  and  the  indigestible 
portions  of  the  food.  But  in  addition  to  the  above-named 
products  there  are  being  formed  constantly,  but  particularly 
during  the  night,  soluble  alkaloidal  substances  of  an  in- 
tensely poisonous  nature,  which  enter  the  portal  circulation, 
and,  if  the  liver  and  kidneys  are  in  a  normal  condition,  are 
rendered  inert  and  eliminated. 

More  than  fifteen  of  these  ptomaines  have  been  isolated, 
their  physiological  effects  resembling  those  of  the  vegetable 
alkaloids,  especially  curare,  strychnine,  atropine,  and  digi- 
taline. 

Marquardt  f  isolated  and  described  the  ptomaine  septi- 
cin,  obtained  from  putrid  meat. 

Schmidt  J  discovered  an  alkaloidal  substance  in  meat> 
which  he  named  sepsin. 

Baginsky  *  found  in  fresh  pancreatic  gland  substance 
large  quantities  of  xanthin,  guanin,  and  hypoxanthin. 

Kossel  II  discovered  and  named  adenin.  Salomen  found 
in  human  urine  a  xanthin  derivative,  naming  it  paraxan- 
thin. 

Gautier  ^  obtained  from  fresh  beef  and  Liebig's  extract 
several  bodies  which  he  described  as  xanthokreatinin,  cruso- 
kreatinin,  amphikreatinin,  and  pseudokreatinin. 

The  first  of  these  is  poisonous,  producing  in  animals 
depression,  lassitude,  and  persistent  diarrhoea. 

Brieger  has  separated  from  animal  matter  in  process  of 
putrefaction  cadaverin,  putrescin,  and  myelin.  A  substance 
with  the  formula  C7II17N3O  has  been  obtained  from  putrid 
meat,  which  is  very  virulemt,  its  effects  resembling  those  of 
curare. 

In  fish  Bocklisch  found  the  ptomaines  neuridin,  me- 

*  Haliburton.  Text-book  of  Chem.  Phy^.  and  Path.,  1891,  p.  694. 
f  Schuschardt,  in  Maschkas's  Handbuch  d.  gericlU.  Med.,  Bd.  ii, 

S.  60. 

\  Uiitersiich.  liber  des  Sejmnn,  etc.    Inaug.  Diss.,  Duport,  1869. 

*  Brieger.     Uniersuch.  iiber  Ptomaine,  1886. 
J  [bid.  A  Ibid. 


April  22,  1893.] 


BATES:   SELF-INFECTION  FROM  THE  INTESTINAL  TRACT. 


43S 


thylamine,  diethylamine,  dimethylamine,  and  trimethyla- 
inine,  cadaverin,  and  putrescin. 

Lecithin  has  been  decomposed  into  a  fatty  acid  and  a 
ptomaine — cholin. 

In  edible  mussels  a  ptomaine  exists  which  is  very  poi- 
sonous. It  manifests  itself  in  three  forms — the  exanthema- 
tous,  choleraic,  and  paralytic.    It  is  named  mytilotoxin. 

Reasoning  by  analogy,  we  may  expect  to  find  that  the 
production  of  these  or  similar  ptomaines  is  responsible  for 
the  evil  consequences  of  self-infection. 

Pathology. — The  effects  of  self-infection  are  seen  in  no 
tissue  changes  which  may  be  regarded  as  specific  lesions. 
That  it  leads  to  alteration  in  structure  and  disturbance  of 
function  can  not  be  denied,  but  its  chief  interest,  from  a 
pathological  standpoint,  is  the  part  it  takes  in  the  produc- 
tion or  aggravation  of  other  diseases,  in  whose  aetiology  it 
occupies  an  important  position. 

Those  connective-tissue  changes  described  as  cirrhosis 
(in  organs)  and  sclerosis  (in  nerve  tissue)  are  justly  attrib- 
uted to  the  action  of  persistent,  passive  congestion,  result- 
ing from  chronic  inflammation. 

That  this  chronic  inflammation  is  induced  and  per- 
petuated by  long-continued  irritation  is  self-evident.  There- 
fore the  poisonous  and  irritating  products  of  abnormal  in- 
testinal digestion,  entering  the  circulation  by  the  means 
described  above  and  circulating  through  various  organs  and 
tissues  of  the  body,  must  necessarily  furnish  that  irritation 
which  is  considered  necessary  to  the  production  of  hard- 
ened atheromatous  arteries,  contracted  kidney,  cirrhotic 
liver,  and  sclerosed  nervous  system. 

It  is  significant  that  as  the  meridian  of  life  is  passed 
these  connective-tissue  changes  make  their  appearance 
with  such  uniformity  as  to  be  considered  a  normal  senile 
change,  and  that  pari  passu  with  those  changes  follow  the 
disturbances  of  the  digestive  system  characteristic  of  old 
age. 

Not  only  the  tissues  through  which  it  circulates,  but  the 
blood  itself,  suffers  from  the  presence  in  it  of  toxic  mate- 
rial ;  anaemia  becomes  pronounced,  and  loss  of  weight  and 
strength  is  noted. 

In  order  that  the  blood  may  contain  the  material  out  of 
which  nerve  tissue  is  generated  and  nourished,  there  must 
be  a  normal  digestion  of  fatty  material,  leading  to  the  pro- 
duction of  lecithin — a  compound  fat  containing  phosphorus 
and  nitrogen. 

Tlie  most  delicate  and  easily  disorganized  element  of 
the  body — the  nerve  tissue — is  the  first  to  manifest  the 
pernicious  effects  of  perverted  digestion.  To  the  anaemia 
of  the  nervous  system  and  its  irritation  by  septic  material 
are  to  be  ascribed  the  nervous  phenomena  which  form  a 
prominent  group  in  the  symptomatology  of  this  condition. 
Many  forms  of  nervous  disease,  notably  melancholia  and 
hypochondriasis,  recurrent  mania  and  the  various  degenera- 
tions, have  their  origin  in  the  daily  absorption  of  toxic 
material  from  the  intestinal  tract.  The  influence  of  this 
condition  in  the  production  of  hysteria  has  been  clearly 
demonstrated.  Irritation  set  up  by  products  of  intestinal 
fermentation  gives  rise  in  many  cases  to  the  paroxysms  of 
asthma. 


Among  the  diseases  depending  upon  perversion  of 
function  of  nerve  centers,  induced  by  persistent  peripheral 
irritation  of  afferent  nerves,  epilepsy  may  be  taken  as  a 

type. 

Among  the  causes  operating  to  set  up  this  irritation, 
the  action  of  the  products  of  intestinal  fermentation  must 
not  be  overlooked,  since  in  many  cases,  especially  if  there 
be  any  intestinal  symptoms  (such  as  diarrhoaa  or  constipa- 
tion preceding  or  following  an  attack),  intestinal  disinfec- 
tion becomes  the  sine  qua  non  of  treatment. 

Remembering  the  prevalence  of  constipation  among  fe- 
males, it  is  a  question  if  the  many  obscure  symptoms  of 
reflex  and  sympathetic  disturbance  accompanying  diseases 
of  the  female  generative  organs  are  not  due  primarily  to 
irritation  originating  in  the  intestinal  canal. 

The  local  influence  of  septic  matter  carried  by  the  por- 
tal and  lacteal  vessels  to  the  lungs  has  been  named  as  a 
predisposing  (Reynolds)  cause  of  phthisis  and  chronic  bron- 
chitis. 

The  effect  upon  the  nerve  centers  of  the  absorption  of 
HgS  is  seen  in  the  attacks  of  syncope  and  collapse.  Dis- 
eases of  the  skin  (acne  vulgaris  and  especially  eczema)  are 
induced  and  aggravated  by  toxic  absorption  from  the  intes- 
tines. Disturbance  of  the  heart's  action,  perversion  of  sen- 
sation, functional  or  intermittent  headaches,  disturbance  of 
the  special  senses,  and  severe  neuralgias  are  some  of  the 
results  of  toxic  intestinal  absorption. 

Etiology. — In  considering  the  aetiology  of  this  condi- 
tion it  must  be  borne  in  mind  that  the  production  of  toxic 
material  in  the  intestinal  tract  is  not  per  se  abnormal,  but 
becomes  pathological  only  when  its  proper  elimination  is 
prevented.  Intestinal  and  gastric  indigestion  may  be  taken 
as  a  preliminary  step  in  its  formation.  All  conditions 
which  impair  the  functional  activity  of  the  liver,  kidneys, 
and  skin  favor  its  development. 

The  neuroses,  alcoholism,  excessive  use  of  tobacco,  the 
anaemias,  malarial  toxaemia,  organic  disease  of  the  respira- 
tory, circulatory,  and  metabolic  systems,  or  of  the  digestive 
tract  and  its  glands,  are  predisposing  causes. 

Heredity  seems  to  exert  an  influence,  but  it  is  a  ques- 
tion if  its  action  can  not  be  traced  to  the  evil  influences  of 
bad  cooking,  irregular  hours,  or  careless  habits  to  which  all 
the  members  of  a  family  are  similarly  subjected. 

The  inability  to  digest  certain  articles  of  food,  although 
craved  and  enjoyed  by  the  palate,  must  be  remembered, 
since  it  is  plain  that  such  material  aids  directly  in  the  pro- 
duction of  intestinal  fermentation  and  putrefaction. 

A  sedentary  life,  lack  of  proper  exercise,  too  generous 
or  too  restricted  diet,  irregular  hours  for  eating,  imperfect 
mastication  and  insalivation  due  to  rapid  eating  (an  Ameri- 
can characteristic),  and  the  dilution  of  the  gastric  juices  by 
excessive  amounts  of  fluid,  aid  in  the  production  of  this 
condition.  But  it  is  the  nervous  system  that  is  especially 
responsible  in  a  majority  of  cases. 

The  proper  secretion  of  the  intestinal  juices  and  eflS- 
cient  peristalsis  are  impossible  when  brain  and  nerves  re- 
ceive no  rest.  The  nervous  control  of  the  higher  centers 
over  the  digestive  functions  is  daily  demonstrated. 

It  is  tlie  man  absorbed  in  the  cares  of  business  or  pro- 


434 


BATES:  SELF-INFECTION  FROM  THE  INTESTINAL  TRACT.        [N.  Y.  Med.  Jour., 


fession,  subjected  not  only  to  prolonged  mental  labor  and 
nervous  strain,  but  to  anxiety  and  worry,  and  the  woman, 
engaged  in  the  exhausting  duties  of  household  or  society, 
who  suffer  most  from  self-infection.  It  is  met  with  rather 
more  frequently  in  men  than  in  women,  and  manifests  it- 
self in  the  middle  or  later  periods  of  life. 

In  the  female,  menstrual  derangements  and  ovarian  ir- 
ritation exert  a  direct  causative  influence,  producing  reflex 
irritation  transmitted  by  the  solar  plexus. 

Constipation,  itself  a  symptom  of  intestinal  derange- 
ment, prevailing  as  extensively  as  it  does,  has,  as  will  be 
easily  understood,  an  especially  favorable  influence. 

Symptomatology. — To  present  the  symptomatology  of 
this  affection  in  a  systematic  and  comprehensive  manner  is 
no  easy  undertaking.  The  history  of  several  cases  taken 
from  the  case-book  will  be  used  as  a  framework  upon  which 
to  construct  a  clinical  picture  of  the  disease. 

Case  I. — A  gentleman,  forty-five  years  of  age,  born  and 
brought  up  on  a  farm,  had  for  twenty  years  been  engaged  in 
a  business  requiring  prolonged  mental  labor  and  nervous  strain. 
Family  history  excellent.  He  was  strictly  temperate,  but  used 
tobacco  to  the  extent  of  two  or  three  cigars  a  day.  Had  en- 
joyed good  health,  with  the  exception  of  an  attack  of  "  chills 
and  fever  "  seven  years  before,  up  to  within  six  months.  Ap- 
petite usually  good,  began  to  be  capricious;  he  became  easily 
tired  and  his  sleep  was  unrefreshing. 

To  concentrate  bis  mind  upon  business  became  more  and 
more  difficult,  and  the  attempt  was  followed  by  mental  exhaus- 
tion. He  grew  irritable  and  easily  worried.  After  meals  he 
noted  a  feeling  of  distention  of  the  abdomen,  shortness  of 
breath,  rumbling  noises  in  the  bowel,  and  the  passage  of  large 
quantities  of  very  offensive  gas  ^^er  anum.  The  bowels  were 
usually  slightly  constipated,  rarely  requiring  medicine ;  the 
stools  light  in  color,  covered  with  mucus,  and  offensive.  Diar- 
rhoea was  sometimes  present,  the  stools  being  black  in  color. 
A  bad  taste  in  the  mouth  in  the  morning  and  the  appearance  of 
minute,  dry  scales  upon  the  back  of  the  forearm  and  hands 
were  ascribed  by  him  to  biliousness. 

The  chief  source  of  annoyance,  however,  lay  in  his  head, 
experiencing  difficulty  in  falling  asleep,  awakening  early  in  the 
morning  unrefreshed,  and  unable  to  sleep  again.  A  constant 
dull  frontal  headache,  tinnitus  aurium,  vertigo,  and  a  feeling 
as  if  the  ground  were  about  to  "fly  up  and  hit  him,"  were  com- 
plained of.  He  became  very  much  depressed  in  spirits,  and 
possessed  of  the  idea  that  his  mind  was  giving  way.  His  heart 
beat  like  a  trip  hammer ;  palpitation  and  sharp  pains  annoyed 
him.  The  sexual  appetite  was  increased  and  seminal  losses 
had  been  noticed,  and  a  constant  loss  in  weight. 

Physical  examination  revealed  a  careworn,  anxious  face; 
deep  lines  about  forehead  and  mouth,  dull  eyes,  and  a  sallow 
skin.  The  heart's  action  was  labored,  respiration  rapid  and 
shallow,  pulse  small  and  compressible,  and  venous  system  full. 
(The  interference  with  the  right  ventricle  is  a  noticeable  feature 
of  this  condition.)  There  were  no  murmurs,  but  the  ai'teries 
were  beginning  to  show  atheromatous  changes,  the  liver  dull- 
ness was  slightly  increased,  spleen  normal.  Abdomen  tym- 
panitic, rumbling  upon  palpation.  Urine  acid.  Specific  gravi- 
ty, 1  025;  contained  excess  of  urates,  nric-acid  crystal^  and 
excess  of  indican.  No  albumin  or  casts.  Patellar  and  other 
reflexes  normal. 

The  case  was  diagnosticated  as  self-infection.  Treatment, 
hereafter  described,  lafd  down,  and  after  a  sea  voyage  the  pa- 
tient returned  a  new  man  and  resumed  business. 


Case  II. — A  young  woman,  twenty-four  years  old,  family 
history  good;  had  been  fairly  well  up  to  within  two  year^-, 
when  the  death  of  a  parent  caused  her  profound  grief  and  men- 
tal dej)ression.  Constipation  of  an  obstinate  nature  had  existed 
for  a  long  time,  to  which  treatment  had  been  applied  with  but 
little  success. 

Menstruation  began  at  thirteen,  had  been  regular  and  nor- 
mal until  within  two  years,  when  it  became  irregular  and 
scanty.  Slie  complained  of  "insomnia,  a  conviction  of  impend- 
ing disasters,"  and  asserted  that  for  six  months  she  had  no- 
ticed a  tumor  growing  in  her  abdomen.  Numbness  and  tingling 
in  the  left  limb,  accompanied  by  a  peculiar  sharp  pain,  which 
was  most  severe  when  she  lay  in  bed  and  lessened  after  exer- 
cise, had  given  rise  to  the  diagnosis  of  "creeping  paralysis"  by 
her  family  physician. 

She  had  experienced  several  attacks  of  sudden  syncope,  pre- 
ceded by  weak,  convulsive  movements  of  the  right  arm  and 
limb;  had  also  felt  dizzy  and  uncertain  upon  awakening  from 
sleep.  Severe  neuralgic  attacks  in  face  and  neck ;  palpitation 
of  the  heart,  and  a  sharp,  lancinating  pain  running  toward  the 
right  shoulder ;  slight  swelling  of  the  feet.  Anaesthesia  of  the 
skin  of  the  feet  and  limbs,  hypersesthesia  of  the  scalp,  irrita- 
bility of  the  bladder — incontinence  at  one  time  and  retention  at 
another — were  present.  Appetite  variable;  flatulence  annoyed 
and  mortified  her ;  physical  weakness  and  marked  melancholia 
completed  her  misery. 

Physical  examination  I'evealed  extreme  anaemia ;  a  sallow, 
anxious  face ;  antemic  murmurs  in  vessels ;  shallow,  quick  res- 
piration and  a  small  and  irregular  pulse.  No  cardiac  murmurs 
detected.  Lungs  normal.  Upon  the  left  side  of  the  abdomen, 
near  the  umbilicus,  an  irregular  swelling  was  noted,  which,  after 
careful  palpation,  was  diagnosticated  as  small  intestine  distend- 
ed with  gas.  Patellar  and  other  reflexes  normal.  Urine  pale, 
weakly  acid  ;  specific  gravity,  1'018,  containing  phosphates  and 
mucus.    No  casts. 

In  this  case  the  diet  test  and  examination  of  the  stools,  mi- 
croscopically and  chemically,  proved  conclusively  that  marked 
derangement  of  the  digestive  and  eliminative  functions  existed. 

Treatment  secured  prompt  amehoration  of  the  condition,  and 
recovery,  although  gradual,  was  complete. 

Case  III. — In  another  case,  that  of  a  middle-aged  man,  pro- 
nounced perversion  of  sensory  and  motor  nerves  simulated 
closely  the  symptoms  produced  by  degenerative  changes.  For- 
mication, flashes  of  heat,  tremor,  girdle  pain,  and  attacks  of  syn- 
cope, sudden  blindness,  double  vision,  drowsiness  by  day,  sleep- 
lessness at  night,  a  darkening  of  the  skin  of  face  and  neck,  pre- 
sented a  gloomy  picture  which  was  intensified  by  the  pronounced 
melancholia  that  existed.  Thorough  intestinal  disinfection,  re- 
stricted diet,  improved  hygiene,  and  a  trip  to  Europe  effected 
a  perfect  cure. 

The  symptoms  referable  to  the  intestinal  tract  may  or 
may  not  occupy  a  prominent  position  in  the  history  of  the 
case. 

There  may  be  distress,  pain,  and  tenderness  referred  to 
the  stomach  or  abdomen,  persistent  flatulence  or  dilated  and 
knotted  intestines ;  or  the  intestinal  symptoms  may  be  veiled 
by  more  prominent  disturbances  of  remote  organs,  especial- 
ly of  the  nervous  system,  and  only  careful  examination 
brings  to  light  the  fact  that  the  intestinal  digestion  is  at 
fault.  The  loss  in  weight,  the  peculiar  careworn  face 
(which  is  often  pathognomonic),  the  condition  of  the  circu- 
lation, the  symptoms  of  irritation  and  derangement  of  nerve 
centers,  and  especially  the  condition  of  the  mind — that  of 
extreme  melancholia  and  hypochondriasis — will  oftentimes 


April  22,  1893.j 


BATES:  SELF-INFEGTION  FROM  THE  INTESTINAL  TRACT. 


435 


suggest  the  possibility  of  intestinal  toxaemia  when  direct 
intestinal  symptoms  are  absent  or  meager. 

Frequently  the  rational  symptoms  may  be  so  numerous 
and  diverse  as  to  suggest  hysteria  or  "  hypo,"  yet  careful 
study  of  them,  together  and  separately,  will  usually  reveal 
the  presence  of  auto-infection  from  the  intestinal  tract. 

Diagnosis. — In  the  diagnosis  of  this  condition  it  is  ne- 
cessary to  bear  in  mind  the  polymorphous  character  of  the 
symptomatology.  Often  easy,  often  difficult,  it  requires  at 
all  times  careful  consideration.  A  methodical  study  of 
symptoms  and  physical  signs,  frequent  examination  of 
urine  and  stools,  and  the  use  of  the  diet  test  must  never 
be  omitted. 

The  diet  test  depends  upon  the  inability  to  digest  one 
or  all  of  the  different  classes  of  food  which  comprise  the 
ordinary  diet.  Sweets  add  to  the  flatulence ;  starches  are 
not  digested,  or  voided  in  excess  ;  fats  appear  undigested 
in  the  fjEces. 

If  carefully  prepared  meats  be  made  a  basis  of  diet,  and 
then  one  or  more  of  the  class  of  foods  not  tolerated  be 
given,  careful  examination  of  the  stools  will  give  conclusive 
results.  It  is  disagreeable  work,  but  the  end  deserves  the 
means. 

Prognosis. — Neglected  or  unskillfullj^  treated,  it  is  a  pro- 
gressive march  from  bad  to  worse,  continuing  for  years, 
making  life  a  burden,  and  ending  frequently  in  asylum  or 
suicide.  Taken  early,  patiently  examined,  and  intelligently 
treated,  results  will  follow  which  will  gratify  both  patient 
and  physician. 

Treatment. — The  indications  for  treatment  are  :  1.  To 
put  the  digestive  system  in,  as  far  as  possible,  a  normal 
condition.  2.  To  remove  all  causes  which  aggravate  the 
condition.  3.  Persistent  and  thorough  disinfection  of  the 
intestinal  tract.  The  diet  must  be  strictly  regulated,  both 
in  quantity  and  quality.  Regularity  in  the  hours  for  eat- 
ing, a  good  breakfast,  midday  dinner,  and,  above  all,  a  light 
tea,  are  the  first  things  to  be  secured.  Meats  should  be  dis- 
pensed with  for  a  time,  fats  withheld,  and  farinaceous  foods 
— the  lightest  and  simplest — should  be  taken.  Milk,  pref- 
erably skimmed,  or  kumyss,  should  be  made  the  principal 
article  of  diet.  To  this  may  be  added  oatmeal  or  barley  in 
the  form  of  gruel.  To  the  milk  diet  may  be  added  well- 
made  soups  free  from  fat,  animal  jellies,  and  some  of  the 
meat  extracts.  To  relieve  the  monotony,  albuminoid  food 
will  be  called  for ;  oysters  eaten  raw,  fish  free  from  fat, 
breast  of  fowl,  and  scraped  raw  beef  in  small  quantities 
may  be  given.  Bread  two  or  three  days  old  and  in  small 
quantity,  lettuce,  spinach,  kale,  and  celery  may  be  al- 
lowed. 

Coffee,  tea,  alcoholic  beverages,  and  tobacco  must  be 
withheld.  The  aim  should  be  to  keep  up  nutrition,  with  as 
little  work  upon  the  digestive  system  as  possible.  Gentle 
means  must  be  used  to  establish  regular  and  free  move- 
ments of  the  bowels.  The  mineral  waters  Friedrichshallc, 
Hunyadi  J^nos,  Geyser,  and  Ilathorn  often  accomplish 
good  results.  If  stronger  means  be  necessary,  drastic  pur- 
gatives must  be  avoided,  since  they  only  aggravate  the  con- 
dition. Cascara  sagrada,  combined  with  berberis  aqui- 
folium  and  hyoscyamus,  as  in  the  following: 


^  Ext.  cascarai  sagradae   ffj; 

Ext.  berberis  aquifolii   f  |  ss. ; 

Ext.  hyoscyami   f  3  ss. ; 

Syr.  pruni  virgiuiana;   3  jss. 

M.  Sig. :  A  teaspoonful  at  night. 
Or  the  cascara  may  be  given  with  extract  of  malt,  the  lat- 
ter acting  as  a  ferment  upon  starches  and  sugar.  Stimula- 
tion by  the  faradaic  current,  small  doses  of  strychnine,  and 
an  abdominal  belt  are  of  service  when  a  relaxed  condition 
exists. 

The  action  of  the  liver  must  be  watched,  and,  if  bile  is 
not  secreted  in  sufficient  quantity,  euonymin,  sanguinarin, 
iridin,  podophyllin,  with  an  occasional  administration  of  the 
"  old  reliable  "  pil.  hydrarg.,  will  be  found  of  service. 

The  action  of  the  skin  must  be  secured  by  sponge  baths, 
salt-water  bathing,  or  the  hydrotherapy  furnished  at  a  good 
sanitarium.  It  will  be  found  useful  in  many  cases  to  ad- 
minister a  good  tonic  ;  an  easily  assimilated  preparation  of 
iron  (such  as  the  ammonio- citrate  with  carbonate  of  am- 
monium, combined  with  quassia,  gentian,  and  nux  vomica) 
gives  good  results,  or  malt  extract  and  the  hypophosphites. 

For  the  severe  headache,  counter-irritation,  preferably 
by  the  electric  current  applied  to  the  cervical  region. 

The  second  indication  for  treatment  is  one  to  which 
special  attention  must  be  rendered.  It  has  been  pointed 
out  in  the  aetiology  that  the  nervous  system  is  responsible 
for  a  great  amount  of  this  trouble ;  therefore  special  stress 
is  laid  upon  this  portion  of  the  treatment  in  view  of  the 
difficulty  in  its  accomplishment. 

Complete  mental  relaxation  and  rest  must  be  secured. 
The  power  of  drugs  to  do  this  is  often  assumed,  and  un- 
satisfactory results  invariably  follow. 

The  only  hope  for  the  business  man  in  this  condition  is 
to  give  up  for  a  time  and  regain  health,  or  give  up  forever. 
There  is  no  middle  course.  Sedentary  pursuits  must  give 
way  to  exercise  in  the  open  air,  and  new  sights  and  scenes 
will  exert  their  favorable  influence  if  mental  worry  and  anx- 
iety be  avoided. 

A  sea  voyage,  mountain  climbing,  rowing,  horseback 
riding,  manual  labor  in  field  or  garden,  pleasant  company — 
in  short,  anything  that  will  effect  a  complete  change  in  the 
thoughts  and  aims  of  the  individual — will  constitute  the 
sine  qua  non  of  proper  treatment. 

There  is  perhaps  nothing  so  detrimental  to  recovery  or 
even  improvement  as  the  practice  of  prescribing  sedatives 
to  patients  in  this  condition. 

Once  used,  they  are  only  with  great  difficulty  dispensed 
with,  while  their  action  does  not  at  all  resemble  Nature's 
efforts.  Rest,  proper  food  and  surroundings,  novelty  and 
change,  are  the  only  therapeutic  agents  to  be  relied  upon. 
Cultivate  pleasure  instead  of  work,  and  Nature  must  do  the 
rest. 

The  third  indication  for  treatment  calls  for  those  agents 
by  whose  action  the  process  of  fermentation  and  putrefac- 
tion may  be  controlled  and  rendered  non-toxic.  The  use  of 
intestinal  disinfectants  has  been  warmly  advocated  and  as 
warmly  opposed,  such  opposition  due  probably  to  deficient 
understanding  and  faulty  administration. 

That  such  drugs  as  benzoate  of  sodium,  salicylate  of 


4SH 

sodium,  sulphate  of  sodium,  benzoate  of  ammonium,  naph- 
thol,  y3-naphtliol,  creolin,  salol,  naplithaline,  and  camphor 
possess  and  exert  antiseptic  properties  can  not  be  denied, 
while  bismuth  and  charcoal  have  proved  their  efficiency  in 
controlling  gaseous  eructation  and  uneasiness. 

But,  as  all  drugs  possess  selective  action  and  are  limited 
in  application,  so  the  antiseptics  exert  their  influences  only 
in  the  portions  of  the  digestive  tract  where  their  solution 
and  absorption  are  possible.  To  attempt  to  disinfect  the 
gastric  portion  of  the  digestive  tract  with  salol,  or  the 
small  intestines  with  naphthaline  or  ^-naphthol,  is  an  un- 
dertaking which  will,  in  all  probability,  discourage  belief 
in  the  efficiency  of  intestinal  disinfection. 

If  the  eructations  of  gas  and  gastric  uneasiness  indicate 
that  the  stomach  digestion  is  at  fault,  bismuth,  charcoal, 
and  calumba  in  combination  will  relieve  that  condition, 
while,  if  the  symptoms  indicate  that  the  small  intestine  is 
at  fault,  salol,  salicylate  or  benzoate  of  sodium,  camphor,  or 
benzoate  of  ammonium  is  indicated. 

Also,  if  the  passage  of  a  considerable  quantity  of  flatus 
or  a  distended  colon  points  to  the  large  intestine  as  the  seat 
of  the  trouble,  |8-naphthol,  naphtliol,  with  the  benzoate  of 
ammonium  and  charcoal  will  give  the  best  results. 

Besides  their  antiseptic  action,  the  benzoate  of  sodium 
and  ammonium  and  salicylate  of  sodium  exert  a  cholagogue 
action  upon  the  liver.  Combinations  of  antiseptics  with 
alkalies  give  better  results  than  antiseptics  alone,  and  a  fre- 
quent interchange  of  these  agents  guard  sagainst  that  toler- 
ation which  follows  the  prolonged  use  of  one  drug. 

In  relaxed  condition  of  the  bowel,  the  combination  of 
benzoate  of  sodium  with  rhubarb  is  indicated. 

In  those  cases  in  which  the  starches  are  imperfectly  di- 
gested and  the  gastric  contents  in  a  state  of  fermentation, 
salicin  renders  efficient  service,  as  it  is  fatal  to  bacteria  and 
vibrio,  and  prevents  the  reaction  of  amygdalin  and  eraulsin 
as  well  as  that  of  ptyalin  upon  starch. 

Resorcin  is  also  a  valuable  agent,  combining  with  marked 
antiseptic  qualities  an  analgesic  action  upon  the  intestinal 
mucous  membrane,  being  superior  in  this  regard  to  carbolic 
acid,  as  producing  less  irritation. 

Ichthyol  has  been  recommended  by  some  writers  as  a 
valuable  remedy ;  but  no  one  of  the  three  indications  for 
treatment  will  prove  sufficient.  They  are  interdependent, 
and  must  be  carefully  and  thoroughly  observed ;  but  in  a 
restricted  and  proper  diet,  relaxation,  and  mental  rest  lies 
the  best-known  treatment  for  the  victim  of  self-infection. 
November  £5,  1892. 


The  United  States  Marine-Hospital  Service. — A  board  of  officers 
will  be  convened  at  Washington,  on  June  26th,  for  the  purpose  of  ex- 
aminin<j;  applicants  for  admission  to  the  grade  of  assistant  surgeon  in 
the  United  States  Marine-Hospital  Service.  Candidates  must  be  be- 
tween twenty-one  and  thirty  years  of  age  and  graduates  of  a  respect- 
able medical  college,  and  must  furnish  testimonials  from  at  least  two 
resjwnsible  persons  as  to  character.  For  further  information,  or  for  an 
invitation  to  appear  for  examination,  address  the  supervising  surgeon 
general,  United  States  Marine-Hospital  Service,  Washington,  D.  C. 

The  College  of  Pharmacy  of  the  City  of  New  York  will  hold  its 
sixty-third  commencement  in  Carnegie  Music  Hall  on  Wednesday  even- 
inf?,  the  26th  inst,  at  7.4,')  o'clock. 


[N.  Y.  Mkd.  Jour., 


THE  RHEUMATIC  THROAT: 

A  CONTRIBUTION  TO 
THE  .ETIOLOGY  OK  CATARRH  OF  THE  NASOPHARYNX. 
A   CLINICAL  STUDY* 

By  WILLIAM  C.  BRAISLIN,  M.  D., 

BROOKLYN. 

The  relation  which  certain  acute  inflammatory  condi- 
tions of  the  faucial  tonsils  bear  to  acute  rheumatism  is  well 
known.  Rheumatic  sore  throat  is  a  familiar  term.  Cases 
presenting  symptoms  and  running  courses  similar  to  the  fol- 
lowing are  not  uncommon : 

Miss  V.  P.,  twenty  years  of  age,  a  native  of  Virginia,  of 
strong,  healthy  appearance,  presented  herself  in  the  throat 
room  of  the  Outdoor  Department  of  the  New  York  Hospital. 
She  gave  a  previous  history  of  having  suffered  a  year  ago  from 
a  rheumatic  inflammation  of  an  acute  character,  which  involved 
the  joints  of  the  left  foot.  For  the  past  two  weeks  she  had  had 
pain  in  and  swelling  of  the  left  ankle  joiut.  There  were  found, 
on  exaniiuation,  evident  symptoms  of  acute  articular  inflamma- 
tion. For  these  symptoms  she  had  had  no  treatment  up  to  this 
tinae.  The  cause  for  presenting  herself,  indeed,  was  not  due  to 
the  above  symptoms,  wliich  were  complained  of  as  only  of  sec- 
ondary importance.  The  chief  complaint  was  that,  for  the  past 
four  days,  she  had  had  a  gradually  increasing  feeling  of  uneasi- 
ness and  pain  in  the  throat.  It  had  been  necessary  for  her  to 
sit  up  during  the  whole  of  the  previous  night  because  of  a  feel- 
ing of  something  sticking  in  the  throat.  She  had  a  slight 
cough.  On  examination,  the  lungs  and  heart  were  found  to  be 
perfectly  normal,  but  tlie  tonsils  presented  the  typical  appear- 
ance of  acute  catarrhal  inflammation. 

She  was  placed  on  a  salicylic  mixture,  a  dose  of  which  was 
to  be  taken  every  four  liours,  and  which  consisted  of  the  fol- 
lowing: 

Acidi  salicylici   gr.  xx; 

Ferri  pyrophos   gr.  v; 

Sodii  phosphat   gr.  j ; 

A  quae  ad  |  ss. 

Three  days  later  she  reported  that  the  inflammation  of  the 
tonsils  had  almost  entirely  subsided.  The  swelling  and  pain  in 
the  foot  still  remained,  with  only  a  slight  improvement.  Fur- 
ther treatment  of  the  same  kind  resulted  in  an  entire  and 
speedy  dissolution  of  the  tonsilliti.s,  while  the  swelling  and  dis- 
comfort of  the  joints  were  of  slower  disappearance. 

I  believe  that  a  still  wider  knowledge  of  the  pathology 
of  rheumatism  will  concede  to  the  rheumatic  diathesis  a 
greater  influence  in  the  tetiology  of  certain  chronic  throat 
disorders  than  is  at  present  attributed  to  it. 

The  basis  for  this  belief  is  founded  upon  a  clinical  study 
embracing  fifty  cases  of  rheumatism,  conducted  for  the 
most  part  in  the  medical  clinic  of  the  Long  Island  College 
Hospital.  The  condition  of  the  throat  was  ascertained  at 
the  time  of  the  patient's  first  application  for  the  relief  of 
rheumatic  symptoms. 

Few  of  the  patients  made  complaint  at  this  time  of  any 
"  throat "  symptoms.  Pain  is  usually  the  symptom  of 
which  a  patient  most  loudly  makes  complaint,  and  this 
symptom  is  not  often  prominent  in  chronic  disorders  of  the 
throat.    A  proportion  of  the  patients,  however,  in  addition 

*  Read  at  a  meeting  of  the  Long  Island  Medical  Society,  Febiiiary 
2,  1898. 


BRAISLIN:    THE  RHEUMATIJ  THROAT. 


April  22,  18y3.J 


BRAISLIN:   THE  RHEUMATIC  THROAT. 


437 


to  the  symptoms  of  painful,  stiff,  and  swollen  joints,  com- 
plained of  the  classical  symptoms  of  post-nasal  catarrh. 
Attention  having  been  directed  to  the  throat  in  rheumatic 
cases  by  these  patients,  systematic  examination  was  there- 
after made,  both  objectively  and  subjectively,  of  every  rheu- 
matic patient  who  presented  himself,  to  the  number  stated 
above. 

The  particular  diseases  of  the  throat  most  commonly 
fouud  in  conjunction  with  the  rheumatic  condition  were 
chronic  disorders  involving  some  portion  of  the  glandular 
ring  of  the  pharynx — namely,  hypertrophy  of  the  faucial 
tonsils,  and  the  condition  of  the  nasopharynx  variously 
termed  by  different  authors,  but  most  commonly  called 
nasopharyngeal  catarrh. 

The  proportion  of  cases  in  which  the  arthritic  and  mus- 
cular symptoms  of  rheumatism  coexisted  with  either  or  both 
of  these  conditions  was  so  large  as  to  change  the  suspicion 
into  a  certainty,  in  the  opinion  of  the  writer,  that  a  com- 
mon aetiology  often  exists  for  both. 

Ignorance  still  shrouds  in  its  mists  much  of  the  pathol- 
ogy and  pathogenesis  of  rheumatism,  but  its  nature  has 
been  sufficiently  elucidated  to  justify  its  being  known  no 
longer  as  a  disease  characterized  by  arthritic  and  cardiac 
symptoms  alone. 

The  hydra-headed  nature  of  the  rheumatic  condition  in 
adolescence  has  recently  been  called  to  the  attention  of  the 
profession  in  a  leading  article  of  the  New  York  Medical 
Journal* 

Chorea,  pericarditis,  pleurisy,  the  fibrous  nodules  which 
suddenly  appear  along  the  margins  of  the  patella,  elbow 
joints,  clavicles,  and  vertebrae,  tonsillitis,  erythema,  and  even 
meningitis,!  are  among  its  manifestations  in  children. 
Cheadle,  J  in  an  exhaustive  treatise  on  rheumatism,  relates 
several  instances  in  which  three,  four,  or  more  of  the  mani- 
festations coexisted.* 

While  in  the  adult  arthritic  symptoms  are  more  regu- 
larly encountered,  it  seems  probable  that  other  conditions 
of  a  chronic  nature  are  yet  to  be  recognized  as  well-known 
complements  of  the  rheumatic  diathesis. 

Howard,  ||  writing  on  rheumatism,  has  noted  the  occur- 
rence of  an  acute  pharyngitis,  characterized  by  extreme  hy- 
persemia  and  hyperaesthesia,  as  a  complication  or  a  manifes- 
tation of  a  rheumatic  crisis. 

When  we  consider  the  manifold  manifestations,  both 
acute  and  chronic,  of  rheumatism,  it  does  not  seem  im- 
probable that  the  rheumatic  virus  should  have  an  irritative 
action  upon  the  glandular  structures  of  the  throat  such  as 
would  result  in  the  chronic  changes  noted.  It  is,  perhaps, 
suggestive  of  need  of  fuller  investigation  that  the  opinion 
of  authorities  varies  so  considerably  as  regards  the  ajtiology 
of  these  chronic  disorders.  This  is  especially  so  of  chronic 
post-nasal  or  nasopharnygeal  catarrh. 

It  is  as  yet  mbjudice  as  to  how  much  its  extreme  preva- 

*  December  17,  1892. 

f  Senator  in  Zienissen's  Handhnth,  vol.  xvi. 

:|:  W.  B.  Cheadle.  Tlte  Rhe.umatmn  of  (JhUdlwcd.  London  :  Sniitli 
Elder,  &  Co. 

*  Cyclopmdvi  of  Diseases  of  Children,  vol.  i,  p.  807,  Philndelpliia. 
I  American  System  of  Medicine,  vol.  ii,  p.  42. 


lence  may  depend  upon  the  condition  known  as  the  rheu- 
matic diathesis  or  chronic  rheumatic  poisoning. 

Sir  Morell  Mackenzie  makes  only  a  passing  reference  to 
rheumatism  as  an  aetiological  factor  in  nasopharyngeal  ca- 
tarrh and  glandular  pharyngitis.  In  the  last  edition  of  his 
work,  while  conceding  the  possibility  that  a  nasopharyn- 
geal catarrh  may  be  inherited,  he  makes  his  chief  references 
to  atmospheric  conditions,  and  especially  to  dust,  as  its  im- 
mediate ffitiologic  factors.* 

Beverley  Eobinson,  who  is  probably  the  most  widely 
quoted  American  author  on  the  aetiology  of  this  affection, 
has  suggested  that  a  special  constitutional  tendency  to  the 
disorder  exists  in  the  individual. f  In  discussing  follicular 
disease  of  the  nasopharynx,  he  states  his  failure  to  discover 
any  atmospheric  cause  for  post-nasal  catarrh.  He  submits 
that  "  an  acute  or  chronic  coryza  is  without  doubt  a  pre- 
disposing and  at  times  a  proximate  and  partially  efficient 
cause  of  its  becoming  manifest.  But,  in  order  to  effect  the 
ingrafting  of  post-nasal  catarrh,  a  certain  diathetic  condi- 
tion is  essential."  J 

Bosworth  considers  the  chief  factors  in  the  aetiology  of 
nasopharyngeal  catarrh  to  be  dependent  upon  and  due  to 
a  diseased  condition  of  the  nasal  passages.* 

Lennox  Browne,  {|  as  quoted  by  Mackenzie,  considers 
"  that  the  diathesis  of  patients  suffering  from  catarrh  of 
the  nasopharynx  is  '  generally  of  a  scrofulous  charac- 
ter.' " 

W^riters  of  another  class  than  the  above-quoted  authori- 
ties broadly  assign  to  the  "  irritating  qualities  of  the  air," 
the  "  trying  climate,"  and  to  "  colds  "  the  entire  responsi- 
bility of  the  causation  of  post-nasal  catarrh.  The  immedi- 
ate causative  influence  of  the  factors  of  atmospheric  phe- 
nomena is  undoubtedly  great ;  but  the  logical  conclusion 
of  the  belief  that  these  are  the  sole  factors  in  the  produc- 
tion of  a  chronic  inflammation  of  the  nasopharynx  is  that 
all  those  under  similar  circumstances  of  climate  and  of 
occupation  are  affected  with  catarrh.  The  other  alterna- 
tive is  to  assume  the  position  of  the  writer  quoted  above — 
that  "  a  special  constitutional  tendency  exists  in  the  indi- 
vidual." This  indeed  seems  to  be  the  only  ground  on 
which  to  explain  the  diversity  of  circumstances  as  regards 
territory,  climate,  and  occupation  under  which  this  disor- 
der exists.  Of  the  particular  constitutional  diatheses  which 
predispose  to  it,  the  rheumatic  diathesis,  in  the  opinion  of 
the  writer,  is  one  of  the  most  common. 

It  is  in  line  with  the  writer's  experience  to  believe  that 
the  clinical  study  of  post- nasal  catarrh,  however,  does  not 
often  lead  one  to  ascribe  its  aetiology  to  the  rheumatic  di- 
athesis. This  is  mainly  due  to  the  fact  that  the  latter  does 
not  always  manifest  its  presence  by  giving  rise  to  arthritic 
symptoms.  The  rarity  with  which  joint  and  muscular 
pains  coexist  simultaneously  with  post-nasal  catarrh  is 
probably  responsible  for  the  small  amount  of  attention 
which  has  been  given  rheumatism  as  an  aetiologic  factor  in 

*  Disoivies  of  the  Throat  and  Nose,  vol.  ii,  p.  337,  New  York, 
f  Nasal  Catarrh,  New  York,  1880. 

X  Op.  cit,  p.  146. 

*  Diseases  of  the  Nose  and  Throat,  vol.  i,  p.  519,  New  York,  188!'. 
II  7'/ie  Throat  and  its  Diseases,  London,  1875,  p.  463. 


438 


BEGK:   AN-TISEPTIC  VALUE  OF  PHENOdOLL  HYDROCHLORIDE.     [N.  Y.  Med.  Jode., 


this  disorder.  The  clinical  study  which  has  been  given  it 
from  the  rheumatic  point  of  view  makes  it  probable  that  it 
often  manifests  itself  alone  by  giving  rise  only  to  a  sub- 
acute or  chronic  inflammation  of  the  glandular  tissue  of  the 
pharynx.  In  these  cases  a  history  of  a  previous  attack  of 
rheumatism  or  of  a  rheumatic  family  history  is  often  the 
only  guide. 

On  the  other  hand,  the  investigations  of  the  writer 
seem  to  indicate  that  a  post-nasal  catarrh  is  an  exceedingly 
common  accompaniment  of  the  forms  of  rheumatism  char- 
acterized by  arthritic  symptoms.  In  only  five  of  the  fifty 
cases  examined,  which  varied  in  age  from  eight  to  sixty- 
three  years,  was  there  an  absence  of  the  symptoms  of  well- 
marked  tonsillar  or  pharyngeal  affection. 

The  cases  presenting  arthritic  symptoms  of  rheumatism, 
for  which  alone  it  should  be  remembered  the  patients  ap- 
plied for  relief,  included  almost  every  variety  of  the  chronic 
and  subacute  forms. 

As  it  has  been  said,  the  ages  of  the  patients  ranged 
from  eight  to  sixty- three  years.  The  average  age  was 
thirty-six  years  and  a  half.  Twenty-three  were  males, 
twenty-seven  females. 

Pain  in  tlie  joints  was  the  most  prominent  symptom 
complained  of  in  forty  of  these  cases.  In  the  remainder 
stiffness  and  swelling  constituted  the  most  prominent  symp- 
toms. The  length  of  time  during  which  arthritic  symp- 
toms had  been  present  varied  from  the  recent  rheumatic 
crisis  of  a  day  to  forty  years.  The  usual  variety  and 
irregularity  regarding  the  particular  joints  affected  were 
presented.  In  some  cases  a  single  joint  was  involved  ;  in 
other  cases  the  number  was  plural. 

The  comparative  duration  of  the  arthritic  and  the  throat 
symptoms  varied.  In  the  majority  the  arthritic  symp- 
toms, as  we  should  expect  in  a  series  of  "  rheumatic  "  pa- 
tients, were  of  longer  duration. 

As  was  stated,  only  five  of  the  cases  were  exempt  from 
either  tonsillar  hypertrophy  or  a  catarrhal  condition  of  the 
nasopharynx ;  some  presented  both  conditions. 

To  be  exact,  forty  cases  presented  symptoms  of  well- 
marked  nasopharyngeal  catarrh.  Almost  without  excep- 
tion, the  type  of  this  catarrh  was  that  known  as  the  hyper- 
trophic form. 

Of  the  three  patients  under  thirteen  years  of  age,  in  all 
of  whom  rheumatism  was  a  family  inheritance,  adenoids  of 
the  pharynx  existed. 

Incidentally,  laryngitis  was  present  in  three  cases  ;  elon- 
gation of  the  uvula  in  two  ;  chronic  catarrh  of  the  middle 
ear  in  three. 

In  the  light  of  the  manifold  manifestations  of  rheuma- 
tism, wliich  later  investigators  of  the  subject  have  shown 
to  exist,  especially  in  the  case  of  children,  it  would  seem 
that  attempts  at  correcting  the  tendency  to  a  rheumatic 
diathesis  might  well  be  exerted. 

Such  an  attempt  would  involve  the  correcting  of  many 
prevailing  abuses  which  seem  the  natural  results  of  our 
boasted  civilization.  Improper  food  and  overfeeding,  in- 
sufficiency of  exercise,  and  improper  clothing  would  figure 
largely  in  the  reform. 

The  clogging  of  the  systerii  with  the  products  of  imper- 


fect oxidation  is  doubtless  one  of  the  most  important  fac- 
tors in  the  establishment  of  such  a  diathesis. 

The  results  of  the  investigations  in  regard  to  the  effects 
upon  the  throat  of  the  condition  under  discussion  have 
led  the  writer  to  the  conclusion  that  the  ajtiology  of  not  a 
small  proportion  of  chronic  nasopharyngeal  and  tonsillar 
disease  is  due  to  the  pathological  condition  at  present 
vaguely  termed  "  the  rheumatic  diathesis." 

515  Clinton  Avenue. 


A  PRELIMINARY  COMMUNICATION 

CONCERNING  THE  ANTISEPTIC  VALUE 
OF  PHENOCOLL  HYDROCHLORIDE. 
By  carl  beck,  M.  D., 

INSTBUCTOB  IN  CLINICAL  8UK0ERT 
AT  THE  NEW  YORK  POST-GRADUATE  MEDICAL  SCHOOL  AND  HOSPITAL  ; 
VISITINQ  SUROBON  TO  ST.  MARK'S  HOSPITAL  AND  THE  GKRMAM  POLIKLINIK. 

Bearing  in  mind  the  derivation  of  the  well-known 
drugs — acetanilide,  phenacetine,  and  phenocoll — it  ought  to 
appear  natural,  from  a  theoretical  standpoint,  that  these 
descendants  of  a  typical  antiseptic  should  have  preserved 
their  characteristic  germicidal  qualities. 

Led  by  this  consideration,  I  determined  last  summer  to 
examine  these  drugs  in  reference  to  their  antiseptic  value 
from  a  practical  standpoint  by  applying  them  on  all  kinds 
of  wounds  and  ulcers  in  the  shape  of  powders,  solutions, 
ointments,  and  gauzes  in  private  practice,  as  well  as  at  St. 
Mark's  Hospital  and  the  German  Poliklinik  with  the  assist- 
ance of  Dr.  Stiebeling,  Dr.  Ileyman,  and  Dr.  Ililndel. 

My  experiments  have  shown  that  all  the  drugs  men- 
tioned above  possess  a  well-marked  antiseptic  power. 

Acetanilide  keeps  a  fresh,  clean,  or  well-granulating 
wound  in  a  good  condition,  but  is  of  little  influence  upon 
infected  wounds  or  upon  ulcers.  It  does  not  seem  to  pro- 
duce irritation  or  eczema,  and  may  rank  the  same  as  boric 
acid.    (Experience  of  seven  cases.) 

Phenacetine  is  undoubtedly  more  powerful,  and  not 
only  keeps  fresh  or  well-granulating  wounds  in  a  good 
state,  but  improves  their  appearance.  A  ten-per-cent. 
gauze  did  not  have  any  odor  three  days  after  it  had  been 
taken  away  from  an  ulcer  of  the  leg.  Poisonous  effects, 
irritation,  or  eczema  were  never  noticed.  So  far  as  its  an- 
tiseptic value  is  concerned,  it  appears  to  me  that  it  takes  its 
place  between  boric  acid  and  iodol.  (Experience  of  thir- 
teen cases.) 

But  I  soon  found  that  phenocoll  far  surpassed  both, 
wherefore  for  the  last  three  months  I  have  experimented 
with  this  only  in  the  form  of — 

1.  Pure  powder. 

2.  Five  per-cent.  watery  solution. 

3.  Ten-  and  fifteen-per-cent.  alcoholic  solutiom. 

4.  Ten-  and  twenty-per-cent.  gauze. 

5.  Ten-  and  twenty-per-cent.  ointment  (vaseline  and 
lanolin). 

Originally  I  only  used  the  powder  by  dusting  it  over 
the  wound  surface  and  covering  the  same  with  sterilized 
gauze  or  moss.  It  was  employed  in  lacerated  wounds  (fire 
cases),  suppurating  glands  of  the  neck  (three  cases),  pana- 


April  23,  1898.J  BERNSTEIN:  NON-OPERATIVE 


TREATMENT  OF  GROSSED  EYES. 


439 


ritium  (three  cases),  bubo  inguinalis  (two  cases),  badly 
granulating  ulcers  of  the  leg  (two  cases),  suppurative  mas- 
titis (one  case),  amputation  of  three  toes  (one  case),  burn 
of  the  second  degree  embracing  the  dorsal  surface  of  the 
foot  and  anterior  part  of  the  leg  (one  case). 

All  these  sores  had  been  granulating  well  and,  with  the 
exception  of  one  amputation  case,  are  cured  to-day. 

No  irritation  of  the  integument  or  any  general  symp- 
toms which  could  be  referred  to  the  action  of  the  drug 
were  observed.  When  I  found  that  I  could  do  just  as  well 
with  the  ten-per-cent.  gauze  I  dropped  the  powder,  and  for 
the  last  two  months,  with  few  exceptions,  have  used  the 
gauze  only. 

The  same  good  effects  were  obtained  by  covering  the 
granulating  surfaces  with  a  tljin  layer  of  the  gauze,  which 
was  protected,  as  a  rule,  by  a  piece  of  sterilized  moss. 
The  dressings  were  usually  changed  every  third  day,  as 
the  secretion  was  scanty.    The  cases  thus  treated  were : 

Lacerated  wounds  caused  by  knives,  pieces  of  glass, 
splinters  of  wood,  or  other  injury  (fourteen  cases) ;  extirpa- 
tion of  tubercular  glands  of  the  neck  (packing  the  cavity 
with  the  gauze — eight  cases) ;  furuncle  of  the  neck  (crucial 
incision — two  cases) ;  caries  sterni  (chiseling  and  pack- 
ing— one  case) ;  suppurative  mastitis  (broad  incisions  and 
packing — five  cases) ;  partial  resection  of  a  tubercular  elbow 
joint  (packing — one  case) ;  panaritium  (eleven  cases) ;  am- 
putation of  the  finger  (gangrene  after  bathing  in  pure  car- 
bolic acid — open  treatment  and  packing) ;  bubo  inguinalis 
(extirpation  of  glands — four  cases) ;  resection  of  tubercular 
hip  joint  (partial  union,  cavity  packed — three  cases) ;  total 
resection  of  tubercular  ankle  joint  (two  cases)  ;  resection  of 
astragalus  for  extreme  equino-varus  (failure  of  union  by 
first  intention,  open  treatment  thereafter) ;  amputation  of 
the  big  toe  for  caries  (open  treatment) ;  amputation  of  three 
toes  for  caries  (previously  treated  with  powder) ;  phlegmon 
of  different  parts  of  the  body  (free  incision,  scraping,  and 
packing — seventeen  cases) ;  ulcers  of  the  leg  (necrosed  sur- 
face scraped  first,  then  a  thin  layer  of  phenocoll  gauze  and 
tight  dressing  applied  over  it  (thi'ee  cases). 

All  these  cases  are  either  cured  at  the  present  time  or 
are  in  an  entirely  satisfactory  condition.  The  healing  pro- 
cess does  not  differ  from  that  observed  during  the  use  of 
iodoform.  Every  patient's  urine  was  examined  repeatedly 
without  anything  abnormal  being  detected,  and  no  irritation 
took  place.  Two  cases — viz.,  one  amputation  of  three  toes 
and  one  phlegmon  of  hand,  mentioned  above — had  formerly 
been  treated  by  iodoform  and  had  extensive  eczema,  while 
phenocoll  did  not  irritate  at  all. 

The  five-per-cent.  watery  solution  was  successfully  ap- 
plied as  a  wet  application  in  one  case  of  dermatitis  and  in 
one  case  of  erysipelas  (arising  from  a  lacerated  wound  on 
the  anterior  part  of  the  leg).  The  same  solution  was  used 
with  apparent  success  in  three  cases  of  recent  gonorrhoea 
and  four  cases  of  leueorrhcca. 

The  ten  per-cent.  alcoholic  solution  was  injected  into 
the  joints  in  two  cases  of  coxitis  and  three  cases  of  tuber- 
cular (?)  intiaramation  of  the  ankle  joint,  without  any  irrita- 
tion. So  far  a.s  tlie  final  result  is  concerned  I  am  still  in 
doubt. 


The  same  injection  was  made  into  a  carcinoma  mamrafe 
(relapse  in  and  around  the  scar  after  amputation  a  year 
ago),  and  it  has  undoubtedly  produced  a  decrease  of  size 
and  painfulness  in  the  cancerous  tissue,  so  that  further  in- 
vestigations seem  certainly  indicated. 

The  injection  of  a  watery  and  especially  of  an  alcoholic 
solution  was  always  followed  by  a  slight  burning  sensa- 
tion, which  never  lasted  longer  than  about  a  minute. 

The  twenty-per-cent.  ointment  (preferably  made  with 
lanolin)  was  used  in  one  case  of  ulcer  of  the  leg  and  two 
cases  of  burns  of  the  second  degree.  The  granulations  were 
of  a  good  character,  but  the  healing  process  seemed  to  take 
longer  than  it  did  under  the  use  of  the  gauze. 

So  far,  it  seems  to  be  evident  from  my  experiments  that 
phenocoll  hydrochloride  is  probably  as  valuable  an  anti- 
septic as  iodoform,  and  stronger  than  dermatol,  aristol, 
iodol,  pyoctanin,  europhen,  etc. 

Furthermore,  it  probably  surpasses  iodoform  because  :  1, 
it  is  odorless  ;  2,  it  dissolves  easily  ;  3,  it  does  not  produce 
eczema  ;  4,  it  is  not  contraindicated  in  kidney  disease ;  5, 
on  account  of  its  non-poisonous  effects  it  can  be  applied  to 
very  extended  surfaces. 

As  a  very  small  amount  of  the  drug  fulfills  its  purpose, 
the  expense  is  small. 

187  Second  Avenuk. 


THE  NON-OPEHATIVE  TREATMENT  OF 
CROSSED  EYES.* 
By  EDWARD  J.  BERNSTEIN,  M.  D., 

BALTIMORE. 

It  has  long  been  apparent  to  all  thinking  ophthalmolo- 
gists that  the  practice  of  operating  on  every  case  of 
squint  not  due  to  paralyses  or  like  causes,  still  upheld  and 
practiced  by  many  eye  surgeons,  was  radically  wrong  when 
applied  to  a  very  large  percentage  of  their  cases.  In  the 
light  of  modern  thought  it  must  be  characterized  as  a  bar- 
barity, as  fallacious  in  theory — if  theory  it  had  at  all — as  it 
was  pernicious  in  practice. 

My  first  rude  awakening  from  my  earliest  teachings  in 
this  regard  was  the  practice  of  "  let  alone "  adopted  in 
Vienna,  in  Munich,  and,  in  fact,  in  all  the  German  schools. 
It  is  not  altogether  a  "  let-alone  policy "  either,  but  rela- 
tively so — that  is  to  say,  "  inasmuch  as  squint  frequently 
disappears  by  itself,  it  is  advisable  to  wait  till  the  children 
are  over  ten  years  of  age.  Should  one  have  operated  ear- 
lier upon  such  a  case  as  would  have  disappeared  if  let  alone, 
strabismus  divergens  would  supervene.  In  order  not  to 
lose  the  time  intervening  between  first  noticing  squint  and 
the  tenth  year,  it  is  advisable  to  cover  the  nonsquinting 
eye  frequently,  and  force  the  patient  to  make  use  of  the 
bad  eye  in  order  to  preserve  its  usefulness,  and  thereby  pre- 
vent loss  of  visual  acuity  through  disuse.  Besides  this,  we 
forbid  the  playing  with  small  playthings,  so  as  to  cause  the 
least  possible  straining  of  accommodation,  and,  when  able, 
to  wear  the  proper  convex  glass.  .  .  .  In  a/^  cases  of  diver- 

*  Read  before  tlie  Hiiltiuiore  Medical  and  Surgical  Society,  February 
23,  1893. 


440 


BERNSTEIN:  NON-OPERATIVE  TREATMENT  OF  GROSSED  EYES.    [N.  Y.  Med.  Joqk., 


gent  squint  operation  is  the  only  cure  "  (Fuclis,  Lehrhuch 
der  Augenheilkunde,  p.  622,  Germ,  ed.,  1892). 

Tliis  is  the  theory.  In  practice  I  doubt  if  I  saw  any 
child  wearing  convex  glasses  for  its  convergent  squint  all 
the  time  I  was  in  Vienna.  At  any  rate,  I  shall  be  safe  in 
saying  that  I  saw  no  attempt  made  to  correct  the  refraction 
before  the  scliool  age,  and  the  vast  majority  of  cases  were 
allowed  to  run  on  till  the  patient  reached  the  operative  age. 

At  Moorfields  every  patient  over  three  years  of  age  was 
tested  and  proper  glasses  were  ordered,  with  what  result  I 
shall  relate  farther  on. 

When  one  waits  for  the  school  age  before  giving  glasses, 
an  amount  of  argamblyopia  *  has  already  made  its  appear- 
ance. And  if  we  wait  for  the  tenth  year,  rarely  shall  we 
find  more  than      vision  left. 

A  squinting  eye  is  usually  more  annoying  to  the  friends 
than  to  the  patient,  until  some  accident  happens  to  the 
good  or  "  steady  "  eye,  when  he  is  made  to  feel  his  helpless- 
ness. Then  he  is  a  burden  to  himself  and  the  community  at 
large,  and  a  brilliant  reflection  on  the  progress  of  surgery. 

I  am  aware  that  the  theory  of  hypermetropia  and  myo- 
pia, as  applied  respectively  to  convergent  and  to  divergent 
strabismus,  is  not  the  only  one.  I  do  not  believe  either 
condition  alone  would  develop  squint,  but,  when  associated 
with  an  insufficiency  of  one  of  the  recti,  it  makes  its  appear- 
ance. 

We  all  know  of  cases  innumerable  where  either  insuffi- 
ciency alone,  or  hypermetropia  or  myopia  alone,  exists,  but 
no  squint. 

Briefly  told,  the  most  important  of  the  other  theories 
are  : 

1.  "That  the  spasm  of  accommodation  in  the  better  eye 
produces  squint  in  tJie  defective  one  "  (Donders,  Landolt). 
This  is  to  explain  which  of  the  two  bad  eyes  shall  be  the 
squinting  one. 

2.  "  Strabismus  is  caused  by  insufficiency  (of  either 
rectus  muscle).  .  .  .  Manifestation  of  latent  insufficiency  or 
its  transition  into  squint  is  caused  by  any  factor  which  re- 
duces the  worth  of  binocular  vision,  or,  in  other  words, 
makes  it  less  agreeable.  We  thus  see  how  it  comes  that 
one  who  has  only  had  insufficiency  develops  manifest  squint 
after  a  macula  corneae  "  (Fuchs,  Lehrb.  der  Auyenh.,  Germ, 
ed.,  1892,  p.  619). 

3.  "  Opacities  in  the  refractive  media,  especially  in  the 
cornea  and  lens." 

4.  "  Intra-ocular  diseases."  Total  loss  of  sight,  readily 
develop  squint. 

5.  "  Thei  e  can  be  little  doubt  that  the  tendency  to  the 
persistence  of  a  definite  state  of  innervation,  which  asserts 
itself  as  a  factor  in  the  production  of  the  latent  position, 
is  also  a  factor,  if  not  the  only  factor,  in  the  causation  of 
the  permanent  element  of  every  convergent  squint,  what- 
ever the  state  of  refraction,"  says  Dr.  George  A.  Berry  in 
his  article  in  the  Helmholtzische  Zeitschrift. 

6.  The  view  that  "  permanent  convergent  strabismus  is 
maintained  by  the  constant  innervation  to  convergence," 
being  held  by  11.  Grub. 


*  Argamblyopia  =  defective  .sight  from  disuse. — Dr.  G.  M.  Gould. 


7.  Stilling  says:  "Whether  convergent  or  divergent,  it 
is  nothing  but  the  assumption  by  the  eyes  of  their  position 
of  rest  on  giving  up  binocular  vision." 

8.  Anatomical  peculiarities  of  shape  in  the  orbit. 

9.  Malpositions  of  the  center  of  the  cornea,  etc.,  arc  also 
among  the  numerous  assignable  causes  of  this  deformity. 

10.  In  a  personal  letter  from  Dr.  II.  II.  Seabrook,  of 
New  York,  he  gives  his  opinion  that  "  in  a  small  but  impor- 
tant class  of  cases,  the  macular  hypermetropia  being  higher 
than  eccentrically  in  the  position  of  internal  squint,  most 
of  the  rays  of  light  pass  through  the  axis  of  least  hyper- 
metropia, and  binocular  vision  may  be  thus  acquired  in 
infancy."  lie  further  adds  that  "  this  satisfies  my  oph- 
thalmological  friends  better  than  it  does  myself." 

It  must  be  evident  to  all  that  the  state  of  refraction  is 
the  primal  cause.  This  does  not  by  any  means  preclude  the 
fact  that  these  above-cited  theories  are,  of  course,  concerned 
to  a  greater  or  less  degree  in  many  cases,  and  may  be  the 
only  cause  in  some  few. 

The  treatment  of  crossed  eyes  which  I  shall  here  ex- 
plain is  especially  adapted  to  young  children — as  young 
as  three  or  four  years.  It  is  at  this  age,  when  the  facul- 
ties are  developing  so  rapidly,  that  the  greatest  good  is 
to  be  awaited  from  an  expectant  plan  of  treatment.  It 
is,  however,  just  as  applicable  to  children  of  maturer  age, 
though  such  brilliant  results  can  not  then  be  expected,  in 
whom  the  trouble  had  not  been  corrected,  with  a  view  to 
save  what  vision  was  left  in  the  bad  eye  and  to  try  and  im- 
prove on  that.  The  method  is  as  follows :  The  total  re- 
fractive error  is  determined  under  complete  atropine  dilata- 
tion by  the  direct  ophthalmoscopic  image  and  skiascopy. 
The  proper  correcting  glass  being  determined  upon — which 
varies  from  the  full  correction,  allowance  being  made  for 
the  mydriatic  and  skiascopy,  in  the  youngest  children  to 
somewhat  less  in  the  older  ones — they  are  directed  to  wear 
these  spectacles  constantly.  The  eyes  are  kept  slightly 
under  the  influence  of  a  half-per-cent.  solution  of  atropine 
(a  drop  being  instilled  into  the  eyes  once  or  twice  a  week), 
in  order  to  prevent  the  stronger  efforts  of  accommodation, 
and  the  parents  are  directed  to  bind  up  the  good  eye  for  at 
least  half  an  hour  each  day  when  the  child  is  at  play  in 
the  house. 

Necessarily  this  use  of  atropine  is  confined  to  children 
younger  than  the  school  age.  In  the  older  ones  the  di- 
section  is  to  use  the  bad  eye — the  good  one  being  band- 
aged— for  increasing  periods  of  time  in  reading  as  small 
type  as  possible,  and  this  to  be  kept  up  so  long  as  pain 
does  not  prevent.  The  Landolt  plan  of  "stereoscopic 
fusion  "  is  also  added,  the  eyes  to  be  thus  exercised  daily. 

In  a  recent  article  in  the  Philadelphia  Medical  News,  by 
Dr.  George  M.  Gould,  on  Amblyopiatrics,  the  views  there 
set  forth  are  so  fully  in  accord  with  my  own  experience  that, 
inasmuch  as  it  has  considerable  bearing  on  the  subject  in 
hand,  I  quote  the  following :  "  The  functionalization  of  ar- 
gamblyopic  eyes  consists,  of  course,  in  three  things:  1.  Cor- 
rection of  the  ametropia.  2.  The  reinstatement  of  muscular 
balance  if  unbalance  exists.    3.  Exercise." 

As  to  the  correction  of  the  ametropia  there  are  a  num- 
ber of  peculiarities  and  problems.    These  each  refraction- 


April  22,  1893.J 

ist  will  overcome  and  answer  according  to  his  teaching,  his 
habit,  and  his  intelligence.  Assuredly  no  hard  and  fast 
rule  will  suffice,  nor  can  such  a  rule  be  even  approximately 
formulated.  Each  case  will  be  a  study  in  itself,  requiring 
the  most  accurate  discrimination  of  judgment  and  the  finest 
delicacy  of  testing.  In  an  eye  of  which  the  neurologic 
elements  and  the  cerebral  centers  are  certainly  weakened 
and  partially  atrophied,  the  failure  to  hit  exactly  the  right 
kind,  degree,  or  precise  proportion  of  help  required,  fore- 
dooms at  once  to  failure.  The  very  breath  of  life  in  such 
an  eye  hangs  trembling  in  the  balance  between  endeavor 
and  renunciation.  A  shadow  of  overcorrection  or  under- 
correction,  a  misplaced  axis  of  astigmatism,  a  misplaced  or 
maladjusted  spectacle,  a  touch  at  the  wrong  place  instead 
of  the  least  wee  bit  of  help  at  the  right  place — anything 
except  the  right  thing — smothers  the  little  remaining  power 
of  recuperation,  and  proves  a  tiny  load  too  great  for  the 
tiny  forces  to  lift. 

We  are  here  dealing  with  infinitesimals,  and  the  keen- 
est and  swiftest  perception  will  win  where  a  less  subtle 
discrimination  will  fail. 

It  is  evident  that  such  eyes  must  be  nursed  and  encour- 
aged, as  it  were,  into  convalescence. 

Would  it  not  be  a  noble  triumph  if  we  could  be  sure  of 
rescuing  such  defective  eyes  from  practical  blindness  ?  Dr. 
Gould  shows  in  a  number  of  instances  the  results  he  has 
already  attained  in  this  direction,  and  the  first  three  cases 
here  cited  show  the  somewhat  similar  results. 

If  this  be  a  gain,  how  much  greater  would  be  the  gain 
if  we  can  prevent  amblyopia  from  occurring  and  at  the  same 
time  correct  an  ugly  deformity  ?  This  is  what  I  hope  for 
by  the  application  of  the  foregoing. 

Cases  I  to  VI  are  from  my  private  practice.  The  rest 
are  related  to  me  by  ray  friend  and  coworker.  Dr.  Robert- 
son Mcintosh,  assistant  in  Moorfields  Eye  Hospital,  Lon- 
don, and  are  taken,  in  answer  to  a  request  of  mine,  from 
the  daily  run  of  cases  at  that  institution.  They  are  fair 
representatives  of  the  work  done  there. 

Case  I. — M.  G.,  aged  thirty-two,  bookkeeper. 
July  28th. — Complains  of  asthenopia  and  poor  sight,  and 
that  he  can  only  see  at  all  "  by  cocking  his  head  "  so  as  to  bring 
the  left  eye  in  better  relation  with  the  page.  Anamnesia 
shows  that  in  early  youth  he  squinted  with  right  eye;  does  not 
remember  whether  in  convergence  or  divergence. 

V.  R.  E.,  1-5-75  D.       V.  L.  E.,  ^\      |-3-25  1). 

—  3.  -\  2  I). 

Ordered  R.  E.  —  3  D.  sph.  C  —  2-75  D.  cyl.  ax.  hor. 
L.  E.  —  2  D.  sph.  3  —  1'25  D.  cyl.  ax.  80°  temp.  |.    To  wear 
glasses  continually  and  use  right  eye  as  much  as  possible,  cov- 
ering the  left  with  a  blind,  attempting  to  read  with  right  for 
increasing  periods  of  time,  and  use  the  stereoscope. 

November  Asthenopia  disappeared.    V.  R.  E.,     ;  V. 

L.  E.,  |. 

Cask  II. — August  12,  John  R.,  aged  eighteen;  asthenopia 
and  convergent  strabismus  of  15°.    V.  R.  E.,  ■^}^;  V.  L.  E.,  ■^■^'i 
lias  been  wearing  right-eye  plane  glass,  L.  -)-  2  D.  sph., 
which  helped  him  somewhat,  but  not  completely,  and  no  effect 
on  the  crossed  eye. 

Skiascopy  under  hoinatropine  (castor-oil  solution) : 
R.  E.      |-(-6D.  L.  E.      1-1-5  D. 

— p-t-7D.  J_4.6D. 


441 

Ophthalmoscope:  Fundi  normal,  deeply  pigmented  and  shot- 
silk  retina. 

Ordered  R.  E.  +  4-5  D.  C  +  1  D-  cyl.  ax.  vert.  ;  L.  E. 
-f-  4  D.  O  -f  1  D.  cyl.  ax.  vert,  f  full ;  and  same  treatment  as 
above  in  Case  I. 

January  3d. — V.  R.  E.,  No  squint  when  he  wears  the 
glasses,  but  appears  as  soon  as  he  removes  them. 

This  patient  does  not  keep  up  the  exercise  ordered,  being 
satisfied  with  this  result. 

Case  III. — August  26th.  Miss  B.,  aged  twenty-four.  Asthe- 
nopia, argamblyopia,  ansmia.  Anamnesia  brings  forth  fact 
that  she  had  convergent  squint  of  left  eye  in  early  childhood. 
Very  nervous  temperament.  V.  E.  E.,  -|?  V.  L.  E.,  Skia- 
scope under  homatropine  (castor-oil  sol.) :  R.  E.,  horizontal  me- 
ridian, -f  2-25 ;  vert.  do.  -f  2  D.  sph. ;  L.  E.,  meridian  of  least 
refractive  error,  -f  3*5  D.,  its  R.  A.,  -f-  4  D.   Fundi  normal. 

Ordered  R.  E.  -|-  1  D.  sph.  C  -l-  0-25  D.  cyl.  ax.  vert,  f  ? 
L.  E.  -f  3  D.  sph.  ^?  and  Blaud's  pills,  one  three  times  a  day. 
Ocular  gymnastics  (covering  good  eye  and  stereoscopic  exer- 
cise). 

January  28th.— V.  R.  E.,  |;  V.  L.  E.,  ^.    No  asthenopia. 

Cask  IV. — George  E.  H.,  aged  nine,  August  30th,  has  had 
convergent  squint  since  five  years  and  a  half  old.  It  is  said 
to  have  appeared  suddenly  on  first  going  to  school.  At  present 
has  convergent  squint  of  45°  in  right  eye.  V.  R.  E.,  ^  ;  L.  E., 
y\.    Ordered  atropine  sulph.  (O'lO  to  lO'O). 

Septeniber  8th. —  Squint  even  more  marked  than  before. 
Skiascopy:  R.  E.  V.,  horizontal  meridian,  -f  7'5  D.  sph.; 
vertical  meridian,  +  3'5  D.  L.  E.  V.,  horizontal  meridian, 
+  4'5  D.  sph. ;  vertical  meridian,  -|-  3'5  D. 

Ordered  R.  E.  +  2-5  D.  sph.  3  -|-  4  D.  cyl.,  vert,  axis,  ^ ; 
L.  E.  -I-  2-5  D.  sph.  C  -I-  1  D.  cyl.,  vert,  axis,  |? 

Ophthalmoscope  shows  fundi  normal,  with  marked  shot- 
silk  retina.  With  glasses,  squint  fully  10°  less.  Ordered  gym- 
nastics. This  case  has  not  reported  lately,  but  has  repeatedly 
promised  to  do  so.    Said  to  be  improved. 

Case  V. — Isidor  B.,  aged  four ;  parents  have  noticed  an  oc- 
casional squint  since  two  years  and  a  half  of  age.  Now  has  an 
alternating  convergent  squint  of  20°. 

September  1st. — Ordered  atropine  solution  (O'lO  to  10"0), 
twice  daily. 

7th. — Skiascopic  examination :  R.  E.,  horizontal  meridian, 
-I-  2*75  D.  sph. ;  vertical  meridian,  -f  3'25  D.  L.  E.,  horizontal 
meridian,  -I-2-50  D.  sph. ;  vertical  meridian,  -f  3  D.  sph.  Fundi 
normal;  shot-silk  retina;  macular  reflex  normal. 

Ordered  +  2-50  D.  sph.  both  eyes,  and  to  be  kept  under  in- 
fluences of  atropine  solution,  0-05  to  10-0,  a  drop  in  each  eye 
once  or  twice  a  week,  the  good  eye  (apparently  the  left  eye)  to 
be  bound  up  for  half  an  hour  each  day  and  all  play  with  right 
eye. 

DecemMr  26th. — Absolutely  no  squint  to  be  seen  while 
wearing  glasses.  The  child  broke  its  glasses  and  had  to  go 
without  them  for  three  days.  For  the  first  day  or  so  the  squint 
remained  unnoticeable,  but  returned  before  he  got  his  glasses, 
when  it  disappeared  as  soon  as  he  put  them  on.  I  ordered  the 
new  pair  to  be  decentered  5  mm. 

Cask  VI. — Joseph  M.,  aged  nine ;  marked  convergent  squint 
of  over  50°.    V.  R.  E.,     ;  V.  L.  E.,  |  ? 

October  SOth. — As  measured  by  Rirshberg's  method,  the 
image  of  the  candle  flame  falls  2'5  mm.  to  external-canthus  side 
of  right  cornea.  Ordered  one-per  cent,  atropine  solution  twice 
daily. 

November  8th. — Skiascopy :  R.  E.,  -f  3  I),  sph.  in  vertical 
meridian,  +  3-5  in  horizontal;  L.  E.,  -I-2-5  1).  sph.  in  horizontal 
meridian,  -f  3-25  in  vertical. 

Ordered  R.  E.  -f  2-75  D.  sph.  C  +  0-50  cyl.  axis,  vortical, 


BERNSTEIN:  NON-OPERATIVE  TREATMENT  OF  CROSSED  EYES. 


442 


PORTEOUS:  SCLEREMA  NEONATORUM. 


[N.  Y,  Med.  Jotib., 


A;  L.  E.  +  1-75  D.  sph.  C  +  0-50  D.  cyl.  axis,  horizontal,  |. 
Fundi  normal;  very  marked  shot-silk  retina.  Ordered  gymnas- 
tics, etc. 

Deceviler  20th. — Squint  very  much  less — about  SS" — and  V. 
R.  E.  ^'j  ?  This  case,  I  think,  will  eventually  have  to  be  oper- 
ated on,  but  in  the  mean  time  he  is  gaining  sight  in  his  bad  eye, 
and  will  probably  save  himself  a  double  tenotomy.  Possibly  a 
division  of  the  right  internal  rectus  will  suffice. 

Case  VII. — M.  D.,  aged  seven,  was  seen  in  1890  with  di- 
vergent squint. 

Skiascopy : 

R.  E.      ,-8D.  L.E.  ,-8D. 

-A  6  D.  -\  6-5  D. 

Ordered  —  6  D.  spherics  for  constant  use. 
November  17,  1892. — No  divergence. 

Case  VIII. — R.  D.,  aged  eight,  came  on  April  7,  1892,  with 
slight  convergent  strabismus.  Complains  of  diplopia  for  both 
near  and  far  and  much  headache. 

V.  R.  E.,  ^,  man.  H.  +  1  D.  =  J ;  V.  L.  E.,  man.  II. 
+  1  D.  =  «. 

Skiascopy  showed  +  1  D.  sph.  in  each  meridian  in  both  eyes. 

Ordered  -f-  1  D.  right  and  left. 

November  19,  1892. — No  diplopia;  eyes  straight. 

Case  IX. — May  1,  1890.  A.  H.,  aged  four;  convergent 
strabismus.  Skiascopy  showed  +  3'5  D.  in  each  meridian  in 
both  eyes. 

R.  E.      ,+3-5.  L.E.      ,  +  3-5  D. 

—  —  +3-5.  — [—  +3-5  D. 

Ordered  -f-  2*25  D.  spheres,  round  glasses,  for  constant  use. 

November  22,  1892. — No  convergence  now  with  glasses. 

Case  X. — G.  A.,  aged  four,  came  October  3,  1889,  with 
history  of  convergent  strabismus  in  right  eye  of  one  year's  stand- 
ing.   Now  has  squint  of  20°. 

Skiascopy : 

R.  E.      1  +  5  D.  L.E.      ,  +  4-5D. 

—I—  +4-5  D. 


1  +  5  D. 
J_  +5  I). 


Ordered  +  4  D.  right  and  left. 

November  24,  1892. — No  convergence  now  with  glasses. 

Case  XI. — G.  I.,  aged  five,  came  in  1888  with  right  conver- 
gent strabismus  10°.  V.  R.  E.,  not  improved  ;  V.  L.  E.,  f ; 
+  3-5  D.  |. 

Skiascopy : 

R.  E.      1  +  7-5  D.  L.E.      ,  +  4  D. 

-J— +9-5D.  -J_  4.4.5  D. 

Ordered  R.  E.  +  5  D.  sph.  C  +2  D.  cyl.  ax.  V.;  L.  E.  +  4D. 

November  25,  1892. — No  strabismus  now. 
Case  XII. — Miss.  G.    Private  case  of  Dr.  Mcintosh.  Has 
divergent  squint: 
V.  R.  and  L.  < 
Skiascopy : 

R.  E.      ,—2  D.  sph.  L.  E.      ,—2  D. 

—^—+4  1).  _j_+4D. 

Ordered  +  2  D.  sph.  ^  +  G  D.  cyl.,  axis  horizontal.  Seen 
fourteen  days  later;  sees  or  so  and  no  divergence  when 
glasses  are  worn. 

In  conclusion,  let  me  add  that  I  am  well  aware  tliat  I 
have  originated  nothing ;  but  I  am  equally  as  well  aware 
that  the  practice  of  the  above,  in  this  country  at  least, 
is  but  seldom  applied,  if  at  all ;  that  when  squint  is  even 
of  high  degree  or  of  long  duration,  much  can  be  done  by 
the  proper  correction  of  the  ametropia.  It  may,  no  doubt, 
when  tried  before  operation  is  decided  upon,  reduce  the 
number  of  cases  which  ordinarily  require  several  operations, 


and  even  then  be  not  thoroughly  corrected  without  the  cor- 
rection of  their  ametropia  to  maintain  the  result. 

Is  not  this,  then,  a  more  potent  reason  for  following  the 
plan  of  giving  the  correcting  glass  in  advance  in  all  cases 
of  squint  to  sec  what  action  will  result  therefrom  ? 

I  have  not  attempted  to  correct  the  muscular  imbalance 
by  prisms  in  any  case  as  yet ;  when  vision  so  far  impro\  es 
as  to  make  binocular  vision  unpleasant  by  confusion  of 
images,  I  shall,  no  doubt, 

218  W.  Kkanklin  Street,  Hai,timoke. 


SCLEREMA  NEONATOKUM. 

By  J.  LINDSAY  PORTEOUS,  M.  D.,  F.R.  C.  S.  En. 

Some  time  ago  I  had  the  good  fortune  to  have  a  case  of  this 
rare  disease  brought  under  my  observation.  When  I  first  saw 
the  infant  it  was  four  days  old.  On  the  second  day  after  its 
birth  the  peculiar  condition  of  the  skin  drew  the  attention  of  a 
neighbor.  When  I  saw  it  the  following  appearances  presented 
themselves:  The  Iegr»,  feet,  arms,  hands,  back  of  shoulders,  and 
upper  part  of  chest  had  the  feeling  of  India  rubber  stretched 
over  a  frame.  The  color  of  the  skin  varied  from  a  deep  purple 
to  a  light  pink.  It  cried  feebly,  and  every  few  seconds  stretched 
its  body  to  its  full  extent,  as  if  struggling  for  breath,  or  as  if  it 
felt  stiff  all  over.  The  pulse  was  120  beats  a  minute,  and  the 
temperature  97°.  I  carefully  examined  the  chest,  but  found 
neither  pulmonic  nor  cardiac  abnormal  sounds.  The  bowels 
had  moved  shortly  after  birth,  but  not  again.  The  constipa- 
tion was  most  obstinate.  Castor  oil  had  been  administered 
three  times.  Suppositories  of  soap  and  soap-and-oil  enemata 
also  proved  ineffectual.  I  ordered  hot-water  baths  and  friction 
of  the  whole  surface  of  the  body.  It  was  enveloped  in  cotton 
wool,  and  a  temperature  of  about  75°  was  maintained  in  the 
room.  I  made  several  punctures  in  the  skin  with  the  view  of 
releasing  any  fluid  that  might  be  there  and  thus  relieving  the 
tension,  but  only  a  very  little  blood  and  yellow  fluid  escaped. 
On  the  sixth  day  the  temperature  fell  to  87°,  and  the  infant 
died  that  night.    Such  were  the  symptoms  which  I  observed. 

According  to  Valleix,  the  pulse  generally  falls  to  about 
60  in  the  minute.  In  this  case  I  never  found  it  below  110. 
Ellis,  in  his  Diseases  of  Children,  says  some  authors  con- 
sider this  disease  to  be  caused  by  lobular  pneumonia  or 
atelectasis  pulmonum,  and  that  after  a  time  cough  comes 
on  and  continues  throughout.  Now,  in  this  case  there  was 
very  little  cough,  which  entirely  disappeared  on  the  fifth 
day  after  birth,  or  the  third  day  after  the  disease  was  no- 
ticed. I  do  not  find  in  any  account  of  sclerema  that  con- 
stipation is  given  as  a  symptom.  I  am  inclined  to  believe 
that  the  disease  is  purely  one  of  the  cellular  tissue,  and  has 
nothing  whatever  to  do  with  the  lungs.  If  there  is  lobular 
pneumonia  or  atelectasis  in  an  infant  suffering  from  this 
malady,  it  is  merely  a  coincidence  and  can  not  be  held  re- 
sponsible for  this  purely  indurated  condition  of  the  cellular 
tissue.  The  name  seems  to  me  an  unfortunate  one.  It  is 
derived  from  the  Greek  word  (TKXr]p6<:,  meaning  "  hard.'' 
Now,  from  my  limited  experience,  I  should  say  the  skin 
was  not  hard,  but,  as  I  have  already  stated,  like  stretched 
rubber.  It  has  been  regarded  by  some  as  a  form  of  ichthy- 
osis, but  it  certainly  has  no  resemblance  to  any  of  the  nu- 
merous forms  of  that  disease  that  I  have  seen.    It  must  not 


April  22,  1893.] 


KRAUSS:   THE  USE  OF  TRIONAL  AS  A  HYPNOTIC. 


443 


be  confounded  with  ichthyosis  cornea,  or  sclerema  of  some 
French  writers. 

The  cause  of  this  rare  disease  is  very  obscure  or,  I  may 
say,  is  unknown.  Although  it  has  been  noticed  in  connec- 
tion with  congenital  syphilis,  still  there  is  no  proof  that  it 
is  caused  by  that  disease.  In  the  case  I  have  mentioned  I 
could  get  no  history  of  syphilis  in  either  parent.  The  mi- 
croscope throws  little  light  on  the  subject.  The  cellular 
tissue  contains  a  yellowish,  gelatinous,  or  stearin-like  de- 
posit. Scleroderma  of  adults  differs  from  it,  as  in  the  for- 
mer there  is  increased  fibrous  tissue,  which  the  latter  has  not. 

As  to  treatment,  nothing  seems  of  any  avail ;  but  by 
some,  who  hold  that  syphilis  is  the  cause,  treatment  for  that 
disease  is  recommended. 


A  NOTE  ON 

THE  USE  OF  TRIONAL  AS  A  HYPNOTIC. 
By  WILLIAM  0.  KRAUSS,  M.  D., 

BUFFALO,  N.  Y. 

Perhaps  no  one  class  of  drugs  attracts  the  attention  of 
the  physician  more  than  the  hypnotics.  This  is  due  partly 
to  the  obstinacy  and  inveteracy  of  the  symptom  insomnia, 
and  partly  to  the  inefficacy  of  many  of  the  drugs  ordinarily 
prescribed  for  this  condition. 

During  the  past  few  months  a  number  of  contributions 
have  appeared  in  medical  literature  laudatory  of  the  prepa- 
ration called  trional  as  a  hypnotic,  especially  in  nervous  and 
mental  disorders.  Trional  is  described  as  a  powder  con- 
sisting of  tablets  of  a  melting  point  of  76°  C,  readily  solu- 
ble in  alcohol  and  ether,  but  less  soluble  in  water,  requiring 
three  hundred  and  twenty  parts  of  water  at  ordinary  tem- 
perature. Trional  belongs  to  the  same  chemical  family  as 
sulphonal  and  tetronal,  but  containing  three  ethyl  groups 
instead  of  two  as  in  sulphonal,  and  four  as  in  tetronal.  Its 
chemical  composition  is  a  diethyl  sulfon  methylmethan,  and 
was  first  described  by  East  and  Baumann.  The  drug  was 
given  in  fifteen-grain  to  twenty-five-grain  doses,  fifteen  to 
forty-five  minutes  before  retiring ;  and  in  those  cases  in 
which  pure  insomnia  existed,  sleep  followed  in  from  fifteen 
minutes  to  an  hour  and  a  half  after  administration.  Trional 
differs  from  sulphonal  in  that  the  latter  takes  effect  later  and 
has  an  accumulative  action ;  from  tetronal  in  that  tetronal 
takes  effect  quicker,  but  the  effect  wears  off  sooner. 

Barth  and  Rumpel,*  who  appear  to  have  been  the  first 
ones  to  use  trional,  were  very  successful  in  their  experi- 
ments in  the  Hamburg  (general  Hospital,  and  consequently 
recommended  it  very  highly  as  a  hypnotic.  Schultze,  of 
Bonn  {Therap.  Monatshcfte,  Oct.,  1891),  used  it  to  good 
advantage  in  treating  seventy-six  cases  of  various  mental 
diseases.  Garnier,f  of  Dijon,  Schaefer,  J  of  Jena,  and 
Boettiger,**  of  llalle,  were  equally  successful  in  its  employ- 
ment. The  latter  employed  it  in  cases  of  uncomplicated 
agrypnia,  in  cases  of  painful  nervous  diseases,  in  mental 

*  Deutsche  mediciniscke  Wochenschrift,  1890,  No.  32. 
t  Progr.  mid.,  Dec.  3,  1892. 
\  Berliner  klinische  Wochenschri/l,  1892,  No.  29. 
«  I&id.,  No.  42. 


diseases  in  which  insomnia  was  complicated  by  slight  psy- 
chical disturbances,  in  cases  of  marked  excitement  with  de- 
lirium, etc.  In  all,  seventy-five  patients  were  under  treat- 
ment, and  in  seven  only  were  the  effects  negative,  while  in 
twenty  cases  sleep  of  short  duration  was  produced. 

Schultze  found  trional  active  in  seventy- five  per  cent, 
of  the  single  doses;  Schaefer,  in  eighty- six  percent.  In 
Boettiger's  cases,  excluding  those  in  whom  there  existed 
pain  along  with  the  insomnia,  fifty-eight  cases  remain,  two 
of  which  were  not  influenced  by  the  drug. 

Brie,*  of  Bonn,  had  similar  favorable  results,  as  his 
subjoined  report  will  indicate.  lie  used  it  chiefly  in  men- 
tal diseases,  dividing  his  cases  into  four  classes.  The  first 
class  included  mild  forms  of  melancholia  and  hypochon- 
dria ;  eleven  cases  were  under  treatment,  and  in  all  seven 
to  nine  hours'  sleep  followed.  The  second  class  included 
four  cases  of  agitated  melancholia ;  these  cases  had  been 
previously  treated  with  opium,  chloral,  etc.,  without  any 
favorable  results.  The  first  two  cases  were  given  thirty 
grains  of  trional  with  happy  effect ;  the  third  patient  was 
obliged  to  take  forty  grains,  and  the  fourth  patient  was 
given  fifteen  grains. 

The  third  group  included  the  maniacal  cases  and  pa- 
retics ;  ten  cases  were  treated  with  but  one  failure,  and  that 
because  of  stomach  irritation,  necessitating  abandonment  of 
the  drug.  In  these  cases  other  hypnotics  had  been  tried — 
such  as  chloral,  paraldehyde,  sulphonal,  and  tetronal — but 
the  results  were  not  as  satisfactory. 

The  fourth  class  included  paranoia  and  the  hallucina- 
tions ;  eight  patients  were  treated,  and  all  were  successful. 
Besides  these  mental  diseases,  in  insomnia  due  to  overwork 
and  worry,  excluding  pain,  trional  gave  refreshing  sleep. 

My  results  with  trional  have  been  very  encouraging  so 
far  as  I  have  gone,  although  I  have  used  it  in  only  eight-  to 
ten-grain  doses,  and  have  not  been  obliged  to  repeat  the 
dose.  The  cases  were  all  of  nervous  diseases — such  as  ex- 
ophthalmic goitre,  epilepsy,  hysteria,  neurasthenia,  trifacial 
and  intercostal  neuralgia,  prurigo,  nervous  disturbances  dur- 
ing the  menopause,  vertigo,  etc.  In  all  of  these  cases,  fifteen 
in  number,  except  in  those  where  there  was  peripheral  nerve 
irritation,  I  obtained  gratifying  results.  In  the  patients 
suffering  from  trifacial  and  intercostal  neuralgia,  trional, 
combined  with  acetanilide  (eight  to  ten  grains  of  each),  was 
rewarded  with  good,  quiet  sleep.  In  but  one  case  was  a 
complete  failure  recorded,  and  that  the  case  of  prurigo  ; 
here  the  trional  seemed  to  exert  just  an  opposite  effect. 

In  none  of  these  cases  were  disagreeable  symptoms 
noted,  although  in  two  of  them  other  hypnotics  had  been 
abandoned  on  account  of  their  irritating  qualities. 

From  my  experience,  it  would  seem  that  trional  is  a 
fairly  good  hypnotic  ;  that  it  produces  no  disagreeable  after- 
effects; that,  combined  with  a  simple  anodyne — such  as 
acetanilide,  etc. — it  may  be  used  in  the  insomnia  of  painful 
nervous  disorders ;  that  its  only  apparent  objection  is  that 
its  producers  have  seen  fit  to  have  it  patented  in  the  United 
States,  thus  making  its  scientific,  humane  importance  sec- 
ondary to  the  commercial. 


*  New-ologischcs  Ccntralbltill,  1892,  No.  24. 


444 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jodb., 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

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


:^EW  YORK,  SATURDAY,  APRIL  22,  1893. 


A  SUCCESSFUL  OPERATION  FOR  SUBCLAVIAN  ANEURYSM. 

The  case  in  which  Mr.  Charles  P.  Coppinger,  of  Dublin,  wjis 
the  operator,  briefly  mentioned  in  the  Journal  for  April  8th,  is 
one  of  the  rare  exan;ples  of  successful  operation  for  subclavian 
aneurysm.  The  innominate  and  carotid  arteries  were  tied  si- 
multaneously. The  date  of  the  performance  of  the  operation 
was  the  9th  of  January,  this  year,  and  the  place  was  the  Mater 
MisericordisB  Hospital,  Dublin.  The  patient  was  a  man,  aged 
fifty  years.  About  a  month  ago  the  patient  was  exhibited  as  a 
"living  specimen"  before  the  Royal  Academy  of  Medicine  in 
Dublin,  and  he  was  probably  the  first  person  with  operative 
occlusion  of  the  innominate  that  ever  stood  up  before  a  Euro- 
pean medical  audience.  The  report  of  the  patient's  condition 
at  that  time  was  favorable;  his  progress  through  the  first 
month  after  the  operation  had  been  satisfactory,  except  that  his 
temperament  had  led  him  to  be  restless  and  disobedient.  The 
operation  wound  had  healed.  The  temperature  and  pulse  had 
been  normal  since  the  seventh  day  after  the  operation.  The 
aneurysm  had  evidently  grown  smaller,  and  was  without  pulsa- 
tion. No  pain  was  complained  of.  The  right  arm  was  nor- 
mal in  tempei-ature,  sensibility,  and  motility,  but  there  was  no 
perceptible  radial  or  brachial  pulse  on  that  side.  The  man's 
general  health  and  spirits  were  good.  His  willful  temper  caused 
much  trouble  to  his  attendants,  more  especially  as  his  restless 
attacks  generally  came  on  at  night.  On  one  occasion  he  him- 
self removed  the  bandage  from  the  wound  in  his  neck.  He 
would  swing  his  arms  about  freely  when  so  inclined,  and  insist 
from  time  to  time  on  getting  out  of  his  bed  and  taking  a  chair 
by  the  fire  "  just  for  a  change,"  as  he  said,  when  a  misstep  or 
other  untoward  accident  might  easily  terminate  his  life  and 
abridge  a  very  interesting  surgical  history.  Up  to  the  time  of 
the  man's  being  shown  there  had  been  no  symptom  of  haemor- 
rhage, and  the  operation  wound  was  represented  by  a  fine  and 
almost  imperceptible  cicatrix.  In  the  particular  of  freedom 
from  hemorrhages  this  case  is  believed  to  be  unique.  The  one 
successful  American  case,  that  of  Dr.  A.  W.  Smyth,  of  New 
Orleans,  was  marked  by  repeated  secondary  haamorrhages,  be- 
ginning on  the  fifteenth  day  after  the  operation,  and  the  pa- 
tient's life  was  only  saved  by  ligation  of  the  vertebral  artery 
on  the  fifty-second  day. 

The  Medical  Press  and  Circular  for  March  1st,  from  which 
many  of  the  foregoing  data  have  been  taken,  refers  briefly  to 
the  position  of  the  late  Valentine  Mott  in  the  history  of  this 
department  of  arterial  surgery,  citing  his  hopeful  view  of  the 
future  of  that  operation  which  he  was  the  first  to  perform  for 
subclavian  aneurysm.    Dr.  Mott  said :  "  My  hopes  are  not  all 


dampened  by  the  hitherto  repeated  failures  of  this  operation, 
and  I  fondly  anticipate  that  the  day  may  come  when  some  one 
of  my  countrymen  may  yet  be  heralded  as  the  successful  opera- 
tor." We  believe  that  it  was  about  a  year  before  the  death  of 
Dr.  Mott  that  the  Smyth  success  was  achieved  and  thus  fulfilled 
the  confident  prognostic  of  the  former  surgeon.  Tlie  Press, 
however,  states  that  Smyth  was  in  reality  a  fellow-countryman 
of  Coppinger's,  and  only  by  adoption  a  citizen  of  New  Orleans. 
The  same  paper  gives  the  following  as  the  fullest  present 
statistics  concerning  this  operation :  Ligature  of  the  innomi- 
nate alone,  fifteen  times,  with  no  recoveries;  simultaneous 
ligature  of  that  artery  and  tiie  carotid,  seven  times  with  five 
deaths;  the  two  recoveries  being  those  of  Smyth's  and  Coppin- 
ger's patients.  The  same  journal  emphasizes  the  significance 
of  secondary  hsemorrhage  after  this  operation,  as  shown  by  the 
history  of  these  twenty-two  cases,  from  that  of  Mott  down ; 
for  without  exception,  since  the  latter  surgeon's  famous  case 
headed  the  list  in  1818,  all  the  patients  who  survived  the  im- 
mediate effects  of  the  operation  suffered  severely  from  haamor- 
rhage,  and  all  lost  their  lives  by  it,  with  the  exception  of 
Smyth's  and  Coppinger's  patients ;  and  in  the  Smyth  case,  as 
we  have  said  above,  tlie  losses  of  blood  were  frequent;  in  fact, 
the  man  was  so  reduced  by  them  at  the  end  of  the  seventh 
week  as  to  seem  to  be  at  death's  door. 


GROSS  AND  VIRCHOW. 

It  is  not  generally  known  that  Professor  Virchow  was  and 
is  a  great  admirer  of  the  late  Dr.  Gross,  of  Philadelphia.  The 
American  Practitioner  and  News  tells  of  the  following  incident, 
brought  to  light  by  Dr.  Lyman  B.  Todd,  of  Lexington,  that 
illustrates  the  feeling  of  the  disciple  toward  the  teacher  enter- 
tained by  the  modern  Harvey,  as  the  great  German  has  been 
styled,  for  his  American  friend  and  predecessor  in  the  field  of 
pathology : 

Several  years  ago  Minister  William  Preston  met  Virchow 
for  the  first  time  at  a  Fourth-of-July  banquet  in  Berlin.  Mr. 
Preston  in  an  after-dinner  speech  alluded  eloquently  to  some  of 
his  American  friends  in  our  profession,  such  as  Mott,  Physic, 
McDowell,  Dudley,  and  Gross,  and  to  their  good  work  for  the 
world  at  large.  When  the  speaker  resumed  his  chair  a  stran- 
ger's hand  was  extended  to  him  and  by  it  his  own  was  most 
warmly  grasped  in  feeling  congratulation.  The  stranger  was 
Virchow,  who  at  once  sought  to  engage  the  speaker  for  dinner 
on  the  following  day.  After  a  delightful  entertainment,  Vir- 
chow invited  Mr.  Preston  into  his  library,  and,  taking  down  a 
special  volume,  which  showed  that  it  had  been  thoroughly 
studied,  he  remarked  with  manifest  seriousness:  "To  this  book 
and  to  its  author,  more  than  to  any  others,  or  possibly  more  than 
to  all  others  combined,  am  I  indebted  for  the  good,  if  any,  that  I 
have  done  in  the  world."  The  title  of  the  book  was  A  Treatise 
on  Pathological  Anatomy.  On  its  fiy-leaf  Mr.  Preston  recog- 
nized a  very  familiar  autograph — its  writer  and  he  had  been 
for  fifteen  years  or  more  fellow-townsmen  at  Louisville — "  I  am 
your  true  friend,  Samuel  D.  Gross."    Many  are  the  autograph 


April  22,  1898.] 


MINOR  PARAGRAPHS. 


445 


volumes  thatliave  been  added  to  the  Berlin  pathologist's  shelves 
since  Gross's,  but  not  one  of  them  has  been  honored  with  any 
more  studious  attention. 


MINOR  PARAGRAPHS. 

OLIVE  OIL  IN  THE  TREATMENT  OF  LEAD  COLIC. 

In  tlie  Union  medicale  for  March  30th  there  is  an  article  in 
which  various  methods  of  treating  lead  colic  are  summarized. 
Among  them  is  that  of  administering  a  tumblerful  of  olive 
oil  (rarely  two  tumblerfuls)  daily  for  from  four  to  eight  days. 
This  treatment,  recommended  as  long  ago  as  in  161(5  by  Citois, 
has  lately  been  extolled  by  Weill,  of  I^yons.  It  is  said  that 
from  the  very  first  day  the  paroxysms  are  overcome,  and  there 
remain  only  dnll  pains  that  are  quite  bearable  and  subside 
on  the  second  or  third  day,  when  the  constipation  begins  to 
yield.  The  first  evacuation  is  generally  scanty,  but  at  the  end 
of  forty  eight  hours  there  is  a  veritable  breaking  up,  and  diar- 
rhoea follows  rapidly.  It  is  immaterial  whether  the  oil  is  given 
at  the  outset  or  not  until  several  days  have  elapsed.  Some^ 
times  the  first  few  glasses  are  vomited,  but  it  is  rare  that  the 
gastric  intolerance  lasts  more  than  two  or  three  days.  It  may 
happen  also  that,  three  or  four  hours  after  taking  it,  the  pa- 
tient experiences  a  sensation  of  weight  in  the  stomach,  without 
nausea,  but  this  is  transitory  and  does  not  interfere  with  the 
curative  action  of  the  oil.  Copious  stools  are  the  signal  of  defini- 
tive cure  not  only  of  the  colic,  but  also  of  the  various  nervous 
derangements  associated  with  it,  such  as  anaesthesia,  cutaneous 
and  muscular  hypersesthesia,  tremor,  and  headache.  The  same 
is  true  of  the  retraction  of  the  liver  and  the  hardness  of  the 
pulse.  Seldom  do  these  phenomena  persist  so  long  as  two  or 
three  days  after  the  colic  has  ceased. 

I 

DECALCIFIED  BONE  BOBBINS  IN  INTESTINAL 
ANASTOMOSIS. 

In  the  British  Medical  Journal  for  April  1st  Mr.  A.  W. 
Mayo  Robson,  surgeon  to  the  General  Infirmary,  Leeds,  de- 
scribes his  method  of  establishing  intestinal  anastomosis  by 
means  of  tubes  or  bobbins  of  decalcified  bone.  As  ordinarily 
employed  by  him,  the  appliance  is  a  spool-shaped  tube  seven 
eighths  of  an  inch  long,  an  inch  and  an  eighth  in  diameter  at 
its  ends,  traversed  by  a  channel  five  eighths  of  an  inch  in  di- 
ameter, the  wall  of  the  tube  being  an  eighth  of  an  inch  thick, 
and  having  at  each  end  a  rim  an  eighth  of  an  inch  wide  and  the 
same  in  height.  The  advantages  alleged  for  the  method  are : 
Rapidity  of  execution ;  simplicity  and  ease  of  performance,  only 
two  continuous  sutures  being  required ;  the  avoidance  of  leav- 
ing large  plates  in  the  intestine;  security  against  leakage  by  the 
double  continuous  suture;  the  certainty  of  having  an  adequate 
and  immediately  patent  opening;  the  avoidance  of  the  danger 
of  after-closure  of  the  opening  by  securing  continuity  of  mucous 
surfaces  through  the  new  channel;  the  avoidance  of  making  in- 
cisions in  the  visceral  walls  larger  than  just  necessary  to  admit 
the  tube;  and  the  adaptability  to  lateral  intestinal  anastomosis, 
lateral  implantation  (as  in  ileocolostomy),  gastro-enterostomy, 
pylorectomy,  end-to-end  enterorrhaphy  after  enterectomy,  and 
cholecystenterostomy.  The  operative  procedure  is  illustrated 
by  means  of  diagrams,  and  notes  of  two  cases  are  included  in 
the  article. 


LAPAROTOMY  FOR  TRAUMATIC  EXTRAVASATION  OF  BILE. 

At  a  recent  meeting  of  the  Paris  Society  of  Surgery  {Ur^ion 
medicale,  April  Ist)  there  was  reported  the  case  of  a  driver  of 
a  rubbish-cart  who  had  fallen  from  his  seat  and  been  injured  by 


the  wheels  passing  over  the  lower  part  of  his  chest.  On  the  fol- 
lowing day  there  was  great  pain  in  the  region  of  the  liver,  together 
with  tympanites,  a  small  and  frequent  pulse,  and  an  altered  ex- 
pression of  the  face.  Bronchopneumonia  supervened  shortly,  and 
the  man's  general  condition  became  so  grave  that  the  surgeon, 
M.  Michaux,  although  he  suspected  rupture  of  the  biliary  pas- 
sages, hesitated  to  resort  to  operative  interference.  So  it  was 
not  until  after  seventeen  days,  when  the  pneumonia  had  nota- 
bly abated,  that  laparotomy  was  performed.  About  ten  fluid- 
ounces  of  bile  were  removed  from  the  peritoneal  cavity.  The 
peritoneum  was  covered  with  false  membranes,  and  the  intes- 
tinal adhesions  were  such  as  not  to  admit  of  access  to  the  re- 
gion of  the  gall-bladder,  rupture  of  which  was  thought  to  have 
been  the  cause  of  the  effusion  of  bile.  Therefore  drainage  and 
irrigation  with  a  boric-acid  solution  were  the  only  further 
measures  employed,  and  the  patient  made  a  good  recovery.  A 
biliary  fistula  persisted  for  three  months,  and  then  closed 
spontaneously. 

TRIONAL  AND  TETRONAL  IN  THE  INSANE. 

In  the  April  number  of  the  American  Journal  of  Insanity 
Dr.  William  Mabon,  of  the  Utica  State  Hospital  for  the  Insane, 
gives  his  experience  with  these  drugs  as  hypnotics  and  sedatives 
in  various  forms  of  insanity.  He  finds  that  both  are  decidedly 
hypnotic  and  sedative,  but  that  trional  is  the  more  serviceable 
as  a  hypnotic,  and  tetronal  as  a  sedative.  Unpleasant  after- 
efiects  were  noted  in  a  few  instances,  but  they  were  of  short 
duration  and  at  no  time  alarming.  The  hypnotic  dose  of  trional 
is  from  ten  to  thirty  grains,  but  it  is  advisable  not  to  give  more 
than  fifteen  grains  at  the  first  dose;  the  sedative  dose  is  from 
ten  to  fifteen  grains,  but  in  some  patients  even  forty-five  grains 
produced  no  efi"ect.  The  hypnotic  dose  of  tetronal  is  from  five 
to  thirty  grains,  but  with  most  patients  fifteen  grains  are  re- 
quired to  procure  satisfactory  sleep ;  the  sedative  dose  is  from 
five  to  ten  grains  once  or  twice  a  day. 


CHLORALOSE  AS  A  HYPNOTIC. 

At  a  meeting  of  the  Paris  Society  of  Biology,  held  on  Feb- 
ruary 25th  (Mercredi  medical,  March  1st),  Dr.  Fer6  reported 
that  he  had  tried  this  drug  in  hysteria,  in  epilepsy,  and  in  cho- 
rea. He  had  very  soon  found  that  much  larger  doses  of  it  could 
be  used  than  had  been  mentioned  by  Richetand  Hanriot.  Some 
of  his  patients  had  taken  as  much  as  thirty-five  grains  without 
harm.  Nevertheless,  the  sleep  produced  by  it  in  the  conditions 
referred  to,  for  example,  in  hysteria,  was  sometimes  of  a  ster- 
torous character;  moreover,  involuntary  micturition  during 
sleep  occasionally  occurred,  and  this  indicated  a  profound  sus- 
pension of  cerebral  activity.  In  some  cases  doses  of  twenty- 
two  or  twenty-three  grains  had  produced  sleep  in  epileptics. 
Excited  subjects  became  tranquil  after  a  sleep  thus  artificially 
induced.  He  had  never  known  the  drug  to  disorder  the  stom- 
ach. Dr.  Chouppe  said  that  for  ten  days  he  had  given  chlora- 
lose  to  a  neurasthenic  wlio  was  afi"ected  with  gastric  trouble, 
and  not  only  had  sleep  been  produced,  but  the  dyspepsia  had 
been  cured. 


ONYCHIA  CIRCINATA. 

At  a  meeting  of  the  Berlin  Society  of  Dermatology  held  on 
July  5,  1892  (Annales  de  derniatologie  et  de  syphiligraphie, 
March,  1893),  Dr.  Joseph  mentioned  what  he  thought  to  be  a 
previously  undescribed  form  of  disease  peculiar  to  the  nails. 
The  patient  was  a  physician  who  had  had  parasitic  sycosis  and 
tinea  tonsurans.  For  some  time  there  had  been  furrows  on  the 
nail  of  the  left  forefinger,  parallel  to  the  border  of  the  nail,  and 
at  these  furrows  the  nail  would  break  spontaneously  or  in  con- 


446 


MINOR  PARAGRAPHS. 


[N.  T.  Mbd.  Jodb., 


seqaenco  of  some  slight  external  cause.  The  speaker  would  call 
this  affection  onychia  circinata.  Its  appearance  had  differed 
essentially  from  that  of  a  mycotic  affection  of  the  nails  termed 
in  the  abstract  "  onycliomycose  tonsurante."  No  fungi  had 
been  found,  but  numerous  micro-organisms.  Corrosive  subli- 
mate had  been  used  in  the  treatment.  Dr.  Lewin  said  he  had 
seen  two  aimilar  cases.  Dr.  Saalfeld  had  in  oue  instance  seen 
the  conTex  surface  of  a  ludl  replaced  by  a  concave  surface. 


SODIUM  IODIDE  IN  ANGINA  PECTORIS. 

Iif  the  Revue  generale  <le  clinique  et  de  therapeutique  for 
March  29th  Dr.  Gingeot,  of  the  Laennec  Hospital,  gives  an  ac- 
count of  a  severe  case  of  angina  pectoris  in  which  sodium  iodide 
was  prescribed,  to  be  used  in  alternation  with  trinitrin — not 
alone  during  the  attacks,  but  continuously.  The  sodium  salt 
was  to  be  taken  for  six  weeks,  and  tiien  the  trinitrin  for  two 
weeks.  The  doses  are  not  mentioned.  After  a  considerable 
period  of  freedom  from  seizures  the  patient  discontinued  the 
use  of  the  remedies,  but  a  recurrence  of  angina  led  to  a  resump- 
tion of  the  treatment,  which  he  then  followed  faithfully.  The 
result  has  been  that  since  March,  1890,  he  has  not  had  the 
slightest  manifestation  of  angina  pectoris.  To  be  sure,  says  Dr. 
Gingeot,  this  is  only  one  case,  but  the  old  saying  applies:  Non 
numermndfp,  sed  perpendewlm  ohsermtionef. 


EXAMINATION   OF  THE  SALIVA  IN  OASES  OE  MORPHINE 
POISONING. 

The  Union  medicale  for  March  23d  contains  a  summary  of 
Dr.  Julius  Kosenthal's  account  published  in  the  Gentralblatt  fur 
klinische  Aledicin,  1893,  No.  1,  of  his  recent  researches  into 
the  salivary  elimination  of  morphine  administered  subcutane- 
ously.  He  has  detected  morphine  in  the  saliva  of  patients  to 
whom  he  was  a<l ministering  morphine  subcutaneously  to  the 
amount  of  a  centigramme  daily,  but  not  until  three  or  four  days 
after  the  use  of  the  drug  had  been  begun.  On  the  other  hand, 
the  reaction  continued  for  several  days  after  it  had  been  given 
up.  This  shows  that  morphine  accumulates  in  the  organism. 
It  is  eliminated  partly  by  the  gastric  mucous  membrane,  but 
the  amount  found  in  the  contents  of  the  stomach  is  not  an  accu- 
rate inde.ic  of  the  quantity  that  has  been  injected,  for  some  of  it 
may  have  been  first  eliminated  in  the  saliva  and  then  swallowed. 


A  MOSQUITO  EXTERMINATOR. 

Thb  Indian  Medical  Record  for  March  16th  says  that  a  Bom- 
bay newspaper  calls  attention  to  the  virtues  of  the  castor-oil 
plant  as  a  means  of  protection  against  mosquitoes.  In  Egypt  it 
is  planted  about  houses  to  drive  the  insects  away.  In  towns,  a 
better  plan  is  to  have  the  young  plants  in  pots,  and  bring  them 
into  the  house  for  a  day  or  two  at  a  time,  but  they  must  not  be 
kept  too  long  in  the  shade,  for  the  Palma  Christi  is  a  sun  lov- 
ing plant.  A  writer  is  cited  as  saying  that  the  mosquitoes  are 
killed  by  a  poison  that  they  find  on  the  lower  side  of  the  leaf, 
but  it  is  stated  that,  if  a  dozen  leaves  are  placed  about  a  room 
that  swarms  with  mosquitoes,  they  will  disappear  without  leav- 
ing any  dead  ones  lying  about. 


NASAL  INSUFFLATION  OF  SOZOIODOL-SODIUM  IN 
WHOOPING-COUGU. 

Db.  Paul  Guttmann  (Therapeutische  Monatahe/te,  .January, 
1893;  Fortschritte  der  Medicin,  April  1,  1893)  reports  favorable 
results  from  this  treatment,  but  not  such  brilliant  ones  as  those 
of  Dr.  Schwarz,  of  Constantinople.    In  no  instance  has  he  .suc- 


ceeded in  cutting  the  course  of  the  disease  short  in  four  or  five 
days  by  means  of  daily  insufflations.  In  a  number  of  cases, 
however,  their  favorable  action  has  been  undeniable.  In  six 
cases  treated  in  the  Moabite  Hospital  diminution  of  the  fre- 
quency and  severity  of  the  paroxysms  was  noted  ;  in  four  of 
them  in  from  three  to  six  days,  in  two  in  eight  days.  In  twenty- 
four  cases  treated  at  the  Poliklinik  also  a  favorable  influence 
upon  the  course  of  the  disease  was  observed. 


CALCIUM  CHLORIDE  IN  THE  TREATMENT  OF  PNEUMONIA. 

In  the  April  number  of  the  Practitioner  Surgeon-Lieuten- 
ant-Colonel Crombie,  of  Calcutta,  having  found  this  drug  supe- 
rior to  calx  sulphurata  in  the  treatment  of  boils  evoked  by  the 
hot  weather  of  India,  inferred  that  it  might  have  a  favorable 
influence  in  jtneumonia,  but  he  acknowledges  that  "it  is  a  far 
cry  from  hot-weather  boils  to  pneumonia."  lie  remarks  that 
peptonuria  is  a  constant  phenomenon  of  pneumonia,  and  thinks 
it  not  impossible  that  the  action  of  calcium  chloride  in  the 
treatment  of  pneumonia  consists  in  its  neutralizing  the  toxic 
action  of  peptones  or  albumoses  circulating  in  the  blood. 
Several  clinical  histories  are  given  to  show  the  favorable  influ- 
ence of  the  drug. 


MENTHOL  IN  PRURITUS  OF  THE  GENITALS. 

Menthol  in  various  forms  is  recommended  by  Colombini 
(cited  in  the  Revue  generale  de  clinique  et  de  therapeutique  for 
April  5th)  in  the  treatment  of  eczema  of  the  vulva  and  of  the 
scrotum.  If  the  surface  is  excoriated,  he  prescribes  a  liniment 
of  one  part  of  menthol  to  ten  parts  of  sweet-almond  oil  or  an 
ointment  of  from  one  to  four  parts  of  menthol,  sixty  of  vaseline, 
and  thirty  each  of  zinc  oxide  and  powdered  starch.  If  there  is 
no  ulceration,  he  orders  an  alcoholic  solution  of  menthol,  from 
five  to  ten  per  cent.,  or  a  powder  of  from  one  to  three  parts  of 
menthol,  fifteen  each  of  zinc  oxide  and  bismuth  subnitrate,  and 
fifty  of  ]>owdered  starch. 


AMMONIUM  CHLORIDE  IN  THE  TREATMENT  OF  ASTHMA. 

RuEL  (Presse  medicale  belfje,  March  19, 1893;  Revue  generale 
de  medecine,  de  chirurgie  et  d''obstetrique,  April  5,  1893)  has 
found  on  the  cornea  spiral  formations  resembling  those  described 
by  Curschmann  in  1882  as  existing  in  the  sputum  of  asthmatics 
and  as  made  up  of  thickened  mucus.  Ruel  finds  that  the  cor- 
neal spirals  are  epithelial  outgrowths,  and,  on  the  strength  of 
bis  observation  of  them  and  of  their  behavior  under  the  admin- 
istration of  ammonium  chloride,  suggests  that  the  spirals  of 
asthma  are  of  like  origin  and  would  be  checked  in  their  forma- 
tion by  the  use  of  the  same  drug. 


WET  APPLICATIONS  IN  ACUTE  ECZEMA. 

At  a  meeting  of  the  Berlin  Dermatological  Union,  the  pro- 
ceedings of  which  are  given  in  the  Deutsche  Medizinal-Zeitung 
for  February  23d,  Dr.  Saalfeld  recommended  the  treatment  of 
acute  eczema  with  applications  of  a  freshly  prepared  mixture  of 
lead-water  and  a  three-per-cent.  solution  of  boric  acid.  The 
proportions  are  not  mentioned.  The  cloths  are  to  be  changed 
every  fifteen  minutes. 


THE  ASSOCIATED  PHYSICIANS  AND  SURGEONS. 

This  is  the  title  of  a  corporation  that  has  been  oi'ganized  in 
New  York,  with  Dr.  Daniel  Lewis  as  president,  "for  the  pur- 
pose of  performing  the  clerical,  financial,  and  legal  work  neces- 
sary to  the  proper  conduct  and  protection  of  the  business  affairs 


April  22,  1893.] 


MINOR  PARAGRAPHS.— ITEMS. 


447 


of  medical  practitioners."  It  is  higli  time  tliat  some  sucb  or- 
ganization was  effected,  and  we  hope  that  a  prominent  feature 
of  its  work  will  be  that  of  attending  to  legal  formalities  and 
expenses  that  may  at  times  be  suddenly  and  undeservedly  en- 
tailed upon  a  busy  practitioner,  as  was  lately  shown  in  our 
columns  by  the  story  of  what  happened  to  a  gentleman  who 
was  unjustly  accused  of  having  produced  a  criminal  abortion. 


DIAPHTHERIN  AS  A  DENTAL  ANTISEPTIC. 

In  the  January  number  of  the  Therapeutische  Monatshefte 
there  is  an  article  by  Dr.  Brandt,  of  Berlin,  in  which,  according 
to  a  summary  published  in  the  Fortschritte  der  Medicin  for 
March  15th,  ho  mentions  the  advantages  of  diaphtherin  (oxy- 
quinaseptol)  for  use  within  the  mouth.  While  it  is  an  energetic 
antiseptic,  it  does  not  irritate  and  its  odor  is  slight. 


ITEMS,  ETC. 

Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
*nd  deaths  reported  during  the  two  weeks  ending  April  18,  1893  : 


DISEASES. 

Week  ending  Apr.  11. 

Week  ending  Apr.  18 

Cases. 

Deaths. 

CaseB. 

Deaths. 

13 

4 

11 

7 

16 

4 

21 

6 

220 

19 

181 

18 

Cerebro-spinal  meningitis. . . . 

10 

7 

7 

4 

117 

7 

127 

5 

182 

S5 

99 

38 

9 

2 

7 

0 

The  Pan-American  Medical  Congress. — The  executive  committee  of 
the  first  Pan-American  Medical  Congress  promulgates  the  following  in- 
formation : 

1.  The  first  Pan-American  Medical  Congress  will  be  opened  under 
the  presidency  of  Professor  William  Pepper,  M.  D.,  LL.  D.,  president  of 
the  University  of  Pennsylvania,  at  Washington,  on  September  5tb,  and 
will  adjourn  on  September  8,  1893. 

2.  The  countries  officially  participating  in  the  congress  are  restricted 
to  the  Argentine  Republic,  Bolivia,  Brazil,  British  North  America,  Brit- 
ish West  Indies  (including  B.  Honduras),  Chile,  the  Dominican  Repub- 
lic, Hondura.?  (Sp.),  Mexico,  Nicaragua,  Paraguay,  Peru,  Salvador,  Co- 
lombia, Costa  Rica,  Ecuador,  Guatemala,  Haiti,  Hawaii,  the  Spanish 
West  Indies,  the  United  States,  Uruguay,  Venezuela,  the  Danish,  Dutch, 
and  the  French  West  Indies. 

Distinguished  representatives  of  the  profession  from  other  countries 
are  expected  to  be  present  as  guests  and  to  participate  in  the  proceed- 
ings. 

3  The  general  sessions  will  be  limited  in  number,  one  for  opening 
and  one  for  closing  the  congress  being  all  that  will  be  held,  unless  some 
necessity  arises  for  a  change  in  this  particular.  This  arrangement  will 
permit  members  to  employ  all  of  the  time  in  the  scientific  work  of  the 
sections,  which  are  as  follows  : 

(1)  General  medicine,  (2)  general  surgery,  (3)  military  medicine  and 
surgery,  (4)  obstetrics,  (5)  gynaecology  and  abdominal  surgery,  (6)  thera- 
peutics, (7)  anatomy,  (8)  physiology,  (9)  diseases  of  children,  (10)  pa- 
thology, (11)  ophthalmology,  (12)  laryngology  and  rhinology,  (13)  otolo- 
gy, (14)  dermatology  and  syphilography,  (15)  general  hygiene  and  de- 
mography, (10)  marine  hygiene  and  quarantine,  (17)  orthopiedic  surgery, 
(18)  diseases  of  the  mind  and  nervous  system,  (19)  oral  and  dental  sur- 
gery, (20)  medical  pedagogics,  (21)  medical  jurisprudence,  (22)  railway 
surgery. 

The  evenings  will  be  devoted  entirely  to  social  features,  the  detailed 
announcements  of  which  will  be  made  by  the  committee  of  arrange- 
ments. 

4.  Membership  is  limited  to  tiie  members  of  the  medical  profession  of 


the  Western  Hemisphere,  including  the  West  Indies  and  Hawaii,  who 
shall  either  register  at  the  meeting  or  shall  serve  the  congress  in  the  ca- 
pacity of  foreign  officers.  No  membership  fee  will  be  accepted  from 
any  member  residing  outside  the  United  States.  The  membership  fee 
for  residents  of  the  United  States  is  ten  dollars.  All  registered  mem- 
bers will  receive  a  copy  of  the  Transaclions.  Prominent  students  of  the 
allied  sciences  will  be  cordially  received  as  guests  and  as  contributors  to 
the  proceedings  upon  invitation  by  the  executive  presidents  of  sections. 
Ladies'  tickets  will  be  issued  upon  application  to  registered  members 
only  and  will  entitle  the  holders  to  reduced  fare  and  to  admission  to  all 
entertainments.  Physicians  of  the  United  States  should  register  at  once 
by  remitting  ten  dollars  to  Dr.  A.  M.  Owen,  treasurer,  Evansville,  In- 
diana. 

5.  Papers  are  solicited,  the  hope  being  entertained  that  the  pro- 
gramme will  be  largely  taken  up  with  contributions  from  outside  the 
United  States.  Papers  may  be  rcfid  in  any  language,  but  a  copy  must 
be  furnished  for  publication  in  either  Spanish,  Portuguese,  French,  or 
English,  and  must  not  occupy  more  than  twenty  minutes  in  reading. 
An  abstract  not  exceeding  six  hundred  words  must  be  furnished  the 
secretary  general  in  one  of  the  above  four  languages  by  not  later  than 
July  10th.  Abstracts  will  then  be  translated  by  the  literary  bureau 
into  the  three  remaining  languages,  and  will  be  published  in  book  form 
before  the  meeting  of  the  congress. 

6.  The  Congress  of  the  United  States  has  adopted  a  joint  resolution 
whereby  all  the  governments  of  the  Western  Hemisphere  have  been  in- 
vited by  the  President  to  send  delegates  to  the  first  Pan-American  Medi- 
cal Congress,  and  has  appropriated  a  liberal  sum  for  the  purposes  of 
entertainment. 

7.  The  reduced  fare  offered  by  all  transportation  companies  on  the 
occasion  of  the  World's  Columbian  Exposition,  to  be  held  in  Chicago, 
will  be  open  to  all  persons  attending  the  Pan-American  Medical  Con- 
gress. The  committee  of  arrangements  will  endeavor  to  secure  still 
greater  reduction  to  members  traveling  between  Chicago  and  Washmg- 
ton,  and  an  efPort  will  be  made  to  arrange  either  excursions  or  circular 
tours  for  those  who  may  desire  to  visit  the  great  universities  of  the 
United  States.  All  such  arrangements  are  open  to  subsequent  an- 
nouncement. 

8.  By  arrangement  with  the  committee  at  Rome,  the  date  of  the 
Eleventh  International  Medical  Congress  has  been  so  appointed  that 
those  who  attend  the  meeting  of  the  Pan-American  Medical  Congress 
may  subsequently  attend  the  former.  The  Pan-American  Medical  Con- 
gress will  adjourn  on  the  afternoon  of  September  8tli ;  a  steamship  will 
sail  from  New  York  on  the  following  day,  going  by  the  Azores  and 
Gibraltar  and  enabling  the  tourist  to  reach  Rome  on  the  morning  of 
September  20th,  where  the  Eleventh  International  Congress  will  be 
opened  on  the  afternoon  of  September  24th.  It  will  thus  be  seen  at  a 
glance  that  in  the  period  usually  allotted  to  a  summer  vacation  the 
medical  tourist  may  spend  a  week  at  the  World's  Columbian  Exposi- 
tion, the  next  week  at  the  Pan-American  Medical  Congress,  the  next 
week  and  a  half  with  delightful  companions  in  a  voyage  to  the  Medi- 
terranean, the  next  few  days  in  witnessing  the  sights  of  Rome,  and  the 
following  week  at  the  Eleventh  International  Medical  Congress.  Spe- 
cial reduced  rates  for  members  and  their  families  are  given  both  ways 
on  the  trip  to  Rome,  particulars  of  which  will  be  furnished  on  applica- 
tion to  the  secretary  general,  311  Elm  Street,  Cincinnati,  Ohio,  who  is 
also  a  member  of  the  American  committee  of  the  Eleventh  Interna- 
tional Congress. 

9.  The  best  possible  arrangements  will  be  made  with  the  excellent 
hotels  with  which  the  national  capital  is  abundantly  supplied.  The  com- 
mittee of  arrangements  will  do  its  utmost  to  secure  desirable  rates  and 
locations  for  members  and  their  families.  The  headquarters  of  the 
committee  of  arrangements  is  at  the  Arlington  Hotel,  where  communi- 
cations may  be  addressed  either  to  Dr.  Samuel  S!  Adams,  chairman,  or 
Dr.  J.  R.  Wellington,  secretary. 

10.  Copies  of  the  official  announcement  of  the  congress,  containing 
the  regulations  and  the  names  of  all  officers  and  committeemen  of  the 
general  congress  and  of  the  various  sections,  and  residing  in  the  vari- 
ous countries,  may  be  obtained  upon  application  to  the  secretary  gen- 
eral, or  to  cither  of  the  members  of  the  international  executive  commit- 
tee, as  follows : 


448 


ITEMS. 


[N.  Y.  Med.  Jouh., 


Argentine  Republic,  Dr.  Pedro  Lagleyze,  Calle  Artes  46,  Buenos 
Aires  ;  Bolivia,  Dr.  Einilio  di  Tomassi,  Calle  Ayacucho  '26,  La  Paz ;  Brit- 
ish West  Indies,  Dr.  James  A.  de  Wolf,  Port  of  Spain  ;  British  North 
America,  Dr.  James  F.  W.  Ross,  481  Sherborne  Street,  Toronto;  Chile, 
Dr.  Moises  Amaral,  Facultad  de  Medicina,  Santiago;  Costa  Rica,  Dr. 
Daniel  Nunez,  San  Jos6 ;  Dominican  Republic,  Dr.  Julio  Leon,  Santo 
Domingo ;  Ecuador,  Dr.  Ricardo  Cucalon,  Guayaquil ;  Guatemala,  Dr. 
Jose  Monteros,  Avenida  Sur  No.  8,  Guatemala  City;  Haiti,  Dr.  T.  La- 
mothe,  Rue  du  Centre,  Port  au  Prince ;  Haw  aii,  Dr.  Joliii  A.  McGrew, 
Honolulu;  Honduras  (Spanish),  Dr.  (ieo.  Bernhardt,  Tegucigalpa;  Mex- 
ico, Dr.  Tomas  Noriega,  Hospital  de  Jesus,  Meiico ;  Nicaragua,  Dr.  J. 

L  Urtecho,  Calle  Real,  Granada ;  Paraguay,  ;  Peru,  Dr.  Manuel 

0.  Darrios,  Facultad  de  Medicina,  Lima ;  Republic  of  Colombia,  Dr.  P. 
M.  Ibaiiez,  Calle  5a  Niimero  99,  Bogota ;  Salvador,  Dr.  David  J.  Guz- 
man, San  Salvador ;  Spanish  West  Indies,  Dr.  Juan  Santos  Fernandez, 
Calle  Reina  No.  92,  Havana ;  United  States  of  America,  Dr.  A.  Vander 
Veer,  28  Eagle  Street,  All)any,  N.  Y. ;  United  States  of  Brazil,  Dr.  Car- 
los Costa,  Rua  Largo  da  Misericordia  V,  Rio  de  Janeiro;  Uruguay,  Dr. 
Jacinto  de  Leon,  Calle  de  Florida  No.  05,  Montevideo ;  Venezuela,  Dr. 
Elias  Rodriguez,  Caracas. 

The  Congress  of  American  Physicians  and  Surgeons. — At  a  recent 
meeting  of  the  executive  comniittee  of  the  Third  Congress  of  American 
Physicians  and  Surgeons  it  was  decided  that  three  afternoons  and  one 
evening  of  the  congress  be  assigned,  in  sessions  of  an  hour  and  a  half 
each,  to  seven  of  the  fourteen  participating  organizations,  and  that  each 
society  selected  should  be  requested  to  prepare  its  own  programme  and 
select  its  own  speakers.  The  selection  of  the  societies,  under  this  reso- 
lution, to  prepare  programmes  for  the  third  congress  was  made  alpha- 
betically, as  follows:  (1)  Anatomists;  (2)  climatologists  ;  (3)  derma- 
tologists ;  (4)  genito-urinary  surgeons ;  (5)  gynaecologists ;  (6)  laryn- 
gologists ;  (7)  neurologists.  The  ophthalmologists,  orthopaedists,  otolo- 
gists, pasdiatrists,  physicians,  physiologists,  and  surgeons,  under  this 
resolution,  will  in  like  manner  prepare  programmes  for  the  fourth  con- 
gre.ss.  The  president  and  the  secretary  of  the  congress  and  the  chairman 
and  the  secretary  of  the  executive  committee  were  made  a  standing  com- 
mittee to  arrange  the  details  of  the  congress.  Dr.  L.  C.  Gray  was  elected 
chairman  of  the  executive  committee,  vice  Dr.  William  Pepper,  re- 
signed. It  was  further  decided  to  hold  the  congress  in  Washington  on 
the  last  Tuesday  in  May,  1894,  and  the  three  succeeding  days. 

Dr.  Benjamin  Franklin  Sherman,  of  Ogdensburgh,  N.  Y.,  lately 
president  of  the  Medical  Society  of  the  State  of  New  York,  is  to  be  given 
a  dinner  on  the  25th  inst.  by  the  Ogdensburgh  Medical  Association. 

A  Congress  of  Medical  Climatology  will  convene  in  the  Art  Build- 
ing in  Chicago  on  May  29th,  and  continue  in  session  for  a  week.  On 
June  1st  there  will  be  a  discussion  on  the  causative  and  curative  rela- 
tions of  climate  to  consumption. 

The  Bichmond  Academy  of  Medicine  and  Surgery. — The  special 
order  for  the  next  meeting,  on  Tuesday  evening,  the  25th  inst.,  is  a  dis- 
cussion on  Purulent  Puerperal  Peritonitis,  to  be  opened  by  Dr.  V.  W. 
Harrison. 

Change  of  Address. — Dr.  M.  J.  Burstein,  to  No.  1V9  Henry  Street. 

Army  Intelligence. — Official  List  of  Changes  in  the  Stations  and 
DtUies  of  Officers  serving  in  the  Medical  Department,  United  States 
Army,  from  April  2  to  April  15,  1893  : 

De  Loffre,  Augustus  A.,  Major  and  Surgeon,  will,  by  direction  of  the 
Secretary  of  War,  be  relieved  from  duty  at  Columbus  Barracks, 
Ohio,  upon  receipt  of  this  order,  and  will  report  in  person  to  the 
commanding  officer  at  Fort  Logan,  Colorado,  for  duty  as  post  surgeon 
at  that  station.  ^ 

Gaudner,  Edwin  F.,  Captain  and  Assistant  Surgeon.  The  leave  of  ab- 
sence granted  for  seven  days  is  extended  twenty-three  days. 

Ireland,  Merrittk  W.,  First  Lieutenant  and  Assistant  Surgeon,  will  be 
relieved  from  duty  at  Fort  Riley,  Kansas,  on  receipt  of  this  order, 
and  will  report  in  person  to  the  commanding  officer.  Fort  Apache, 
Arizona,  for  duty  at  that  post,  relieving  Jarvis,  Nathan  S.,  Captain 
and  Assistant  Surgeon.  Captain  Jarvis,  upon  being  relieved  by 
First  Lieutenant  Ireland,  will  report  in  person  to  the  commanding 


officer,  David's  Island,  New  York,  for  duty  at  that  post,  relieving 
Brewer,  Madison  M.,  First  Lieutenant  and  Assistant  Surgeon.  First 
Lieutenant  Brewer,  upon  being  relieved  by  (Japtain  .Jarvis,  will  re- 
port in  person  to  the  commanding  officer.  Fort  Riley,  Kansas,  for 
duty  at  that  post. 

KiLBOURNE,  Hknry  S.,  Captain  and  Assistant  Surgeon,  will  be  relieved 
from  duty  at  Fort  Riley,  Kansas,  on  receipt  of  this  order  at  that 
station,  and  will  report  in  person  to  the  commanding  officer,  Fort 
Clark,  Texas,  for  duty  at  that  post. 

Mason,  Charles  F.,  First  Lieutenant  and  Assistant  Surgeon,  will  pro- 
ceed to  New  York  city  on  Monday,  April  24,  1893,  and  report  in 
person  to  Colonel  Charles  H.  Alden,  Assistant  Surgeon  General, 
President  of  the  Army  Medical  Board  in  that  city,  for  examination 
by  the  board  with  a  view  of  determining  his  fitness  for  promotion. 

Appel,  Daniel  M.,  Captain  and  Assistant  Surgeon,  will  be  relieved 
from  duty  at  Fort  Bliss,  Texas,  as  soon  as  possible  after  the  receipt 
of  this  order,  and  will  then  proceed  to  Chicago,  111.,  and  report  to 
the  Commanding  General,  Department  of  the  Missouri,  for  assign- 
ment to  duty  pertaining  to  the  World's  Columbian  Exposition  as 
attending  surgeon  for  the  officers  and  enlisted  men  on  duty  in  the 
Exposition  grounds. 

MosELEY,  Edward  B.,  Major  and  Surgeon,  will  be  relieved  from  duty  in 
the  office  of  the  Surgeon  General  of  the  army  not  later  than  May  I, 
1893,  and  will  report  in  person  to  the  commanding  officer.  Fort 
Monroe,  Virginia,  for  duty  at  that  post,  to  relieve  Polhemus,  Adrian 
S.,  Captain  and  Assistant  Surgeon. 

Naval  Intelligence. —  Official  List  of  Changes  in  tfie  Medical  Corps 
of  the  United  States  Navy  for  the  two  weeks  ending  April  15,  1893 : 
DiEHL,  Oliver,  Passed  Assistant  Surgeon.    Detached  from  the  U.  S. 

Steamer  Essex. 

Snipp,  E.  M.,  Assistant  Surgeon.  Ordered  to  Naval  Hospital,  Boston, 
Mass. 

Herndon,  C.  G.,  Surgeon.   Detached  from  the  Marine  Rendezvous,  New 

York,  April  12th,  and  placed  on  waiting  orders. 
Drake,  N.  H.,  Surgeon.     Ordered  to  the  Marine  Rendezvous,  New 

York. 

Marine-Hospital  Service. —  Official  List  of  the  Changes  of  Stations 
and  Duties  of  Medical  Officers  of  the  United  States  Marine-Hospital 
Service  for  the  fve  weeks  ending  April  8,  1893 : 

Bailiiache,  p.  H.,  Surgeon.  Detailed  as  chairman  of  Board  for  physi- 
cal examination  of  officers,  Revenue-Marine  Service.  March  21, 
1893. 

Sawtelle,  H.  W.,  Surgeon.  Detailed  as  chairman  of  Board  for  physi- 
cal examination  of  officers,  Revenue-Marine  Service.  March  7, 
1893. 

Austin,  H.  W.,  Surgeon.  Detailed  as  chairman  of  Board  to  prepare 
Quarantine  Regulations.    March  10,  1893. 

Gassaway,  J.  M.,  Surgeon.  To  proceed  to  Ellis  Island,  New  York,  for 
temporary  duty,  then  to  proceed  to  Cincinnati,  Oliio,  St.  Louis,  Mo., 
Cairo,  111.,  and  Memphis,  Tenn.,  as  Inspector.    April  3,  1893. 

Stoner,  G.  W.,  Surgeon.  To  inspect  Hogg  Island,  Maryland,  for  quar- 
antine purpose.    March  17,  1893. 

Mead,  T.  W.,  Surgeon.  Detailed  as  chairman  of  Board  for  physical  ex- 
amination of  officers  and  candidates,  Revenue-Marine  Service.  March 
28,  1893. 

Carter,  11.  R.,  Surgeon.  Detailed  as  member  of  Board  to  prepare  Quar- 
antine Regulations.    March  10,  1893. 

Banks,  C.  E.,  Passed  Assistant  Surgeon.  To  proceed  to  Halifax,  N.  S., 
for  temporary  duty.    March  29,  1893. 

Kalloch,  p.  C,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  ten  days.    March  24,  1893. 

Glennan,  a.  H.,  Passed  Assistant  Surgeon.  To  proceed  to  Vineyard 
Haven,  Mass.,  for  temporary  duty.  March  6,  1893.  To  proceed  to 
Cairo,  111.,  for  duty.    March  22,  1893. 

Wasdin,  Eugene,  Passed  Assistant  Surgeon.  To  proceed  to  South  At- 
lantic Quarantine  Station  for  duty.    March  22,  1893. 

Carrinoton,  p.  M.,  Passed  Assistant  Surgeon.  To  report  at  this  Bureau 
for  instructions  preparatory  to  going  to  Hamburg.    April  8,  1893. 


April  22,  1893.] 


ITEMS.— LETTERS 


TO  THE  EDITOR. 


449 


Williams,  L.  L.,  Passed  Assistant  Surgeon.  Detailed  for  duty  in  the 
office  of  the  United  States  Consul,  Liverpool,  England.  April  5, 
1893. 

Bratton,  W.  D.,  Passed  Assistant  Surgeon.    To  proceed  to  Buffalo, 

N.  Y.,  for  duty.    March  6,  1893. 
McIntosh,  W.  p.,  Passed  Assistant  Surgeon.    Detailed  as  member  of 

Board  for  physical  examination  of  officers,  Revenue-Marine  Service. 

March  7,  1893. 

Pettus,  VV.  J.,  Passed  Assistant  Surgeon.  Detailed  for  duty  in  the  of- 
fice of  the  United  States  Consul,  Southampton,  England. 

KiNYOUN,  J.  J.,  Passed  Assistant  Surgeon.  Detailed  as  member  of 
Board  to  prepare  Quarantine  Regulations.    March  10,  1893. 

Woodward,  R.  M.,  Passed  Assistant  Surgeon.  Detailed  for  duty  in  the 
office  of  the  United  States  Consul,  Rotterdam,  Netherlands. 

Geddings,  H.  D.,  Passed  Assistant  Surgeon.  Detailed  as  recorder  of 
Board  to  prepare  Quarantine  Regulations.  March  10,  1893.  De- 
tailed as  member  of  Board  for  physical  examination  of  officers  and 
candidates,  Revenue- Marine  Service.    March  28,  1893. 

HussEY,  S.  n..  Assistant  Surgeon.  To  proceed  to  Cincinnati,  Ohio,  for 
duty.  March  21,  1893.  Granted  leave  of  absence  for  thirty  days. 
March  24,  1893. 

Perry,  J.  C,  Assistant  Surgeon.  To  proceed  to  Vineyard  Haven,  Mass., 
for  duty.    March  13,  1893. 

Young,  G.  B.,  Assistant  S\irgeon.  Detailed  for  duty  in  the  office  of  the 
United  States  Consul,  Naples,  Italy.    March  G,  1893. 

Brown,  B.  W.,  Assistant  Surgeon.  Detailed  for  duty  in  the  office  of 
the  United  States  Consul,  Genoa,  Italy. 

Houghton,  E.  R.,  Assistant  Surgeon.  Detailed  for  duty  in  the  office  of 
the  United  States  Consul,  Havre,  France. 

Nydegger,  J.  A.,  Assistant  Surgeon.  To  proceed  to  Pittsburgh,  Pa.,  for 
duty.    March  6,  1893. 

Stewart,  W.  J.  S.,  Assistant  Surgeon.  Granted  leave  of  absence  for 
five  days.  March  8,  1893.  To  proceed  to  South  Atlantic  Quaran- 
tine for  temporary  duty.  March  10, 1893.  To  proceed  to  Baltimore, 
Md.,  for  duty.    March  22,  1893. 

Strayer,  Edgar,  Assistant  Surgeon.  To  proceed  to  Portland,  Me.,  for 
temporary  duty.    March  29,  1893. 

Blue,  Rupert,  Assistant  Surgeon.  To  proceed  to  Cairo,  111.,  for  tempo- 
rary duty.  March  7,  1893.  To  proceed  to  Galveston,  Texas,  for 
duty.    March  22,  1893. 

Oakley,  J.  U.,  Assistant  Surgeon.  Assigned  to  duty  at  Savannah,  Ga. 
March  23,  1893. 

Norman,  Skaton,  Assistant  Surgeon.  Assigned  to  duty  at  Evansville, 
Ind.    April  8,  1893. 

Appointments. 

Blue,  Rupert,  of  South  Carolina.  Commissioned  Assistant  Surgeon. 
March  3,  1893. 

Oakley,  James  H.,  of  Illinois.  Commissioned  Assistant  Surgeon. 
March  22,  1893. 

Norman,  Seaton,  of  Indiana.  Commissioned  Assistant  Surgeon.  April 
6,  1893. 

Resiffnations. 

CoNDiCT,  A.  W.,  Assistant  Surgeon.  Resigned,  to  take  effect  August 
1,  1893. 

Hussey,  S.  H.,  Assistant  Surgeon.  Resigned,  to  take  effect  .lune  30, 
1893. 

Society  Meetings  for  the  Coming  Week : 

Monday,  April  ZJ/th  :  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  Z5th ;  New  York  Derrnatological  Society  (private) ; 
Buffalo  Obstetrical  Society ;  Medical  Society  of  the  County  of  Put- 
nam (quarterly),  N.  Y. ;  Hunterdon,  N.  J.,  County  Medical  Society 
(Fleinington) ;  Litchfield,  Conn.,  County  Medical  Society  (semi- 
annual);  Boston  Society  of  Medical  Sciences;  Richmond,  Va.,  Acad- 
emy of  Medicine  and  Surgery. 

Wednesday,  April  SGlh :  New  York  Academy  of  Medicine  (Section  in 
Laryngology  and  Rhinology) ;  New  York  Surgical  Society ;  New 


York  Pathological  Society ;  American  Microscopical  Society  of  the 
City  of  New  York  ;  Metropolitan  Medical  Society  (private) ;  Medical 
Society  of  the  County  of  Albany,  N.  Y. ;  Aul)urn,  N.  Y.,  City  Medical 
Association  ;  Philadelphia  County  Medical  Society  ;  Berkshire,  Mass. 
(Pittsfield — annual),  and  Middlesex,  Mass.,  North  District  (annual — 
Lowell),  Medical  Societies;  Gloucester,  N.  J.,  County  Medical  Society 
(quarterly). 

Thursday,  April  27th :  New  York  Academy  of  Medicine  (Section  in 
Obstetrics  and  Gynascology) ;  New  York  Orthopaedic  Society  ;  Brook- 
lyn Pathological  Society ;  Roxbury,  Mass.,  Society  for  Medical  Im- 
provement (private — annual) ;  Hartford,  Conn.,  County  Medical  As- 
sociation (annual) ;  Pathological  Society  of  Philadelphia. 

Friday,  April  28th :  Yorkville  Medical  Association  (private) ;  New 
York  Society  of  German  Physicians ;  New  York  Clinical  Society 
(jjrivate) ;  Philadelphia  Clinical  Society  ;  Philadelphia  Laryngologi- 
cal  Society. 

Answers  to  Correspondents : 

No.  400. — In  our  opinion,  the  course  you  mention  is  perfectly 
proper. 


Ictte  to  iht  dBbitor. 

THE  SEX  QUESTION. 

7  Halsey  Street,  Brooklyn. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir  :  I  ask  space  in  your  esteemed  Joiirnal  for  a  few  com- 
ments on  a  communication  in  your  number  of  July  2d  last  from 
D.  E.  Keefe,  M.  D.,  entitled  Controlling  Sex  in  Generation.  I 
ask  it  as  the  author  of  a  book  I  copyrighted  in  1884  on  this 
subject,  under  the  title  Controlling  Sex  in  Generation,  which 
has  been  on  the  market  for  sale  ever  since,  and  which  Dr. 
Keefe  makes  reference  to  simply  as  "Mr.  Terry's  little  book," 
he  using  tlie  title  as  the  heading  to  his  communication,  without 
any  footnote  to  indicate  to  his  readers  that  it  is  the  title  of  my 
book,  though  such  footnotes  otherwise  ahound  giving  the  titles 
of  the  books  quoted  from  or  referred  to  by  him. 

While  I  might  well  he  gratified  by  the  additional  and  sub- 
stantial proof  of  my  theory  his  investigations  give,  the  manner 
in  which  he  ignores  the  details  in  my  book  while  aspiring  to 
erect  a  structure  for  himself  on  its  foundations  is,  to  put  it 
mildly,  not  the  liberal  and  fair  dealing  one  feels  naturally  en- 
titled to  receive  from  a  man  who  writes  M.  D.  after  his  name. 

Though  fully  accepting  my  theory  that  "the  parent  sexually 
prepotent  at  the  moment  of  conce[>tion  impresses  not  his  or 
her  own,  but  the  opposite  sex  on  the  offspring,"  he  objects  to 
my  phrase  " highest  degree  of  sexual  excitement"  to  express 
the  condition  which  gives  this  prepotency,  and  substitutes 
"  highest  degree  of  sexual  and  general  bodily  and  mental  vigor." 
Then  he  claims  not  only  this  change,  but  the  dominant  idea  as 
his  theory. 

Now,  a  dis])Ute  over  words  to  expre-s  ideas  so  nearly  related 
is  usually  profitless.  Dr.  Keete  admits  that  in  my  book  the  ele- 
ment of  "sexual  vigor"  is  embraced  in  "sexual  excitement"; 
in  fact,  the  numerous  passages  he  quotes  from  my  book  show 
this.  The  error  which  led  to  his  objection  to  my  torni  lies  in 
his  misconception  of  the  meaning  of  the  word  "excitement," 
whicli  is  as  given  in  Welmter:  "3.  Med.  A  state  of  aroused  or 
exalted  vital  activity  in  the  body  or  any  of  its  parts."  The 
neurotic  persons  he  refers  to  are  in  a  morbid  condition  through 
which  thoy  possess  a  high  excitahility,  wiiich  is  quite  a  differ- 
ent thing.  '■^  Erethism,''^  which  is,  according  to  Webster,  "a 
morbid  degree  of  excitement  or  irritation  in  an  organ,"  is  the 
medical  term  applicable  to  the  condition  of  such  persons. 
Their  disordered  nervous  and  usually  sexual  condition  renders 


450 


LETTERS  TO  THE  EDITOR. 


[N.  Y.  M»D.  JouB., 


them  unable  to  bear  even  a  low  tension  of  sexual  excitement,  a 
disruptive  discharge  of  the  electric  condition  occurring  at  the 
slightest  strain  on  the  organism.  One  might,  with  equal  pro- 
priety, maintain  that  materials  most  inflammable — that  is,  most 
readily  set  on  fire — produce  the  greatest  heat. 

I  carefully  drew  this  distinction  between  excitement  and 
excitability  in  different  places  in  Jiiy  book  as  the  subject  cameui) 
practically  (see  paragraph  i,  page  7C,  and  pages  132,  136);  and 
the  word  excitement  was  not  used  by  me  without  due  consid- 
eration of  its  weight  and  propriety.  It  is  a  word  widely  used 
in  medical  practice  in  the  sense  quoted  from  Webster,  and  is  a 
common  one  to  express  the  somewhat  allied  cundition  of  an  in- 
sulated person  charged  with  electricity  from  a  battery.  He  is 
said  to  be  electrically  excited. 

The  highest  degree  of  sexual  vigor,  which  Dr.  Keefe  prefers, 
is  rather  the  capacity  to  ordinarily  take  on  the  highest  degree 
of  excitement.  It  presents  more  visibly  the  probability  of  a 
higher  excitement,  so  that  by  it  such  classifications  as  Dr.  Keefe 
makes  are  possible.  But  its  power  may  be  overborne  in  the 
conjugal  embrace  by  a  partner  of  less  sexual  vigor  more  highly 
aroused  by  sexual  ardor.  The  results  in  Dr.  Keefe's  second  and 
third  classes  show  this — in  one  25-6  per  cent.,  and  in  the  other 
7'35  per  cent. ;  the  higher  sexual  vigor  is  shown  to  have  been 
overcome  by  the  increased  ardor  of  the  one  inferior  in  vigor. 
The  highest  sexual  vigor  may  be  easily  placed  in  the  inferior 
position  by  an  emetic  sufficient  to  produce  nausea.  It  is  only 
when  all  things  run  in  their  natural  course,  and  conditions  on 
both  sides  are  equal,  that  highest  sexual  vigor  gives  highest 
sexual  excitement  to  the  determination  of  offspring  of  the  oppo- 
site sex. 

But  this  is  not  really  controlling  the  sex,  which  goes  a  step 
beyond,  and  requires  often  that  the  parent  with  less  sexual 
vigor  shall,  for  the  occasion,  have  his  or  her  passion  aroused  or 
exalted  in  a  higher  degree,  and  thus  become  prepotent  through 
a  higher  state  of  sexual  excitement. 

On  what  other  principle  is  Dr.  Keefe  to  change  the  92-64 
per  cent,  of  the  husbands  in  his  third  class  so  they  will  be  pre- 
potent? He  certainly  can  not  expect  these  basic  qualities  of 
sexual,  bodily,  and  mental  vigor  can  be  materially  increased  in 
a  day  or  a  year.  As  is  shown  near  the  close  of  his  article,  he 
relies  for  producing  this  prepotency  on  such  conditions  as  tend 
to  increase  the  power  to  take  on  a  higher  excitement. 

In  introducing  what  he  calls  his  theory  of  the  reason  why  a 
parent  impresses  on  his  or  her  progeny  not  his  or  her  own  but 
the  opposite  sex,  he  remarks  :  "  Mr.  Terry  has  offered  no  ade- 
quate explanation  of  this ;  he  only  gives  experiments  proving  the 
fact,  but  not  the  reason  for  it."  Surely  Dr.  Keefe  must  have  read 
my  book  with  very  little  attention.  Chapter  XI  (fifteen  pages 
in  the  first  edition)  is  wholly  devoted  to  this  subject,  and  a  hy- 
pothesis is  there  presented  scientific  in  character,  logical,  and 
consistent  throughout.  Note  H  (nine  pages  more  in  the  appen- 
dix to  the  later  editions)  is  confirmatory.  No  attempt  has  ever 
been  made  to  controvert  the  hypothesis  or  to  show  in  it  any 
fallacy. 

Dr.  K.'s  hypothesis  for  this  presents  no  physiological  law 
that  will  apply  to  the  lower  orders,  and,  so  far  as  it  applies  to 
human  beings,  it  is  based  on  the  condition  of  highest  sexual  ex- 
citement— a  condition  which  he  aptly  describes,  though  in 
different  words.  I  shall  not,  however,  attempt  to  controvert 
his  hypothesis  in  this,  as  all  such  are  necessarily  speculative; 
and,  like  the  ])hysicians'  hypothesis  as  to  the  principle  on  which 
many  medicines  act  to  effect  a  cure,  they  must  rely  for  accept- 
ance on  their  rationality ;  they  can  not  be  proved. 

I  might  take  exception  to  much  the  doctor  says  about  his 
theory  and  the  rules  for  controlling  sex,  as  the  same  ideas,  often 
in  the  same  words,  are  found  throughout  my  book  (see  pages 


82,  83,  86,  89  to  93,  112,  113,  116,  120.  121,  188,  20.5,  and 
Chapter  X  throughout,  as  well  as  Notes  A,  C,  and  G  in  the  ap- 
pendix) ;  but  I  pass  this  over.  I  have  lived  long  enough  to 
know  that  a  busy  man  may,  in  reading  a  book,  treasure  up  in 
his  memory  the  leading  ideas,  while  those  less  prominent  es- 
cape him ;  and  years  after,  when  these  latter  come  to  him  in 
considering  over  the  princijjal  ideas,  he  honestly  thinks  they 
are  the  conclusions  of  his  own  brain. 

That  Dr.  Keefe  has  good  perceptive  faculties  is  shown  by 
the  results  of  his  classifications;  but  his  capacity  for  drawing 
logical  conclusions  is  less  acute,  as  shown  by  his  remarks  on 
Dr.  W.  n.  Cook's  theory  that  in  conceptions  occurring  in  the 
earlier  night  males  are  more  frequent,  and  in  tliose  toward 
morning  females.  Paragraph  «,  jiage  07  in  my  book,  and  one 
on  pages  82  and  83,  though  written  before  the  promulgation  of 
Dr.  Cook's  theory,  show  how  this  may  be  in  some  families,  yet 
exactly  the  reverse  in  others.  But  Dr.  Keefe  assumes  to  show 
the  fallacy  of  Dr.  Cook's  theory  by  a  classification  of  biilhs  oc- 
curring between  different  hours  of  the  day  and  night.  Finding 
a  hundred  and  twenty-nine  on  his  list  born  between  12  m.  and 
12  p.  M.,  of  which  44"96  per  cent,  were  females  and  65"04  per 
cent,  males,  he  deduces  from  this  the  falsity  of  Dr.  Cook's  theory. 
There  is  a  stretch  of  occult  intelligence  in  this  I  can  not  fathom, 
and  the  doctor  does  not  explain.  It  is  how  Dr.  Keefe  satisfied 
himself  that  all  these  hundred  and  twenty-nine  children  bom 
between  12  m.  and  12  p.  m.  were  begotten  between  midnight 
and  morning. 

Controlling  sex  under  this  theory — that  is,  the  making 
of  the  parent  of  less  sexual  vigor  prepotent  at  the  moment 
of  conception — is  not  so  simple  a  matter  as  Dr.  Keefe  pre- 
sents it;  there  are  many  factors  in  the  problem  which  have 
to  be  considered.  Under  the  governing  influence  of  his  "high- 
est sexual  and  bodily  and  mental  vigor"  alone,  the  parents  in 
his  second  class  should  always  have  girls  and  those  in  his  third 
class  always  boys.  Twins  and  triplets  should  always  be  of  one 
sex;  and  all  the  progeny  of  any  one  parturition  of  multiparous 
animals  should  be  of  one  sex.  But  notably  this  is  not  so,  and 
in  the  fact  that  it  is  not  has  largely  lain  the  mystery  that  en- 
virons the  subject.  When  we  saw  that  onr  smaller  domesti- 
cated animals  gave  birth  to  five  to  ten  young  at  a  time,  usually 
with  varying  proportions  of  each  sex,  it  was  very  manifest  that 
the  influence  determining  the  sex  vibrated  from  one  side  to  the 
other  at  very  short  intervals  and  on  apparently  slight  grounds. 

Having  myself  been  the  fir.st  to  advance  the  theory  that  the 
prepotent  parent  impressed  at  the  time  of  conception  the  oppo- 
site sex  on  the  offspring — a  theory  which  has  already  been  quite 
widely  accepted,  and  concerning  which  a  critic  of  my  book  very 
sapiently  remarked  :  "  This  throwing  of  the  sex  to  the  weaker 
side  of  the  parent  seems  to  be  one  of  the  all-wise  provisions  of 
Nature  in  maintaining  the  equilibrium  of  the  sexes  in  man  and 
beast  throughout  the  whole  animal  kingdom  :  by  this  the  side 
of  the  weak  is  constantly  strengthened  from  the  side  of  the 
strong,  and  thus  the  equilibrium  is  preserved  "  ;  and  believing, 
as  I  thoroughly  do  from  my  lifelong  experiences  and  investiga- 
tions, that  among  married  couples  the  sex  of  their  offspring  can, 
by  attention  to  the  matter,  be  male  or  female  as  they  may  de- 
sire ;  and,  further,  believing  that  much  of  the  unhappiness,  mis- 
ery, and  vice  now  existing  in  society  is  wholly  due  to  the  less 
proportion  of  men  in  the  community — I  feel  the  importance  of 
endeavoring  to  keep  the  theory  asset  forth  in  my  book  free  from 
all  needless  divarications  about  minor  matters. 

I  hail  with  gladness  all  such  tabulated  statements  as  Dr. 
Keefe  presents,  tending  as  they  do  to  strengthen  and  confirm 
the  theory. 

But  what  is  now  more  especially  needed  is  a  consideration 
of  the  various  specific  causes  which  will  surely  enable  the  mar- 


April  22,  1893.] 


LETTERS  TO 


THE  EDITOR. 


451 


ried  partner  of  less  sexual  vigor  to  take  on  the  increased  ardor 
which  in  the  conjugal  embrace  makes  him  or  her  prepotent,  in- 
ducing in  the  offspring  a  sex  other  than  would  be  the  case  natu- 
rally. In  this  my  book  is  admittedly  deficient.  At  the  time  it 
was  written  only  the  more  general  principles  could  be  given, 
just  as  Dr.  Keefe  gives  them  in  his  article.  This  is  a  subject 
more  especially  open  to  the  medical  profession  to  encompass. 
The  need  is  to  arrive  at  such  a  knowledge  of  these  causes  that 
a  physician,  especially  one  practicing  in  an  old  settled  commu- 
nity, can,  from  the  knowledge  ordinarily  obtainable  in  his  prac- 
tice, proscribe  such  a  course  of  living,  of  diet,  perhaps  of  medi- 
cal remedies  to  that  end,  to  those  among  whom  he  practices, 
that  they  may  have  in  their  offspring  eitiier  sex  they  desire, 
with  all  the  certainty  lie  can  prescribe  a  pill  that  will  induce 
purgation.  This  is  already  done  to  some  extent  among  breed- 
ers of  stock,  where  the  control  of  sex  is  often  of  great  pecuniary 
gain  to  the  breeder.  There  is,  of  course,  more  difficulty  with 
human  beings,  owing  to  their  artificial  and  more  varied  manner 
of  living,  and  these  give  rise  to  the  many  exceptions.  While 
Dr.  Keefe's  tables  are  valuable,  they  would  have  been  invaluable 
had  he  traced  out  and  given  us  the  reasons  why  the  2-5*6  per 
cent,  of  the  husbands  in  his  second  class  and  the  7'35  per  cent, 
of  wives  in  his  third  class  were  not  prepotent,  as  by  his  obser- 
vations they  should  have  been.  It  is  true  his  diagnoses  from  ex- 
ternal appearances  may  have  been  at  fault,  but  that  is  just  what 
is  wanted — why  were  they  at  fault  ? 

To  present  somewhat  of  the  lines  in  which  investigation 
must  work  to  ascertain  |the  cause  for  jthese  exceptions,  I  note 
three  which  came  under  my  notice : 

Some  fifteen  years  ago,  between  the  completion  of  the 
manuscript  of  my  book  and  its  publication,  and  while  I  was 
still  watching  for  corroborations  or  refutations  of  my  theory,  I 
casually  met  at  a  summer  resort  a  buxom  young  woman  fresh 
from  boarding  school  who  to  the  eye  seemed  the  beau-ideal 
of  lusty  womanhood.  She  was  accompanied  by  her  betrothed, 
a  puny,  boyish-looking  youth,  of  little  apparent  vigor  of  any 
kind.  Naturally  I  predicted  in  the  union,  soon  to  come  off, 
male  offspring.  But  to  my  surprise  she  had  a  daughter;  and  it 
almost  upset  my  established  theory  in  my  own  mind.  But  a 
year  or  so  later  I  sat  at  the  same  table  with  them,  and  took 
note  that  she  was  a  very  dainty  eater,  while  he  had  an  appe- 
tite like  an  outdoor  laborer.  I  found  also  that  after  his  mar- 
riage he  had  embarked  in  business,  and  was  known  in  it  as  an 
ardent  and  tireless  worker.  She,  on  the  other  hand,  though 
still  retaining  her  buxom  appearance,  had  been  unable  to  nurse 
her  child,  and  was  then  a  semi-invalid.  The  second  case  came 
to  my  notice  in  this  wise : 

A  stranger  in  a  distant  city,  the  principal  of  a  public  school, 
having  purchased  a  copy  of  my  book,  and,  like  Dr.  Keefe,  being 
impressed  with  its  probable  truth,  set  out  to  verify  it  by  obser- 
vation among  his  intimate  acquaintances.  He  found  one  excep- 
tion so  remarkable  tliat  he  wrote  me  about  it,  all  the  other 
cases  satisfactorily  conforming  to  my  theory.  In  this  exception 
the  wife,  who  was  a  near  relative  of  his,  gave  no  characteristics 
of  any  sexual  ardor,  while  the  husband  did.  Not  only  this,  but 
it  was  known  among  some  of  his  jolly  friends  that  he  actually 
kept  a  mistress  to  satisfy  his  craving  passion  ;  and  yet  his  wife 
had  mostly  boys.  I  cogitated  long  over  this,  till  one  day 
Charles  Readc's  story,  Put  Younelf  in  His  Place,  came  to  my 
mind,  and  it  occurred  to  me  that  if  his  wife  suspected  his  infi- 
delity, and  he  was  desirous  of  sustaining  with  her  a  rei)utation 
for  morality,  it  would  induce  him,  on  retirement  at  night  with 
his  wife,  after  spending  an  evening  in  the  arms  of  his  mistress, 
to  assume  a  sexual  desire  when  he  really  had  none ;  so  that  in 
the  embrace  she  would  bo  prepotent.  1  wrote  this  to  my  cor- 
respondent, who  acce[)tcd  it  as  fully  accounting  for  the  sex  of 


their  children,  writing  me  that  his  wife  did  suspect  him  of  be- 
ing untrue  to  her,  sometimes  insinuating  as  much  to  him,  which 
he  strove  to  confute. 

The  third  case  is  something  like  the  first,  though  on  the 
other  side.  I  was  slightly  acquainted  with  a  young  professional 
man,  a  sort  of  amateur  athlete,  fond  of  hunting,  fishing,  and 
outdoor  sports  generally ;  of  good  manly  figure  and,  withal, 
somewhat  noted  for  his  gallantry.  Later  I  heard  of  his  mar- 
riage to  a  frail,  delicate-appearing  woman  of  slight  figure  and 
weight,  and  that  they  had  a  son.  I  was  somewhat  inclined  to 
suspect  the  same  circumstances  existing  in  his  case  as  in  the 
second  above,  as  it  was  the  current  belief  of  those  who  knew 
him  well  that  the  marriage  on  his  side  was  a  mercenary  one, 
but  a  year  later  1  was  a  visitor  at  a  summer  resort  for  some 
time  where  they  sojourned,  and  sat  at  the  same  table  with 
them.  The  same  conditions  as  seen  in  the  first  case,  only  re- 
versed, were  very  obvious.  He  was  often  complaining  that  the 
food  did  not  agree  with  him,  having  special  dishes  of  farina  or 
gluten  and  milk,  or  the  like,  prepared  for  himself ;  while  she  ate 
ravenously  of  anything  set  before  her — "all  was  fish  that  came 
to  her  net" — without  ever  a  complaint  of  indigestion.  Not 
only  this,  but  with  all  his  fondness  for  athletics  and  his  appar- 
ent muscle,  he  was  often  deficient  in  muscular  energy.  It  came 
to  my  knowledge  that  if,  when  riding  out  together  aa  they  did 
every  day,  his  horse  became  fractious  and  difficult  of  control, 
he  sometimes  surrendered  the  reins  to  his  wife  to  bring  the 
horse  to  subjecflton.  They  have  since  had  two  children,  an- 
other boy  and  a  girl. 

In  the  first  of  these  cases  the  probable  cause  for  the  failure 
of  the  wife  to  impress  her  influence  on  the  sex  of  her  child  lay 
in  the  indolent  life  she  had  led  as  a  school  girl.  Her  vital  ener- 
gies, though  healthy,  were  not  accustomed  to  respond  prompt- 
ly, or  be  readily  incited  to  an  exalted  action,  as  in  one  trained 
by  exercise.  Consequently  she  was  incapacitated  to  take  on  a 
high  condition  of  sexual  or  any  other  excitement.  This  want 
of  energy  caused  her  to  break  down  under  the  strain  of  child- 
bearing  and  lactation — a  not  uncommon  result  among  young 
wives  brought  up  in  luxury  and  idleness  {vide  my  book,  page 
67,  paragraph  I). 

In  the  third  case  the  husband's  failure  was  probably  due  to 
periods  of  indigestion,  during  which  there  would  naturally  be  a 
depression  of  the  vital  powers.  Although  he  had  a  superior 
degree  of  "  sexual,  bodily,  and  mental  vigor,"  it  was  at  such 
times  incapable  of  being  aroused  to  any  high  state  of  excite- 
ment, just  as  would  be  the  case  when  recently  exhausted  by 
sexual  congress  with  another  than  his  wife,  as  was  suggested  in 
the  second  above  case. 

It  is  such  disturbing  factors  as  these  that  need  to  be  sought 
out  by  further  investigation,  and  classified  and  made  known,  to 
fully  complete  my  book,  and  these,  as  said  above,  can  best  be 
ascertained  by  physicians  if  they  would  give  the  subject  their 
attention. 

From  some  later  observations  I  am  inclined  to  believe  that 
a  rheumatic,  condition  tends  to  obstruct  or  hinder  the  taking  on 
of  that  higher  state  of  sexual  excitement  necessary  to  prepo- 
tency, even  when  the  individual  seems  endowed  with  all  the 
prerequisites — the  nervous  system  not  responding  so  actively  to 
the  desire.  The  wife  (mentioned  on  page  59  of  my  book)  who 
had  so  largo  a  proportion  of  daughters  was  a  chronic  sufferer 
wit])  rlieuinatism.  Du  Bois  Reymond,  the  celebrated  Gorman 
naturalist,  in  bis  work  on  Animal  Electricity,  mentions  investi- 
gations tending  to  show  the  existence  of  free  electricity  in  both 
men  and  women,  but  that  its  manifestations  sink  to  zero  in  per- 
sons seriously  afflicted  with  rheumatism.  I  have  referred  to 
this  in  note  H  in  the  appendix  to  my  book  in  connection  with 
a  different  subject.  SAianKL  H.  Tebky. 


452 


PROCEEDINGS 


OF  SOCIETIES. 


[N.  Y.  Mro.  JouK., 


^rocfftrings  of  ^cactus. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 
Meeting  of  April  4,  1893. 
The  President,  Dr.  M.  Allen  Stahk,  in  tlie  Chair. 

"  Cerebrine  "  in  the  Treatment  of  Locomotor  Ataxia.— 

Dr.  GbvBmb  M.  Hammond  presented  a  case  of  locomotor  ataxia 
which  he  had  been  treating  with  hypodermic  injections  of  cere- 
brine.  Six  years  ago  the  patient,  a  man  aged  forty,  had  begun 
to  suffer  with  double  vision.  Tliis,  after  several  months  of 
treatment,  had  disappeared  and  for  a  time  lie  had  been  quite 
well.  Then  the  typical  symptoms  of  locomotor  ataxia  came 
on.  There  was  complete  loss  of  the  knee-jerks;  he  had  sharp 
pains  in  his  legs ;  the  ataxic  gait  was  well  marked ;  there  was 
inability  to  stand  with  the  eyes  closed,  even  when  the  legs  were 
some  distance  apart;  he  had  difficulty  in  evacuating  his  bladder 
and  bowels;  his  sexual  power  was  lost;  and  he  had  a  sense  of 
constriction  around  the  waist.  There  were  no  eye  symptoms. 
The  man  denied  syphilis.  Treatment  was  begun  about  ten 
weeks  ago,  and  consisted  of  a  daily  hypodermic  injection  of 
cerebrine,  five  minims,  combined  with  five  minims  of  water. 
Dr.  Hammond  said  he  presented  the  case  with  some  diffidence,  on 
account  of  the  method  of  treatment  employed;  no  one  had  had 
less  faith  in  tiiese  animal  extracts  than  himself.  The  improve- 
ment in  this  case,  however,  had  been  very  marked.  The  man's 
sexual  functions  had  been  perfectly  restored,  he  had  complete 
control  over  his  bladder  and  bowels,  the  sharp  pains  had  disap- 
peared, his  general  health  had  improved,  he  was  able  to  run 
up  and  down  stairs,  and  could  stand  fairly  steady  with  his  eyes 
closed.  The  knee-jerks,  however,  had  not  returned.  No  other 
treatment  had  been  employed.  The  improvement  had  been 
gradual  and  steady,  and  had  begun  about  a  week  after  the  first 
injection.  The  cerebrine  employed  was  that  prepared  by  Dr. 
William  A.  Hammond. 

Dr.  Joseph  Collins  had  employed  subcutaneous  injections 
of  cerebrine,  as  prepared  by  Dr.  Paul  Gibier,  in  a  few  cases  of 
locomotor  ataxia;  the  improvement  in  those  cases  had  been 
about  equal  to  that  in  Dr.  Hammond's  patient.  It  was  not  un- 
common, ho  said,  to  see  the  virile  powers  return  in  these  pa- 
tients; this  had  occurred  after  applying  blisters  to  the  back. 
A  case  had  also  been  reported  in  which  the  shooting  pains  had 
disappeared  after  injections  of  phosphate  of  sodium. 

Progfressive  Muscular  Atrophy,  probably  Syphilitic— 
Dr.  Hammond  also  presented  a  boy  with  the  following  history : 
Two  years  before,  while  he  was  rowing  a  boat,  the  oar  in  the  left 
hand  slipped  from  his  grasp  and  his  fingers  lost  their  power.  In 
about  five  minutes  he  was  able  to  use  his  fingers,  but  not  the 
thumb,  and  from  that  time  on  the  paralysis  had  progressed,  first 
spreading  to  the  other  muscles  of  the  hand  and  gradually  to 
those  of  the  arm.  Fibrillary  twitcbings  were  now  very  marked. 
There  were  hemiatrophy  of  the  tongue  and  paralysis  of  one  of  the 
ocular  muscles,  with  double  vision.  The  boy  had  lost  the  power 
of  whistling  and  of  speaking  certain  words.  There  was  inco- 
ordination on  standing  with  the  eyes  closed,  also  loss  of  the 
knee-jerk  on  each  side.  There  were  no  other  ataxic  symptoms, 
no  sharp  pains,  no  bladder  or  bowel  symptoms,  and  no  anais- 
thesia  or  para>sthesia.  Tiie  expression  of  the  boy's  face  was 
rather  characteristic  of  hereditary  syphilis,  and  the  boy's  father 
was  now  under  treatment  for  syphilis.  There  was  no  history  of 
.icquired  syphilis  in  the  boy.  There  were  no  objective  symp- 
toms. 

Syphilis  of  the  Spinal  Cord.— Dr.  B.  Saohs  opened  a  dis- 
cussion in  which  he  first  reviewed  the  recent  work  of  Erb  on 


this  subject.  Erb  had  sought  to  establish  a  "type"  of  spinal- 
cord  disease  which  he  proposed  to  label  "syphilitic  spinal  pa- 
ralysis." This  special  type  wss  to  be  recognized  by  the  follow- 
ing characteristics:  1.  The  usual  symptoms  of  spastic  paraplegia, 
with  its  peculiar  gait,  carriage,  and  movements.  2.  The  re- 
fiexes  being  very  much  exaggerated.  3.  The  muscular  con- 
tractures being  slight  as  compared  with  the  exaggeration  of  the 
reflexes.  4.  Involvement  of  the  bladder.  5.  Slight  but  dis- 
tinct disturbance  of  sensation.  0.  The  gradual  onset  of  the 
disease.    7.  A  decided  tendency  to  improvement. 

Dr.  Sachs  said  that,  while  he  did  not  mean  to  dispute  the 
existence  and  the  propriety  of  establishing  Erb's  type  of  spinal 
disease,  he  believed  there  were  other  and  broader  points  ot 
diagnosis  which  should  not  be  disregarded.  To  illustrate  these 
points  he  gave  the  history  of  four  cases  of  undoubted  syphilitic 
disease  of  the  spinal  cord.  In  these  cases  the  following  were  the 
salient  features  that  had  led  to  the  diagnosis:  In  three  of  them 
there  had  been  spattic  paraplegia  of  the  most  pronounced  type. 
In  these  the  reflexes  had  been  excessively  exaggerated.  In  two 
the  muscular  contractures  had  been  slight;  in  one  of  them  they 
had  been  extreme.  In  one  there  had  been  permanent  involve- 
ment of  the  bladder;  in  the  others  there  had  been  no  such  in- 
volvement. In  all  but  one  of  them  sensation  had  been  dis- 
turbed. In  two  the  onset  had  been  gradual;  in  the  others  it 
had  been  quite  sudden.  All  of  them  had  shown  a  decided  tend- 
ency to  improvement.  In  one  instance  there  had  been  a  dis- 
tinct atrophic  paralysis,  with  all  the  symptoms  that  pointed  to  a 
widespread  affection  of  the  gray  matter  of  the  cord.  In  one 
case,  in  which  the  diagnosis  of  syphilitic  disease  had  been  more 
evident  than  in  any  of  the  others,  the  contractures  had  been 
extreme,  the  bladder  had  remained  involved  up  to  the  present 
time,  and  bedsores  had  formed,  as  in  the  most  typical  case  of 
acute  transverse  myelitis. 

The  following  points  had  impressed  themselves  on  the 
speaker's  mind  as  the  more  characteristic  of  spinal-cord  syphi- 
lis: 1.  The  unusual  distribution  of  the  disease  over  the  greater 
portion  of  the  cord,  involving  in  some  cases  the  cervical,  lower 
dorsal,  and  lumbar  enlargements.  2.  The  relatively  slight  in- 
tensity of  the  morbid  process  as  compared  with  the  extensive 
area  involved,  as  shown  by  the  preservation  of  some  of  the 
functions  of  the  cord  with  complete  loss  of  others.  3.  The 
rapid  dwindling  of  some  of  the  symptoms  and  a  very  chronio 
persistence  of  others.  4.  The  very  frequent  history  of  other 
symptoms  pointing  to  syphilitic  disease  in  the  same  or  in  other 
parts  of  the  central  nervous  system. 

In  syphilitic  spinal-cord  disease  there  was  not,  as  in  cases 
of  acute  myelitis,  a  morbid  process  that  was  rapidly  destruc- 
tive and  that  quickly  advanced  through  the  entire  cross-section 
of  the  cord,  entailing  all  the  symptoms  due  to  loss  of  function 
of  the  various  spinal  systems.  If  the  syphilitic  disease  was 
the  result  of  a  specific  endarteritis  of  the  cord,  we  knew  that 
some,  but  by  no  means  all,  of  these  vessels  were  affected,  and 
that  the  disease  advanced  slowly  from  one  group  to  another. 
If  there  was  diffuse  specific  infiltration,  it  also  invaded  very 
slowly  one  part  after  another.  It  had  a  remarkable  tendency, 
too,  to  increase  for  a  time  and  then  to  recede,  whether  as  a  re- 
sult of  treatment  or  not,  and  then  possibly  to  increase  with 
renewed  force.  If  the  infiltration  started  from  the  meninges, 
it  most  frequently  invade<l  the  lateral  columns  first,  often  at 
symmetrical  points,  and  advanced  very  slowly  from  white  to 
gray  matter.  The  intensity  of  the  process  was  spent  upon  the 
lateral  columns;  hence  the  frequency  of  the  spastic  symptoms. 
It  might  invade  the  gray  matter,  giving  rise  to  sensory  symp- 
toms, sometimes  to  atrophic  symptoms. 

Dr.  CiiAULES  L.  Dana  said  that  in  one  case  of  spinal-cord 
syphilis  that  had  come  under  his  observation  the  patient  had 


April  22,  1893.] 


PROCEEDimS 


OF  SOCIETIES. 


453 


died  of  an  intercurrent  disease.  The  type  of  symptoms  in  tbat 
case  had  resembled  so  closely  what  Gowers  had  described  as 
ataxic  paraplegia  that  that  had  been  the  clinical  term  applied  to 
it.  The  autopsy  had  shown  a  transverse  myelitis,  of  syphilitic 
origin,  in  the  dorsal  region,  and  the  appearance  of  the  lesion 
had  been  much  like  that  described  by  Dr.  Sachs — it  had  started 
from  the  meninges  and  gradually  invaded  the  substance  of  the 
cord.  The  speaker  had  almost  come  to  the  conclusion  tbat 
whenever  there  was  a  transverse  myelitis  which  was  not  mani- 
festly due  to  haemorrhage,  tumor,  injury,  or  the  like,  and 
which  did  not  develop  suddenly,  but  came  on  gradually  and 
irregularly,  there  was  presumptive  evidence  of  its  syphilitic 
origin. 

Dr.  Edwakd  0.  Seqoin  said  that  Dr.  Sachs's  description  of 
syphilitic  disease  of  the  cord  coincided  very  much  with  his  own 
experience.  The  irregularity  or  lack  of  completeness  of  the 
symptom  group  was  a  very  characteristic  feature  in  these  cases. 
The  speaker  also  referred  to  another  class  of  cases — namely, 
those  in  which  the  symptoms  were  those  of  pressure  upon  the 
spinal  cord,  as  was  seen  in  paraplegia  dolorosa,  or  the  myelitis 
of  compression.  He  gave  the  histories  of  two  such  cases  that  had 
come  under  his  observation. 

Dr.  Landon  Caktkr  Gray  had  long  regarded  with  suspi- 
cion any  case  of  paralysis  of  the  upper  or  lower  extremities 
with  marked  contractures  and  with  or  without  increase  of  the 
tendon  reflexes.  This  was  particularly  true  in  cases  where  the 
symptoms  were  unequal  or  asymmetrical.  The  poison  of 
syphilis,  however,  was  so  diffused  that  it  was  unsafe  to  assume 
that  its  effect  was  spent  entirely  upon  any  particular  set  of 
fibers  in  the  spinal  cord,  and  it  was  difficult  to  lay  down  a  cer- 
tain set  of  symptoms  which  should  be  present  in  these  cases. 

Dr.  Egbert  S.  Newton  gave  the  history  of  a  patient  in 
whom  the  symptoms  of  transverse  myelitis  had  developed 
while  he  was  under  active  treatment  for  syphilis,  which  bad 
been  persisted  in  for  over  a  year. 

The  Present  Status  of  Craniectomy.— Dr.  Gray  opened  a 
discussion  on  this  subject.  He  stated  that  about  three  years 
before  Lannelongue  bad  proposed  the  operation  for  the  relief  of 
mental  defects  in  children.  The  causes  of  such  mental  defects 
were,  in  the  main,  the  following:  Porencephalitis;  meningitis 
and  meningo-encephalitis;  hajmorrhage,  either  difiused  or  local- 
ized ;  trauma;  hydrocephalus;  myxoedema;  possible  prema- 
ture ossification  of  the  skull,  mainly  in  the  region  of  the  sutures 
and  fontanelles.  The  latter  cause  had  been  brought  into  promi- 
nence lately  by  Lannelongue's  operation,  although  the  idea  had 
not  originated  with  him;  it  had  been  advocated  as  far  back  aa 
in  1851  by  Virchow,  in  his  memoir  on  cretinism,  and  it  had 
been  under  discussion  since  in  various  other  writings.  It  was 
impossible  to  obtain,  in  this  country  at  least,  a  sufficient  num- 
ber of  skulls  of  idiots  whose  histories  had  been  carefully  re- 
corded to  pass  upon  any  question  of  this  kind  by  the  examina- 
tion of  skulls.  Tacquet  had  examined  twenty-nine  skulls  of 
idiots,  and  believed  as  a  result  of  this  investigation  that  oblit- 
eration of  the  sutures  of  the  cranium  was  not  more  premature 
in  idiots  than  in  healthy  individuals,  so  that  the  arrest  of  cere- 
bral development  had  in  none  of  his  cases  been  the  result  of  an 
arrest  of  development  of  the  skull.  The  speaker  was  entirely 
at  a  loss  to  understand  how  it  could  be  for  one  moment  sup- 
posed that  the  examination  of  the  skulls  of  these  idiots  could 
throw  any  light  upon  the  question  as  to  whether  primary  ossi- 
fication of  the  sutures  and  fontanelles  arrested  the  development 
of  the  cerebrum.  Taccjuet's  conclusions,  he  thought,  were  not 
supported  by  his  cases. 

Of  all  the  causes  of  idiocy  above  mentioned,  only  the  prema- 
ture ossification  of  the  sutures  and  fontanelles,  recent  traumatic 
injuries,  and  hremorrbages  could  possibly  be  benefited  by  crani- 


ectomy, for  encephaloporosis,  meningitis,  meningo-encephalitis, 
and  myxoedema  were  lesions  that  the  surgeon's  knife  could  not 
in  any  way  affect.  A  correct  diagnosis  in  these  cases  was  of 
the  utmost  importance.  If  in  any  case  of  idiocy  we  could  ob- 
tain a  reliable  history  from  some  one  who  had  been  with  the 
child  since  its  birth,  best  of  all  its  own  mother,  and  we  could 
positively  exclude  trauma,  meningitis,  hsmorrhage,  and  myx- 
oedema, wo  should  have  to  deal  only  with  so-called  tuberous 
hypertrophy,  encephaloporosis,  and  premature  ossification  of 
the  sutures  and  fontanelles.  Tuberous  hypertrophy  was  so 
rare  as  to  be  practically  of  no  account.  Encephaloporosis  oc- 
curred generally  in  foetal  or  early  infantile  life,  and  would  in  a 
vast  majority  of  cases  cause  some  paralysis  of  motion  or  sensa- 
tion. Encephaloporosis,  meningitis,  hajmorrhage,  trauma,  and 
tuberous  hypertrophy  were  very  likely  to  cause  some  organic 
destruction  of  the  cerebrum  or  cerebellum,  and  this  must  mani- 
fest itself  by  mutism,  blindness,  motor  paralysis,  localized  con- 
vulsions, or  contracture  of  a  single  limb  or  of  both  an  upper 
and  lower  limb  on  the  same  side.  If  in  an  idiot  child  we  could 
exclude  these  symptoms,  it  seemed  quite  reasonable  to  make  a 
diagnosis  of  premature  ossification  of  the  sutures  and  fontanelles 
as  causative  of  the  mental  condition.  The  sj)eaker  was  quite 
willing  to  believe  that  the  pressure  of  a  non-expanding  skull 
upon  a  cerebrum  expansile  with  developing  tendencies  was 
quite  sufficient  to  cause  such  symptoms  of  cerebral  irritation  as 
strabismus,  generalized  convulsions,  inability  to  walk,  contrac- 
tures, violent  temper,  involuntary  micturition  and  defecation, 
and  various  general  muscular  movements  that  could  not  be 
classified.  This  was  precisely  the  point  that  had  not  yet  been 
tested  by  the  operations  that  had  been  done.  In  concluding  his 
remarks,  the  speaker  narrated  five  cases  of  craniectomy  that 
had  come  under  his  observation. 

Dr.  Dana  presented  a  boy,  six  years  old,  upon  whom  Dr.  S. 
D.  Powell  had  performed  craniectomy  about  a  year  before. 
The  child  was  illegitimate,  and  nothing  was  known  of  his  his- 
tory up  to  his  attaining  the  age  of  a  year.  He  was  rhachitic; 
the  fontanelles  were  large  and  had  closed  during  the  third  year. 
During  the  first  three  years  of  his  life  the  boy  had  suffered  with 
general  convulsions,  three  or  four  such  attacks  occurring  daily. 
Up  to  the  time  of  the  operation  he  had  been  unable  to  swallow 
except  when  in  the  semirecumbent  posture,  and  had  been  able 
to  take  only  liquid  food.  He  had  not  been  able  to  say  a  word 
or  express  a  thought.  Measurements  of  the  head  had  shown 
it  to  be  of  less  than  the  normal  size.  A  few  weeks  after  the 
operation  he  had  begun  to  talk  and  been  able  to  masticate  and 
swallow  solid  food.  There  had  been  a  very  decided  and  strik- 
ing increase  in  his  intelligence.  This  had  become  noticeable  a 
few  weeks  after  the  operation.  Measurements  of  the  skull 
since  the  operation  had  not  been  particularly  instructive.  The 
great  circumference  of  the  head  had  increased  only  half  a  centi- 
metre; the  naso-occipital  circumference  had  increased  nearly 
two  centimetres.  From  this  it  would  be  observed  that  the  head 
had  grown  a  little  faster  than  was  usual  in  children  of  that 
age. 

Dr.  Dana  also  narrated  three  other  cases  of  craniectomy 
that  he  had  observed.  All  three  of  these  patients  had  died 
from  shock  soon  after  the  operation.  In  conclusion,  he  stated 
that  ho  did  not  see  bow  we  could  draw  any  conclusions,  one 
way  or  the  other,  as  regarded  the  determination  of  what  class 
of  patients  should  be  operated  on.  The  subjects  of  infantile 
hemiplegia,  with  epilepsy  and  idiocy,  could  liardly  ever  be  bene- 
fited by  the  operation. 

Dr.  S.  D.  Powell  gave  the  details  of  his  operation  in  the 
first  case  narrated  by  Dr.  Dana.  A  longitudinal  incision  five 
inches  and  a  half  long  had  been  made,  and,  extending  from  this, 
two  cross-sections  of  bone  been  removed,  each  t  wo  inches  Ion 


454 


NFW  INVENTIONS. 


[N.  Y.  Med,  Joub., 


The  longitudinal  incision  had  been  a  quarter  of  an  inch  wide. 
The  child  had  made  an  uneventful  recovery,  and  by  the  fifth  day 
there  had  been  perfect  union.  The  dura  had  not  been  opened. 
It  had  appeared  to  be  much  thickened,  and  there  had  seemed  to 
be  a  collection  of  fluid  beneath  it. 

Dr.  Sachs  gave  the  histories  of  three  cases  of  craniectomy. 
In  the  first  and  second  death  had  rapidly  resulted  from  shock. 
In  tlie  third  case  a  longitudinal  section  of-  bone  had  been  re- 
moved from  one  side  of  the  skull  and  the  child  had  recovered. 
Some  mouths  afterward  a  second  operation  had  been  under- 
taken for  the  purpose  of  removing  a  like  section  of  bone  on  the 
opposite  side  of  the  head.  This  operation  had  proved  fatal. 
The  speaker  presented  the  skull  of  this  patient.  It  showed  that 
the  longitudinal  opening  made  at  the  flrst  operation  had  become 
firmly  closed  by  the  dura  (which  liad  not  been  opened}  and  by  a 
dense  fibrous  mass.  This  had  occurred  during  the  two  months  in- 
tervening between  the  first  o|)eration  and  the  time  of  the  child's 
death.  This  specimen  clearly  showed,  the  speaker  said,  that 
the  removal  of  a  long  stri])  of  bone,  as  suggested  by  Lanne- 
longue,  was  not  eflfective  and  did  not  relieve  the  general  press- 
ure, as  he  had  said  it  would.  Our  results  would  no  doubt  be 
better  if  we  took  out  a  large  flap  of  bone  in  the  frontal  region, 
thus  giving  that  portion  of  the  brain  which  needed  it  most  a 
chance  to  develop.  In  a  considerable  number  of  cases  of  idiocy 
it  was  the  frontal  portion  of  the  brain  that  was  deficient.  The 
proper  cases  for  operation,  the  speaker  thought,  were  those  in 
which  there  were  all  the  symptoms  of  idiocy  without  any 
symptoms  of  organic  disease  of  the  brain,  except  in  retarded 
development.  ' 

Dr.  Hammond  said  that  five  cases  of  idiocy  for  which  crani- 
ectomy had  been  performed  had  come  under  his  observation. 
His  own  experience,  as  well  as  the  experience  of  others,  with 
Lannelongue's  operation  had  led  him  to  the  conclusion  that  it 
stopped  idiocy  only  by  stopping  the  child's  life.  In  his  five 
cases,  two  patients  had  died;  the  three  others  had  improved 
very  slightly.  There  was  not  a  single  case  on  record  where 
the  operation  had  cured  idiocy.  It  simply  transferred  the  pa- 
tient from  one  degree  of  idiocy  to  another.  The  proper  cases 
to  select  for  operation,  he  thought,  were  those  where  the  pa- 
tients were  but  slightly  idiotic,  not  the  hopeless  cases.  The 
operation  should  be  done  as  early  as  possible,  before  degenera- 
tive changes  had  set  in.  It  should  not  be  undertaken  after  the 
sixth  or  seventh  year  of  life. 

The  President,  in  reply  to  a  question,  stated  that  the  oper- 
ation of  craniectomy  had  been  performed,  apparently,  without 
regard  to  the  age  of  the  patient.  Keen  had  operated  on  one 
patient  nineteen  years  old  ;  Hammond,  Sr.,  had  operated  on  one 
aged  twenty-two  years;  Weir  had  operated  on  one  aged  eight- 
een years. 

Dr.  Newton  gave  a  short  review  of  the  literature  of  this 
subject.  He  stated  that  the  operation  for  microcephalia  had 
originated  from  statements  made  by  Virchow,  in  1851,  in  which 
he  had  attributed  cretinism  to  the  early  closure  of  the  cranial 
sutures.  Later  on,  however  (1875),  he  had  modified  his  state- 
ments in  this  regard. 

Dr.  Seuuin  said  that  foi-  a  long  time  he  had  held  the  opinion 
that  the  early  closure  of  the  fontanelles  and  the  premature 
ossification  of  the  cranium  were  secondary  to  the  arrest  of  de- 
velopment of  the  brain,  and  he  had  always  advised  against 
operative  interference  in  these  cases.  Now  he  stood  ready  to 
be  convinoed  as  to  the  value  of  craniectomy  for  the  relief  of  such 
patients.  The  cases  thus  far  reported,  he  thought,  were  not 
very  hopeful.  The  improvement  noted  in  a  few  cases- had 
been  slight,  while  the  surgical  results  were  far  from  encour- 
aging. 

Dr.  Mahy  p.  .Jaooki  said  that,  acc   ding  to  her  recollection 


of  Virchow's  monograph,  his  observations  regarding  the  early 
closure  of  the  sutures  had  only  referred  to  the  sutures  at  the  base 
of  the  skull — the  union  of  the  basilar  process  with  the  sphenoid 
bone. 

Dr.  Sachs  regarded  the  operation  of  craniectomy  as  an  ex- 
tremely dangerous  one — much  more  dangerous  than  operations 
for  epilepsy,  tumor,  etc.  The  patients  were  usually  very  young, 
and  the  shock  and  haimorrhage  were  severe. 

The  Pkesident  thought  the  members  took  too  pessimistic 
a  view  of  the  operation.  He  had  had  six  patients'operated  on 
without  a  single  death.  The  total  number  of  cases  reported 
by  the  speakers,  he  said,  was  twenty-three;  of  these,  seven  had 
proved  fatal.  Aside  from  these,  he  had  collected  thirty-seven 
cases  with  fourteen  deaths— a  mortality  of  about  thirty-three 
per  cent.  This  rate  of  mortality,  he  thought,  was  not  so  very 
high  when  we  bore  in  mind  that  the  operation  was  undertaken 
to  relieve  an  apparently  hopeless  condition. 

Of  the  six  patients  that  had  come  under  his  observation,  three 
had  materially  improved  in  intelligence  ;  the  other  three  had 
been  oj)erated  on  too  recently  to  warrant  any  definite  report  at 
present.  The  operations  had  been  performed  by  Dr.  McBurney. 
Lannelongue's  mode  of  operation  had  been  found  ineflicient,  a* 
the  space  left  by  the  bone  removed  soon  became  filled  up  with 
a  dense  fibrous  tissue.  Wagner's  operation  had  been  adopted. 
With  the  grooved  chisel  a  curved,  omega-shaped  incision  was 
made  through  the  skull  on  each  side.  These  flaps  of  bone  were 
then  firmly  grasped  and  raised  upward  until  they  became  frac- 
tured, thus  giving  plenty  of  room  to  the  brain  beneath.  Tiie 
flaps  of  bone  were  permanently  fixed  in  their  raised  position. 
In  one  case  both  sides  of  the  skull  had  been  treated  in  this  way. 
The  chisel,  when  properly  used,  caused  very  little  shock.  By 
means  of  it  the  work  went  on  much  faster  than  with  the  tre- 
phine. The  chisel  must  be  very  sharp,  such  as  was  used  for  cut- 
ting ivory.  In  conclusion,  the  president's  experience  in  these 
cerebral  cases  had  led  him  to  believe  that  we  knaw  as  yet  very 
little  about  the  varied  pathological  conditions  of  the  brain. 


ftcfaj  Inbmtions,  etr. 


A  NEW  NASAL  INSTRUMENT. 

By  Walter  Vulpius,  M.  D., 
assistant  stibgbon  to  the  eab  department  op  the  hew  tokk 
ophthalmic  and  aubal  institute. 

A  YEAR  and  a  half  ago  the  author  published  in  the  Archiv 
fur  Ohrenheilkunde  the  construction  and  use  of  a  nasal  instru- 
ment which,  after  having  somewhat  modified  and  improved,  he 
hereby  presents  anew  to  the  American  profession. 

It  was  intended  and  has  proved  to  answer  a  purpose  which 
hitherto  could  be  obtained  by  no  other  instrument  in  an  equally 
thorough,  simple,  and  sparing  way — viz.,  the  removal  of  broad- 
based  intumescences  of  any  kind  of  soft  tissue  in  the  continuity 
or  at  the  extremities  of  the  turbinated  bones,  at  the  sajptum  or 
around  the  choanae,  but,  above  all,  the  hypertrophies  of  the  pos- 
terior ends  of  the  inferior  turbinated  bones  (especially  if  they 
are  not  pedunculated  or  pendulous),  chronic  swellings  of  the 
erectile  tissue  at  the  anterior  and  middle  part  of  the  inferior, 
and  the  broad  sessile  papillomatous  excrescences  at  the  inferior 
edges  of  both  the  middle  and  inferior  turbinated  bones. 

Hitherto  there  were  two  different  methods  of  operating,  and 
one  combination  of  both  generally  applied  for  the  removal  of 
such  intumescences — viz.,  the  galvano-cautery,  by  means  of 
flattened  or  pointed  burners,  and  the  ecrasement  by  the  cold 


April  22,  1893.J 


MISCELLANY. 


455 


in  tlie  instrument  lierc 


galvano-cautery  snare.  Snaring  is  easily  ap|)licable  in  cases  of 
polypoid  growths  or  other  pedunculated  hypertrophies,  but  even 
with  the  additional  help  of  Jarvis'a  transfixion  needle  it  is  often 
very  difficult  to  catch  a  sessile  tumor  in  the  elastic  snare  and 
prevent  its  partly  or  entirely  slipping  out  when  the  latter  is 
constricted. 

Galvano-cautery,  which  does  not  restrict  itself  to  a  mere  su- 
perficial sloughing  effect  like  that  produced  by  one  of  the 
chemical  caustics,  but  tends  to  really  carbonize  any  greater 
amount  of  tissue,  is  a  very  tiresome  and  barbarous  procedure, 
particularly  as  it  implies  burning  of  the  neighboring  sound  tis- 
sue by  radiating  heat,  and  has  thus  sometimes  produced  firm 
attachments  between  the  sseptum  and  the  inferior  turbinated 
bones. 

Knife-shaped  galvano-caustic  instruments  for  cutting  pur- 
poses have  justly  never  been  much  used,  for  the  galvano-caustic 
division  of  tissue 
is  best  effected  by 
means  of  a  thin 
wire,  either  in  the 
form  of  a  contract- 
ing snare,  or  on  the 
principle  of  a  soap- 
cutter,  as  is  the  case 
presented. 

The  main  parts  of  the  instrument  consist  of 
two  brass  wire  shanks  of  four-inch  length  di- 
verging for  the  first  half  of  their  course,  in 
which  they  are  a  little  flattened  and  stiffened 
by  hammering;  then  running — about  an  inch 
apart — parallel  to  their  blunt-pointed  ends, 
which  are  connected  by  a  semicircular  loop  of 
platinum  wire  (No.  27,  Brown  and  Sharp's 
gauge),  stiffened  by  the  addition  of  iridium. 

Mr.  Stohlmann  (of  Tiemann  &  Co.)  called 
the  writer's  attention  to  the  excellent  qualities 
of  this  metallic  combination,  and  thus  enabled 
him  to  preserve  to  the  instrument  that  slender- 
ness  which  he  had  formerly  considered  one  of 
its  greatest  advantages,  but  feared  he  would  be 
obliged  to  abandon  on  account  of  the  great  plia- 
bility of  the  thin  copper-wire  shanks  and  the 
pure  platinum  loop  originally  employed. 

By  cause  of  the  heat,  which  the  soldering  of 
the  loop  to  the  .shanks  requires,  the  extremities 
of  the  latter  obtain  more  pliability  than  the 
rest,  which  eventually  serves  to  permit  of  an  easier  and  more 
perfect  adaptation  to  every  individual  case,  while  the  ham- 
mered parts  secure  the  necessary  strength  and  resistance.  The 
shanks  run  into  the  handle  at  an  angle  of  about  120°.  This 

handle  is  provided  with  an 
electric  key  and  connects 
the  shanks  with  a  battery  of 
such  strength  that  by  clos- 
ing the  circuit  a  quick  and 
bright  glowing  of  the  loop  is 
effected.  The  instrument  is 
introduced  into  the  nostril 
through  a  spacious  nasal  speculum  (for  instance,  Voltolini's), 
after  having  shaped  its  loop  and  shank  fend  to  exactly  suit  the 
individual  case  (lateral  curvatures  are  required  by  projections 
of  the  turbinated  bones  or  of  the  sicptum,  vertical  ones  by  the 
occasional  vaulting  of  the  floor  of  the  nostril),  so  that  the  loop 
embraces  the  hypertrophy  or  tumor  to  bo  removed  from  behind, 
the  shanks  bordering  it  from  above  and  below. 

A  great  advantage  of  the  instrument  is  found  in  that  it  does 


not  at  all  obstruct  the  view  of  the  pathological  object.  By  a 
gentle  pressure  and  a  short  glow  the  loop  is  easily  made  to  pene- 
trate the  tissue  and  severs  the  intumescence  by  intermittent 
sliort  glows  and  traction,  peeling  it  clean  from  its  base,  being 
itself  covered  by  the  amputated  strip  which  protects  the  sur- 
rounding mucous  membrane  from  the  radiating  heat. 

During  the  whole  procedure  it  is  well  to  maintain  a  slight 
side  pressure,  or  the  loop  might  prematurely  emerge  on  the  sur- 
face. 

There  is  hardly  any  hosmorrbage  if  the  intermittent  glows 
are  short  enough,  so  that  no  severance  of  blood-vessels  by  non- 
coagulating  white  glow  heat  is  produced. 

After  a  thorough  operation  the  rough  denuded  surface  of 
the  underlying  bone  can  sometimes  be  felt  with  a  probe,  but  it 
is  covered  in  due  time  by  smooth,  dense,  cicatricial  tissue,  and 
has  never  been  observed  to  become  necrotic. 

The  writer  hopes  that  his  American  colleagues  will  find  the 
instrument  in  its  new  shape  as  useful  as  it  has  proved  to  him 
and  others  for  several  years,  even  in  its  former  imperfection,  and 
acknowledge  as  special  virtues  its  simplicity  and  cleanliness  as 
well  as  the  ease  and  universality  of  its  successful  application. 

79  East  Fifty-sixth  Street. 


The  Recent  Conference  of  State  Sanitary  Officials,  held  in  New  York, 
has  called  forth  the  following  editorial  article  from  the  Boston  Medical 

and  Surgical  Journal  : 

"  The  recent  conference  of  State  boards  of  health  held  in  New  York 
has  happily  adjourned.  As  the  most  graceful  and  desirable  thing  about 
the  vaut  rien^s  life  was  his  leaving  it,  so  it  may  be  said  of  this  confer- 
ence, that  the  best  and  most  useful  thing  it  did  was  to  adjourn.  It  is  a 
self-constituted  body  without  representative  powers  or  privileges,  com- 
posed of  officials  connected  in  some  capacity  with  various  State  boards 
of  health.  The  personal  action  or  opinion  of  these  individual  officials 
in  no  way  binds  the  health  boards  with  which  they  are  connected,  and 
may  not  even  correctly  represent  the  course  which  will  be  adopted  by 
those  boards  in  regard  to  a  given  question.  The  power  and  jurisdiction 
of  the  boards  themselves  is  limited  by  legislative  appropriations  and  en- 
actments. If  measured  by  the  appropriations,  the  power  in  many  in- 
stances must  be  very  small.  If  these  officials  would  devote  them.selves 
— their  time,  their  energies,  and  such  powers  and  means  as  their  re. 
spective  States  grant  them — to  encouraging,  developing,  and  applying 
measures  of  internal  sanitation,  to  making  sure  that  water-supplies  were 
pure  and  uncontaminated  when  brought  to  the  consiuner  and  properly 
disposed  of  when  rejected  as  effluents,  they  woidd  be  doing  a  work  at 
once  of  the  greatest  benefit  to  the  people  at  large,  and  one  needing  no 
less  than  all  the  time  and  thought  of  all  these  boards.  When,  however, 
the  officials  of  these  boards  undertake  to  regulate  interstate  commerce 
and  lay  down  rules  for  the  great  interstate  transportation  companies  at 
epidemic  periods,  they  are  transcending  their  proper  sphere  of  action 
anil  in  so  far  as  they  are  not  wasting  their  time,  such  a  course  will  tend 
to  make  confusion  worse  confounded,  especially  if  the  independent  ac- 
tion of  each  State  is  advocated. 

"  The  regidatiou  of  interstate  traffic  and  travel — wliother  from  the 
commercial  or  the  sanitary  (joint  of  view — must  be  and  can  only  be  ef- 
fected by  the  Federal  Government.  Congress  has  failed  to  supply  suit- 
able or  sufficient  machinery  to  effect  this  object,  and  the  country  must 
accept  the  consequences  in  having  precautions  neglected  in  times  of 
tranquillity  and  ridiculously  exaggerated  in  periods  of  excitement  and 
panic.  The  recent  act  to  increase  the  powers  and  duties  of  the  Marine- 
Hospital  Service  may  be  made  efficient  and  effective  for  the  protection 
of  the  coast  line  and  possibly  of  the  Canada  line,  especially  with  the 
cordial  co-oijeration  of  the  locnl  quarantine  ollicials,  but  its  unfortunate 
limitations  are  made  |)1  aili  in  tlio  lijjjht  of  this  conference  in  New  York. 


456 


MISCELLANY. 


[N.  Y.  Med,  Johb. 


"A  good  deal  of  attention  is  I)eing  given  to  water-supplies.  This  in 
itself  is  reassuring ;  but  where  the  chief  result  is  to  prove  that  a  supply 
is  contaminated,  which  before  was  only  suspected,  and  this  without  cor- 
recting the  evil  or  only  attempting  to  correct  it  in  a  manner  at  once  tem- 
porary, costly,  unscientific,  and  grotesque,  then  this  talk  about  water- 
supplies  and  drainage  is  quite  the  reverse  of  reassuring.  The  water- 
supplies  of  several  of  our  largest  cities  (it  is  entirely  unnecessary  to 
name  names),  to  say  nothing  of  smaller  cities  and  towns,  are  very  far 
from  being  protected  as  they  should  be.  This  is  so  generally  under- 
stood that  there  will  probably  lie  no  '  unsuspecting '  stranger  to  be 
warned  against  thein.  All  the  strangers  will  be  suspicious  strangers. 
The  warnings  had  better  be  reserved  for  the  natives,  who  have  grown 
callous  to  these  conditions." 

The  Fan-American  Medical  Congress. — The  Hection  in  Otology  has 
been  organized  as  follows:  Executive  president:  Dr.  C.  M.  Hobby, 
Iowa  City,  Iowa.  Honorary  presidents :  Dr.  Adolpli  Alt,  St.  Louis  ;  Dr. 
Albert  11.  Buck,  New  York ;  Dr.  Gorham  Bacon,  New  York ;  Dr.  \V. 
Cheatham,  Louisville ;  Dr.  Francisco  de  P.  Chacon,  City  of  Mexico ;  Dr. 
Sebastian  Cuervoy  Serrano,  Santo  Spiritu,  Cuba ;  Dr.  J.  C.  Connel, 
Toronto ;  Dr.  Stephen  Dodge,  Halifax,  Nova  Scotia ;  Dr.  J.  B.  Eaton, 
Portland,  Oregon ;  Dr.  A.  A.  Foucher,  Montreal ;  Dr.  John  F.  Fulton, 
St.  Paul;  Dr.  J.  Wilford  Good,  Winnipeg,  Manitoba;  Dr.  Francis  B. 
Loring,  Washington ;  Dr.  Henry  D.  Noyes,  New  York ;  Dr.  Arturo 
Costa  Pruneda,  Santiago  Chile;  Dr.  Charles  Inslee  Pardee,  New  York; 
Dr.  G.  Sterling  Ryerson,  Toronto;  Dr.  D.  B.  St.  John  Roosa,  New 
York ;  Dr.  W.  H.  Sanders,  Mobile  ;  Dr.  Belisario  Sosa,  Lima,  Peru  ;  Dr. 

G.  C.  Savage,  Nashville,  Tenn. ;  Dr.  J.  J.  B.  Vermyne,  New  Bedford, 
Kass.  Secretaries :  Dr.  Max  Thomer  (Engli.sh-8peaking),  Cincinnati ; 
Dr.  H.  McHatton  (Spanish-speaking),  Macon,  Ga. ;  Dr.  Fernando  Perez, 
Buenos  Ayj-es,  Argentine  Republic;  Dr.  Ernesto  Mazize,  La  Paz,  Bo- 
livia ;  Dr.  Theodoro  Peckolt,  Rio  de  Janeiro,  U.  S.  of  Brazil ;  Dr.  J. 

H.  Wishart,  Toronto ;  Dr.  Carlos  Desvernine,  Havana,  Cuba ;  Dr.  Car- 
los Esguerra,  Bogota,  Colombia;  Dr.  Demetrio  Orantes,  Guatemala 
City,  Guatemala ;  Dr.  H.  G.  McGrew,  Honolulu,  Hawaii ;  Dr.  Antonio 
Penafiel,  City  of  Mexico,  Mexico;  Dr.  Montenegro,  Leon,  Nicaragua; 
Dr.  N.  Surh,  Montevideo,  Uruguay ;  Dr.  Fociou  F.  Cordero,  Merida, 
Venezuela.  Advisory  Council :  Dr.  F.  N.  Lewis,  New  York ;  Dr.  M.  D. 
Jones,  St.  Louis ;  Dr.  J.  IL  Thompson,  Kansas  City,  Mo. ;  Dr.  Robert 
Tilly,  Chicago ;  Dr.  Thomas  E.  Murrell,  Little  Rock,  Ark. ;  Dr.  N.  J. 
Hepburn,  New  York ;  Dr.  Harold  GifPord,  Omaha,  Neb.  ;  Dr.  H.  C. 
Hawley,  Sioux  Falls,  South  Dakota ;  Dr.  Edward  M.  Whitney,  New  Bed- 
ford, Mass. ;  Dr.  T.  J.  Tyner,  Austin,  Texas. 

No  "  Sun-down  "  Medical  Students  in  New  York. — The  Sun  has 

made  a  fitting  answer  to  the  following  query : 

"  Will  you  please  inform  me  if  there  is  a  medical  school  in  New 
York  in  which  the  lectures  for  the  first  year  are  given  in  the  evening 
or  any  time  after  3  P.  m.  ?  Duffy." 

The  Sun's  reply  is  as  follows  :  "  Duffy,  you  and  dozens  of  other 
'would-be  doctors'  think  you  can  study  medicine  in  the  happy-go-lucky 
way  the  law-pills  study  law — lectures  in  the  afternoon,  office  work  in 
the  morning.  You  must  give  up  that  idea  at  once.  Medicine  requires 
twenty-five  hours  out  of  twenty-four,  and  more  on  Sundays  and  holi- 
days. The  lectures  in  every  medical  school  are  given  when  the  pro- 
fessors and  lecturers  can  find  time  for  them.  They're  given  in  the 
morning,  and  in  the  afternoon,  and  the  evening ;  and  .some  of  the  pri- 
vate 'quizzes'  begin  at  10.30  or  11  p.  m.,  and  stop  in  time  to  get  ready 
for  breakfast  if  you  dress  quickly.  Now,  Duffy,  if  you  ask  because 
you  think  medicine  is  a  snap  like  these  afternoon  law  schools,  you'd 
better  keep  out  of  it;  but  if  you  can  stand  the  pace,  and  ask  simply 
because  you're  ignorant,  why,  go  ahead,  and  with  good  health  and  hard 
work  you  may  get  your  license  to  '  kill,  kill,  kill,  kill,  kill'  " 

The  Medical  Society  of  the  State  of  North  Carolina  will  hold  its 
fortieth  annual  meeting  in  Raleigh  on  the  '.)th,  loth,  and  11th  of  May, 
under  the  presidency  of  Dr.  J.  W.  McNeill,  of  Fayetteville.  The  pre- 
liminary announcement  contains  the  following  : 

A  Report  on  the  Practice  of  Medicine,  by  Dr.  E.  M.  Summerell,  of 
Mill  Bridge  ;  A  Report  on  Surgery  (Inguinal  Hernia),  by  Dr.  J.  P.  Mun- 
roe,  of  Davidson  College ;  A  Report  on  Obstetrics,  by  Dr.  J.  H.  Marsh, 


of  Fayetteville  ;  A  Report  on  Gynaecology,  by  Dr.  R.  H.  Whitehead,  of 
Chapel  Hill ;  A  Report  on  Materia  Medica,  by  Dr.  Thomas  Stamps,  of 
Lumber  Bridge  ;  A  Report  on  Therapeutics,  by  Dr.  C.  E.  Billiard,  of 
Asheville  ;  A  Report  on  Pathology  and  Microscopy,  by  Dr.  W.  T.  Pate, 
of  Gibson's  Station  ;  A  Report  on  State  Medicine,  by  Dr.  S.  J.  Montji- 
gue,  of  Winston  ;  Cerebro-spinal  Meningitis,  by  Dr.  Thomas  Stamps,  of 
Lumber  Bridge ;  A  Report  of  Cases,  by  Dr.  J.  M.  Hays,  of  Oxford ;  Vis 
Natura;  et  Vis  Medicatrix  Naturic,  by  Dr.  A.  M.  Ballard,  of  Asheville  ; 
Pneumonia,  by  Dr.  J.  N.  Peace,  of  Creedmore ;  Appendicitis,  viewed 
from  a  Personal  Standpoint,  by  Dr.  J.  W.  Long,  of  Randleman  ;  Dipli- 
theria,  by  Dr.  R.  A.  Patterson,  of  Aurelian  Spi  ings  ;  a  paper  by  Dr.  K. 
L.  Payne,  of  Lexington;  The  Regimen  and  Treatment  of  Ilyperchlorhy- 
dric  Dyspepsia,  The  Necessity  for  Vaccination  in  North  Carolina,  and 
Some  of  the  Defects  of  the  Country  Asylum  for  the  Care  and  Treatment 
of  the  Pauper  Insane,  by  Dr.  J.  Allison  Hodges,  of  Wilmington.  Thert 
will  be  a  discussion  on  Rheumatism,  to  be  opened  by  Dr.  D.  T.  Taylo(- 
of  Washington. 


To  Contributors  and  Correspondents. —  The  attnUiou  of  all  who  jmrfxnx 
favorbuj  us  with  commniiicatiom  is  respectfully  called  to  tlie  follou: 
imj  : 

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contributions  "  are  respectfully  informed  that,  iti  acccptiny  such  arti- 
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tions are  to  be  observed  -•  (/)  v'hcn  a  manmcrij>t  is  sent  to  this  jour- 
nal, a  similar  manuscript  or  any  abstract  tliercof  must  not  be  or 
have  been  sent  to  any  other  periodical,  urtless  we  are  specially  notifed 
of  tlie  fact  at  the  time  the  article  is  sent  to  us  ;  (S)  accepted  articl(< 
arc  subject  to  the  customary  rule^  of  editorial  revision,  and  will  In 
published  as  promptly  as  our  other  engagemetils  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  anu 
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7iew  conditions  can  be  considered  after  the  rnanmcript  lias  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
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not  suitable  for  publication  in  thii  journal,  either  because  they  ore 
too  long,  or  are  loaded  with  tabular  jnatter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  proj'essiof 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
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to  our  readers  will  be  considered  as  doing  them  a7id  us  a  favor,  and, 
i  f  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  commu7iications. 

All  communuatioyis  intended  for  the  editor  s/iould  be  addressed  to  hin. 
in  care  of  the  publishers. 

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should  be  sent  to  the  publishtrs,  and  not  to  the  editor. 


THE  JS^EW  YORK  MEDICAL  JOURNAL,  April  29,  1893. 


Original  Communications. 


SARCOLOGY  AND  SARCO-TIIERAPEUTICS. 
By  WALLACE  WOOD,  M.  D., 

I>KOPESBOB  IN  THE  TTNIVERSITY  OB"  THE  CITT  OP  NEW  YORK. 

The  experiments  of  the  eminent  French  physician 
Brown- Sdquard  in  producing  a  scientific  elixir  vitce  from 
the  fiesli  of  the  guinea  pig,  and  the  equally  rational  and  le- 
gitimate experiments  of  Dr.  Hammond  in  injecting  cerel)rine 
into  the  hlood  for  tired  brains,  and  cardine  in  cases  of  heart 
failure,  are  not  only  interesting,  but  they  bring  the  practical 
physician  and  the  medical  profession  generally  to  fields  and 
pastures  singularly  and  utterly  new.  Not  only  is  the  ma- 
teria medica  left  behind,  but  one  no  longer  deals  either  with 
anatomy  or  physiology,  or  with  organs  or  tissues,  or  cells 
or  molecules  ;  he  is  brought  face  to  face  with  the  naked 
tiesh,  and  the  miracle  of  transubstantiation  is  reduced  to  a 
formula.    We  are  iutroduced  to  a  new  medical  science. 

Of  the  well  known  official  categories  of  mundane  tilings, 
the  world,  the  flesh,  and  the  devil,  the  first  and  the  last  es- 
cape the  "  knife  and  glass,"  but  the  second,  amenable  to 
facts  and  laws,  offers  a  true  foundation,  and  sarcology  may 
be  a  science  as  legitimate  as  that  of  chemistry  or  histology. 

How  many  kinds  of  flesh  are  there  in  the  organism  ? 
Four,  and  these  are  elementary,  cardinal  ;  they  are  nerve, 
muscle,  vessel,  and  gland. 

These  four  radicals  are  vital  and  palpitating.  These 
four  kinds  of  flesh  live  and  throb,  each  with  its  peculiar 
kind  of  life  or  life  force ;  excitement,  motion,  nutrition, 
production. 

If  a  poet  were  writing  the  great  epic  of  Prometheus  he 
might  in  Homeric  line  describe  the  analysis  and  synthesis  of 
man.  Setting  aside  the  skin  and  the  bones,  exoskeleton  and 
endoskeleton,  the  rest  would  be  thrown  into  four  huge  mor- 
tars and  reduced  to  pulp — primordial  plasma.  Into  the  first 
mortar  would  go  the  brain  and  nerves,  into  the  second  the 
muscles  and  sinews,  into  the  third  every  vessel  of  the  body, 
heart,  veins,  arteries,  lymphatics,  intestines,  all  the  body 
tubing,  the  flesh  of  supply  ;  and  into  the  fourth  go  the 
glands  and  parenchymes,  lungs,  liver,  kidney,  testes. 

The  result  would  be  four  kinds  of  human  pulp — that  is, 
nervous  pulp,  muscular  pulp,  vascular  pulp,  and  parenchy- 
matous or  glandular  pulp.  All  the  makings  of  a  man  are 
there,  and  in  the  next  canto  the  exulting  Titan  might  pro- 
ceed to  mold  the  organism  anew. 

This  process,  formidable  and  wild,  no  doubt,  fit  only  for 
the  Titan  or  the  poet,  would  appear  much  less  wild  and  formi- 
dable if  for  a  man  we  substitute  a  corpus  vile,  the  guinea  pig, 
and  the  scene  be  changed  from  Olympus  to  one  of  the  ad- 
mirably constructed  new  laboratories  in  the  Rue  de  i'P^cole 
de  medecine  in  Paris.  Skin  and  skeleton  being  set  aside, 
all  the  brain  and  nerve  of  the  little  animal  is  put  together, 
all  the  muscle  and  sinew  in  the  second  place,  vessel  both 
sanguiniferous  and  chymiferous  in  the  third,  and  finally  the 
gland  and  parenchyme.  Each  part  may  then  be  desiccated 
and  reduced  to  an  impalpable  powder.    All  the  vital  flesh 


of  the  guinea-pig  would  thus  come  to  lie  in  four  little  heaps 
of  dust — "dust  thou  art" — yet  it  is  vital  dust.  These  four 
powders  contain  neurine,  vasculine,  musculine,  glanduline  ; 
treated  with  spirit,  these  become  elixirs — nerve  elixir,  elixir 
of  muscle,  elixir  of  vessel,  elixir  of  gland  ;  theoretically,  they 
are  the  true  elixirs  of  life.  Theoretically,  we  could  intro- 
duce these  particles  into  the  blood  and  build  up  or  restore 
worn-out  or  exhausted  parts. 

Whether  the  guinea  pig  or  any  rodent  would  be  the 
best  animal  for  the  purpose  is  a  question ;  one  might  take 
higher  animals — for  instance,  the  bullock.  Dr.  Hammond, 
in  making  testine,  very  naturally  selected  the  ram  as  the 
proper  subject. 

The  only  preparations  I  have  made  of  the  kind  are 
from  the  squirrel.  I  have  in  my  ofiice  four  small  phials 
containing  together  a  powdered  red  squirrel,  nerve  powder, 
muscle  powder,  vascular  powder,  gland  powder.  Until  the 
experiments  of  Brown- Sequard  and  Dr.  Hammond  I  had 
regarded  them  rather  in  the  light  of  foods,  and  my  thought 
was  how  to  get  their  extract  into  the  duodenum  without 
risking  dissolution  in  the  stomach.  But  the  idea  of  an 
elixir  vitce  has  a  greater  fascination. 

It  would  be  very  easy  for  a  practical  or  experimental 
physician  to  have  an  entire  bullock  served  in  this  way  by 
some  large  manufacturing  house  like  Reed  &  Carnrick. 
Subjected  to  their  ovens  and  mills,  in  less  than  eight  hours 
the  entire  carcass  would  be  reduced  to  these  four  heaps  of 
impalpable  powder.  If  this  life  powder  could  be  transub- 
stantiated— that  is,  if  it  could  be  introduced  into  the  circu- 
lation and  transferred  to  the  pail  to  which  it  belongs — or  if 
an  extractive  form  could,  by  gelatin  coating,  be  intro- 
duced into  the  duodenum  and  taken  up  by  the  lacteals,  and 
thus  transferred  to  the  part,  no  assimilation  would  be  re- 
quired ;  each  part  would  select  its  part. 

Who  knows  but  that  the  powdered  calomel  and  jalap 
of  the  opening  nineteenth  century  may  give  way  in  the 
opening  twentieth  century  to  powdered  nerve,  muscle,  or 
gland  ! 

If  instead  of  desiccating  and  pulverizing  these  four 
radical  and  elementary  parts  of  the  flesh,  I  had  used  Brown- 
Sequard's  method  of  simply  expressing  the  liquid,  I  should 
have  had  squirrel  juice  instead  of  squirrel  powder — that  is, 
nerve  juice,  muscle  juice,  vessel  juice,  gland  juice.  Such 
liquids,  if  used  for  medical  purposes,  must  of  necessity  be 
used  fresh,  as  they  quickly  undergo  change ;  but  by  em- 
ploying the  method  described  by  Dr.  Hammond,  treating 
with  boric  acid,  glycerin,  and  absolute  alcohol,  I  should 
obtain  what  in  theory  would  be  the  four  radical  and  ele- 
mentary extracts  of  the  organism — neurine,  musculine, 
vasculine,  glanduline ;  and  if  these  were  injected  into  the 
blood,  or  placed  by  means  of  capsules  at  the  rootlets  of  the 
organism  in  the  duodenum,  they  ought  to  mend,  recon- 
struct, or  build  up  exhausted,  broken-down,  or  worn-out 
organisms,  and  constitute  a  true  and  scientific  elixir  vitce, 
realizing  in  part  the  dreams  of  ancient  philosophers. 

The  objection  that  the  liver  and  kidney  are  excretory 
and  might  be  poisonous,  valid  if  applied  to  concentrated 
extracts  of  these  organs  taken  singly,  would  not  perhaps 


458 


BISHOP:  KAUFMAKN'S  STAINING  OF  TUBERCLE  BACILLI        [N.  Y.  Med,  Joni,., 


be  valid  in  case  where  tLe  whole  mass  of  glandular  flesh  is 
taken  together  (liver  and  kidney  are  very  good  food,  but 
of  course  they  are  both  transformed  in  the  stomach)  ;  ex- 
periment might  show  that  in  making  glanduline  only  small 
portions  of  these  organs  should  be  used,  and  one  might 
add  such  organs  as  the  ovaries  and  mammie ;  and  in  fact, 
if  it  is  a  question  of  making  glanduline  of  a  s])ecial  kind, 
the  ovaries  of  hens  and  the  udders  of  cows  naturally  sug- 
gest themselves. 

The  end  sought  in  these  four  extracts,  or  cardinal  forms 
of  elixir  vitce,  would  be  to  raise,  respectively,  the  nervous 
or  excitatory  power,  the  motor  power,  the  vital  or  growth 
power,  vigor,  vitality,  and  the  effusive  or  sympathetic 
power. 


KAUFMANN'S  METHOD  FOE 
THE  STAINING  OF  TUBERCLE  BACILLI. 

FROM  THE  LABORATORY  OF  CLINICAL  MEDICINE, 
UNIVERSITY  OF  MICHIGAN. 

By  FANNIE  LEWIS  BISHOP, 

ASSISTANT  TO  THE  PKOKESSOR  OP  THEORY  AND  PB ACTIO E  OK  MEDICINE. 

In  the  Centralblatt  fur  Bakteriologie  und  Parasitenkunde, 
Bd.  xii,  1892,  p.  142,  Kaufmann,  of  Cairo,  described  a 
method  of  decolorization  in  the  staining  of  tubercle  bacilli 
which  he  maintains  has  an  advantage  over  former  ones  be- 
cause of  its  simplicity.    His  method  is  as  follows  : 

After  the  sputum  has  been  spread  on  the  cover  glass, 
fixed  in  the  flame,  and  stained  with  the  carbolic- fuchsin  so- 
lution in  the  usual  way,  the  cover  glass  is  washed  in  boiling 
water  for  a  minute  and  a  half  to  three  minutes.  Examined 
now  in  water,  the  tubercle  bacilli  show  dark  red  on  a  gray- 
ish-white background. 

In  staining  tubercle  bacilli  perfect  technique  has  been 
proved  to  be  more  important  than  the  method,  by  the  man- 
ner in  which  numerous  methods,  vaunted  as  superior  by 
their  discoverers,  have  fallen  into  oblivion.  Nevertheless, 
this  modification  of  Kaufmann's  seemed  to  deserve  a  trial, 
especially  as  it  does  not  introduce  a  new  stain,  but  uses  the 
well-tried  Ziehl's  solution. 

At  the  suggestion  of  Dr.  Dock,  I  have  made  some  in- 
vestigations with  the  method  of  Kaufmann  with  the  follow- 
ing results :  Using  tuberculous  sputum  in  the  way  described,  I 
found  that  the  tubercle  bacilli  retained  their  color  longer  than 
the  other  organisms  in  the  preparations.  In  pus  from  a  tu- 
berculous empyema,  containing  an  almost  pure  culture  of  the 
tubercle  bacillus,  with  a  few  cocci,  there  was  apparently  no 
diminution  of  the  actual  number  of  the  former  up  to  the 
time  the  cocci  were  totally  decolorized.  But  by  continuing 
the  boiling  process  all  the  bacteria,  even  the  tubercle  bacilli, 
entirely  lost  their  color.  The  time  for  this  varied  from  four 
to  six  minutes. 

So  far  as  sputum  is  concerned,  there  is  evidently  no 
doubt  about  the  certainty  of  this  method,  and  it  adds  an 
interesting  item  to  our  knowledge  of  the  characteristics  of 
the  tubercle  bacillus.  But  the  question  of  the  utility  of  the 
process  must  be  considered. 

I  found  that  distilled  water  gave  better  results  than  hy- 
drant water,  which  caused  a  deposit  upon  the  preparation. 


If  the  same  water  was  used  for  a  second  cover  glass  a  de- 
posit of  fuchsine  was  produced  and  decolorization  was  slower 
than  in  clean  water. 

I  also  found  that  if  the  cover  glasses  were  boiled  in  an 
evaporating  dish  over  the  flame,  it  was  not  necessary  to  hold 
them  with  a  forceps  and  "  swill  "  them,  as  they  were  kept  in 
constant  motion  and  in  a  perpendicular  position  by  the  up- 
ward currents  in  the  water. 

Kaufmann  supposed  that  his  method  would  be  used  less 
in  the  laboratory  than  in  general  practice,  and  especially  in 
country  practice.  But  as  the  cover  glass  must  be  carefully 
watched  and  taken  from  the  boiling  water  at  the  exact  time 
of  decolorization  of  the  other  organisms  and  nuclei,  as  pure 
water  fresh  for  each  specimen  is  needed,  and  as  the  water 
must  be  kept  at  or  near  the  boiling  point  during  the  pro- 
cess, it  offers  no  advantage  in  simplicity  over  the  usual 
methods  of  decolorization  by  dilute  acids  or  by  the  action 
of  a  contrast  stain ;  and  as  every  physician  is  supposed  to 
have  nitric  acid  in  his  oflSce  or  workroom,  the  substitution 
of  water  for  acid  is  less  of  an  advantage  than  might  be  sup- 
posed. It  could  only  be  by  the  merest  accident  that  a  phy- 
sician would  have  microscope,  fuchsine  solution,  and  sputum 
in  a  place  where  he  could  not  get  nitric  or  sulphuric  acid  \ 
in  such  a  rare  event  it  would  of  course  be  of  service  to  hira 
to  know  the  possibility  of  substituting  the  water  for  the 
acid. 

The  time  necessary  for  staining  is  not  materially  short- 
ened by  Kaufmann's  method.  I  have  been  unable  to  take 
a  specimen  through  the  whole  process  of  decolorizing  by 
boiling  in  less  than  three  minutes ;  usually  the  time  has 
been  nearer  five  minutes.  But  with  the  acid  decolorization 
one  can  usually  perform  the  whole  process  in  less  than  two 
minutes. 

Obviously  no  comparison  can  be  made  regarding  the 
durability  of  the  color  in  permanent  mounts,  Kaufmann's 
method  being  of  so  recent  a  date.  I  have  recently  exam- 
ined a  slide  in  Dr.  Dock's  collection  which  was  mounted  in 
November,  1888.  It  was  stained  with  carbol-fuchsine,  de- 
colorized with  thirty-per-cent.  nitric  acid,  and  contrast- 
stained  with  Loefl3er's  methylin-blue,  and  shows  now,  after 
more  than  four  years,  brilliantly  stained  tubercle  bacilli. 

In  conclusion,  one  can  say  that  Kaufmann's  discovery, 
though  interesting  and  under  some  circumstances  valuable, 
does  not  alter  the  force  of  the  statement  that,  in  staining 
for  tubercle  bacilli,  mastery  of  the  technique  is  the  most 
important  thing,  and  that  the  control  of  a  simple  and  well- 
known  method  should  precede  essays  with  newer  ones. 


ON  SURGICAL  DISEASES  OF  THE  NECK, 

INCLUDING  THE  FIRST  ANNUAL  REPORT  OF 
THE  SPF.CIAL  DEPARTMENT  OP  SURGICAL  DISEASES  OF  THE  NECK 

at  the  german  poliklinik  of  the  city  of  new  york. 
By  carl  beck,  M.D. 

At  first  sight  it  may  appear  rather  unnecessary  or  even 
odd  to  have  created  a  new  specialty  as  indicated  above,  but 
a  closer  contemplation  of  the  subject  will  produce  a  great 
many  points  in  its  favor. 

The  field  of  surgery  has,  thanks  to  the  great  inventions 


April  29,  1893.] 


BECK:  SURGICAL  DISEASES  OF  THE  NECK. 


459 


of  the  last  two  decades,  become  so  broad  that  there  is  no 
brain  imaginable  which  could  master  all  the  details  of 
general  surgery.  Therefore  it  appears  not  more  than 
natural  that  there  are  specialists  for  orthopaedic,  for  ab- 
dominal, as  well  as  for  gcnito-urinary  surgery.  Since  the 
last  few  years  specialties  even  for  surgical  diseases  of  the 
face  and  mouth,  for  cancer,  for  hernia,  and,  last  but  not 
least,  for  diseases  of  the  rectum  have  been  created. 

I  see  no  reason  why  the  neck  should  not  be  entitled  to 
rank  with  the  latter  organ,  for  instance,  as  far  as  impor- 
tance and  scientific  interest  are  concerned.  The  one  fact  is 
indisputable,  that  among  all  regions  of  the  body  it  shows, 
in  spite  of  its  small  extent,  the  greatest  number  and  variety 
of  all  kinds  of  tumors. 

As  by  chance  it  was  my  good  fortune  during  a  period 
of  nine  years  to  observe  a  more  than  usual  number  of  sur- 
gical diseases  of  the  neck  at  the  German  Poliklinik,  I  fre- 
quently had  the  opportunity  to  witness  capital  errors  on 
the  part  of  distinguished  members  of  the  profession  in 
reference  to  diagnosis  as  well  as  to  treatment. 

Thus,  for  instance,  last  year  not  fewer  than  five  so-called 
cold  abscesses  were  sent  to  me  by  prominent  physicians 
with  the  diagnosis  lymphosarcoma  and  fibroma ;  undoubt- 
edly the  slow  growth,  and  particularly  the  hard  consistence 
of  the  deep-seated  collection  of  pus,  had  produced  the  idea 
of  a  solid  tumor. 

How  remarkably  the  views  of  the  faculty  differ  could, 
by  the  way,  be  observed  recently  in  a  controversy  between 
two  distinguished  members  of  the  profession  which  for 
nearly  the  whole  month  of  March  filled  the  space  of  the 
Medical  Record. 

One  of  the  gentlemen,  a  laryngologist,  published  an  in- 
teresting case  in  which  the  patient  had  died,  as  he  supposed, 
from  infectious  pharyngitis.  The  other  gentleman,  a  sur- 
geon, maintains  that  the  patient's  disease  was  angina  Ludo- 
vici,  and  that  probably  by  early  incisions  he  would  have 
been  cured. 

I  do  not  hesitate  to  confess  that  I,  especially  before 
having  enjoyed  the  chances  of  the  special  department,  fre- 
quently had  to  correct  my  initial  diagnosis  after  having 
observed  similar  cases  more  closely. 

The  importance  of  the  organs  alone,  the  complicated 
anatomical  condition,  the  great  dancrer  of  the  bold  as  well 
as  the  elegant  operations  which  can  be  performed  on  the 
neck,  could  already  justify  a  special  position  for  surgical 
diseases  of  the  neck,  which,  ever  since  surgery  existed,  had 
been  its  piece  de  resistance. 

But  the  diagnosis  seeming  to  me  paramount,  it  became 
clear  to  me  that  only  a  careful  and  constant  clinical  study, 
which  can  not  be  obtained  except  from  a  multitude  of  pa- 
tients afflicted  alike,  can  grant  that  amount  of  experience 
which  is  demanded  for  clear  indications  for  treatment. 

Without  undervaluing  the  various  ingenious  modern 
apparatuses  for  diagnostic  purposes,  particularly  the  micro- 
scope, I  dare  say  that  especially  at  an  early  stage  of  serious 
diseases — i.  e.,  at  a  period  when  not  only  the  best  but  very 
often  the  only  chances  for  a  cure  are  offered — the  clinical 
experience  alone,  as  a  rule,  furnishes  the  guide  for  interfer- 
ence. 


The  sad  and  well-known  case  of  Emperor  Frederick  of 
Germany  may  illustrate  this  somewhat,  as  some  of  the 
greatest  authorities  alive  disagreed  remarkably  in  regard 
to  the  character  of  the  tumor  of  his  larynx. 

It  is  or  was  generally  believed  that  it  was  cancerous,  but 
that  there  was  a  strong  suspicion  for  syphilis  was  evident 
by  the  fact  that  for  a  long  time  the  unfortunate  distin- 
guished patient  had  been  treated  with  inunctions  of  mer- 
cury and  was  fed  with  large  doses  of  iodide  of  potassium, 
and  only  when  no  decrease  of  the  swollen  glands  of  the  neck 
could  be  obtained  specific  treatment  was  abstained  from. 

Be  it  well  remembered,  too,  that  at  an  early  stage  of  the 
fatal  disease,  when  a  piece  of  the  tumor  was  removed  for 
microscopic  examination,  no  less  a  man  than  Rudolf  Vir- 
chow  found  no  evidence  of  either  syphilis  or  carcinoma, 
but  a  simple  verruca. 

It  is  supertiuous  to  say  that  a  different  opinion  in 
reference  to  the  character  of  the  disease  corresponds  with 
a  different  therapy — so  different,  in  fact,  that  the  life  may 
depend  upon  it. 

As  mentioned  already,  the  neck,  the  narrow  joining 
link  between  the  head  and  trunk — or,  as  Hyrtl  calls  it,  the 
pedicle  of  the  head — is  distinguished  by  the  great  number 
^nd  variety  of  all  kinds  of  tumors,  so  that  there  is  scarcely 
a  species  in  existence  which  can  not  be  found  in  this  little 
space. 

Besides  sarcoma,  carcinoma,  syphilis,  gummata  or  glands, 
and  tuberculosis,  I  should  like  to  mention  the  hyperplastic, 
the  leucajinic,  and  the  malignant  lymphoma,  lymphangeioma, 
lymphosarcoma,  fibrosarcoma,  fibroma,  enchondroma,  oste- 
oma, steatoma,  neuroma,  lipoma,  struma,  myxoma,  athero- 
ma, aneurysm,  simple  angeioma,  and  the  raonolocular  and 
multilocular  cyst — that  is,  cystic  tumor  of  the  visceral 
arches  :  air  cyst,  serous  cyst  (hydrocele  colli),  deep-seated 
dermatoid  cyst,  blood  cyst  (hsematocele  colli),  synovial  cyst 
(hygroma  of  the  thyreoid  region),  echinococcus  colli ;  fur- 
thermore, tumors  produced  by  leucaimia  or  pseudoleuc;«mia. 

Among  the  various  kinds  of  abscesses  I  may  mention 
the  idiopathic  ones,  the  phlegmonous,  the  previsceral,  retro- 
visceral,  retropharyngeal,  and  retro- a'sophageal  abscesses. 

Of  great  importance  are  the  inflammatory  processes 
following  infectious  diseases  of  pharynx  and  nasopharynx, 
the  spondylitis,  the  torticollis,  the  caries,  the  congenital  fis- 
tula, and  the  disfiguring  scars  following  extensive  burns. 

Regarding  the  diificulty  of  differentiation,  Liicke  (Liicke, 
Pitha- Billroth,  iii.  Bd.,  1.  Abth.)  has  worked  out  a  scheme 
by  dividing  the  tumors  of  the  neck  in  groups  according  to 
the  various  regions. 

Inside  of  each  group  the  tumors  are  classified  in  refer- 
ence to  their  physical  marks,  thereby  discriminating  be- 
tween cystic,  solid,  and  pulsating  tumors. 

This  very  complicated  scheme  works  beautifully  so 
long  as  it  answers  only  a  theoretical  want,  hut  is  of  no 
practical  value. 

It  seems  to  me  much  more  advisable,  therefore,  to 
make,  following  Albert  (E.  Albert,  Lehrhuch  der  Chiriir- 
gie  und  Operationslehre,  Vienna  and  Leipsic,  1 884),  a  dis- 
tinction between  a  few  possibilities  from  a  clinical  stand- 
{)oint,  as  it  is  the  custom  to  do  in  all  other  doubtful  ques- 


460 


BECK:   SURGICAL  DISEASES  OF  THE  NECK. 


|N.  Y.  Mkd.  Jouk., 


tions.  Furthermore,  to  pay  regard  to  the  general  healtli  of 
the  j)atient. 

When  a  new-born  child,  for  instance,  is  suffering  from 
a  tumor  of  the  neck,  this  can  only  be  an  angeioma  caverno- 
sum,  or  a  hygroma,  or  a  congenital  struma. 

A  struma  is  occupying  the  region  of  the  thyreoid  gland 
and  is  in  close  connection  with  the  trachea,  which  can 
easily  be  recognized  by  the  corresponding  upward  move- 
ment of  the  growth  while  swallowing'. 

An  angeioma  might  establish  itself  anywhere.  Its  red- 
dish-blue color,  the  spongy  feeling  by  touch,  the  fact  that 
it  can  not  be  compressed,  and  that  it  swells  up  while  the 
patient  is  crying,  furnish  the  evidence  of  its  character. 

The  congenital  hygroma,  when  starting,  has  its  domi- 
cile in  the  submaxillary  region,  and  is  cliaracterized  by  the 
multiple  cystic  cavities  of  which  it  consists. 

In  older  children  the  usual  form  of  tumors  is  repre- 
sented by  the  lymphatic  growth — that  is,  the  so-called 
scrofular  lymphoma,  a  term  which,  by  the  way,  since  the 
discovery  of  the  tubercular  bacillus,  has  become  obsolete,  as 
the  majority  of  these  ill-defined  lesions,  which  are  grouped 
under  that  indefinite  and  vague  word  scrofula,  have  been 
shown  by  recent  researches  to  be  aetiologically  and  clinically, 
as  well  as  anatomically,  identical  with  the  recognized  forms 
of  tuberculosis. 

Among  a  great  number  of  cases  a  whole  chain  of  tuber- 
cular glands  is  well  marked.  The  appearance  of  the  chil- 
dren afflicted  therewith  is  what  is  generally  called  scrofulous 
— that  is,  they  look  badly  nourished  and  anajmic.  One 
or  the  other  gland  might  already  have  broke'n  down,  so 
that  there  is  scarcely  any  doubt  as  to  the  character  of  the 
disease. 

On  the  other  hand,  one  simple  gland  is  swollen,  the 
child  bears  a  healthy  appearance,  and  there  may  be  no  fam- 
ily history  of  a  tubercular  disposition.  Then  a  simple 
lymphoma  is  suspected. 

If  the  little  tumor  is  situated  in  a  region  wliere  glands 
normally  have  to  be  expected,  if  it  can  be  easily  moved 
and  separated  from  its  surroundings,  and  if  it  is  of  small 
size,  the  diagnosis  is  corroborated. 

In  adults,  struma,  malignant  lymphoma,  and  aneurysm, 
in  old  age  carcinoma  of  the  oesophagus,  the  thyreoid  gland, 
or  of  the  lymphatic  glands,  may  be  suspected. 

The  an;emic  child,  the  young  consumptive  and  the  old, 
suffering  from  carcinomatous  cachexia,  in  their  general  ap- 
pearance at  once  have  to  point  our  suspicion  toward  a  cer- 
tain direction. 

Besides  this  general  view  we  have  to  regard  the  topog- 
raphy. Hygromas  occupy  the  thyreoid  region,  echinococ- 
cus  cysts  only  the  supraclavicular  region,  especially  below 
the  sterno-cleido-mastoid.  The  visceral-arch  cysts  establish 
themselves  only  at  the  anterior  margin  of  the  sterno-cleido- 
mastoid. 

Besides  this,  we  have  to  take  note  of  a  very  striking 
physical  symptom  of  only  a  limited  number  of  tumors — i.  e., 
the  distinct  pulsation. 

There  it  is  essential  to  know  whether  this  pulsation 
originated  from  the  tumor  itself.  If  this  is  not  the  case,  a 
great  number  of  possibilities  have  to  be  taken  into  consid- 


eration, as  the  pulsation  of  a  tumor  can  be  carried  to  any 
growth  which  may  be  situated  above  an  artery. 

If  the  tumor  itself  is  the  seat  of  the  pulsation,  then  the 
only  differentiation  would  be  between  an  aneurysm  or  a 
pulsating  vascular  sarcoma. 

This  sometimes  is  very  difficult  if  not  impossible  to  de- 
termine, as  the  character  of  the  pulsations  in  both  such 
cases  is  perfectly  identical  ;  the  sha{)e  and  situation,  besides, 
might  show  nothing  extraordinary. 

I^ven  the  consistence  may  leave  a  reasonable  doubt,  as 
in  the  various  portions  of  a  vascular  sarcoma  it  often  may 
be  irregular. 

Another  important  point  may  be  where  there  is  a  differ- 
ence in  the  pulse  of  the  afflicted  and  of  the  healthy  side. 
This  may  indicate  an  aneurysm. 

Furthermore,  an  aneurysm  grows  slowly,  while  a  sarco- 
ma, as  a  rule,  increases  more  rapidly.  Besides,  if  thorough- 
ly observed,  pulsation  may  have  been  noticed  already  at  a 
time  when  the  tumor  is  still  of  small  circumference,  and 
then  the  aneurysm  from  its  start  may  have  shown  a  soft 
consistence,  while  the  sarcoma  is  hard  and  resistant. 

Many  more  doubts  are  possible  in  tumors  the  contents 
of  which  are  liquid.  Take  the  case  of  a  well-defined  fluc- 
tuating tumor  of  peanut  size  at  the  anterior  margin  of  the 
sterno-cleido-mastoid.  It  may  be  what  is  termed  a  cold 
lymphadenitic  abscess  just  as  well  as  a  visceral- arch  cyst  or 
a  thyreoid,  or  a  blood  or  an  echinococcus  cyst.  To  make  a 
diagnosis  in  this  case  we,  in  the  first  place,  have  to  decide 
if  the  tumor  ascends  or  descends  synchronously  with  swal- 
lowing. 

Second,  we  have  to  find  if  it  is  adherent  to  the  thyreoid 
gland.  If  this  is  so,  it  is  a  thyreoid  cyst ;  if  not,  we  have  to 
examine  if  a  part  of  the  tumor  can  be  partially  emptied.  If 
this  can  be  done,  a  blood  cyst  is  probable ;  if  not,  its  mo- 
bility comes  in  play.  In  case  the  base  of  the  tumor  is 
movable,  we  probably  have  to  deal  with  a  lymphoma  with 
softened  contents  ;  but  in  case  the  mobility  is  doubtful,  it 
may  be  an  echinococcus  or  visceral-arch  cyst. 

The  differentiation  between  these  two  conditions  can 
only  be  made  from  the  history,  as  the  latter  presents  itself 
only  during  puberty,  while  the  echinococcus  occurs  at  any 
period  of  life. 

An  aspirated  blood  cyst  naturally  yields  blood,  while  a 
visceral- arch  cyst  yields  a  pappy  mass. 

These  few  examples  may  suffice  to  show  the  difficulties 
of  differentiation,  these  being,  as  a  rule,  of  much  more  im- 
portance, so  far  as  the  patient's  life  is  concerned,  than  the 
operations,  in  reference  to  which  some  special  principles 
unlike  those  governing  the  surgeon  on  other  regions  of  the 
body  have  to  be  observed. 

I  will  not  speak  of  such  masterly  proceeding  as  the 
ligation  of  the  innominata,  which  will  forever  immortalize 
the  name  of  Valentine  Mott. 

But  I  may  lay  stress  upon  some  points  like  the  neces- 
sity to  perform  operations  on  the  neck  with  blunt  instru- 
ments. It  is  remarkable  how  rarely  1  cut  a  large  vessel  un- 
expectedly since  I  have  adopted  this  principle.  The  most 
valuable  instrument  for  this  purpose  is  the  blunt-pointed 
scissors,  curved  on  the  flat  (so-called  Cooper's),  which, 


April  29,  1893.J 


BECK:  SURGICAL  DISEASES  OF  THE  NECK. 


461 


when  closed,  adapt  themselves  to  the  convexity  of  the 
tumor. 

Large  and  deeply  situated  tumors  naturally  cause  great 
difficulties  in  operations.  Here  it  is  of  great  importance  to 
make  extensive  incisions,  always  exceeding  the  limits  of 
the  tumor  on  each  side. 

A  vertical  cut  alone  generally  does  not  suffice,  where- 
fore it  always  is  wise  to  make  a  cross  incision  besides  right 
at  the  beginning  of  the  operation.  Often  I  have  found  it 
useful  to  add  a  so-called  trap  door  cut. 

I  have  never  tried  to  ligate  the  large  vessels  methodi- 
cally before  the  extirpation  of  a  tumor,  as  advised  by  Lan- 
genbeck,  but  by  proceeding  bluntly  I  was  always  able  to 
catch  the  vessels  between  two  forceps  before  they  were  cut 
through.  It  is  practical  to  ligate  the  vessels  first  in  the 
centripetal  direction  and  after  this  on  the  opposite  side  of 
the  tumor.  This  procedure  is  especially  useful  if  the  tumor 
has  been  growing  around  the  vessels.  Deep  down,  where 
the  usual  forceps  makes  it  quite  troublesome  sometimes  to 
apply  the  ligature,  my  own  artery  clamp — which,  on  account 
of  its  rectangular  shape,  makes  sliding  over  easy — has  done 
mfi  considerable  service. 

During  extirpation  the  tumor  should  be  only  slightly 
pulled,  as  strong  traction  might  empty  large  veins,  so  that 
they  might  be  taken  for  connective  tissue  and  incised.  A 
less  experienced  surgeon  may  then  be  astonished  about  the 
large  amount  of  bleeding  following  relaxation.  Besides  the 
danger  of  bleeding,  the  patient  should  never  be  exposed  to 
the  great  risk  of  the  entrance  of  air  into  the  vessel.  By  re- 
laxing the  growth  every  time  before  doubtful  tissues  are  in- 
cised, this  undoubtedly  frequent  occurrence  can  be  avoided. 

I  have  always  succeeded  in  extirpating  atheromata  of 
the  neck,  if  movable,  by  my  own  method,  which  in  short  I 
may  describe  once  more  on  this  occasion  (cf.  N.  Y.  medi- 
cinische  Monatsschrift,  December,  1886).  With  a  sharp- 
pointed  bistourj'  I  make  a  small  cut  anywhere  into  the  skin 
covering  the  tumor,  and  just  large  enough  to  allow  a  probe 
or  small  blunt  curved  scissors  to  pass  through.  (A  strong 
probe  is  to  be  preferred.) 

After  having  loosened  the  sac  with  the  instrument  from 
its  adhesions  thoroughly,  I  open  the  cyst,  introduce  a  small 
Pean  forceps,  seize  the  sac  somewhere,  and  pull  slowly.  At 
the  same  time  I  am  squeezing  the  contents  out  as  the  pla- 
centa is  expressed  from  the  uterus  in  Crede's  method.  Thus 
by  exercising  patience  I  can  remove  the  largest  sac  in  the 
same  manner  as  a  large  ovarian  cyst  is  withdrawn  through 
a  small  abdominal  opening,  after  having  it  emptied  or  oth- 
erwise diminished  its  size  in  the  abdominal  cavity. 

After  the  removal  the  cavity  is  irrigated  with  a  one-pro- 
mille  bichloride  solution  and  a  light  dressing  is  applied. 

The  greatest  advantage  I  allege  for  this  my  method  is, 
that  it  leaves  no  scar,  a  circumstance  which  for  cosmetic 
reasons  is  probably  more  appreciated  by  the  fair  sex.  (It 
is  evident  that  the  same  procedure  can  be  employed  for 
atheromas  of  the  face.) 

Besides  the  method  described,  it  makes  sewing  unneces- 
sary, it  causes  nearly  no  bleeding  at  all,  and  grants  recovery 
after  two  or  three  days  as  a  rule. 

Where  thick  adhesions  are  present  it  naturally  is  im- 


possible to  separate  them  with  a  blunt  instrument,  and  then 
they  have  to  be  shelled  out  like  other  small  movable  tumors 
such  as  lymphomas.  Here  the  tumor  is  seized  and  pushed 
against  the  integument.  An  incision  is  made  down  to  the 
sheaths  of  the  gland  and  the  blunt  scissors  finish  the  sepa- 
ration. 

The  prototype  of  such  tumors  is  the  hyperplastic  lym- 
phoma, or  lymphoma  as  it  is  ordinarily  called,  and  which 
consists  in  a  hypertrophy  of  the  gland.  It  either  has  a  soft 
consistence  if  the  cellular  elements  are  hypertrophic,  or  a 
hard  one  if  the  reticular  tissue  between  has  proliferated. 

In  most  cases  a  peripherical  irritation  can  be  found  as 
their  source  of  origin. 

Inflammatory  processes,  ulceration,  dermatitis,  or  eczema 
occasionally  make  neighboring  glands  swell. 

At  our  department  we  have  observed  a  typical  cause  for 
swollen  glands  which  we  have  named  "  dirt  inflammation." 
Those  immigrants  coming  from  barbarous  districts  and  who 
regard  even  an  annual  wash  to  be  an  exorbitant  and  foolish 
luxury,  carry  Mother  Earth  in  the  most  various  shapes  on  all 
such  surfaces  of  the  body  which  are  not  covered  by  cloth- 
ing. When  they  are  scratching  themselves — sometimes  for 
very  good  reasons — they  "  leffe  artis  "  inoculate  themselves 
with  their  antique  and  well-preserved  filth. 

As  shown  below,  four  cases  of  lymphadenitis  had  been 
undoubtedly  due  to  the  presence  of  the  invasion  of  an  army 
of  "  pediculi  capitis,"  which  was  fought  successfully  by 
anointing  the  skull  with  blue  mass.  It  was  remarkable  how 
quickly  the  size  of  the  glands  was  reduced  after  the  original 
cause  was  removed. 

Only  in  case  the  irritation  should  be  an  internal  one  sup- 
puration may  set  in,  but  generally  the  hypertrophied  glands 
disappear  as  soon  as  the  irritating  process  is  healing. 

But  in  a  certain  number  of  cases,  even  after  the  cause 
has  been  removed,  the  sequelaj  in  the  shape  of  a  lymphoma 
remain.  If  not  too  much  time  has  elapsed,  the  therapy  as 
described  below  may  still  be  successful  ;  otherwise  extirpa- 
tion is  in  order. 

If  no  suppuration  exists  in  or  around  the  glands,  I  in 
extirpating  them  always  strive  toward  union  by  first  inten- 
tion. If  there  is  any  sign  of  suppuration  or  even  only  soft- 
ening in  the  center  of  the  gland,  I  never  sew  up  the  wound. 
With  few  exceptions,  so  far  as  my  experience  goes,  such 
conditions  are  apt  to  produce  inflammation  even  after  union 
by  first  intention  had  been  obtained  already.  The  scar  opens 
somewhere,  new  incisions  have  to  be  made,  scraping  has  re- 
peatedly to  be  done,  and  the  process,  which  under  open  treat- 
ment will  have  been  ended  in  one  or  two  months,  may  take 
even  years  or  end  fatally  through  the  retention  or  the  bur- 
rowing of  pus. 

In  suppurative  processes  the  existence  of  tuberculosis 
has  to  be  borne  in  mind,  this  disease  being  of  terrible  fre- 
quency. 

There  is  indeed  no  region  where  tuberculosis  can  so  easi- 
ly and  so  exhaustively  be  studied  as  on  the  neck,  where- 
fore I  may  be  allowed  to  make  some  more  extended  remarks 
concerning  this  subject. 

Why  tubercular  glands  of  the  neck  are  still  called  lymph- 
adenitis scrofulosa,  or  scrofulous  glands,  is  a  conundrum  to 


465 


BECK:  SUEOICAL  DISEASES  OF  THE  NECK. 


[N.  Y.  Med.  Joub. 


me.  The  time  has  passed  where  tuberculosis  would  only  be 
identified  with  an  ulcerated  process  in  the  lungs. 

Since  Robert  Koch  made  his  great  discovery  it  has 
been  shown  that  there  is  scarcely  a  tissue  in  the  body  which 
could  not  become  tubercular.  Those  diseases  which  so  in- 
definitely are  called  scrofula  are  nothing  but  tubercular  af- 
fections. Langenbeck,  Volkmann,  and  Sayre,  even  before 
the  antiseptic  era,  showed  that  there  was  such  a  thing  as 
local  tuberculosis,  or,  as  it  is  practically  expressed,  surgical 
tuberculosis,  and  that  by  thorough  resection  in  numerous 
cases  a  cure  of  these  tubercular  processes  could  be  effected. 

I  do  not  see  why  the  same  principle  should  not  be  kept 
up  in  tubercular  disease  on  the  neck.  As  Whittier  says,  it 
may  occur  that  from  a  caseous  nodule,  wherein  the  tuber- 
cular virus  is  locked  up  in  temporary  innocence,  absorption 
may  take  place  under  favorable  circumstances  and  a  new 
outbreak  of  tubercular  symptoms  appear,  the  quantity  of 
virus  thus  set  free  determining  to  a  great  extent  perhaps 
the  virulence  of  the  symptoms.  While  the  virus  is  locked 
up  thus  the  disease  would  be  latent,  and  when  set  free  mani- 
fest itself. 

From  this  recent  point  of  view  it  is  evident  that  the 
true  tubercular  nature  of  a  gland  can  only  be  furnished  by 
bacteriological  investigations.  But  this  can  not  be  de 
manded  from  the  general  practitioner  at  all  for  practical 
reasons.  Therefore,  though  I  do  not  at  all  underestimate 
the  great  value  of  the  microscope,  I  recommend  for  the  pur- 
pose of  determining  a  character  of  a  doubtful  gland  a 
strictly  practical  method.  I  inject  one  hypodermic  syringe- 
ful  of  a  saturated  solution  of  iodoform  ether  into  the  sub- 
stance of  the  gland,  and  repeat  this  about  every  third  or 
fourth  day.  If  after  three  or  four  injections  the  gland  has 
decreased,  I  am  sure  that  a  cheesy  process  is  going  on  in 
the  center ;  in  other  words,  that  there  is  a  tubercular  focus. 
As  soon  as  I  have  gained  this  conviction  I  immediately 
proceed  to  extirpation. 

In  fact,  among  a  great  number  of  cases  treated  thus  I 
have  always  found  that  after  an  unsuccessful  treatment  by 
the  use  of  iodoform  injections  the  center  of  the  gland  was 
degenerated. 

An  early  extirpation  is  of  the  same  value  as  in  the  treat- 
ment of  malignant  growths.  It  is  nearly  certain  that  if  the 
glands  are  taken  out  before  the  tubercular  process  has  ex- 
tended beyond  the  capsule,  the  neighboring  glands,  and 
hereby  the  whole  system,  will  be  prevented  from  successive 
infection.  Without  any  exception,  all  the  numerous  cases 
which  I  have  treated  by  early  extirpation  have  been  cured. 

The  time  of  observation,  however,  is  extending  over  too 
short  a  period  to  have  a  clear  judgment  about  the  future 
results,  but  it  is  remarkable  that  all  these  tubercular  pa- 
tients have  quickly  improved  in  every  way,  and  are  all  in  a 
decidedly  normal  condition  at  the  present  time. 

The  main  reason  for  having  had  such  splendid  results  I 
see  not  only  in  making  it  a  rule  to  make  large  incisions  and 
to  remove  all  suspicious  tissue  thoroughly,  but  especially  in 
the  open  treatment  of  the  wound.  The  tissues  in  which 
suppurating  glands  were  imbedded  have  little  tendency  to 
union  per  primum,  although  I  do  not  deny  that  it  can  be 
obtained  sometimes. 


But  it  seems  to  me  to  be  essential  that,  after  the  re- 
moval, the  whole  operation  field  should  be  washed  with  an 
eight- per- cent,  solution  of  chloride  of  zinc  and  then  packed 
with  iodoform  gauze  (fifty  per  cent.). 

By  uniting  the  edges  of  the  wound  and  putting  in  one 
or  more  drainage-tubes  we  renounce — 

1.  The  peculiar  antitubercular  influence  of  the  iodo- 
form, which  can  only  be  obtained  if  it  remains  in  close  con- 
tact with  the  tissues,  as  there  is  no  such  thing  as  an  effect 
of  iodoform  by  distance.  The  gauze  which  covers  the 
united  wound  and  the  outer  ends  of  the  drainage  tubes 
only  prevents  the  decomposition  of  the  wound  secretion  in 
the  gauze,  but  is  of  no  influence  upon  the  process  in  the 
wound  or  cavity  itself. 

2.  We  renounce  the  absorbing  qualities  of  the  gauze, 
which  is  of  great  value.  If  packed,  every  little  bit  of  the 
secretion  must  be  absorbed  by  the  gauze,  and,  no  matter 
how  large  the  cavity  is,  the  pus  must  be  in  the  gauze  only 
and  the  wound  surface  must  appear  dry.  Regarding  the 
fact  that  dryness  is  the  strongest  enemy  of  bacteria,  we 
may  herein  find  some  other  point  of  importance.  The 
drainage-tube  is  not  so  polite  as  to  pull  out  the  matter,  as 
the  public  at  large  are  inclined  to  express  themselves. 
There  is  no  magnetism  of  any  kind  in  the  dressing  as  to 
aspirate  pus  which  rather  passes  a  drainage-tube  only  if 
the  cavity  produces  it  in  abundance ;  if,  in  other  words, 
there  is  the  first  step  to,  or,  most  frequently,  the  real  cause 
of  a  retention  of  pus. 

My  experience  in  former  years  has  taught  me  sufficient- 
ly how  much  needless  work  I  was  doing  in  always  using 
other  antiseptics  or  other  dressings,  or  in  making  innumer- 
able scrapings  or  counter  incisions,  so  that  a  year's  time  of 
treatment  was  nothing  astonishing  to  me,  while  since  I 
have  adopted  these  principles  the  average  time  has  amount- 
ed to  five  weeks.  I  may  add  that  I  have  dispensed  with 
irrigation  entirely,  because  the  wound  surfaces  look  so  dry 
and  healthy  that  there  is  nothing  left  to  be  washed  off. 

3.  We  remove  a  valuable  point  of  observation  in  clos- 
ing up  our  operation  field.  Just  as  I  make  large  incisions 
in  order  to  see  and  not  only  feel  every  gland  which  I  want 
to  extirpate,  I  like  to  be  able  to  look  over  the  whole  field 
during  the  after-treatment,  thus  being  enabled  to  make 
corrections — for  instance,  when  by  mistake  I  have  left  dis- 
eased tissue. 

It  sometimes  may  occur  that,  shortly  after  the  opera- 
tion, the  surface  of  the  wound  may  be  covered  by  a  thick 
layer  of  badly  granulating  tissue,  which  shows  the  charac- 
teristics of  tubercles.  There  the  repeated  use  of  chloride 
of  zinc  and  sometimes  renewed  scraping  is  indicated.  It 
is  further  remarkable  that  even  very  large  incisions  heal 
without  as  ugly  a  scar  as  presumably  should  be  expected, 
this  being  probably  due  to  the  quickness  of  the  healing 
process. 

The  dressings,  as  a  rule,  are  changed  every  second  day 
in  the  beginning  ;  later  on,  only  every  third  or  fourth  day. 

After  the  cavity  has  been  packed,  a  piece  of  "  Neu- 
strelitz  sterilized  moss  "  surrounds  the  entire  neck.  This 
moss,  besides  its  excellent  absorbing  qualities  (it  soaks  five 
times  as  nmch  water  as  any  gauze),  has  the  great  advan- 


April  29,  1893.] 


BECK:  SURGICAL  DISEASES  OF  THE  NECK. 


463 


tage  that,  slightly  dipped  in  water  (or  preferably  in  a  bi- 
chloride solution),  it  adapts  the  shape  of  the  body,  so  that 
it  immobilizes  like  a  plaster-of-Paris  splint,  over  which  it 
has  the  great  advantage  of  being  absorptive  and  of  being 
much  lighter. 

The  results  obtained  by  rae  are  in  strong  opposition  to 
Frankels,  wlio  maintains  that  the  average  time  of  the  heal- 
ing process  in  tubercular  glands  is  from  three  to  four  years. 

Regarding  the  undeniable  fact  that  in  all  these  cases, 
sooner  or  later,  pulmonary  or  diflEuse  general  tuberculosis 
could  necessarily  have  taken  place,  I,  with  all  due  respect 
to  my  colleagues,  am  unable  to  conceive  that  many  of  them 
still  advise  building  up  the  system  first,  and  then  do  an 
extirpation,  a  view  which  shows  a  deep  misunderstanding 
of  the  pathological  cause  of  tubercular  glands. 

Internally  I  have  administered  Roncegno  water  in  the 
summer  time ;  pale  Norwegian  cod  liver  oil  (never  the 
emulsion)  during  the  winter  season.  When  even  the  slight- 
est disturbance  of  the  stomach  was  present,  I  prefer  the 
syrup  of  the  iodide  of  iron.  At  the  same  time  every  pa- 
tient was  advised  to  take  a  salt-water  bath  (one  to  five 
pounds  of  rock  salt  to  a  tubful)  every  day  for  years. 

Treatment  with  Koch's  tuberculin,  as  well  as  with 
Klebs's  tuberculocidin,  has  repeatedly  been  tried,  but  with 
no  satisfactory  results. 

Report  of  Cases. — 1.  Hyperplastic  lymphoma,  57  cases 
(89  males,  18  females). 

Among  these  were  six  under  the  age  of  three  years, 
24  between  three  and  thirteen  years  of  age,  20  between 
thirteen  and  twenty-five  years  of  age,  and  7  over  twenty- 
five  years  of  age. 

All  except  14  had  been  born  or  had  mostly  lived  in  the 
plains. 

Twenty-six  were  born  and  mostly  dwelling  on  the  sea- 
shore ;  14  came  from  Russia,  12  from  Austria,  8  from  Ger- 
many, 20  from  New  York  city,  and  3  from  other  countries. 

Among  26  the  glands  were  located  on  the  left,  among 
21  on  the  right,  and  among  10  on  each  side.  In  7  cases 
operations  had  already  previously  been  performed. 

In  14  cases  the  axillary  and  inguinal  glands  were  en- 
larged also. 

Twice  the  sterno-cleido- mastoid  had  to  be  cut  through, 
and  was  united  again  after  extirpation  was  completed. 

Forty  cases  were  cured  by  the  use  of  Roncegno  water, 
cod-liver  oil,  salt-water  baths,  and  the  application  of  iodo- 
form collodium,  changing  with  the  green  soap,  the  foam  of 
which  had  remained  over  the  glands  during  nighttime. 

Fifteen  were  cured  by  the  injection  of  iodoform  ether. 
Some  glands  were  injected  between  twenty  and  thirty 
times. 

In  2  cases,  where  I  failed  to  reach  the  center  of  the 
gland  tlirough  the  great  nervousness  of  the  patients,  iodo- 
form ether  was  distributed  under  the  skin,  where  it  pro- 
duced slight  gangrene — an  occurrence  which,  through 
greater  care,  i)robably  could  have  been  avoided. 

All  patients  complain  of  great  pain  caused  by  the  injec- 
tion. Hut  this  usually  does  not  last  longer  than  one  or  two 
minutes. 

In  2  cases,  which  were  of  more  than  one  year's  stand- 


ing already  before  they  underwent  treatment  at  our  depart- 
ment, repeated  iodoform  injections  produced  decrease  of 
the  glands,  but  could  not  make  them  disappear  entirely, 
wherefore  I  extirpated  them. 

In  9  of  these  cases  a  tubercular  history  could  be  made 

out. 

It  was  of  interest  that  in  most  of  these  cases  an  origi- 
nal cause  for  the  glands  could  be  found.  Three  cases  were 
depending  upon  dermatitis ;  4  from  eczema,  6  from  inflam- 
matory and  4  from  ulcerative  processes ;  5  had  followed 
scarlet  fever,  and  6  diphtheria.  In  5  cases  adenoid  growths 
of  the  nasopharyngeal  space  and  in  4  pediculi  capitis  were 
found  ;  8  cases  probably  were  inoculated  by  dirt.  In  such 
cases  the  use  of  green  soap  is  of  double  value.  In  12  cases 
the  original  cause  could  not  be  found. 

As  far  as  the  ii'tiology  is  concerned,  the  term  "scrofula" 
was  found  to  be  practical  so  far  as  it  covers  our  own  igno- 
rance of  many  points  about  the  patients. 

Suppurat'uKj  Glands  (irritation  diagnosticated). — Nine- 
teen cases,  among  which  6  were  dependent  from  eczema,  5 
from  dermatitis,  4  from  inflammatory  and  4  from  ulcerative 
processes  (11  males,  8  females). 

All  of  them  were  cured  by  incision,  scraping,  and  pack- 
ing with  iodoform  gauze. 

Among  them  were  6  children  below  three,  7  below  thir- 
teen, and  6  individuals  over  thirteen  years  of  age. 

Fifteen  were  born  or  had  always  lived  on  flat  land  (13 
on  the  seashore),  5  came  from  Russia,  4  from  Austria,  3 
from  Germany,  6  from  New  York  city,  and  1  from  Switzer- 
land. 

Ten  were  located  on  the  left,  7  on  the  right,  and  2  on 
each  side.  In  4  cases  previous  operations  had  been  per- 
formed. In  4  cases  the  axillary  and  inguinal  glands  were 
slightly  enlarged. 

Suppurati/iff  Glands  (probably  tubercular). — One  hun- 
dred and  twenty-four  cases  (81  males,  43  females).  Among 
them  were  44  up  to  three  years  of  age,  28  between  three 
and  thirteen,  24  between  thirteen  and  twenty-five,  17  be- 
tween twenty-five  and  fifty,  and  11  over  fifty. 

One  hundred  and  fifteen  of  them  were  born  and  had 
mostly  lived  on  the  flat  land. 

Only  19  were  born  or  brought  up  in  the  mountains,  82 
were  born  and  mostly  residing  on  the  seashore,  31  were 
born  in  Russia,  22  in  Austria,  26  in  Germany,  39  in  the 
United  States  (New  York  city),  and  6  in  other  countries. 

Fifty-eight  were  located  on  the  left,  49  on  the  right, 
and  17  on  each  side. 

In  28  cases  previous  operations  had  been  performed. 

In  39  cases  the  axillary  and  inguiiuil  glands  were  en- 
larged also. 

In  29  of  these  cases  where  the  suppurating  process 
could  not  be  diagnosticated  by  me  beforehand,  iodoform- 
ether  injections  had  repeatedly  been  made  without  success 
before  extirpation  was  done.  Five  times  the  sterno-cleido- 
mastoid  had  to  be  cut  through,  and  was  always  united  again 
after  the  extirpation  was  completed.  The  internal  jugular 
vein  was  ligated  before  separation  twice  ;  once  the  ligation 
was  temporary  only. 

In  34  cases  three  or  less  glands  had  to  l)e  removed,  in 


464 


BECK:  SURGICAL  DISEASES  OF  THE  NECK. 


[N.  Y.  Mkd.  Joto,, 


55  between  three  and  six,  in  23  between  six  and  ten,  and  in 
12  more  than  ten  (in  some  cases  between  30  and  35)  glands 
had  to  be  extirpated. 

In  21  cases  I  had  to  repeat  extirpation  by  removing 
neighboring  glands,  which  were  not  noticeable  at  the  time 
of  the  operation,  or  which  had  been  overlooked  by  me. 

In  63  cases  the  family  history  gave  me  the  suspicion  of 
tuberculosis.  Seventy-four  patients  had  frequently  suffered 
from  bronchitis,  pneumonia,  pleuritis,  and  chlorosis. 

All  the  patients  showed  an  anfemic  appearance  and  were 
generally  thin  and  slimly  built.  Twenty-nine  were  rhachitic 
at  the  same  time  ;  thirty-one  suffered  from  chronic  rhinitis. 
Adults  complained  of  great  weakness  and  loss  of  appetite 
as  a  rule. 

The  operation  was  always  performed  under  an  anais- 
thetic.  Adults  were  anaisthetized  with  ether,  children  he- 
low  six  years  of  age  with  chloroform. 

Two  patients  (see  history)  died  ;  nineteen  are  still  under 
treatment  and  are  doing  well. 

The  following  few  cases  may  serve  as  an  illustration  : 

Case  I. — Saraii  R.,  sixteen  years  of  age,  thin  and  over- 
grown, born  in  Russia,  flat  land.  Parents  alive  and  well.  (Elder 
brother  operated  on  by  me  in  summer,  1892,  for  caries  cla- 
viculffi.    Recovery.)    Menses  since  her  thirteenth  year. 

Five  years  ago  about  eight  subauricular  suppurating  glands 
had  been  removed  by  ine.  Rubber  drainage.  Recovery  after 
eleven  months.  In  December,  1891,  after  having  been  well 
ever  since  the  last  operation,  the  glands  of  the  same  region  be- 
came enlarged.  Iodoform  ether  was  injected  immediately  and 
recovery  followed  after  seven  injections;  at  the  same  time  in- 
ternal treatment  was  given. 

In  January,  1893,  she  presented  herself  again,  suffering  from 
an  enlarged  gland  in  the  same  region.  Iodoform  ether,  injected 
three  times,  made  it  disappear. 

Case  II. — Fred  L.,  nineteen  years  of  age,  tall  and  thin,  born 
in  Germany,  flat  land  ;  family  history  good.  Since  five  months 
a  slow-growing  painless  tumor  has  appeared  in  the  left  upper 
trigonum.  Treatment  by  several  gentlemen  consisted  in  iodine 
preparations  externally  and  internally.  Sent  to  me  with  the 
diagnosis  of  fibroma.  Patient  looks  very  anjemic,  shows  loss 
of  appetite,  great  weakness.  Temperature  101°,  pulse  106.  The 
very  hard  non-movable  tumor  of  goose-egg  size  yielded  pus  by 
aspiration.  Vertical  incision ;  scraping  and  packing.  Perfect 
recovery  after  two  months. 

Diagnosis. — Suppurative  melting  of  gland  or  glands,  forming  a 
so-called  cold  abscess.  (Patient  is  reportetd  o  be  well  up  to  date.) 

Case  III. — Josef  N.,  seventeen  years  of  age,  tall  and  thin, 
born  in  Russia,  flat  land;  six  years  in  the  United  States; 
family  history  good.  Three  months  ago  he  noticed  a  small,  soft 
tumor  in  the  right  middle  of  his  neck,  which  grew  slowly  and 
without  causing  any  pain.  For  several  months,  without  any 
effect,  medical  treatment  by  his  house  physician,  who  had  sent 
him  under  the  diagnosis  hydrocele  colli,  and  had  told  him  that 
a  few  injections  would  cure  him.  Examination  at  our  depart- 
ment. May  3,  1892,  revealed  a  fluctuating  tumor  of  hen's-egg 
size  at  the  right  upper  trigonum.  A  part  of  the  same  could  be 
emptied.  No  mobility  was  present;  but  the  aspiration  yielded 
pus,  wherefore  the  diagnosis  of  a  cold  abscess  probably  caused 
by  broken-down  gland  tissue  was  evident.  Scraping  and  pack- 
ing within  ten  weeks  cured  the  patient. 

Case  IV.  —  Agathe  S.,  sixty-five  years  of  age,  widow; 
stout;  born  in  Germany,  flat  land;  in  New  York  city  for  tiie 
last  thirty  years.    Family  history  good.    Of  her  six  children, 


two  died  early — one  from  meningitis,  another  one  from  pneu- 
monia. She  has  always  been  well  till  nine  months  ago  she 
noticed  a  painless  tumor  in  the  left  supraclavicular  region 
which  was  growing  slowly.  Slight  i)ain  appeared  during  the 
last  two  months,  variously  treated  before.  Sent  with  the  diag- 
nosis carcinoma. 

The  patient  was  first  seen  at  our  department  on  A[)ril  17, 
1892,  and  looked  cachectic.  Great  debility;  temperature,  101°; 
pulse,  90.  The  clavicula  in  its  whole  length  represented  tiie 
base  of  a  hard  tumor  of  the  size  of  the  head  of  a  new-born 
child,  which  extended  in  an  elliptic  shape  up  to  the  angle  of  the 
inferior  maxilla.  Turning  the  head  is  very  painful;  in  a  quiet 
state  only  temporary  pains  are  experienced.  No  fluctuation. 
Aspiration  on  three  different  points  yielded  blood.  No  mo- 
bility. Although  there  were  many  ])oints  in  favor  of  a  diag- 
nosis of  carcinoma,  I  suspected  tubercular  glands  for  the  fol- 
lowing reasons : 

a.  In  the  case  of  carcinotna  of  nine  months'  standing  some 
neighboring  glands  ought  to  have  been  infiltrated. 

1>.  The  surface  of  the  tumor  would  have  been  less  even. 

The  operation,  started  by  a  trap-door  flap  incision,  showed 
eleven  glands,  nine  of  them  in  a  state  of  cheesy  degeneration. 
Scraping  and  packing  cured  the  patient  within  ten  weeks.  She 
has  remained  well  up  to  date. 

Case  V. — Elizabeth  J.,  fifty-seven  years  of  age,  housewife; 
small  and  thin  ;  born  in  Germany  (on  the  hills) ;  in  New  York 
since  forty-seven  years;  family  history  favorable.  Among  her 
four  children  one  had  died  from  bronchitis  at  an  early  age. 
She  herself  had  suffered  from  pneumonia  eleven  years  ago. 
Eight  months  ago  she  first  noticed  a  small,  painless  swelling  in 
the  middle  of  her  right  neck.  It  increased  slowly  in  size.  For 
the  last  two  months  it  once  in  a  while  felt  painful.  She  had 
treated  herself  with  linseed  poultices  until  she  was  told  that 
she  was  suffering  from  "  cancer,"  and  was  sent  to  our  depart- 
ment for  removal. 

On  February  15,  1892,  when  she  first  showed  up,  she  looked 
cachectic.  Debility  and  loss  of  appetite  were  present.  The 
trigonum  cervicale  superius  is  occupied  by  a  hard  tumor  of  the 
size  of  a  man's  fist.  Slight  mobility  is  present.  No  fluctuation. 
Turning  of  head  is  almost  impossible.  Temperature,  100'5° ; 
pulse,  94.  Aspiration,  repeated  three  times,  yields  blood.  No 
neighboring  glands  are  affected.  The  well-defined  tumor  shows 
a  smooth  globular  surface. 

Diagnosis. — Infiltration  caused  by  tubercular  glands. 

Removal  was  quite  difficult.  After  a  T-shaped  incision  was 
made,  the  sterno-cleido-niastoid  was  cut  through  and  the  in- 
ternal jugular  vein  ligated  before  being  cut.  Open  treatment. 
Perfect  recovery  after  three  months.  Patient  was  reported  to 
be  well  only  a  few  weeks  ago. 

Case  Vl. — Anton  B.,  twenty-one  years  of  age;  tall  and 
thin;  born  in  Bohemia  (flat  land) ;  in  United  States  since  two 
years;  family  history  unknown.  Since  four  years  suffering 
from  "suppurative  glands."  He  reports  that  for  quite  a  length 
of  time  in  Bohemia  he  was  treated  with  the  dried-up  faeces  of 
a  cow  in  the  shape  of  a  poultice,  moistened  with  lukewarm 
water.  On  December  9,  1892,  .when  he  first  came  under  our 
observation,  he  looked  anfemic ;  was  quite  weak ;  temperature, 
101°;  pulse,  106.  The  submaxillary  glands  from  one  angle  of 
the  inferior  maxilla  to  the  other  were  infiltrated,  and  averaged 
in  size  from  a  bean  to  a  peanut.  No  less  than  seventeen  fistulsB 
were  spread  over  the  infiltrated  region,  and.  in  fact,  increased 
the  circumference  of  the  whole  neck  to  such  size  as  if  it  was 
surrcumded  with  heavy  padding. 

Diagnosis. — Tubercular  glands  of  neck,  infiltration  of  con- 
nective tissue,  retention  of  pus,  and  disfiguring  scars  around 
the  fistulic. 


April  29,  1893.J 


BECK:  SURGICAL  DISEASES  OF  THE  NECK. 


465 


Incision  from  one  angle  of  the  jaw  to  the  other;  excision  of 
all  sciir  tissue ;  removal  of  nineteen  glands;  scraping  of  several 
pockets,  where  undoubtedly  glands  had  previously  broken  down. 
Next  day  temperature,  104"5°;  pulse,  130.  As  retention  of  pus 
was  suspected,  the  dressing  was  changed ;  nothing  extraordinary 
was  found.  One  day  later,  as  the  fever  symptoms  continued, 
the  dressing  was  changed  again.  This  time  a  swelling  on  the 
posterior  margin  of  the  left  sterno  cleido-inastoid  at  its  insertion 
was  noticed.  An  incision  revealed  a  suppurating  gland,  which, 
unfortunately,  had  been  overlooked  at  the  operation. 

The  patient  improved  rapidly.  A  month  later  the  whole 
left  side  of  the  neck  was  closed.  Two  cavities  on  the  right  side 
were  still  suppurating,  and  had  been  scraped  twice  more.  On 
January  14th  a  chill;  renewed  swelling  of  four  submaxillary 
glands,  which  were  removed.  Eapid  improvement  and  closure 
of  all  the  cavities  followed  with  the  exception  of  one,  which 
was  repeatedly  cauterized  with  an  eight-per-cent.  solution  of 
chloride  of  zinc.  Patient  is  still  under  treatment,  but  has  gained 
twenty-four  pounds,  is  strong,  has  normal  temperature  and 
good  appetite. 

Case  VII. — Benjamin  K.,  aged  twenty,  of  medium  size  and 
thin;  born  in  Russia,  flat  land;  family  history  good.  Patient 
Las  always  been  well  until  two  years  ago,  when  he  started  to 
form  a  suppurating  gland,  as  he  says,  right  below  the  left  angle 
of  the  inferior  maxilla.  Extirpation  was  done  twice  (for  the  last 
time  at  a  hospital  of  this  city). 

The  wound  had  been  sewed  up  in  its  entirety  the  first  time. 
After  the  second  operation  it  had  been  drained  by  a  rubber 
tube.  After  the  first  time  the  edges  had  sloughed  ;  the  second 
time,  eight  months  ago,  a  fistula  had  remained,  which  secreted 
yellow  pus. 

On  February  11,  1893,  when  he  first  underwent  treatment 
at  our  department,  he  looked  anasmic,  he  had  a  good  appetite, 
was  not  feeling  very  bad,  and  had  a  normal  pulse  and  tempera- 
ture. 

The  operation  consisted  in  the  removal  of  all  thick  scar  tis- 
sue and  of  the  hardened  bed  of  a  macerated  gland,  which  could 
be  lifted  up  with  a  sharp  spoon.  Packing.  Perfect  recovery 
already  three  weeks  after.  (Patient  recently  has  shown  symp- 
toms of  renal  calculi.) 

Case  VIII. — Gussie  W.,  aged  five  years,  tall  and  thin,  very 
ansemic,  born  in  New  York  city.  Since  four  months,  formation 
of  a  painless  tumor  in  the  right  subauricular  region.  Treat- 
ment expectant  by  several  gentlemen. 

On  August  10th,  when  first  seen,  she  showed  two  conflu- 
ent soft  tumors,  the  lower  one  of  goose-egg,  the  upper  one  of 
hen's  egg  size.  Fluctuation  was  well  marked,  temperature  nor- 
mal, pulse  106.  Through  a  long  incision  two  tablespoonfuls  of 
yellow  pus  were  evacuated ;  below  the  pus  cavity  seven  infil- 
trated glands  were  removed.  The  emaciated  patient  improved 
rapidly  until,  four  weeks  later,  she  was  taken  sick  with  croup- 
ous pneumonia.  It  seemed  to  me  that  during  the  pneumonic 
process  the  cavity  was  closing  quicker  than  before.  Perfect 
i-ecovery  from  the  pneumonia  two  weeks  after  its  onset.  At 
the  same  time  the  closure  of  the  cavity  was  perfect.  The  treat- 
ment of  the  cavity  had  been  kept  up  just  the  same  during  the 
pneumonia.    (Has  been  well  up  to  date.) 

Cask  IX. — William  N.,  aged  fourteen  years,  tall  and  thin, 
born  and  brought  up  in  New  York  city.  Father  died  from  con- 
sumption in  his  thirtieth  year.  (Only  child.)  Four  years  ago 
he  had  sufl'ered  from  ])neuinonia.  About  a  year  ago  he  noticed 
at  his  right  supraclavicular  region  a  small,  painless  tumor,  which 
grew  slowly.  On  April  4,  1892,  when  first  seen,  he  looked 
anramic ;  complained  of  great  debility  and  loss  of  appetite.  For 
the  last  three  weeks  the  swelling  had  been  painful ;  temperature, 
102°;  pulse,  110.     On  the  right  side  the  subauricular,  sub- 


maxillary, and  supraclavicular  glands  together  composed  a  tu- 
mor of  the  size  of  a  new-born  child's  head.  No  fluctuation.  On 
the  left  side  the  submaxillary  glands  were  also  enlarged. 

A  T-shaped  incision  was  made  on  the  right  side  along  the 
posterior  margin  of  the  sterno-cleido-mastoid,  and  fourteen 
glands,  all  being  in  a  state  of  cheesy  degeneration,  were  removed 
under  great  difficulties.  Underneath  the  supraclavicular  glands 
an  abscess,  containing  about  two  tablespoonfuls  of  yellow  pus 
and  extending  about  an  inch  below  the  inferior  margin  of  the 
chivicle,  was  opened. 

At  the  same  time  four  degenerated  glands,  situated  at  the 
left  supraclavicular  region,  were  removed.  The  patient  was 
doing  well  after  the  oi)eration  until,  three  weeks  later,  he  be- 
came feverish  and  delirious.  Repeated  vomiting  set  in,  and 
facial  paresis  pointed  to  a  cerebral  proctess.  Five  weeks  after 
the  operation,  death  from  meningitis. 

Case  X. — Amanda  K.,  aged  fifteen  years,  tall  and  very  thin, 
born  and  educated  in  New  York  city,  family  history  favorable. 
Her  sister,  aged  six  months,  suffers  from  several  lympljomas  of 
the  neck.  Menstruated  first  in  her  thirteenth  year.  She  has 
not  felt  well  for  the  last  year,  and  has  been  treated  for  chlorosis 
during  six  months.  Several  glands,  as  the  patient  reports,  had 
been  observed  at  the  middle  of  her  neck  for  years,  and  had 
never  been  treated.  Six  weeks  ago  they  commenced  to  swell, 
and  caused  considerable,  but  only  temporary,  pain.  Two  weeks 
ago  her  family  physician  made  an  incision,  which  was  followed 
by  short  relief.  Then  her  general  condition  became  worse, 
and  swellings  were  observed. 

On  October  9,  1892,  when  she  was  seen  for  the  first  time, 
she  appeared  very  anaemic  and  weak;  temperature,  103°;  pulse, 
130. 

In  the  left  supraclavicular  region  a  hard  tumor  of  goose-egg 
size.  No  mobility  or  fluctuation.  In  the  upper  trigonum  of  the 
same  side  was  a  .small  opening  filled  out  by  a  rubber  drainage- 
tube,  through  which,  on  pressure,  about  a  teaspoonful  of  grayish 
pus  could  be  emptied. 

The  operation  consisted  in  the  extirpation  of  seven  more  or 
less  cheesy  glands  and  of  some  infiltrated  tissue,  and  in  scraping 
the  cavity,  which  had  been  opened  previously. 

Great  relief  and  improvement  of  general  condition  followed, 
but  four  weeks  later  some  supraclavicular  glands  of  the  other 
side  commenced  to  swell ;  at  the  same  time  the  temperature, 
which  never  had  risen  above  100°,  went  up  to  103°  again.  Ex- 
tirpation was  declined.  Five  weeks  after  the  operation  the 
cough,  which  had  for  a  year  been  present  to  a  slight  degree,  be- 
came frequent  and  vehement.  The  house  physician  reported  to 
me  later  that,  two  months  after  my  operation,  the  patient  died 
from  phthisis  pulmonalis. 

Tuberculosis  of  Glands,  Clavicle,  and  Sternum. — Moses  B., 
aged  thirty  years,  middle  sized  and  very  thin,  born  in  Russia, 
four  years  in  United  States  (New  York  city). 

For  three  years  he  has  been  suffering  from  suppurating 
glands  of  the  whole  right  region  of  the  neck.  Incisions  and 
treatment  by  poultices  were  tried  in  turn. 

On  February  27,  l.s92,  when  he  was  seen  first,  he  was  show- 
ing the  characteristic  ap|)earauce  of  a  consumptive. 

Temperature,  105-2°;  pulse,  118;  great  debility;  loss  of  ap- 
petite; night-sweats. 

The  submaxillary  glands  were  swollen  ;  on  the  supraclavicu- 
lar region,  extending  from  the  acromial  joint  to  the  opposite 
left  sternal  joint  of  the  clavicle,  a  tumor  of  the  size  of  a  new- 
born child's  head  was  noticed.  In  the  middle  of  the  right 
clavicle  and  on  the  right  sterno-clavicular  joint  fistulte  secreting 
serous  pus  had  been  established.  The  probe  revealed  bare  bone 
on  the  posterior  surface  of  the  clavicle  as  well  as  of  the  mann- 
briuni  sterni.    Operation  consisted  in  extirpation  of  four  de- 


466 


LEADING 


ARTICLES. 


[N.  Y.  Meu.  Jock., 


generated  submaxillary  and  nine  broken-down  supraclavicular 
glands. 

A  small  portion  of  the  clavicle  was  found  to  be  carious  and 
therefore  chiseled  away.  The  posterior  surface  of  the  manubrium 
sterni  could  only  be  apjiroached  after  having  dissected  the  sterno- 
hyoid muscles.  Now  the  upper  fourth  of  the  sternum  could  be 
made  out  to  be  denuded  of  its  periosteum.  The  grayish-looking 
bone  portions  were  chiseled  away  and  the  large  cavity  packed. 
Improvement  followed.  Three  weeks  later,  when  the  temj)era- 
ture  ro.-^e  to  104°,  an  abscess  below  the  acromio-clavicular  joint 
was  opened. 

Piitient  is  doing  excellently,  although  the  large  cavity  above 
the  sternum  has  not  been  entirely  closed.  This  case  shows  the 
advantMgo  of  the  gauze  very  characteristically,  as  a  drainage- 
tube  inserted  behind  the  sternum  surely,  after  simple  mathe- 
matical laws,  could  not  have  driven  the  discharge  uj)ward. 

Alalignant  Lymphoma. — Kenata  L.,  aged  thirty-one,  mar- 
ried;  two  healthy  children  ;  born  in  Austrian  highlands;  twenty- 
one  years  in  United  States  (New  York  city);  family  history 
good.  Two  months  ago  she  noticed  in  the  left  supraclavicular 
region  a  small  lump  which  grew  rapidly. 

On  May  3,  1892,  when  she  first  made  her  appearance,  she 
showed  a  tumor  of  goose-egg  size  right  above  the  clavicle, 
another  one  of  the  same  size  in  the  upper  trigonum,  and  a  tljird 
one  before  and  slightly  overlapping  larynx  and  trachea.  The 
patient  made  a  healthy  impression,  showed  normal  temperature 
and  pulse,  felt  strong,  and  had  a  good  appetite.  The  axillary  as 
well  as  the  inguinal  glands  were  slightly  swollen.  As  the  patient 
especially  declined  an  operation  on  account  of  her  good  general 
condition  and  the  entire  absence  of  pain,  she  was  given  Roncegno 
water  in  doses  of  six  tablespoonf uls  ^ro  die.  The  tumors  at  the 
same  time  were  injected  with  three  drops  of  Fowler's  solution 
every  other  day  for  three  weeks,  a  procedure  which  was  always 
followed  by  considerable  pain. 

As  no  decrease  in  size  of  the  tumors  could  be  obtained,  the 
patient  left  our  department  and  was  later  reported  to  me  as 
having  died  at  the  end  of  September  of  the  same  year. 

yTo  be  conrliidcd.) 


The  New  Jersey  Academy  of  Medicine. — At  the  annual  meeting, 
held  on  Wednesday,  the  19th  iust.,  officers  were  elected  as  follows: 
President,  Dr.  John  D.  McGill,  of  Jersey  City ;  vice-presidents,  Dr. 
Robert  F.  Biuridge,  of  Xewark  ;  Dr.  R.  F.  Chabert,  of  Hoboken ;  and 
Dr.  A.  K.  Baldwin,  of  Newark ;  recording  secretary,  Dr.  John  J.  Brod- 
erick,  of  Jersey  City  ;  corresponding  secretary,  Dr.  William  Perry  Wat- 
son, of  Jersey  City  ;  treasurer,  Dr.  Lott  Southard,  of  Newark.  The 
next  meeting  will  be  held  in  Newark  on  Wednesday,  May  IVth. 

The  Buffalo  Academy  of  Medicine. — At  the  next  meeting  of  the 
Surgical  .Section,  on  Tuesday,  May  2d,  the  subject  of  intestinal  obsti-uc- 
tion  is  to  be  considered.  Dr.  Henry  R.  Hopkins  will  speak  of  its 
symptomatology  and  medical  treatment,  and  Dr.  Roswell  Park  will 
treat  of  its  surgical  treatment.  Dr.  Matthew  D.  Mann  and  Dr.  Charles 
G.  Stockton  will  take  part  in  the  discussion. 

Mount  Sinai  Hospital. — Dr.  Charles  H.  May  has  been  appointed 
adjunct  visiting  ophthalmic  surgeon. 

The  Death  of  Dr.  Edwin  T.  Doubleday  occurred  very  suddenly  on 
Sunday,  the  'I'.id  inst.  Dr.  Doubleday  was  a  graduate  of  Bellevue  Hos- 
pital Medical  College,  of  the  class  of  188'2,  and  had  served  his  time  on 
the  house  staif  of  the  New  York  Hospital. 

The  Death  of  Dr.  Henry  Schweig  took  place  on  Wednesday,  the 
19th  inst.,  as  the  result  of  general  paresis,  it  is  announced.  The  de- 
ceased was  a  graduate  of  Bellevue  Hospital  Medical  College,  of  the 
class  of  ISVy,  and  was  recognized  as  a  promising  laryngologist. 


THB 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

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


NEW  YORK,  SATURDAY,  APRIL  29,  1893. 


THE  STRYCHNINE  TREATMENT  OF  SNAKE-BITES. 

In  our  issue  for  March  lltb  we  published  a  brief  note  on 
the  strychnine  treatment  of  snake-bites  as  it  is  carried  out  in 
Australia.  We  founded  our  statements  on  a  number  of  articles 
that  had  appeared  in  the  January  number  of  the  Australasian 
Medical  Gazette.  In  the  March  number  of  the  same  excellent 
journal  there  is  an  article,  justly  entitled  A  Remarkable  Case 
of  Death  from  Snake-bite,  by  Dr.  D.  Skinner,  of  Beecliworth, 
in  whose  practice  the  case  occurred,  and  Dr.  August  Mueller, 
of  Yackandandah,  Victoria,  the  great  promoter  of  the  strych- 
nine treatment,  who  saw  the  i)atieut  in  consultation. 

It  appears  from  Dr.  Skinner's  account  that  a  girl,  seventeen 
years  old,  of  excellent  physique  and  apparently  in  perfect 
health,  stepped  out  of  her  bath  at  about  6.30  p.  m.  on  January 
29th,  and  experienced  a  sharp  pain  in  the  second  toe  of  her 
right  foot.  She  perceived  that  the  toe  was  bleeding  a  little, 
and  she  began  to  feel  faint.  To  dispel  the  faintness,  and  at  the 
same  time  to  wash  the  blood  from  her  toe,  she  stepped  back 
into  the  bath;  but,  finding  lierself  growing  worse,  she  partially 
dressed  herself  and  attempted  to  regain  her  room,  when  her 
collapsed  condition  was  noticed  by  some  of  the  members  of  the 
family,  and  they  immediately  carried  her  up  stairs  to  bed.  She 
was  then  almost  speechless,  her  surface  was  cold,  and  her  face 
and  lips  were  bluish.  It  was  ascertained  about  an  hour  subse- 
quently that  she  had  realized  at  the  time  that  her  toe  had  been 
bitten  by  a  snake,  but  she  did  not  mention  the  fact  until  she 
was  questioned  about  it.  "  The  shock  to  the  nervous  system 
and  subsequent  collapse,"  says  Dr.  Skinner,  "appeared  to  have 
deprived  her  of  any  recollection  of  the  occurrence  until  it  was 
revived  by  the  mention  of  the  snake."  The  nature  of  the 
wounds  on  the  toe  was  not  obvious,  and  she  had  some  time  be- 
fore been  subject  to  fainting  tits;  so  it  is  no  wonder  that  her 
peril  was  not  at  first  appreciated.  However,  she  was  caused 
to  swallow  moderate  doses  of  brandy,  and,  after  vomiting  some 
blood-stained  fluid,  she  rallied  considerably.  It  was  at  about 
this  time,  an  hour  after  the  infliction  of  the  bite,  that  a  member 
of  the  family  saw  a  half-grown  tiger-snake,  about  thirty  inches 
long,  issuing  from  the  bath-room,  and  it  was  while  he  was  kill- 
ing the  reptile  that  the  truth  dawned  on  him.  Now  the  usual 
domestic  measures  were  resorted  to.  They  included  the  appli- 
cation of  a  tight  ligature  above  the  ankle  and  another  above 
the  knee.  The  punctures  were  then  probed  with  the  point  of  a 
knife  and  well  sucked.  A  messenger  was  sent  to  a  neighboring 
homestead  for  a  "hypodermic  strychnine  case" — an  article 
that  seems  to  have  come  into  widespread  popular  use  in  Aus- 
tralia since  the  reports  of  the  success  attending  Dr.  Mueller's 


April  29,  1893.J 


LEADING  ARTICLES. 


467 


treatment  have  come  to  be  generally  known — and  another  mes- 
senger was  sent  to  bring  Dr.  Skinner,  who,  being  twelve  miles 
away,  did  not  reach  the  patient's  home  until  about  10.30  p.m., 
four  hours  after  the  infliction  of  the  bite. 

On  his  arrival,  Dr.  Skinner  found  the  young  lady  in  a  nor- 
mal condition,  except  that  her  face  was  somewhat  flushed  and 
expressive  of  a  moderate  degree  of  suffering.  The  ligature 
above  the  ankle  was  giving  her  great  pain,  and  her  only  desire 
was  to  have  it  removed.  The  one  above  the  knee  had  been 
taken  off  some  time  before,  owing  to  the  intolerable  suffering 
it  had  caused.  On  the  bitten  toe  there  were  found,  not  "  the 
classical  two  punctures,"  but  three  somewhat  irregular  marks 
— a  longitndinal  scratch  an  eighth  of  an  inch  long  over  the  root 
of  the  nail,  a  well-marked  puncture  in  the  middle  of  a  bluish, 
rounded  elevation  over  the  distal  joint,  and  an  almost  invisible 
puncture  in  a  similar  swelling  over  the  second  joint.  Dr.  Skin- 
ner cut  deep  into  all  tlie  punctures  till  they  bled  freely,  and  had 
the  sucking  continued  for  twenty  minutes  more.  He  removed 
the  remaining  lifrature,  the  one  above  the  ankle,  and  gave  a 
small  dose  of  brandy.  In  less  than  half  an  hour  the  patient  ap- 
peared perfectly  comfortable  and  inclined  to  sleep.  At  mid- 
night the  doctor  was  called  on  account  of  a  rather  free  oozing 
of  blood  from  the  wounds.  He  estimated  that  three  or  four 
ounces  of  blood  had  been  lost,  and  it  was  still  welling  out  free- 
ly, showing  no  tendency  to  coagulate.  The  bleeding  was  readi- 
ly controlled  by  means  of  pressure  and  a  dry  dressing.  The  pa- 
tient's general  condition  was  now  all  that  could  be  desired,  and 
two  hours  later  Dr.  Skinner  left,  feeling  assured  that  she  would 
be  "herself  again"  by  morning.  On  the  following  afternoon, 
however,  he  was  notified  by  telegraph  that  at  midday  she  had 
been  somewhat  feverish,  and  had  complained  of  some  stiffness 
in  the  neck  and  slight  difficulty  in  swallowing.  This  was  eight- 
een hours  after  the  bite,  and  it  was  hard  to  believe  that  the  poi- 
son was  beginning  to  act  after  that  lapse  of  time,  but  in  the 
evening  he  learned  that  the  unpleasant  symptoms  were  persist- 
ing, and  he  saw  the  young  lady  again  soon  after  eight  o'clock, 
twenty-six  hours  after  the  infliction  of  the  bite. 

She  then  had  dyspnoea,  her  articulation  was  somewhat  inter- 
fered with,  her  tongue  was  not  under  complete  control,  and  her 
pupils  responded  to  light  with  rather  abnormal  readiness.  She 
had  taken  a  fair  amount  of  li(}uid  food,  with  small  quantities  of 
wine  and  brandy.  She  had  passed  no  urine  or  faeces  since  the 
accident.  Defective  elimination  was  held  to  be  the  cause  of  the 
tardy  symptoms  of  poisoning.  Six  grains  of  calomel  were  given, 
to  be  followed  by  a  seidlitz  powder,  also  a  diuretic  mixture  con. 
sisting  of  solution  of  ammonium  citrate,  aromatic  sj)irit  of  am- 
monia, and  tincture  of  digitalis.  These  remedies  did  not  act. 
At  8.30  p.  M.  a  twentieth  of  a  grain  of  strychnine  sulphate  was 
administered  subcutaneously.  Within  ten  minutes  the  speech, 
swalhjwing,  and  breathing  became  nearly  normal,  and  there  was 
no  return  of  the  respiratory  trou\)le  until  5  a.m.  At  3  a.m.  she 
passed  six  ounces  of  urine,  which,  on  his  return  home.  Dr.  Skin- 
ner found  to  be  acid,  of  the  specific  gravity  of  1"028,  of  a  dirty- 
brown,  muddy  look,  and  containing  a  third  of  its  volume  of  al- 
bumin.   At  5.30  A.  M.  a  fifteenth  of  a  grain  of  strychnine  was 


injected.  This  gave  relief  as  before,  but  for  a  much  shorter 
time.  At  7  a.  m.,  however,  the  patient  seemed  fairly  comfort- 
able, and  Dr.  Skinner  left  her  for  a  few  hours,  having  directed 
a  repetition  of  the  injection  in  case  the  symptoms  returned 
without  muscular  twitching.  The  urine  was  now  found  (in  the 
same  specimen  before  examined  chemically — the  only  one  passed 
until  the  patient  died)  to  contain  an  abundance  of  shrunken  red 
blood-corpuscles,  a  few  blood  casts,  numerous  granular  and 
cloudy  epithelial  casts,  and  general  epithelial  dehris. 

At  1  p.  M.  Dr.  Skinner  saw  the  patient  again,  this  time  with 
Dr.  Mueller.  Two  strychnine  injections  had  been  given  in  the 
mean  time,  of  one  fifteenth  and  one  twentieth  of  a  grain  re- 
spectively, but  their  results  had  grown  less  favorable.  There 
was  now  extreme  dyspnoea ;  the  speech  was  jerky  and  mono- 
syllabic; and  deglutition  was  very  painful  and  difficult,  fluid 
finding  its  way  into  the  larynx  and  lungs.  The  pulse  was  110, 
becoming  somewhat  thready;  the  mind  was  clear  and  bright. 
Five  injections  of  a  tenth  of  a  grain  of  strychnine  were  given, 
one  every  half-hour  from  1.30  to  3.30  p.  m.,  but  their  favorable 
action  grew  less  and  less.  Soon  after  the  fifth  of  these  injec- 
tions a  weak  (;onvulsion  took  place  and  breathing  ceased.  The 
heart's  action  continued  for  about  ten  minutes  more,  and  arti- 
ficial respiration  was  resorted  to,  but  without  success.  Death 
took  place  in  forty-five  hours  after  the  infliction  of  the  bite, 
twenty  seven  hours  after  the  onset  of  special  symptoms,' and 
nineteen  hours  after  the  first  strychnine  injection.  In  all,  about 
four  fifths  of  a  grain  had  been  injected. 

"The  remarkable  features  of  the  case,"  says  Dr.  Skinner, 
"are  these:  First,  the  complete  recovery  from  the  initial  shock 
and  collapse  without  any  special  treatment ;  second,  the  failure 
of  elimination,  owing  to  toxic  nephritis;  third,  the  slow  and 
fatal  poisoning  of  nerve  centers,  for  which  special  treatment 
proved  futile.  Moreover,  a  careful  study  of  this  case,  the  slow 
march  of  which  afforded  unusual  opportunities  for  observation, 
is  capable  of  throwing  considerable  light  on  several  vexed  ques- 
tions in  connection  with  snake-bite. 

"1.  To  those  medical  authorities  that  are  in  the  habit  of 
decrying  the  lethal  [)owers  of  Australian  snakes  the  perusal  of 
such  a  case  will  give  food  for  reflection.  A  half-grown  tiger- 
snake  biting  a  healthy  subject  under  favorable  circumstances 
(/.  e.,  favorable  to  the  snake)  produced  a  fatal  result  to  which 
neither  fear  nor  alcoholism  contributed. 

"2.  The  classical  description  of  a  double  puncture  does  not 
necessarily  apply  to  every  case.  Here  we  found  three  marks 
in  the  middle  line  of  the  upper  surface  of  the  toe.  Underneath, 
after  death,  a  small  ecchymosis  was  found  oi)posite  the  upper- 
most mark.  We  can  account  for  this  only  on  the  supposition 
that  the  snake  did  not  strike  but  actually  chewed  the  toe,  as 
appeared  to  have  been  the  case  in  one  of  Dr.  Mueller's  recorded 
cases.  This  would  give  ample  time  for  the  injection  of  all  the 
venom  in  its  gland. 

"3.  The  mode  of  action  of  snake  venom  is  here  fully  illus- 
trated. It  was  first  a  general  depressant  of  all  the  nerve  cen- 
ters, voluntary  and  involuntary.  Afterward  it  appears  to  have 
acted  on  the  blood,  diminishing  its  coagulability,  and  on  the 


468 


LEADING  ARTICLES. 


[N.  Y.  Med.  Joub., 


renal  epithelium,  destroying  its  vitality  and  causing  it  to  be 
shed  in  large  quantities;  and  finally  it  exercised  a  selective  in- 
fluence CMi  the  adjacent  centers  of  respiration  and  deglutition, 
and  by  paralyzing  them  brought  about  death  by  asphyxia. 

"4.  I  consider  that  this  case  will  help  us  to  a  fairer  appre- 
ciation of  the  true  value  of  the  strychnine  treatment  than  will 
any  number  of  sensational  cures.  It  proved  to  be  an  extraor- 
dinary stimulant  to  the  special  nerve  centers  attacked  by  the 
venom,  and  under  more  favorable  circumstances  might  doubt- 
less have  helped  to  sustain  life  till  the  poison  was  got  rid  of; 
but  on  the  absolute  failure  of  elimination  its  stimulative  proper- 
ties gradually  failed. 

"5.  At  one  stage  of  the  treatment  the  use  of  pilocarpine 
suggested  itself,  but  was  considered  too  risky  in  view  of  possi- 
ble heart  failure ;  and  the  use  of  strychnine  had  the  sanction  of 
much  greater  authority.  I  am  bound  to  say,  however,  that  in 
a  similar  case,  with  the  same  kidney  complications,  I  would  un- 
hesitatingly use  it,  probably  in  combination  with  strychnine 
and  alcohol." 

Dr.  Mueller's  comments  are  as  follows: 
"The  symptoms  presented  by  Miss  D.  when  I  first  saw  her, 
two  hours  and  a  half  before  she  died,  were  dyspnoea  and  dys- 
phagia, together  with  complete  blockage  of  the  kidneys,  caus- 
ing urinary  changes  of  an  unusual  kind.  The  paretic  condition 
of  the  respiratory  and  glossopharyngeal  centers,  which  at  any 
moment  threatened  to  culminate  in  paralysis,  were  unlike  any- 
thing I  have  ever  observed  in  tiger-snake-bite,  but  presented  a 
complete  facsimile  of  the  picture,  so  graphically  drawn  by  Dr. 
Wall,  of  the  victims  to  cobra-bite.  Vincent  Richards,  writing 
some  years  ago  in  the  Australasian  journal  on  Indian  and  Aus- 
tralian snakes,  called  our  tiger-snake  the  Australian  cobra,  but 
dwelt  principally  on  its  great  similarity  to  the  cobra  de  capello 
in  appearance.  That  this  external  likeness  of  the  two  reptiles 
could  extend  in  rare  cases  of  tiger-snake-bite  to  an  absolute 
identity  in  the  effect  of  their  poison,  and  that  even  a  small, 
half-grown  tiger-snake  could  produce  the  formidable  symptoms 
of  cobra  poison,  was  not  known  at  the  time,  and  Miss  D.'s  is 
the  first  case  to  place  this  interesting  fact  on  record.  The 
small,  insignificant-looking  animal,  barely  thirty  inches  long, 
which  was  shown  to  me  as  having  inflicted  the  fatal  bite,  could 
not  even  have  insei'ted  the  poison  fangs  on  the  back  of  the  toe 
to  their  full  length.  The  quantity  of  poison  it  imparted  can, 
therefore,  have  been  but  small,  and  this  probably  accounts  for 
its  insidious,  slow,  and  deceiving  action.  It  must,  however, 
have  been  absorbed  before  ligatures  were  applied,  for  it  ap- 
pears to  have  spread  over  all  the  motor  nerve  centers  in  the 
usual  rapid  manner  of  tiger  snake  poison.  Being  too  small  in 
quantity  to  maintain  its  hold  on  them,  it  was  thrown  ofl'  in  a 
few  hours,  then — strange  to  relate — remained  inert  for  hours, 
and,  stranger  yet,  appeared  again  on  the  following  day  with  a 
fatal  hold  on  the  centers  it  touches  but  slightly  in  its  usual 
course,  as  if  by  some  mysterious  process  it  had,  on  its  reap- 
pearance, been  converted  into  cobra  poison.  In  this  new  role 
another  symptom,  in  addition  to  those  mentioned,  appeared 
conspicuously.    Coma  was  completely  absent,  the  action  of  the 


cortical  centers,  usually  suspended  in  tiger-snake  bite,  was  pain- 
fully intact.  Even  a  short  time  before  her  death,  when  artica- 
lation  had  been  reduced  to  a  mere  whisper,  the  young  lady 
conversed  with  her  friends  by  her  fingers,  in  the  manner  of  the 
deaf  and  dumb.  Finally,  to  complete  the  picture,  paralysis  was 
ushered  in  by  convulsions,  exactly  as  it  is  in  cobra  bite. 

"The  question  why  the  antidote,  after  acting  satisfactorily 
at  first,  failed  toward  the  end,  admits  of  several  answers,  all  of 
which,  however,  at  our  present  state  of  knowledge,  mu>-t  neces- 
sarily be  hypothetical.  The  most  probable  one  is  that,  after 
the  nerve  centers  have  been  for  many  hours  under  the  influ- 
ence of  the  poison,  structural  changes  take  place  in  them 
which  preclude  their  being  roused  into  normal  action  by  the 
antidote. 

"  That  during  the  period  of  apparent  recovery,  and  even 
after  the  first  successful  injections,  the  snake  poison  would 
have  been  thrown  out  and  given  no  further  trouble  if  the 
kidneys  had  not  been  blocked  at  an  early  stage,  can  scarcely 
admit  of  doubt;  but  it  is  very  doubtful  whether,  under  such  cir- 
cumstances, an  appeal  to  the  skin  by  pilocarpin  can  be  efi'ectu- 
ally  carried  out,  for  the  blood  generally  recedes  from  the  sur- 
face and  accumulates  in  the  distended  large  veins  of  the 
abdomen,  the  skin  becoming  cold  and  blanched.  I  must  also 
express  my  doubts  as  to  the  condition  of  the  kidneys,  disclosed 
by  the  examination  of  the  urine,  having  been  acute  nephritis. 
There  was  no  pain,  at  least  none  complained  of,  and  it  appears 
to  me  more  probable  that  the  complete  blockage  of  the  kidneys 
was  brought  about  by  the  process  known  as  diapedesis. 

"  It  has  been  shown  by  Feoktistow  that  when  the  mesen- 
tery of  an  animal  is  sprinkled  over  with  a  two-per-cent.  solution 
of  snake  poison  the  capillaries  become  dilated  at  once  wher- 
ever they  are  touched  by  the  poison,  and  immediately  blood- 
corpuscles  pass  through  them,  together  with  more  or  less  plas- 
ma. If  during  the  passage  of  the  poison  through  the  kidneys 
the  same  process  takes  place  in  exceptional  cases,  the  appear- 
ance of  shrunken  red  blood-corpuscles,  blood  casts,  and  epithe- 
lial dehria  in  the  urine  would  necessarily  follow,  together  with 
a  complete  blockage  of  the  kidneys  and  an  abundance  of  albu- 
min in  their  scanty  secretion,  which,  under  these  circum- 
stance?, would  largely  consist  of  blood  plasma.  That  actual 
hsematuria  takes  place  here,  as  in  Indian  viper- bite,  was  hither- 
to unknown  to  me,  but  recently  a  fatal  case  of  tiger-snake-bite 
has  been  reported  to  me  of  a  girl  of  nine  years  who  voided 
urethram  a  pint  of  almost  pure  blood,  and  whose  kidneys  ap- 
pear to  have  also  been  blocked  at  an  early  stage.  These  cases 
precluding  elimination  and  all  chance  of  recovery  are  fortu- 
nately rare." 

This  case  is  indeed  remarkable  from  more  than  one  point  of 
view — most  of  all,  perhaps,  by  its  illustration  of  the  reviving 
power  of  strychnine  in  cases  of  depression  of  certain  nerve 
centers.  We  know  not  how  close  a  similarity  of  action  there 
may  be  between  the  venom  of  Australian  snakes  and  that  of 
American  serpents,  but  the  strychnine  treatment  of  the  victims 
of  venomous  bites  seems  to  us  worthy  of  trial  elsewhere  than 
in  Australasia. 


April  29,  1893.] 


MINOR  PARAGRAPHS. 


469 


MI  NOB    PA  RA  GRA  PUS. 

ANOTHER  POLLUTED  WATER  SUPPLY. 

The  Ridgewood  water  of  Brooklyn  is  reported  to  be  not 
above  suspicion.  In  its  early  history  that  water  had  the  repu- 
tation of  being  an  exceptionally  pure  article,  but  during  recent 
years  the  encroachments  of  an  increased  population  at  many 
points  along  its  watershed,  as  well  as  some  other  causes,  have 
tarnislied  that  reputation.  We  find  in  one  of  the  Brooklyn 
papers  a  communication  from  Dr.  G.  G.  Hopkins,  which  gives 
public  warning  to  the  authorities  of  that  city  that  they  have  a 
very  important  duty  before  them  in  the  matter  of  a  thorough 
policing  of  the  Ridgewood  watershed.  He  says  he  does  not 
wish  to  play  the  part  of  an  alarmist,  but  he  is  strong  enough  in 
his  knowledge  of  the  facts,  he  thinks,  to  predict  that,  if  harm 
by  reason  of  cholera  reaches  Brooklyn  next  summer,  it  will 
come  by  way  of  a  neglected  water  supply.  He  says:  "But  our 
greatest  danger  lies  in  our  water  supply ;  yet  there  is  hardly 
another  city  in  the  Union  that  can  so  readily  protect  that.  Here 
we  need  an  intelligent  corps  of  watchful  inspectors.  If  the 
people  generally  could  see  the  filth  that  enters  one  of  the  streams 
that  supply  part  of  our  water,  they  would  wonder  how  it  is  so 
good.  You  can  see  any  day  the  village  cattle  passing  through 
this  stream,  and  ducks  and  geese  swimming  in  it  and  not  leaving 
it  in  a  very  inviting  state.  Yet  all  this  can  be  easily  remedied) 
and  should  be  at  once.  I  am  not  desirous  of  raising  a  panic.  I 
only  hope  to  avert  one  during  any  part  of  this  summer.  There 
is  no  question  that,  should  the  proper  precautions  be  taken,  even 
should  cholera  get  a  footing  in  this  country,  Brooklyn  can  run 
very  little  risk  it  she  will  only  prepare  to  starve  it  out  by  giving 
it  as  little  as  possible  to  feed  upon.  To  this  end  I  would  like 
to  see  the  city  place  in  the  hands  of  the  health  board  at  least 
$500,000  for  the  carrying  out  of  some  i)lan  that  will  make  chol- 
era an  unwelcome  guest  here,  instead  of  a  welcome  one,  as  she 
will  be  if  the  city  is  left  as  it  is." 


THE  TREATMENT  OF  PUERPERAL  CONVULSIONS. 

M.  Charpkntier  {Gazette  des  hopitaux,  January  21,  1893; 
Sheffield  Medical  Journal.,  April,  1893)  closed  a  recent  com- 
munication to  the  Paris  Academy  of  Medicine  with  the  follow- 
ing conclusions :  If  during  pregnancy  there  is  albumin  in  the 
urine,  however  small  the  amount,  an  absolute  and  exclusive  milk 
diet  should  be  insisted  upon  from  the  start.  It  is  par  excellence 
the  preventive  treatment  of  eclampsia.  If  a  convulsion  occurs 
and  the  patient  is  vigorous  and  very  cyanotic,  she  may  be  bled 
to  the  extent  of  sixteen  ounces,  and  then  chloral  and  milk  given 
as  soon  as  possible ;  if  she  is  not  so  strong,  if  the  cyanosis  is  less 
marked,  and  if  the  attacks  are  not  so  frequent,  chloral  alone  is 
enough.  Labor  should  be  allowed  to  begin  spontaneously,  and, 
if  possible,  it  should  be  allowed  to  terminate  without  interfer- 
ence. If  it  is  delayed  by  feebleness  of  the  uterine  contractions, 
the  forceps  may  be  applied  or  the  child  turned  if  it  is  living ;  if 
it  is  dead,  craniotomy  may  be  resorted  to.  Before  instruments 
are  used  the  os  uteri  should  be  completely  dilated  or  dilatable. 
It  is  only  in  exceptional  cases,  where  medicinal  treatment  has 
failed,  that  labor  should  be  brought  on.  The  Caesarean  o|)era- 
tion  and  accouchement  force,  especially  by  deep  incisions  into  the 
cervix,  should  be  absolutely  rejected. 


THE  ARTIFICIAL  TINTIN(i  AND  FLAVORING  OF  FRUIT. 

It  appears  from  an  article  in  the  Journal  d?hygiene  for  Feb- 
ruary 16th,  summarized  in  the  Union  medicale  for  April  (ith,  that 
various  frui  s  are  colored  on  the  surface  or  in  their  substance 


to  suit  the  fancy  of  purchasers  in  France.  For  example,  straw- 
berries that  are  unripe  are  given  a  fine  red  color  by  means  of  a 
fuchsine  preparation ;  ordinary  oranges  of  poor  quality  are  made 
to  ])as8  for  blood-oranges  by  injecting  roccelline  into  their  pulp  ; 
and  melons  are  rendered  of  a  fine  orange  color  by  injecting  a 
solution  of  tropoeoline,  and  at  the  same  time  aromatized  with 
an  artificial  melon  essence.  At  a  certain  dinner  party  the  pears 
had  the  outward  look  proper  to  pears,  but,  on  being  cut  open, 
displayed  on  the  section  the  national  colors  of  France.  Many 
of  the  substances  made  use  of  in  these  pranks  may  be  harmless, 
but  it  seems  to  us  that  the  practices  in  (juestion  are  apt,  if  un- 
checked, to  lead  to  dangerous  ventures. 


COMPRESSION  OF  THE  BRAIN. 

At  the  seventh  meeting  of  the  French  Congress  of  Sur- 
gery, reported  in  the  Mercredi  medical  for  April  5th,  Dr.  Van 
Stockum  presented  an  experimental  study  of  what  may  be  called 
the  mechanism  of  the  condition  known  as  compression  of  the 
brain.  His  conclusions  were  as  follows:  The  general  symptoms 
are  not  caused  by  increased  tension  of  the  cerebro-spinal  fluid  ; 
they  depend  on  disordered  circulation  in  the  medulla  oblongata, 
not  due  to  a  mechanical  cause,  but  having  their  point  of  depart- 
ure in  the  cerebral  cortex.  The  cortex,  iriitated  and  rendered 
anfemic  by  the  foreign  body  that  is  compressing  it,  sets  up  an 
embarrassment  of  the  cerebral  circulation  by  virtue  of  contain- 
ing a  vaso-raotor  center  acting  specially  upon  the  brain. 


PRENATAL  BAPTISM  ACCORDING  TO  GREGORY. 

The  Province  medicale  for  April  1st  quote.s  from  a  letter 
said  to  have  been  written  by  Diderot  to  Mile.  Volland  in  1760, 
recounting  that  a  certain  English  physician  named  Gregory, 
being  convinced  that  in  the  next  world  it  would  go  hard  with 
any  child  that  had  died  without  having  undergone  sprinkling  of 
its  head  with  cold  water,  accompimied  by  a  certain  verbal  for- 
mula, always  baptized  the  child  in  utero  in  cases  of  difficult 
labor.  Having  first  pronounced  the  formula  "Child,  I  baptize 
thee,"  he  filled  his  mouth  with  water,  then  applied  it  suitably 
(appliquait  convenaMement),  and  squirted  the  water  as  far  as  he 
could.  As  he  wiped  his  lips  with  a  napkin  he  was  wont  to  re- 
mark: "It  takes  but  the  hundred-thousandth  part  of  a  drop  to 
make  an  angel."  We  are  not  told  the  Gregorian  method  of 
dealing  with  a  difficult  case  of  breech  presentation. 


ANTINERVINE. 

This  villainous  name  has  been  given  to  a  mixture  of  acet- 
anilide,  salicylic  acid,  and  ammonium  bromide.  Dr.  Reich  has 
submitted  before  the  Medical  Society  of  Buda-Fest  {Uiiion 
medicale,  Api  il  4-,  1893)  certain  conclusions  as  to  its  action.  He 
finds  that  it  acts  more  rapidly  as  an  antipyretic  tlnin  antipyrine, 
more  rapidly  than  sodium  salicylate,  but  less  rapidly  than  acet- 
anilide.  Doses  of  less  than  seven  or  eight  grains  do  not  lower 
the  temperature  so  much  as  antipyrine  or  sodium  salicylate,  but 
larger  doses  reduce  it  more  decidedly.  Even  in  this  respect, 
however,  it  is  inferior  to  acetanilide.  The  duration  of  its  anti- 
thermic effect  is  twice  as  great  as  that  of  antipyrine,  almost  as 
great  as  that  of  sodium  salicylate,  but  less  than  that  of  acet- 
anilide. If  Reich  is  correct  in  all  this,  it  is  difficult  to  see  what 
"antinervine"  has  to  recommend  it. 


LOSS  OF  LIFE  BY  COLD  IN  THE  EAST. 

The  almost  unprecedented  occurrence  of  deaths  by  freezing 
in  the  torrid  zcme  was  one  of  the  features  of  the  past  winter  in 


470 


MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Med.  Jouh., 


the  far  East.  During  the  rigorous  weather  of  Jiinuary  of  tliis 
year  there  were  reported  as  many  as  four  hundred  deaths  by 
exposure  and  cold  at  Canton;  also  a  considerable  number  at 
Macao.  It  is  estimated  that  thous'inds  perished  in  the  southern 
belt  of  China  during  one  memorable  week  in  January.  Dr.  E. 
P.  Thwing,  formerly  of  Brooklyn,  now  of  Canton,  has  stated 
that  the  mercury  showed  a  drop  of  90°  F.  in  the  open  air  at  his 
residence.  Although  nine  degrees  below  freezing  was  the  lowest 
reading  on  the  thermometer  that  was  observed,  yet  there  was  a 
velocity  of  the  wind  and  a  fall  of  sleet  that  added  to  the  afflic- 
tions of  the  people,  whose  houses  and  dress  are  fashioned  to 
meet  the  demands  of  heat  only.  In  some  districts  it  became 
needful  for  the  charitably  disjfosed  to  distribute  clothing  and 
hot  soup  in  order  to  assist  in  saving  the  lives  of  the  poor. 


THE  CARE  OF  THE  CHOLERA  PATIENTS  AT  HAMBUR(j. 

The  deaconesses  of  Kaiservverth,  who  volunteered  for  ser- 
vice at  Hamburg  during  the  height  of  the  cholera  epidemic, 
have  all  returned  alive  to  their  institution.  Besides  a  sister  of 
a  i)erson  taken  sick  who  went  to  Hamburg  quite  early,  there 
also  went,  first  eight,  then  six,  to  that  city  of  pestilence  and 
panic.  One  of  their  local  ])hysicians  deplored  their  action,  it  is 
said,  and  predicted  that  none  of  the  fourteen  would  see  Kaiser- 
werth  again.  But,  fortunately,  these  ladies  were  all  spared  from 
any  of  the  dreaded  results  of  exposure  except  those  incident  to 
constant  responsibility,  vigils,  and  night-work. 


THE  AFTER-EFFECTS  OF  CHLOROFORM. 

Luther's  observations  of  the  use  of  chloroform  as  an  anaes- 
thetic in  Breunecke's  gynaecological  clinic  in  Magdeburg  (Mun- 
chener  medicinische  Wochensehrift,  1893,  i ;  CcntraUilatt  fur 
Chirvrgie.,  April  8, 1893)  go  to  show  that  the  disagreeable  after- 
effects, such  as  nausea,  vomiting,  jaundice,  etc.,  are  always  the 
accompaniments  of  a  morbid  condition  of  the  kidneys,  as  shown 
by  the  presence  of  albumin  and  casts  in  the  urine,  and  that  they 
disappear  on  the  subsidence  of  the  renal  disturbance. 


QUININE  IN  AURAL  VERTIGO. 

LAR(iE  doses  of  quinine,  says  the  American  T herapist.i  cause 
congestion  of  the  entire  aural  tract,  and  up  to  a  certain  point 
increased  nutrition  follows,  provided  this  effect  is  not  too  long 
continued.  When  aural  vertigo  is  found  to  be  due  to  functional 
disturbance,  the  administration  of  full  doses  of  quinine  for  pe- 
riods of  three  days,  with  intervals  of  the  same  duration,  will 
be  found  of  great  value.  Calcium  sulphide  given  during  the 
interval  will  "favor  the  absorption  of  morbid  products  depend- 
ent upon  the  quinine  congestion.'" 


THE  SAINT  CATHARINE  HOSPITAL  OF  BROOKLYN. 

A  NEW  article  of  incorporation  has  been  framed  for  the  en- 
largement of  the  powers  and  efficiency  of  this  already  benefi- 
cent institution.  There  is  to  be  formed  hereafter  the  Saint 
Catharine  Hospital  Association  for  the  purpose  of  extending 
the  present  buildings  used  as  hospitals  and  to  erect  and  main- 
tain others  as  infirmaries,  dispensaries,  and  homes,  which  may 
be  located  in  any  of  the  counties  of  Long  Island. 


A  NEW  SANITARY  LEAGUE. 

Under  the  auspices  of  Dr.  John  S.  Billings,  of  the  army,  and 
others,  there  has  been  formed  in  Washington  a  new  sanitary  or- 


ganization called  the  Sanitary  League  of  the  District  of  Colum- 
bia. The  health  of  the  domicile  of  persons  well  to  do  will  be 
one  of  the  features  of  the  movement,  but  it  will  also  Hcrve  as  a 
defense  against  panic  in  the  event  of  the  incursion  of  cholera. 
House-to-house  inspection,  the  disposal  of  house  refuse,  and  the 
prevention  of  water-contamination  are  also  subjects  to  be  duly 
considered.  The  league  aims  to  disseminate  sanitary  intelli- 
gence and  to  encourage  good  citizens  to  do  voluntary  inspec- 
tion work  and  to  report  as  to  particulars  which  exceed  the 
powers  and  endurance  of  the  local  officers  of  health. 


I'ENTAL  AS  AN  ANyfiSTHETIC. 

Dk.  H.  Kieth  (Beitrdf/e  zur  k/inische  Chirurgie,  x  ;  Central- 
Matt  far  Chirurgie,  April  8,  1893)  finds  that  pental  anfesthe^ia 
in  dogs  is  accompanied  by  a  notable  redaction  of  the  blood 
pressure,  and  that  pental  is  by  no  ineans  free  from  the  danger- 
ous properties  of  the  impure  ainylene  formerly  used.  It  is  use- 
ful as  an  anesthetic  in  cases  where  the  o|)eration  is  to  be  of 
brief  duration  and  full  muscular  relaxation  is  not  required. 


ITEMS,  ETC. 

Infectioos  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  April  '2.j,  1893 : 


DISEASES. 

Week  ending  Apr.  18 

Week  ending  Apr.  25. 

Caees. 

Deaths. 

Casea. 

Deaths. 

11 

7 

12 

8 

21 

6 

14 

7 

181 

18 

160 

18 

Cerebro-spinal  meningitis.  . .  . 

7 

4 

It; 

10 

127 

5 

1()2 

e. 

99 

38 

115 

38 

7 

0 

8 

4 

The  lUinois  State  Medical  Society  will  hold  its  forty-third  annual 
meeting  in  Chicago  on  the  16th,  17th,  and  18th  of  May. 

Change  of  Address. — Dr.  Wendell  C.  Pliillips,  to  No.  350  Madison 

Avenue. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Staiicms  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  Sla/eg 
Army,  from  April  16  to  April  22,  1893  : 

Cronkuite,  Henry  M.,  Major  and  Surgeon,  will  proceed  to  Fort  Wads- 
woith.  New  York  Harbor,  and  report  to  the  po.st  commander  for 
temporary  duty. 

Naval  Intelligence. — Official  Lut  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  April  22,  1893 : 
GoRGAS,  A.  C,  Medical  Director.    Relieved  from  the  Naval  Hospital, 

Philadelphia,  Pa.,  and  assigned  to  special  duty,  Philadelphia,  Pa. 
KiNDi.EnERGER,  D.,  Mcdical  Director.     Relieved  from  special  duty, 
Philadelphia,  Pa.,  and  ordered  to  the  Naval  Hospital,  Philadel- 
phia, Pa. 

PusEY,  A.  B.,  A.ssistant  Surgeon.  Ordered  to  the  Naval  Hospital,  Nor- 
folk, Va. 

La  Motte,  Henry,  Assistant  Surgeon.  Detached  from  the  U.  S. 
Steamer  Vesuvius,  and  ordered  to  the  Naval  Hospital,  Norfolk,  for 
treatment. 

De  Valin,  C.  W.,  Assistant  Surgeon.  Detached  from  the  Naval  Hos- 
pital, Norfolk,  Va.,  and  ordered  to  the  U.  S.  Steamer  Vesuvius. 

Wise,  John  C,  Surgeon.  Detached  from  the  U.  S.  Steamer  Alliance 
and  ordered  to  the  Naval  Hospital,  Norfolk,  Va.,  for  treatment. 


April  29,  1893.J 


ITEMS.— PEOCEEDimS  OF  SOCIETIES. 


471 


Society  Meetings  for  the  Coming  Week : 

Monday,  Maij  Isf :  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  Surgical 
Society  (private) ;  Utica  Medical  Library  Association ;  Corning, 
N.  Y.,  Academy  of  Medicine ;  Boston  Society  for  Medical  Observa- 
tion ;  Boston  Medical  Association  (annual);  St.  Albans,  Vt.,  Medi- 
cal Association ;  Providence,  R.  I.,  Medical  Association ;  Hartford, 
Conn.,  Medical  Society ;  Chicago  Medical  Society. 

Tuesday,  Jim/  2d:  New  York  Obstetrical  Society  (private);  New  York 
Neurological  Society  ;  Elmira  Academy  of  Medicine  ;  Buffalo  Medi- 
cal and  Surgical  Association;  Buffalo  Academy  of  Medicine  (Surgical 
Section) ;  Ogdensb\irgh  Medical  Association ;  Hudson,  N.  J.  (Jersey 
City — annual),  and  Mercer,  N.  J.  (annual).  County  Medical  Societies; 
Connecticut  River  Valley  Medical  Association  (Bellows  Falls,  Vt.) ; 
Androscoggin,  Me.,  County  Medical  Association  (Lewiston) ;  Balti- 
more Academy  of  Medicine. 

Wednesday,  May  3d:  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) ;  Bridgeport,  Conn.,  Medical  Association  ; 
Penobscot,  Me.,  County  Medical  Society  (Bangor);  Essex,  Ma.ss., 
North  (annual — Haverhill),  and  Plymouth,  Mass.  (annual).  District 
Medical  Societies. 

Thur.sday,  May  J^th:  New  York  Academy  of  Medicine;  Society  of  Phy- 
sicians of  the  Village  of  Canandaigua ;  Brooklyn  Surgical  Society ; 
Medical  Society  of  the  County  of  Orleans  (semi-annual — Albion), 
N.  Y. ;  Boston  Medico-psychological  Association ;  Obstetrical  Soci- 
ety of  Philadelphia;  United  States  Naval  Medical  Society  (Washing- 
ton); Ocean  County  (Tom's  River),  N.  J.,  Medical  Society. 

Friday',  May  6th :  Practitioners'  Society  of  New  York  (private) ;  Balti- 
more Clinical  Society. 

Saturday,  May  6lh :  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. 


Proceedings  of  Societies. 


PHILADELPHIA  COUNTY  MEDICAL  SOCIETY. 

Meeting  of  March  22,  1893. 

The  Present  Position  of  the  Hypodermic  Method  in  the 
Treatment  of  Syphilis.  — Dr.  J.  William  White  read  a  i)aper 
on  this  subject,  the  concluding  portion  of  which  was  as  follows : 

I  must  confess  that  I  attach  much  importance  to  the  opin- 
ions and  practice  of  my  colleagues  in  that  society,  composed  of 
the  leading  syphilographers  and  genito-urinary  surgeons  of  this 
country  ;  1  know  them  to  be  intelligent,  alert,  and  ever  on  the 
lookout  for  anything  that  can  improve  tlieir  results  as  to  either 
the  comfort  or  the  safety  of  their  patients;  their  views  and  the 
opinions  of  such  men  as  Fournier  and  Hutchinson,  who  stand 
in  the  front  rank  ot  syphilographers,  not  only  of  to-day,  but  of 
all  time,  far  outweigh  with  me  the  one-sided  statements,  hasty 
generalizations,  and  untrustworthy  reports  of  results  whioli 
constitute  so  large  a  jjortion  of  the  literature  of  hypodermic 
injection.  I  do  not  mean  to  deny  that  there  are  men  of  great 
eminence  and  undoubted  scientific  ability  who  are  among  its 
advocates,  but  if  we  look  for  them  among  those  who  give  it 
first  place  in  tlie  treatment  of  syphilis  they  are  relatively  so 
few  that  they  are  lost  among  the  seekers  for  novelties  and  tiie 
untrained  and  inaccurate  observers  who  come  to  the  front  in  such 
large  numbers  whenever  an  op[)()rtunity  like  tins  occurs. 

In  the  light  of  the  evidence  presented  above  it  seems  to  me 
safe  to  assert  that :  1.  The  hypodermic  treatment  of  syphilis  has 


not  as  yet  shown  results  which  warrant  its  adoption  as  a  rou- 
tine method  to  the  exclusion  of  or  in  reference  to  other  meth- 
ods, but,  on  the  contrary,  has  some  apparently  insuperable  dis- 
advantages and  even  dangers  which  render  it  improbable  that 
it  ever  will  be  so  adojited. 

2.  The  circumstances  under  which  hypodermic  medication 
should  be  employed  may  be  summarized  as  follows :  a.  Those 
cases  in  which  other  methods  of  treatment  have  been  tried  and 
failed.  J>.  Those  cases  in  which,  owing  to  idiosyncrasy  or  in- 
tercurrent disease,  the  skin  and  the  digestive  tract  can  not  be 
used  for  the  introduction  of  mercury,  c.  Those  cases  in  which, 
owing  to  grave  and  advancing  lesions,  rapid  mercurialization  is 
absolutely  necessary,  d.  Those  cases  in  which  obstinate  local- 
ized lesions  can  be  most  directly  reached  by  this  plan.  e.  Pos- 
sibly those  cases  referred  to  by  Jullien,  in  which  early  differen- 
tiation between  syphilis  and  malignant  disease,  or  tubercular 
ulceration,  is  extremely  important,  should  be  included  in  this 
list.  I  certainly  feel  inclined  to  employ  the  method  in  all 
doubtful  cases  which  admit  of  it,  particularly  in  those  condiiions 
of  the  tongue  which  often  leave  the  surgeon  for  a  considerable 
time  in  doubt  as  to  their  exact  nature.  Anything  which  prom- 
ises to  shorten  this  period  of  doubt  by  rendering  the  therapeutic 
test  more  rapid  and  more  certain  would  be  of  great  advantage. 
I  should,  however,  in  such  instances  feel  obliged  to  use  potas- 
sium iodide  by  the  mouth  at  the  same  time.  f.  A  theoretical 
possibility  of  the  employment  of  mercury  hypoderinically  has 
suggested  itself  to  me,  but  I  have  not  as  yet  actually  employed 
it.  It  may  be  that  its  use  by  this  method  will  aid  in  shortening 
the  period  of  doubt  which  often  intervenes  between  the  appear- 
ance of  the  primary  sore  and  the  development  of  general  aden- 
opathy or  of  the  exanthemata.  If,  in  the  presence  of  a  sore  of 
uncertain  character,  the  em[)loyment  of  mercury  hypodermic- 
ally  resulted  in  rapid  cicatrization,  no  local  treatment  being 
employed  other  than  cleanliness,  it  might  occasionally  throw- 
light  upon  the  case  without  being  open  to  all  the  objections  which 
attend  the  systematic  and  slower  administration  of  mercury  by 
the  mouth.  It  is  possible  that  the  idea  is  worth  a  trial  in  ex- 
ceptional cases,  but  I  do  not  think  it  should  be  adopted  as  a 
routine  practice. 

3.  As  to  the  choice  between  the  two  great  classes  of  mercu- 
rials, the  soluble  salts  are  to  be  preferred  to  the  insoluble  in 
the  large  majority  of  cases,  as  more  exact  in  the  matt>'r  of  dos- 
age and  much  less  dangerous  and  less  likely  to  be  followed  by 
local  disturbances.  They  are  always  to  be  used  when  there  is 
need  for  rapid  mercurialization.  The  insoluble  salts  should 
probably  be  reserved  for  those  cases  in  which  frequent  visits  to 
the  surgeon  are  impossible  and  in  which  no  contra-indications 
exist.  In  cases  of  defective  kidneys,  diabetes,  profound  aiiR>mi;i, 
marked  atheroma,  great  debility,  etc.,  such  methods  ;ne  dan- 
gerous, and  the  case,  even  if  urgent,  will  probably  do  better 
under  some  other  form  of  treatment. 

4.  Finally,  as  to  the  special  preparation  to  be  eniployeil : 
Among  the  soluble  salts  the  bichloride  is  probably  to  be  pre- 
ferred. The  results  Irom  its  use  are  not  strikingly  different 
from  those  obtained  from  the  other  compounds  of  this  class, 
but  its  stability  and  great  solubility  and  its  germicidal  (juali- 
ties  seem  to  warrant  its  selection  The  disadvantage  is  the 
pain  which  it  causes,  but  the  evidence  in  this  direction  shows 
that  in  the  bands  of  impartial  investigators,  not  responsible  for 
the  introduction  of  the  [)articular  substance  employed,  each  of 
the  salts  on  the  list  i>roduces  a  considerable  amount  of  pain 
and  a  not  inconsiderable  number  of  accidents  or  complications- 
Probably  the  bichloride  is  freer  from  objectionable  features,  in 
respect  especially  to  the  i)ro(iuction  of  suppuration,  than  any  of 
the  salts  of  mercury. 

Among  the  insoluble  salts,  calomel  and  the  yellow  oxide  are 


472 


PROCEEDINOS  OF  SOCIETIES. 


[N.  Y.  Mkd.  Joub. 


to  be  preferred.  It  would  appear  that  the  latter  is  a  little  less 
active,  but  at  the  same  time  much  less  irritating.  Gray  oil  is 
the  most  available  form  of  administering  metallic  mercury. 

Criminal  Abortion.— Dr.  William  II.  Parish  read  the  fol- 
lowing pa[)er : 

In  submitting  a  paper  this  evening  upon  the  subject  of  crimi- 
nal abortion,  I  must  refer  to  some  extent  to  the  law  relating  to 
it,  and  I  shall  do  so  with  no  little  hesitation  in  the  presence  of 
the  learned  legal  gentlemen  with  us. 

I  am  very  forcibly  reminded  of  something  I  read  during  my 
college  days,  in  one  of  those  dead  languages  which  we  learn  so 
slowly  and  forget  so  quickly — namely,  that  he  who  is  ignorant 
of  the  science  of  warfare  should  not  discuss  military  matters  in 
the  presence  of  Hannibal — so  I,  ignorant  of  law,  might  well  be 
silent  in  reference  to  matters  of  law  in  the  presence  of  that  legal 
Hannibal,  our  very  able  district  attorney.  But  I  hope  he  will 
correct  me  when  in  error,  and  I  am  sure  that  he  and  the  other 
legal  gentlemen  present,  and  our  coroner,  Mr.  Ashbridge,  will 
present,  in  a  most  interesting  and  instructive  manner,  the  cor- 
rect relations,  under  the  law,  of  the  physician  to  cases  of  crimi- 
nal abortiiin,  when  the  after-treatment  comes  under  his  charge. 

The  practice  of  destroying  the  fietus  in  ntero  is  not  of  mod- 
ern introduction,  but  is  recorded  in  liistory  from  the  earlier  na- 
tions, with  the  sole  exception  of  the  Jews.  Aristotle  and  Plato 
defend  it  (Trarels  of  Anacharsis,  v,  p.  270;  ihid.,  iv,  p.  342). 
It  is  mentioned  by  Juvenal,  Ovid,  Seneca,  and  Cicero,  and  de- 
nounced by  the  earlier  Christians.  It  was  common  in  Europe 
tlirough  the  Middle  Ages  and  still  prevails  among  the  Moham- 
medans, Chinese,  Japanese,  Hindus;  and  it  has  been  so  exten- 
sively resorted  to  in  most  of  the  nations  of  Africa  and  Polynesia 
that  it  is  doubtful  if  more  have  died  in  these  countries  by  plague, 
famine,  and  the  sword. 

In  approaching  the  consideration  of  criminal  abortion  the 
first  query  which  very  naturally  presents  itself  is,  "  What  con- 
stitutes criminal  abortion?"  In  attempting  to  reply  to  this 
question  we  must  not  confound  the  different  interpretations 
given  to  the  term  abortion.  In  medical  language  the  word  in- 
dicates delivery  prior  to  the  viability  of  the  child,  or  it  is  re- 
stricted by  some  to  delivery  prior  to  the  formation  of  the  pla- 
centa;  in  other  words,  it  is  limited  to  delivery  during  the  first 
six  months  or  the  first  three  months  of  pregnancy.  In  law  this 
term  is  not  thus  limited,  but  is  applied  to  delivery  at  any  time 
prior  to  intrauterine  maturity. 

The  expulsion  of  the  ovum,  foetus,  or  child  by  criminal  vio- 
lence, at  any  period  of  utero-gestation,  is  regarded  as  a  miscar- 
riage or  abortion  in  law.  Criminal  abortion,  then,  is  criminal 
delivery  prior  to  maturity.  What  constitutes  criminal  abortion 
as  distinguished  from  non-criminal  abortion?  Wherein  rests  its 
criminality  under  human  or  Divine  law  ? 

"  Abortion  "  has  been  legally  defined  thus :  "  Any  person  who 
does  any  act  cah^ulated  to  prevent  a  child  from  being  born  alive 
is  guilty  of  abortion.  The  intention  constitutes  the  crime,  not 
the  means  employed.  The  drugs  may  even  be  harmless."  He, 
then,  who  resorts  to  any  procedure,  however  harmless  in  itself, 
with  the  intention  of  producing  an  abortion,  is  guilty. 

If  the  pregnant  woman,  with  or  without  the  advice  of  an- 
other, administers  to  herself  a  drug  or  resorts  to  some  mechani- 
cal procedure  with  the  intention  of  producing  an  abortion,  she 
is  herself  guilty  and  liable  to  punishment  under  the  law,  even 
though  the  drug  or  the  procedure  be  itself  harmless. 

If  she  voluntarily  submits  to  the  use  by  another  of  mechani- 
cal means  which  she  knows  are  intended  to  produce  on  her  an 
abortion,  she  is  guilty  along  with  him  who  uses  the  instrument 
or  other  means. 

In  order  that  an  attempt  to  produce  an  abortion  may  con- 
stitute a  felony,  it  is  not  necessary  that  the  woman  be  pregnant 


— even  though  she  be  not  pregnant,  the  intention  constitutes  the 
crime. 

I  will  not  argue  before  this  society  the  great  moral  criminal- 
ity of  what  is  known  under  the  law  as  criminal  abortion.  The 
medical  profession  looks  upon  this  crime  as  one  of  the  most 
heinous,  and  as  closely  allied  to  infanticide.  He  who  is  believed 
to  be  guilty  of  such  a  crime  could  never  be  received  into  mem- 
bership in  this  or  any  other  medical  society  ;  or  if  a  member 
should  so  far  forget  his  high  calling  as  to  be  guilty  of  this  crime, 
his  expulsion  would  (juickly  follow  upon  the  presentation  of  ade- 
quate evidence  of  his  guilt. 

The  physician  who  resorts  to  criminal  abortion  does  so  in 
the  most  secret  manner,  for  he  knows  not  only  that  he  is  pun- 
ishable under  the  law,  but  he  also  knows  that  professional  os- 
tracism will  make  him  forever  an  outcast  from  the  medical  pro- 
fession. 

Undoubtedly  many  criminal  abortions  are  produced  by  legal- 
ized practitioners  of  medicine,  but  in  this  State  the  law  legaliz- 
ing the  practice  of  medicine  is  a  very  lax  one,  and  in  some  States 
there  is  no  law  determining  who  shall  practice  medicine.  I  do 
not  believe  that  criminal  abortion  is  frequently  performed,  even 
ever  so  secretly,  by  men  or  women  of  recognized  professional 
standing ;  but  that  it  is  at  times  produced  by  some  such  mem- 
bers is  certainly  the  case,  as  the  records  of  the  criminal  docket 
show.  The  habitual  abortionist,  if  a  legalized  practitioner,  is 
nearly  always  one  around  whom  suspicion,  at  least,  has  rested, 
and  tliis  suspicion  has  been  sufficient  to  debar  him  from  that  af- 
filiation with  the  worthy  members  of  the  medical  profession 
which  constitutes  to  a  large  degree  the  stamp  of  professional 
respectability.  The  medical  profession  draws  a  wide  distinction 
between  a  legalized  practitioner  of  medicine  and  a  worthy,  repu- 
table physician.  Unfortunately,  this  distinction  is  not  sharply 
drawn  by  some  lay  minds. 

Graduates  of  the  best  medical  schools  have  proved  false  to 
their  noble  vocation,  and  have  brought  dishonor  upon  them- 
selves and,  to  a  certain  degree,  discredit  upon  the  profession  of 
medicine.  But  this  experience  is  not  limited  to  our  |)rofession 
— a  like  experience  occurs  in  the  sister  professions  of  theology 
and  of  law,  and,  in  fact,  we  may  say  in  all  vocations  of  life. 

There  are  those,  however,  who  produce,  or  attempt  to  pro- 
duce, criminal  abortion  who  are  not  legalized  practitioners  of 
medicine — are  not  practitioners  of  medicine  at  all.  Often  such 
persons  are  exceedingly  ignorant ;  they  know  nothing  of  the 
anatomy  concerned  ;  they  possess  no  manual  skill  in  the  manoeu- 
vres undertaken  ;  they  have  only  the  most  vague  knowledge  of 
the  injuries  which  may  be  inflicted  ;  they  know  nothing,  or  al- 
most nothing,  of  the  effects  of  the  drugs  administered;  they  only 
believe  that  certain  procedures  and  certain  drugs  have  the  repu- 
tation of  producing  abortion;  yet  he  who  attempts  to  produce 
an  abortion  alwajs  knows  that  what  he  is  doing  is  criminal. 

Criminal  abortion,  however,  is  not  infrequently  produced  or 
attempted  by  the  pregnant  woman  herself.  I  think  that  such 
women  are  not  always  cognizant  of  the  fact  that  they  are  liable 
to  the  law  for  such  an  act.  Each  one  knows  that  if  she  commits 
the  crime  on  another  she  is  amenable  to  punishment ;  but  for  a 
self-produced  abortion  she  seems  not  to  know  that  she  is  pun- 
ishable. 

A  few  words  in  reference  to  the  justifiable  production  of 
abortion  or  of  premature  labor  by  members  of  the  medical  pro- 
fession. That  the  production  of  delivery  before  the  viability  of 
the  child — i.  e.,  before  the  end  of  the  sixth  month — is  at  times 
justifiable,  is  recognized  in  the  courts  and  by  the  medical  pro- 
fession. But  the  conditions  which  justify  such  a  radical  pro- 
cedure are  not  numerous. 

Whenever  it  is  necessary  to  terminate  pregnancy  in  order  to 
save  the  life  of  the  mother,  such  a  procedure  is  justifiable;  it 


April  29,  1893.] 


PROGEEDimS  OF  SOCIETIES. 


473 


not  thus  necessary,  tlie  procedure  is  criminal.  I  grant  tliat 
there  is  room  for  difference  of  opinion  in  the  medical  profession 
as  to  what  conditions  justify  the  production  of  abortion.  The 
resort  to  an  abortion  may  be  reprehensible  though  not  crimi- 
nal ;  for  instance,  when  it  is  performed  by  a  practitioner  of 
medicine  under  the  mistaken,  though  honest,  opinion  that  an 
abortion  is  necessary  to  save  the  life  of  tlie  mother.  It  is  quite 
generally  acce[)ted  that  there  are  cases  of  disorders  of  the  kid- 
neys, or  of  the  Iieart,  of  degenerations  of  the  ovum — as  myxoma 
of  the  chorion  and  polyhydramnios — and  very  rarely  instances 
of  uncontrollable  vomiting,  in  which  the  production  of  early  or 
late  abortion  is  demanded  and  justifiable,  because  it  is  necessary 
to  save  the  life  of  the  mother,  and  also  because  the  death  of  the 
mother  always  involves  the  death  of  the  embryo  and  usually 
that  of  the  child  approaching  maturity.  The  authoritative 
works  on  medical  jurisprudence  class  among  the  conditions 
justifying  abortion,  extreme  pelvic  deformity.  Although  this 
statement  was  a  proper  one  at  one  time,  it  is  not  so  at  present, 
in  my  opinion. 

The  very  favorable  results  of  the  Cassarean  section,  and  of 
its  modification,  the  Porro  operation,  and  of  >ymphysiotomy  so 
recently  introduced  into  this  country — the  results,  I  say,  of 
these  operations  are  now  so  very  favorable,  both  to  the  mother 
and  to  the  child,  that  it  is  time  to  eliminate  even  extreme  pel- 
vic deformity  from  the  list  of  conditions  justifying  early  abor- 
tion. The  law  leaves  it  quite  entirely  to  the  medical  profession 
to  determine  what  constitutes  justifiable  abortion,  either  early 
or  late  The  responsibility  in  this  direction  thus  placed  upon  us 
is  a  very  weighty  one,  and  the  privilege  conferred  with  it  should 
be  exercised  with  the  utmost  discretion.  I  have,  in  a  very 
few  instances,  felt  that  the  physician  was  getting  very  close  to 
criminal  ground  when  he  produced  an  abortion  under  tbe  plea 
of  justifiability.  For  instance,  a  lady  pregnant  three  months 
wanted  an  abortion  produced,  and  so  did  her  husband,  because 
she,  having  had  one  very  painful  labor,  had  great  dread  of  an- 
other labor  in  advanced  pregnancy.  They  both  expressed  great 
fear  that  insanity  would  develop  if  her  pregnancy  was  not 
terminated.  Her  physician  asked  me  in  consultation.  We  de- 
cided that  an  abortion  was  unjustifiable.  She  returned  to  her 
former  home  in  a  distant  city  and  there  the  abortion  was  pro- 
duced by  a  regular  practitioner.  I  saw  a  letter  from  this  physi- 
cian in  which  he  attempted  to  justify  on  medical  grounds,  not 
only  this  abortion,  but  also  two  previous  ones  on  the  same  lady. 
His  plea  was  that  of  justifiability  because  of  apprehended  in- 
sanity. Such  and  similar  cases  seem  to  me  to  quite  merge  into 
criminality.  Professional  opinion  in  reference  to  what  consti- 
tutes justifiable  abortion  should  be  so  firmly  crystallized  that 
criminal  abortion  could  not  be  performed  under  a  false  plea  of 
justifiability. 

As  to  the  frequency  of  the  occurrence  of  criminal  abortion, 
it  is  impossible  to  give  any  statement  of  even  approximate  ac- 
curacy. Secrecy  is  so  closely  associated  with  its  performance 
that  it  is  impossible  to  arrive  at  more  than  the  crudest  opinion 
as  to  the  frequency  of  its  occurrence. 

I  suppose  every  physician  of  some  reputation  as  an  obstetri- 
cian or  gynajcologist  has  applications  from  those  desiring  that 
an  abortion  should  be  produced.  Probably  a  half  dozen  such 
applicants  call  upon  me  during  each  year.  Doubtless  the  same 
women  visit  other  physicians  on  like  errands.  Also,  nearly 
every  physician  is  called  in  to  take  charge  of  the  after-treat- 
ment of  cases  of  criminal  abortion.  He  will  suspect  some  of 
them  to  be  criminal,  but  in  most  instances  he  is  unable  to  assert 
that  the  abortion  is  or  is  not  a  criminal  one.  Many  cases  of 
early  criminal  abortion  do  not  come  under  reputable  profes- 
sional care  at  any  period  of  their  course.  Even  all  the  fatal 
cases  are  not  recognized  as  criminal.    For  these  reasons  it  is 


impossible  to  do  more  than  to  form  an  opinion  that  criminal 
abortion  is  performed  with  considerable  frequency.  All  statis- 
tical statements  as  to  the  frequency  of  criminal  abortion  are, 
however,  valueless,  and  are  merely  expressions  of  opinion. 

It  is  well  recognized  that  criminal  abortion  brings  to  the  pa- 
tient enhanced  dangers — dangers  greater  than  tho.'e  pertaining 
to  accidental  or  justifiably  produced  abortion.  The  increased 
dangers  are  due  to  the  character  of  tbe  manoeuvres  and  to  the 
drugs  resorted  to.  The  mechanical  mea.sures  are  often  carried 
out  in  a  bungling,  unskilled  manner,  and  without  regard  to  the 
liability  of  conveying  a  septic  poison.  Often  drugs  are  used 
which,  when  given  in  too  large  quantities,  endanger  the  life  of 
the  patient  whether  or  not  an  abortion  is  produced.  The 
woman,  desirous  of  securing  secrecy,  often  does  not  call  in  a 
physician  sufficiently  early  to  enable  him  to  prevent  a  fatal  re- 
sult. 

The  methods  of  producing,  or  of  attempting  to  produce, 
criminal  abortion  are  numerous  and  widely  diverse  in  character. 
Of  the  drugs  resorted  to  in  this  country,  probably  the  ones  most 
frequently  used,  and  also  the  ones  most  likely  to  effect  the  re- 
sult aimed  at,  are  the  preparations  of  ergot  and  of  cotton  root. 
These  drugs  act  by  stimulating  directly  the  contraction  of  the 
uterus.  I  have  known  a  patient  to  treasure  up  a  bottle  of  ergot 
left  over  from  her  labor,  and  to  successfully  partake  of  its  con- 
tents at  the  incipiency  of  her  next  pregnancy.  But  even  these 
drugs  usually  fail  to  efi'ect  an  abortion  at  any  period  of  preg- 
nancy. Among  other  drugs  frequently  administered  are  aloes 
and  savine.  The  entire  list  of  medicines  occasionally  resorted 
to  would  be  a  long  one — among  them  may  be  mentioned  ela- 
teriura,  croton  oil,  colocjnth,  gamboge,  cantharides,  arsenic, 
strychnine,  corrosive  sublimate,  and  other  forms  of  mercury ; 
pennyroyal,  tansy,  black  hellebore,  and  not  a  few  others,  some 
of  which  are  active  poisons,  others  are  dangerous  in  large  quan- 
tities, and  some  are  harmless.  None  of  them  produce  abortion 
except  occasionally,  and  then  only  through  their  injurious  ef- 
fects upon  other  organs  or  upon  the  general  system.  Some  of 
them  will  produce  the  death  of  the  patient  without  producing 
an  abortion. 

Tardieu,  in  his  classical  treatise,  gives  numerous  cases  of 
abortion  produced,  or  attempted,  by  mechanical  means.  The 
professional  abortionist  usually  dilates  the  cervix  with  a  metal- 
lic dilator,  and  introduces  a  slender  instrument  into  the  uterus 
and  punctures  tbe  membrane — or  he  may  use  the  latter  instru- 
ment without  previous  dilatation  of  the  cervix.  Very  usually, 
after  the  membranes  have  been  punctured,  he  dismisses  the  pa- 
tient and  an  abortion  comes  on  in  generally  from  three  to  ten 
days. 

The  more  modern  method  of  the  criminal  abortionist  of  ad- 
vanced ideas  is  to  dilate  the  uterus  with  graduated  dilators, 
under  ether,  and  at  once  to  empty  the  uterus  with  all  antiseptic 
precaution,  usually  receiving  the  woman  into  his  private  hos- 
pital for  this  operation.  A  lady  apjdied  to  one  of  the  medical 
men  who  advertised  in  the  New  York  papers.  He  admitted 
her  info  his  hospital  in  New  York  city,  and  practiced  the  im- 
mediate removal  of  the  ovum.  She  retm-ned  to  riiiladelphia  at 
the  expiration  of  a  week's  absence. 

But  sometimes  the  operator  is  ignorant  and  unskilled,  and  a 
great  variety  of  instruments  have  been  carried  into  the  uterus: 
wooden  skewer,  crochet- needle,  hair-pin,  knitting-nee<lle,  a 
weaver's  spindle,  whalebone,  wire,  umbrella-ribs,  jien-bolders, 
catheters,  bougie,  sounds,  tents,  and  dilators.  Tardieu  speaks  of 
the  frequent  use  in  France  of  what  is  there  termed  a  hedgehog, 
which  I  believe  is  a  slender  instrument  having  near  the  end  a 
number  of  bristles,  which  lie  close  to  the  handle  when  intro- 
duced into  the  uterus,  but  expand  after  introduction,  and,  when 
rotated,  very  effectually  break  up  the  ovum,  but  which  has 


474 


PROGEEDINOS 


OF  SOCIETIES. 


[N.  Y.  Med.  Jock., 


proved  disastrous  also  to  tlio  mother.  Electricity  is  also  eftect- 
ually  resorted  to,  one  pole  being  usually  introduced  into  the 
uterus. 

Injections  of  corrosive  or  other  irritant  substances  into  the 
vagina  are  occasionally  resorted  to  by  the  patient  or  by  an  ig- 
norant abortionist.  I  have  know  n  a  patient  to  produce  an  ex- 
foliation of  almost  all  of  the  epithelial  lining  of  the  vagina  by 
means  of  a  strong  solution  of  alum  without  [)roducing  an  abor- 
tion. Injections  of  different  liuids,  even  water,  into  the  uterus 
are  resorted  to,  and  if  the  membranes  are  largely  detached  or 
ruptured,  abortion  inevitably  follows.  In  a  few  instances  the 
most  violent  measures,  such  as  the  introduction  of  the  liand 
into  the  uterus  and  attempts  to  drag  out  the  entire  uterus^ 
have  produced  most  disastrous  effects. 

What  lesions  do  we  find  following  attempts  at  criminal 
abortion?  Naturally,  from  the  variety  of  the  means  resorted 
to,  these  are  vnrious,  and  may  be  numerous  in  an  individual 
case.  In  one  authentic  case  the  patient  herself  carried  an  um- 
brella-rib into  the  uterus,  perforate<l  its  wall,  entered  and 
passed  upward  and  through  the  abdomen,  through  the  dia- 
phragm, and  into  the  lungs.  She  did  not  desist  in  her  efforts 
until  coughing  of  blood  and  troubled  breathing  alarmed  her. 
She  concealed  her  manoeuvres,  and  the  umbrella-rib  was  found 
in  situ  in  a  post-mortem  examination.  During  pregnancy  the 
physiological  softening  of  the  uterine  tissue  permits  the  easy 
passage  of  a  somewhat  sharp  instrument  through  it  into  the 
peritoneal  cavity,  and  generally,  with  resultant  fatal  peritoni- 
tis. When  mechanical  means  are  resorted  to,  if  perforation  of 
the  uterus  does  not  occur,  there  is  usually,  though  not  invaria- 
bly, laceration — it  may  be  a  slight  one— of  the  neck  of  the 
uterus  or  of  the  vagina.  Rupture  of  the  vagina  or  of  the  uterus 
has  occurred  from  the  introduction  of  the  hand.  Abscesses  at 
various  points  in  the  uterus  or  in  close  proximity  to  it  may  fol- 
low. Hlood  poisoning,  with  local  intlammatious,  constitute  the 
pathological  conditions  following  many  cases  of  criminal  abor- 
tion. When  drugs  have  been  administered,  gastric  and  intesti- 
nal inflammation  may  result,  and  evidences  of  such  be  seen 
after  death. 

It  is  not  usually  difficult  to  determine  that  an  abortion  is  in 
progress;  but  it  is  by  no  means  an  easy  matter  to  determine 
with  certainty,  from  the  examination  of  the  patient  during  life, 
whether  or  not  the  abortion  is  criminal  in  character.  Even 
fatal  perforations  of  th«  uterus  are  not  usually  recognizable 
during  life.  The  i^tatements  of  the  patient  may  give  this  infor- 
mation, but  she  may,  and  usually  does,  deny  that  any  attempt 
has  been  made  to  produce  an  abortion.  Her  statements,  if  ac- 
cepted, would  usually  be  misleading.  Hence  cases  which  re- 
cover, and  the  very  great  majority  do  recover,  can  usually  be 
only  diagnosticated  as  probably  criminal  abortions. 

In  the  lesions  lotmd  post  mortem  there  is  no  characteristic 
evidence  that  the  abortion  has  been  a  criminal  one,  excepting 
the  wounds,  which  are  usually,  though  not  always,  present  in 
such  cases  as  have  resulted  from  the  use  of  mechanical  means. 
Even  then  the  history  of  the  case  must  he  looked  into,  for  the 
abortion  may  have  been  innocently  produced  by  a  reputable 
physician,  who  had  failed  to  recognize  the  existence  of  preg- 
nancy. Lacerations  of  the  vulva,  perinieum,  or  vagina  may 
result  from  violent  sexual  intercourse,  and  excessive  or  violent 
sexual  intercourse  is  not  an  infrequent  cause  of  abortion  in  the 
young. 

The  after-treatment  of  criminal  abortion  must  he  according 
to  the  peculiarities  of  the  case.  If  the  abortion  is  incomplete, 
the  indications  are  absolute  to  immediately  empty  the  uterus 
and  to  render  it  asei)tic.  Here  the  expectant  treatment  is 
fraught  with  great  danger.  Such  cases  usually  call  for  tlie  ut- 
most skill  of  the  expert  to  effect  the  recovery  of  the  woman. 


Most  frequently  the  underlying  cause  of  a  fatal  result  is 
septic  infection  or  blood-poisoning.  The  traumatism  produced 
is  in  itself  usually  slight  and  insignificant,  hut  septic  poison  de- 
velopes  in  the  retained  frasiments  of  the  products  of  conce[)ti()ri, 
or  is  carried  info  the  genitals  by  the  abortionist.  Blood-poison- 
ing and  the  associated  inflammatory  lesions  result. 

Abdominal  section  with  ablation  of  the  uterus  and  its  ap- 
pendages, or  of  the  appendages  alone,  may  be  necessitated. 

When  a  patient  suffering  from  a  criminal  abortion  is  sent 
to  a  hos|)ital,  it  should  be  to  one  having  a  maternity  or  a 
gyniecological  ward  ;  otherwise  the  best  treatment  mfiy  not  be 
secured. 

In  the  management  of  cases  of  (;i-iminal  abortion  the  jdiy- 
sician  is  often  placed  in  a  most  trying  position.  If,  perchance, 
he  has  been  informed  by  the  patient,  or  if  in  his  examinations 
he  has  discovered  that  measures  or  drugs  have  been  resorted  to 
with  the  view  of  producing  an  abortion,  what  becomes  bis  duty 
under  the  law?  Here  we  would  like  to  have  an  expression  of 
the  views  of  the  coroner,  tfie  district  attorney,  and  the  other 
lawyers  present. 

Is  it  incumbent  upon  the  physician  to  notify  the  officers  of 
the  law  that  an  abortion  has  been  produced,  or  attempted,  ille- 
gally? If  he  does  not  thus  furnish  this  information,  to  what 
extent,  if  any,  does  he  render  \\\m»Q\\'  &  particcps  criminiiiun<\QT 
the  law?  Should  the  information  thus  gained  in  the  practice 
of  his  profession  be  held  sacred  in  deference  to  the  good  name 
of  Ilia  pntient,  who  is  usually,  though  not  always,  more  sinned 
against  than  sinning,  or  in  deference  often  to  the  fair  fame  and 
happiness  of  the  other  members  of  the  family  ? 

I  believe  that  very  often  the  physician  does  all  that  is  in  his 
power  to  conceal  both  the  fact  that  an  illegitimate  pregnancy 
has  occurred  and  also  that  an  abortion,  even  though  criminal, 
has  resulted.  Is  the  physician  then  acting  with  justice  to  him- 
self and  with  a  proper  appreciation  of  his  duties  under  the  cir- 
cumstances? Is  it  incumbent  upon  him  to  become  an  in- 
former? 

I  know  that  in  this  State  the  information  gained  in  the 
practice  of  his  profession,  and  necessary  to  the  proper  treatment 
of  his  patient — I  know  that  such  information  is  not  privileged, 
but  may  be  extorted  from  him  in  our  courts.  Yet  must  he 
voluntarily  convey  this  information  to  the  officers  of  the  law? 
Or  shall  he  draw  a  distinction  between  the  fatal  and  the  non-fatal 
cases?  Shall  he  report  only  the  fatal  cases  to  an  officer  of  the 
law,  withholding  his  certificate  of  death  in  such  instances  and  let- 
ting the  coroner  investigate  the  circumstances  ?  Certainly,  if  the 
case  is  about  to  terminate  fatally,  the  proper  information  should 
be  given  in  order  that  an  ante-mortem  statement  may  be  se- 
cured, and  undoubtedly  also  no  physician  should  give  a  death 
certificate  in  any  case  in  which  the  death  has  resulted  from 
what  he  strongly  suspects  or  believes  or  knows  to  have  been  a 
criminal  abortion. 

These  rules  are  in  accord  with  justice  to  the  physician  whose 
reputation  is  at  stake,  and  are  also  in  accord  with  law  and  the 
welfare  of  the  community.  But  if  the  patient  is  recovering,  is 
it  required  by  law,  or  is  it  in  accord  with  the  general  we'faie 
of  the  community,  that  information  bearing  upon  the  character 
of  the  abortion  should  be  formally  brought  by  the  physician 
before  the  officers  of  the  law  ?  I  will  answer  the  question  in 
the  negative,  and  will  ask  the  gentlemen  present  to  tell  us  in 
the  discussion  whether  or  not  I  am  correct.  In  my  opinion, 
the  physician  should  not  become  an  informer. 

1  will  further  say  that  he  should  not  elicit  or  extort  fro 
the  patient  any  information  bearing  upon  her  criminality  otner 
than  that  which  is  necessary  for  his  guidance  in  the  perform- 
ance of  his  professional  duties.    He  must  not  {)erform  the  func- 
tions of  a  detective. 


April  29,  1893.] 


PROCEEDINGS 


OF  SOCIETIES. 


475 


In  all  serious  cases  of  abortion,  especially  if  criminal,  the 
physician  should  secure  another  physician  in  consultation  for 
the  protection  of  his  own  reputation,  as  well  as  for  the  welfare 
of  the  patient.  Let  the  physician  remember,  also,  that  he  can 
examine  the  patient's  genitals  only  with  her  consent.  If  he, 
by  an  exercise  of  force,  secures  such  examination,  he  renders 
himself  liable  to  punishment  by  legal  process. 

The  consideration  of  the  measures  which  may  tend  to  dimin- 
ish the  number  of  criminal  abortions  becomes  very  important 
in  every  large  city,  for  it  is  believed  that  where  the  population 
has  become  concentrated,  there  this  crime  occurs  with  greatest 
frequency.  These  conditions  or  habits  of  life,  which  diminish 
the  number  of  marriages,  increase  the  number  of  illegitiinato 
pregnancies  and  the  number  of  criminal  abortions.  But  many 
such  abortions  occur  in  the  married,  and  largely  in  proportion 
to  the  tendencies  on  the  part  of  the  married  to  indulge  in  ex- 
pensive habits  of  life  beyond  their  financial  abilities. 

The  disgrace  and  shame  attendant  upon  illegitimate  preg- 
j  nancy  or  maternity  are  the  impelling  motive  on  the  part  of  the 
great  majority  of  tlje  unmarried.  A  recognition  of  the  difficul- 
ties and  of  tlie  disgrace  attendant  upon  the  care  of  an  iilegiti- 
!  mate  child,  on  the  part  of  its  unmarried  mother,  impels  some  to 
secure  criminal  abc)rtion. 

With  all,  however,  there  is  an  underlying  immorality,  usu- 
ally on  tlje  i)art  of  both  sexes,  which  leads  up  to  the  commis- 
sion of  an  act  as  unnatural  as  it  is  criminal.  The  preservation 
of  the  purity  of  morals,  then,  of  the  youth  of  both  sexes  con- 
stitutes the  only  efficient  safeguard  against  the  occurrence  in 
any  community  of  criminal  abortion;  other  measures  are  ad- 
juncts only. 

The  Law  of  Criminal  Abortion  in  Pennsylvania  was  the 

title  of  the  following  paper  by  Mr.  Lorenzo  D.  Bulette,  of 
the  Pliiladelphia  bar: 
I  .  The  differences  of  opinion  among  the  courts  of  England  and 
the  various  States  as  to  the  stage  of  gestation  at  which  the 
common  law  crime  of  abortion  may  be  ])erpetrated  causes  any 
extended  examination  of  their  decisions  to  partake  of  a  specu- 
lative rather  than  practical  character;  especially  so  in  view  of 
the  fact  that  the  question  is  now  very  generally  settled  by  stat- 
ute, and  nearly  all  indictments  are  founded  on  tliese  statutes, 
the  provisions  of  which  and  the  judicial  interpretation  thereof, 
even  on  similar  provisions,  vary  in  the  courts  of  the  different 
States. 

And  when,  in  addition  to  this,  it  is  recalled  that  the  law  of 
this  State,  in  the  severer  view  it  has  always  taken  of  the  crime 
and  the  milder  view  it  has  always  taken  of  the  consequences 
thereof  where  they  result  in  the  death  of  the  woman,  presents 
peculiarities  which  sharply  differentiate  it  from  the  law  of 
other  States,  thus  causing  it  to  stand  practically  alone,  it  will 
be  apparent  that  the  course  most  fruitful  of  results,  for  the  pur- 
poses of  the  present  occasion,  is  to  confine  our  inquiry  to  the 
law  of  criminal  abortion  as  it  stands  to-day  under  the  Criminal 
Code  of  Pennsylvania  and  the  decisions  of  her  courts  interpret- 
ing that  code. 

The  first  and  only  legislative  enactment  aimed  at  this  crime 
appears  as  the  87tii  and  88th  sections  of  the  Penal  Code,  which 
is  known  as  the  Act  of  March  31,  1800. 

Section  87  is  in  the  following  language  : 

"If  any  person  shall  unlawfully  administer  to  any  woman, 
pregnant  or  (juick  with  child,  or  supposed  and  believed  to  be 
pregnant  or  quick  with  child,  any  drug,  poison,  or  other  sub- 
stance whatsoever,  or  shall  unlawfully  use  any  instrument  or 
other  means  whatsoever,  with  the  intent  to  procure  the  miscar- 
riage of  sucli  woman,  and  such  woman,  or  any  child  with  which 
she  may  be  quick,  shall  die  in  consequence  of  either  of  said  un- 
lawful acts,  the  person  so  offending  shall  bo  guilty  of  felony. 


and  shall  be  sentenced  to  pay  a  tine  not  exceeding  five  hundred 
dollars,  and  to  undergo  an  imprisonment  by  separate  or  solitary 
confinement  at  labor  not  exceeding  seven  years."* 
Section  88  is  in  language  as  follows: 

"If  any  person,  with  intent  to  procure  the  miscarriage  of 
any  woman,  shall  unlawfully  administer  to  her  any  poison,  drug, 
or  substance  whatsoever,  or  shall  unlawfully  use  any  instrument, 
or  other  means  whatsoever  with  the  like  intent,  such  person 
shall  be  guilty  of  felony,  and,  being  thereof  convicted,  shall  be 
sentenced  to  pay  a  fine  not  exceeding  five  hundred  dollars  and 
undergo  an  imprisonment  by  separate  or  solitary  confinement  at 
labor  not  exceeding  three  years."  t 

Both  these  sections  are  new  in  the  criminal  statutes  of  Penn- 
sylvania; and,  contrasting  them  broadly,  it  is  clear  that  Section 
87  is  intended  to  meet  the  case  of  the  death  of  a  |)regnant 
woman  following  any  criminal  intent  to  procure  her  miscar- 
riage, or  the  death  of  the  child  with  which  she  may  he  preg- 
nant. It  also  meets  the  case  of  the  death  of  a  woman  from 
drugs  administered,  or  instruments  applied,  with  the  intent  to 
produce  abortion,  where  such  woman  is  not  actually  pregnant. 

Section  88  punishes  the  administration  of  drugs  or  the  use 
of  instruments  with  intent  to  procure  abortion,  although  no 
abortion  is  actually  produced,  and  although  the  female  survives 
the  operation.  This  section,  it  was  hoped  by  the  commission- 
ers v/ho  drafted  the  Penal  Code,  might  tend  to  put  a  ^top  to  a 
crime  of  too  frequent  occurrence.  X 

With  this  much  for  the  language  and  purpose  of  the  statute, 
we  next  proceed  to  the  decisions  of  the  courts  explaining  and 
interpreting  it;  and  these  may  be  arranged  for  convenience  and 
clearness  under  the  following  heads  : 

1.  Definition  and  Degree  of  the  Crime. 

2.  Interpretation  of  the  Statute. 

3.  Means  Employed  and  the  Intention. 

4.  Legal  Responsibility  of  the  Obstetrician  in  his  Relations 
with  Abortion. 

Of  Definition  and  Degree  of  the  Grime. — Miscarriage,  both 
in  law  and  i)hilology,  means  the  bringing  forth  the  foetus  before 
it  is  perfectly  formed  and  capable  of  living. 

Abortion  is  synonymous  and  equivalent  to  miscarriage  in  its 
primary  meaning;  and,  when  it  is  brought  about  with  a  mali- 
cious design,  or  for  an  unlawful  purpose,  it  is  a  crime  in  law. 

Any  person,  therefore,  who  does  any  unlawful  act  calculated 
to  prevent  a  child  from  being  born  alive  is  guilty  of  criminal 
abortion.  This  is  justly  regarded  as  an  offense  of  great  enor- 
mity ;  because,  to  procure  the  miscarriage  of  the  woman  inter- 
feres with  and  violates  the  mysteries  of  Nature  in  that  process 
by  which  the  human  race  is  propagated  and  continued.  The 
attempt,  by  wicked  means,  to  interfere  with  that  process  and 
destroy  the  fruit  of  the  womb  thus  becomes  a  crime  against  Na- 
ture, closely  allied  to  murder,  and  therefore  deserving  of  severe 
and  ignominious  punishment.* 

"It  is  not,"  says  Mr.  Justice  Coulter,  " necessary  that  the 
mother  have  quickened  to  constitute  the  crime  of  committing 
abortion.  But,  although  it  lias  been  so  held  in  Massachusetts 
and  some  other  States,  it  is  not,  I  apprehend,  the  law  in  Penn- 
sylvania, and  never  ought  to  have  been  the  law  anywhere.  It  is 
not  the  murder  of  the  living  child  which  constitutes  the  offense, 
but  the  destruction  of  gestation  by  wicked  means  and  against 
Nature.  The  moment  the  womb  is  instinct  with  embryo  life, 
and  gestation  has  begun,  the  crime  may  be  (lerpetrated."  || 


*  Act,  March  31,  1860,  Sec.  87.  Piu-don's  Digest,  Sec.  150,  p.  431. 
•|-  Act,  March  31,  186(1,  Sec.  88.  Pardon's  Digest,  Sec.  167,  p.  481. 
\  Report  of  Commhisioners  on  the  Penal  Code,  p.  'i."). 

*  Mills  vs.  Conimoiiwealth,  13  Pa.  St.,  633  (1850). 

II  Commonwealth  vs.  W  ,  3  Pittsburgh,  462  (1871). 


476 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mud.  Joob., 


In  this  connection  it  must  be  borne  in  mind  that  at  common 
law  it  was  never  a  punishable  offense  to  perform  an  operation 
on  a  pregnant  woman,  with  her  consent,  before  the  child  quick- 
ened ;  nor  was  it  murder,  at  common  law,  to  take  the  life  of  a 
child  at  any  period  of  gestation,  even  in  the  very  act  of  deliv- 
ery, or  while  any  portion  of  the  child,  except  the  umbilical  cord, 
remained  within  the  vulva.  * 

Preliminary  to  a  discussion  of  Section  87,  which  applies  to 
the  crime  of  committing  an  abortion  resulting  in  the  death  of 
either  or  both  mother  and  child,  it  may  be  profitable  to  con- 
trast the  degree  of  criminality  of  the  offense,  resulting  in  the 
death  of  the  mother,  as  viewed  by  the  common  law,  with  the 
degree  of  criminality  of  the  same  offense  as  viewed  by  the  law 
of  Pennsylvania  as  it  existed  previously  to  March  31,  1860. 

Of  the  degree  of  turpitude  of  this  offense,  one  of  tlie  most 
learned  and  humane  sages  of  the  common  law,  Sir  Mattliew 
Hale,  gives  the  following  as  the  doctrine  ruled  by  him  at  Bury 
Assizes  in  the  year  1672 : 

"  If  a  woman  be  with  child,  and  any  gives  her  a  potion  to 
destroy  the  child  within  her,  and  she  takes  it  and  it  works  so 
strongly  that  it  kills  hor,  this  is  murder:  for  it  was  not  to  cure 
her  of  a  disease,  but  unlawfully  to  destroy  her  child  within  her ; 
and,  therefore,  he  that  gives  a  potion  to  this  end  must  take  the 
hazard,  and  if  it  kills  the  mother  it  is  murder."  t  And  the 
same  doctrine  has  been  held  in  more  recent  times.  :|: 

In  Pennsylvania,  however,  it  was  decided  in  a  more  lenient 
spirit  that  although  death  was  not  intended,  yet  the  acts  are  of 
a  nature  deliberate  and  malicious,  and  necessarily  attended  with 
great  danger  to  the  persons  on  whom  they  are  practiced ;  and, 
consequently,  those  who  perpetrate  them  are  answerable  for 
their  results.  And  although  by  the  common  law  such  a  crime 
would  therefore  have  been  murder,  yet  in  Pennsylvania  it  can 
hardly  be  regarded  as  exceeding  that  crime  in  the  second  degree, 
unless  there  existed  in  the  perpetrator  of  the  mischief  an  intent 
as  well  to  take  away  the  life  of  the  mother  as  to  destroy  her 
offspring.  It  is  the  nature  of  the  intention  with  which  the 
criminal  act  is  committed  that  constitutes  the  great  distinguish- 
ing feature  between  murder  as  it  stands  at  the  common  law  and 
murder  as  it  is  understood  in  the  criminal  code  of  this  Com- 
monwealth. Where  the  illegal  act  which  produces  death  is 
malicious  and  perpetrated  with  an  intent  to  take  life,  the  offense 
becomes  murder  in  the  first  degree  and  punishable  with  death ; 
where  no  such  attempt  is  apparent,  the  crime  is  reduced  to 
murder  of  the  second  degree,  and  punishable  by  penal  imprison- 
m  ent. 

At  common  law  the  death  of  the  mother  following  criminal 
abortion  is  murder,  not  because  the  agent  accomplishing  the  act 
intended  to  kill  the  female,  but  because  the  act  being  unlawful 
in  itself  he  is  held  responsible  for  all  its  results.  In  Pennsylva- 
nia, however,  that  murder  only  is  felony  of  death  where  the 
act  producing  the  homicide  is  not  only  unlawful  but  perpetrated 
with  an  intent  to  kill  the  victim  of  the  crime.  The  common 
law  murder  following  criminal  abortion  is  the  exact  kind  of 
crime  which  the  Legislature  intended  by  the  Act  of  1794  to  re- 
duce to  the  grade  of  murder  in  the  second  degree,  being  a  homi- 
cide arising  from  an  unlawful  act,  unaccompanied  with  an  at- 
tempt to  take  away  life.* 

Thus  stood  the  law  relating  to  this  offense  prior  to  the  Abor- 
tion Act  of  March  31,  1860.    But  since  that  time  the  Supreme 


*  Mitchell  vs.  Commonwealth,  78  Ky.,  210  (1879). 
f  1  Hale's  Picas  of  Ike  Crown,  pp.  429-430. 

\  Tinkler's  Case,  1  East  P.  C,  ch.  5,  sec.  16. 

*  King,  V.  J.,  in  Commonwealth  vs.  Keeper  of  Prison,  2  Ashm.,  235 
(1839). 


Court  has  decided  *  that  the  eff'ect  of  Section  87  of  that  Act  was 
to  take  the  crime  therein  specified  out  of  the  class  designated 
as  murder  in  the  second  degree,  and  make  it  a  felony  of  lesser 
grade  and  jjrescribe  the  punishment  therefor.  As  a  consequence 
of  this  decision,  if  a  person  cause  the  death  of  a  woman  in  at- 
tempting to  procure  a  miscarriage,  he  can  not  be  indicted  for 
murder  ;  and  this  is  the  law  in  Pennsylvania  at  this  time. 

Of  the  Interpretation  of  the  Statute. — As  compared  with  the 
offense  specified  in  Section  87,  that  described  in  Section  88  is 
complete  without  the  death  of  either  the  woman  or  the  child. 
"  In  both  cases,"  says  Mr.  Justice  Green,  "  the  grade  of  the 
offense  is  the  same — viz.,  felony.  In  both  cases  the  acts  done 
are  the  same.  In  the  first,  if  those  acts  are  followed  by  the 
death  of  the  mother  or  child  as  a  consequence — that  is,  in  the 
relation  of  effect  to  a  cause — a  difference  results  in  one  of  the 
penalties  imposed.  The  possible  fine  is  the  same,  but  the  pos- 
sible imi)risonraent  is  longer — seven  years  instead  of  tliree. 
The  facts  which  constitute  the  crime  are  precisely  the  same  in 
both  cases — to  wit,  the  administering  the  drug  or  using  the  in- 
strument with  intent  to  procure  a  miscarriage.  It  follows  that 
the  death  is  no  part  of  the  facts  which  go  to  make  up  or  con- 
stitute the  crime.  It  is  complete  with  the  death  or  without  it. 
The  death,  therefore,  considered  in  and  of  itself,  is  not  a  con- 
stituent element  of  the  offense.  It  may  happen  or  it  may  not. 
If  it  does  not  happen,  a  certain  possibility  of  penalty  follows.  If 
it  does  happen,  the  same  character  of  penalty  follows,  but  with 
a  lai'ger  possibility,  not  a  certainty,  in  one  of  its  items.  This 
seems  to  be  a  precise  expression  of  the  difference  between  the 
cases  provided  for  in  the  two  sections. 

"  In  case  the  woman  does  die  in  consequence  of  the  unlaw- 
ful acts,  the  crime  charged  and  tried  is  not  homicide  in  any  of 
its  forms,  but  the  felony  of  administering  a  drug  or  using  an  in- 
strument with  intent  to  procure  a  miscarriage.  In  its  facts  and 
in  its  essence  it  is  the  same  crime  that  is  charged  and  tried  if 
no  death  results.  The  death,  when  it  occurs,  is  an  incident  the 
sole  purpose  of  which  is  to  determine  whether  the  imprison- 
ment of  the  defendant  may  be  longer  than  when  death  does 
not  occur.  The  crime  is  as  fully  completed  without  the  death 
as  with  it.  The  death,  therefore,  is  not  an  essential  ingredient 
of  it.  Its  function  under  the  statute,  when  it  occurs  as  a  conse- 
quence, is  not  to  determine  thQ  factum,  or  the  character,  or  the 
grade  of  the  crime,  but  the  character  of  the  penalty  to  be  en- 
dured by  the  criminal."  t 

Of  the  Means  employed  and  the  Intention. — The  terms  of 
the  statute  specifying  the  means  employed  are  so  sweeping  and 
comprehensive  that  one  could  scarcely  suppose  a  doubt  in  this 
respect  possible:  "any  drug,  poison,  or  other  substance  what- 
soever, or  shall  unlawfully  use  any  instrument  or  other  means 
whatsoever,"  is  the  language  of  the  statute.  But  the  question 
did  arise  during  the  trial  of  an  indictment  charging  the  accused 
with  prescribing  and  advising  the  use  of  immoderate  and 
excessive  exercise  with  intent  to  induce  abortion.  And  the 
Court,  in  answer  to  the  objection  of  defendant's  counsel  that 
such  means  do  not  constitute  any  offense  under  Section  88,  con- 
tending that  the  words  defining  the  crime,  "  or  shall  use  any 
instrument  or  other  means  whatsoever,"  imply  some  act  to  be 
done  by  the  defendant  and  not  by  the  woman  herself  at  his  in- 
stigation, or  under  his  advice,  persuasion,  or  influence,  said : 
"We  are  not  prepared  to  adopt  the  view  of  the  law  presented 
by  the  defendant's  counsel,  for  the  reason  that  such  an  interpre- 
tation would  greatly  abridge  what  we  conceive  to  be  the  reme- 
dial design  of  the  statute,  and,  to  a  great  extent,  frustrate  the 
expressed  intention  of  its  framers.    If  a  person  intent  on  in- 

*  Commonwealth  vs.  Railing,  113  Pa.  St.,  37  (1886). 
f  Railing  vs.  Commonwealth,  110  Pa.  St.,  104  (1885). 


April  29,  1893.] 


PROCEEDINGS  OF  SOCIETIES. 


477 


diu'infj;  abortion  must  not  odIv  [)rescribe  the  drug  but  with  liis 
own  hiuid  put  it  to'liis  victim's  lips,  or,  after  contriving  the 
mechanical  means,  must  to  moral  constraint  superadd  })liysi(!al 
force,  we  can  readily  jjerceive  how  the  abortionist  may  practice 
his  nefarious  schemes  with  impunity  in  the  very  face  of  the 
statute.  The  defendant,  according  to  the  evidence,  contrived 
these  means  and  used  tlie  prosecutrix  as  a  blind  instrument  in 
rendering  them  efficacious;  what  she  did  was  as  much  his  act 
as  if  siio  had  been  moved  to  it  by  outward  constraint."  And, 
as  the  evidence  produced  by  the  prosecution  tended  to  prove 
the  charge  of  advising  the  use  of  immoderate  and  excessive  ex- 
ercise to  induce  (he  abortion,  the  Court  instructed  the  jury  that 
such  mt'Mns  were  within  the  intent  and  meaning  of  Section  88, 
and  that  they  were  used  by  the  defendant  just  as  much  so  as  if 
he  had  been  present  and  employed  j)]iysical  instead  of  moral 
force.* 

And  in  another  case  it  was  said  that  if  any  person  adminis- 
ters any  matter  or  thing  to  a  woman  who  is  pregnant  or  quick 
with  child,  with  intent  to  produce  an  abortion,  and  the  woman 
or  child  shall  die,  notwithstanding  the  matter  or  thing  adminis- 
tered is  but  a  crumb  of  bread,  such  person  is  within  the  statute 
and  may,  upon  proper  evidence,  be  convicted. -f- 

The  question,  therefore,  is  one  of  intention  and  not  of  the 
means  employed  ;  it  is  whether  the  drug  was  used  or  the  means 
were  employed  with  the  intent  to  induce  abortion. 

It  is  not  necessary  that  the  substance  administered  have 
some  inherent  tendency  to  accomplish  the  imputed  design.  If 
a  person  administers  any  harmful  substance  to  a  pregnant  wom- 
an, or  to  one  supposed  at  the  time  to  be  pregnant,  with  the  in- 
tent to  procure  her  miscarriage,  although  the  substance  adminis- 
tered may  fail  of  the  effect  designed,  and  although  it  may  have 
no  tendency  to  produce  such  effect,  he  will  be  guilty  of  the 
offense  of  criminal  abortion  within  the  contemplation  of  the 
statute. 

And  it  is  not  necessary  for  the  Commonwealth  to  establish 
beyond  doubt  what  was  the  direct  and  immediate  cause  of  the 
miscarriage;  the  question  is  whether  the  means  employed  were 
calculated  to  produce  it,  and  with  intent  to  do  so. J 

Summarizing  briefly,  we  conclude:  a.  That  in  respect  to  the 
crime  of  abortion  the  law  of  Pennsylvania  has  always  taken  an 
advanced  and  enlightened  view  as  compared  with  the  history 
of  the  law  relating  to  this  crime  in  other  States — its  policy  and 
first  care  throughout  being  the  preservation  of  foetal  life  and 
the  punishment  of  the  unlawful  destruction  thereof  severely  as 
compared  with  the  punishment  inflicted  upon  the  same  offense 
where  it  results  fatally. 

h.  That  the  intention,  not  the  means  employed,  constitutes 
the  crime,  which  is  complete  although  the  means  employed 
have  no  inherent  tendency  to  produce  the  designed  effect,  and 
although  the  woman  be  not  pregnant. 

c.  That  the  crime  under  our  statute  is  not  homicide  in  any 
of  its  forms,  but  simply  the  statutory  crime  of  committing  or 
attempting  to  commit  abortion;  and  that  in  its  essence  the  de- 
gree of  criminality  is  the  same  whether  the  results  are  fatal  or 
otherwise,  the  only  difference  being  a  slightly  increased  punish- 
ment in  the  former  case. 

Of  the  Legal  Reaiionsibility  of  the  Obstetrician  in  his  liela- 
tions  with  Abortion. — It  seems  a  proper  addition  to  this  state- 
ment of  the  law  to  offer  also  the  precautions  tiiereby  suggested 
for  the  guidance  of  the  professional  conduct  of  the  obstetrician 
in  order  to  shield  him  from  reproach,  suspicion,  or,  perhaps. 


*  Achcson,  P.  J.,  in  Commonwealth  v.t.  W  ,  3  Pittsburgh,  162 

(1871). 

f  Comniouwealtli  I's.  (Jumpert,  1  Luz.  Leg.  Reg.,  187  (1877). 

X  Acheson,  P.  J.,  in  Conunonwealth  vs.  W  ,  3  Pittsb.,  402  (1871). 


prosecution  in  those  relations  with  abortion  in  which  he  is 
likely  to  be  placed. 

That  abortion  may  in  some  cases  be  lawful  is  undoubted. 
This  fact,  while  not  expressed  in  the  terms,  is  true  as  a  neces- 
sary inference  from  the  language  of  the  statute:  it  is  the  un- 
lawful administration  of  drugs  and  the  unlawful  use  of  instru- 
ments that  is  denounced  by  its  sanctions.  Any  question,  there- 
fore, respecting  the  illegality  of  inducing  premature  labor  in 
certain  cases  where  the  life  of  the  woman  is  seriously  endan- 
gered, as  in  deformity  of  the  pelvis  or  in  excessive  vomiting 
from  pregnancy,  can  not  now  be  entertained ;  for  the  means 
are  administered  or  applied  with  the  bona  fide  intention  of  bene- 
fiting the  female,  and  not  with  any  criminal  design. 

Says  an  authority  :  *  "The  necessity  for  the  practice  ought 
to  be  apparent;  thus,  for  instance,  it  should  be  shown  that  de- 
livery was  not  likely  to  take  place  naturally  without  seriously 
endangering  the  life  of  the  woman.  It  is  questionable  whether, 
under  any  circumstances,  it  would  be  justifiable  to  bring  on 
premature  expulsion  merely  for  the  purpose  of  attempting  to 
save  tbe  life  of  the  child,  since  the  operation,  even  when  per- 
formed with  care,  is  accompanied  with  risk  to  the  life  of  the 
mother.  Hence  a  cautious  selection  of  cases  should  be  made, 
as  the  operation  is  necessarily  attended  with  some  risk  to  both. 

"All  that  we  can  say  is  that,  according  to  the  general  pro- 
fessional experience,  it  should  place  tlie  woman  in  a  better  posi- 
tion than  she  would  be  if  the  case  were  left  to  itself.  But  be- 
fore a  practitioner  resolves  upon  performing  an  operation  of 
this  kind  he  should  consult  with  his  colleagues;  and,  before  it 
is  performed,  he  should  feel  assured  that  natural  delivery  can 
not  take  place  without  greater  risk  to  the  life  of  the  woman 
than  the  operation  would  itself  create. 

"The  non-observance  of  these  rules  is  necessarily  attended 
with  some  responsibility  to  the  general  practitioner.  In  the 
event  of  the  death  of  the  woman  or  child  he  exposes  himself  to 
a  prosecution  for  a  criminal  offense,  from  the  imputation  of 
which  even  an  acquittal  will  not  always  clear  him  in  tbe  eyes 
of  the  public." 

The  physician  is  also  liable  to  be  brought  into  another  and 
different  relation  with  abortion — that  is,  when  he  is  called  to 
attend  a  patient  suffering  from  the  effects  of  a  criminal  opera- 
tion and  the  question  arises  as  to  his  legal  duty  in  order  to 
shield  himself  from  the  consequences  attending  his  after-ac- 
quired knowledge  of  the  crime. 

The  only  safe  course  for  such  physician,  after  being  satisfied 
with  the  correctness  of  his  diagnosis — confirmed  by  one  or, 
better  still,  two  of  his  colleagues — is  to  lay  the  information  so 
acquired  of  the  crime  before  the  prosecuting  attorney  of  the 
county.  But  it  may,  perhaps,  be  more  satisfactory  to  the  medi- 
cal profession  to  have  the  reasons  for  this  advice  set  forth  some- 
what in  detail. 

In  its  interpretation  of  the  two  sections  of  the  Abortion  Act, 
the  Supreme  Court,  as  mentioned  above,  has  decided,  and  ex- 
pressed its  opinion  with  some  emphasis,  that  the  two  offenses 
therein  described  are  the  same ;  consequently,  the  duty  of  the 
physician  in  his  relations  with  each  case — that  is,  whether  the 
woman  dies  or  survives  the  operation — is  the  same. 

That  Court  has  also  decided  that  dying  declarations  are  ad- 
missible in  evidence  only  in  cases  of  homicide ;  and,  as  the  same 
Court  has  further  declared,  as  above  stated,  that  criminal  abor- 
tion is  not,  in  this  State,  homicide  in  any  of  its  forms,  it  neces- 
sarily follows  that  the  dying  declarations  of  the  victim  of  an 
abortion  are  not  admissible  in  evidence  at  the  trial  of  a  person 
ciiarged  with  the  latter  crime.  And  as  it  frequently  happens, 
from  the  peculiar  circumstances  surrounding  cases  of  this  sort, 

*  Tiiylor's  Medical  Jui-ixprudence,  p.  529. 


478 


BOOK  NOTICES. 


(N.  Y.  Med.  Jo0b., 


tliat  this  is  the  only  evidence,  it  would  be  worse  than  useless  to 
make  any  exposure  of  a  matter,  the  only  effect  of  which  would 
be  to  bring  additional  shame  and  disgrace  upon  the  innocent 
family  and  relatives  of  the  victim,  with  no  possibility  of  con- 
victing the  accused. 

Hence  will  be  seen  the  wisdom  of  first  informing  the  jirose- 
cuting  ofScer  of  the  county  rather  than  the  coroner  or  the  police 
authorities.  For  it  is  the  duty  of  the  prosecuting  officer,  or  dis- 
trict attorney,  as  he  is  called  in  this  State,  to  prosecute  offend- 
ers against  the  law.  lie  is  skilled  in  tlie  law  and  able  to  weigh 
such  evidence  and  judge  of  its  probative  effect;  and  if,  for  any 
legal  I'eason,  such  as  stated  in  the  preceding  paragraph,  the  facts 
constituting  the  information  be  either  incompetent  or  insufficient 
as  evidence,  that  reason  will  be  known  to  the  district  attorney, 
and  unnecessary  public  exposure  will  be  avoided.  On  the 
other  hand,  the  subordinate  officers  referred  to  are  not  required 
to  be  skilled  in  the  law;  their  jurisdiction  is  limited  and  the 
sphere  of  their  official  duty  circumscrilied,  so  that  it  often  hap- 
pens that  unnecessary  publication  of  such  facts  results  fi'om  a 
mistaken  notion  of  their  duty.  Moreover,  they  are,  in  a  sense, 
merely  a  pnrt  of  the  machinery  in  the  hands  of  the  district  at- 
torney, that  may  be  employed  by  him  in  bringing  criminals  to 
justice. 

From  all  of  which  it  is  clear  that  the  proper  course  for  the 
physician,  in  every  instance,  is  to  lay  the  information  that 
comes  to  his  knowledge,  of  a  criminal  abortion,  before  the  dis- 
trict attorney.  This  may  be  done  either  in  person  or  by  letter 
to  that  officer,  setting  forth  the  facts,  and  it  then  becomes  his 
duty  to  take  whatever  subsecjuent  action  such  facts  may  seem 
to  warrant.  In  any  event,  the  physician  is  thus  relieved  of  fur- 
ther persona!  responsibility  in  the  matter. 

Furthermore,  such  a  course  on  the  part  of  a  physician  does 
not  render  him  liable  either  to  the  imputation  of  being  an  in- 
former or  a  detective,  nor  is  he  chargeable  with  a  violation  of 
professional  confidence.  Tlie  reason  is,  that  the  Legislature 
has  declared  criminal  abortion  to  be  a  felony,  and  to  conceal  a 
felony  is  an  offense  known  as  misprision  of  felony,  which,  under 
the  Criminal  Code  of  Pennsylvania,  renders  the  person  guilty 
thereof  liable,  if  convicted,  to  be  punished  as  an  accessory  after 
the  fact,  by  a  tine  not  exceeding  five  hundred  dollars  and  to 
undergo  an  imprisonment,  with  or  without  labor,  at  the  discre- 
tiim  of  the  Court,  not  exceeding  two  years.* 

Consequently,  the  physician  who,  in  the  face  of  the  power- 
ful and  persuasive  infiuences  against  disclosure  that  are  some- 
times brought  to  bear  upon  him  in  these  cases,  and  who, 
although  iiubued  with  a  tine  sense  of  the  sacredness  of  the  rela- 
tion of  physician  and  patient,  and  the  obligation  thereby  im- 
posed to  preserve  the  secrets  thereof  inviolate,  yet  yields  obedi- 
ence to  the  higlier  law,  not  only  discharges  a  high  and  solemn 
duty  to  the  public  by  making  such  information  as  will  aid  in  the 
punishment  and  prevention  of  a  crime,  so  dark  and  hidden,  that 
strikes  at  the  very  foundations  of  society,  but  also  relieves  his 
own  conscience  from  any  share  in  the  guilt  of  the  principal 
offender,  and  at  the  same  time  pursues  the  plain  course  marked 
out  by  law  to  shield  himself  from  any  liability  to  prosecution  by 
reason  thereof. 

The  observance,  therefore,  by  the  medical  practitioner  of 
these  simple  prudential  measures,  either  when  it  becomes  neces- 
sary to  induce  premature  labor  or  when  he  is  called  to  attend 
the  victim  of  an  abortion,  will  not  only  free  him  from  the  lia- 
bility of  any  criminal  charge,  but  commend  him  in  the  eyes  of 
the  law. 

( To  be  concluded.) 


*  Act,  March  31,  1860,  Sec.  180;  Pardon's  Digest,  Sec.  356,  p. 
469. 


|3ooIi  lloticfs. 


FtomaineH^  Leucomaines,  and  Bacterial  Proteidx ;  or  the 
Chemical  Factors  in  the  Causation  of  Disease.  By  Victok 
C.  Vaughan,  IMi.  D.,  M.  D.,  Professor  of  Hygiene  and 
Physiological  Chemistry  in  the  University  of  Michigan  and 
Director  of  the  Hygienic  Laboratory  ;  and  Fuedkrick  G. 
NovY,  Sc.  D.,  M.  D.,  Assistant  Professor  of  Hygiene  and 
Physiological  Chemistry  in  the  University  of  Michigan. 
Second  edition,  revised  and  enlarged.  Pliiladelphia :  Lea 
Brothers  &  Co.,  1891.    Pp.  391. 

A  GLANCE  at  an  author's  preface  and  at  his  table  of  contents 
almost  inevitably  precedes  the  perusal  of  his  book,  and  in  the 
present  instance,  events  having  occurred  in  their  logical  se- 
quence, we  feel  a  certain  disposition  to  slightly  criticise  our 
authors.  It  has  been  the  usage,  from  time  immemorial,  to 
utilize  a  i)reface  and  an  introduction  in  the  setting  forth  of  the 
author's  plan  and  intention — as  a  prologue,  in  fact.  "  To  col- 
lect, arrange,  and  systematize  the  facts  concerning  ptomaines 
and  leucomaines  has  been  the  first  object "  of  our  authors,  and 
for  this,  we  are  told,  everything  pnblisiied  to  1891  has  been 
made  use  of.  It  is  a  supposable  case  that  the  present  work 
should  fall  into  the  hands  of  a  i)erson  unprepared  by  previous 
technical  learning  for  the  study  before  him,  who  would  neces- 
sarily expect  to  have  a  reasonable  ainoimt  of  explanations  of 
the  terms  used.  Now,  if  this  j)erson  finds  the  entire  introduc- 
tion devoted  to  an  incidental  disquisition  on  bacteria  without 
any  statement  being  proffered  him  as  to  the  causal  relations 
existing  between  bacteria  and  ptomaines,  he  is  likely  to  be  dis- 
turbed and  far  from  satisfied.  Moreover,  although  the  deriva- 
tion and  u-age  of  the  word  ptomaine  are  duly  set  forth  in  the 
first  chapter,  we'are  obliged  to  wait  until  the  twelfth  before 
being  enlightened  as  to  the  nature  of  leucomaines  or  told 
wherein  they  diUVr,  if  at  all,  from  [jtomaines.  This  omission 
is  the  more  singular,  as  the  third  subject  of  the  book,  Bac- 
terial Proteids,  is  defined  at  the  same  time  as  the  ptomaines 
are,  in  the  first  chapter,  so  that  an  unprejudiced  person  might 
be  excusable  for  surmising  the  word  leucomaine  to  be  pnssibly 
a  synonym  of  one  or  the  other  of  the  two  terms.  We  believe 
also  that  Chapters  II,  III,  and  X  should  be  consecutive,  as  re- 
lating to  the  same  order  of  facts,  and  that  the  continuity  of  the 
historical  sequence  is  broken  by  the  enumeration  of  the  chemical 
and  physiological  reactions  of  each  ptomaine  and  the  conclu- 
sions of  their  discoverer.  The  index  of  Chapter  X,  as  given  in 
the  table  of  contents,  is  inadequate  to  expose  the  real  nature 
and  importance  of  the  subjects  treated  therein.  In  appearance, 
we  have  a  simple  enumeration  of  the  alkaloids;  in  reality,  we 
find  the  diagnosis  between  the  alkaloids  and  the  ptomaines. 
We  regret  having  to  call  attention  to  such  easily  rectified  over- 
sights in  a  work  of  so  much  erudition  and  vital  importance. 
We  are  sure  the  authors  deserve  the  thanks  of  all  interested  in 
their  subjects  for  their  painstaking  collation  of  so  many  inter- 
esting data. 

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Report  of  a  Case  of  Syringomyelia,  with  Exhibition  of  Sec- 
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in  the  City  of  New  York  for  the  Year  1892. 

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fessor of  Obstetrics  in  the  University  of  Pennsylvania,  and 
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ogy in  the  University  of  Pennsylvania.  Part  IV.  Illustrated 
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New  York,  etc.  Illustrated.  New  York :  E.  B.  Treat,  1898. 
Pp.  16-17  to  380.    [Price,  $2.75.] 

The  Meaning  of  the  Method  of  Life.  A  Search  for  Religion 
in  Biology.  By  George  M.  Gould.  A.  M.,  M.  D.  New  York 
and  London  :  G.  P.  Putnam's  Sons,  1893.  Pp.  iii-297.  [Price, 
$1.75.] 

Cholera,  its  Protean  Aspects  and  its  Management.  By  G. 
Archie  Stockwell,  F.  Z.  S.  In  Two  Volumes.  Vol.  I  and  II. 
Detroit:  George  S.  Davis,  1893.    Pp.  vii-306. 

Methods  of  Precision  in  the  Investigation  of  Disorders  of 
Digestion.  By  J.  II.  Kellogg,  M.  D.,  Battle  Creek,  Mich.  [Re- 
printed by  the  Modern  Medicine  Publishing  Comjiany.] 

A  Remarkable  Respiration  Record  in  Infantile  Pneumonia. 
By  William  A.  Edwards,  M.  D.,  San  Diego,  Cal.  [Reprinted 
from  the  Archives  of  Pcediatrics.] 

Albuminate  of  Iron.  By  W.  Blair  Stewart,  A.  M.,  M.  D., 
Philadelphia.    [Reprinted  from  the  American  Therapeutist.] 


480 


MISCELLANY. 


[N.  Y.  Med.  Jons., 


Experiments  with  Cocaine  Phenate  as  a  Local  Anesthetic. 
By  0.  A.  Veasey,  M.  D.,  Philadelphia.  [Reprinted  from  the 
Medical  News.^ 

A  Foreign  liody  impacted  in  the  Larjnx  Seventeen  Months; 
Removal  by  Laryngo-tracheotomy ;  Kecovery.  By  J.  F.  Kline- 
dinst,  M.  D.,  York,  Pa.    [Reprinted  from  the  Medical  News.] 

Practical  Experiments  in  the  Treatment  of  Cholera  in  St. 
Petersburg,  Russia,  and  Hamburg,  Germany,  in  the  Epidemic 
of  1892.  By  Elmer  Lee,  A.  M.,  M.  D.,  Chicago,  111.  [Reprinted 
from  the  Medical  Record.^ 


Ht  i  s  t  c  1  hi  IT  n . 


The  Treatment  of  Suppuration  in  the  Maxillary  Antrum. — In  the 

April  number  of  the  Dublin  Jourjial  of  Medical  iSeieiire  tliere  is  a  trans- 
lation, by  Dr.  Arthur  W.  Baker,  of  a  chapter  in  a  recent  text  book  of 
dentistry  by  Professor  Partsch,  of  Breslau,  on  Diseases  of  the  Antrum. 

The  treatment  of  suppuration  in  the  antrum  must,  in  the  first  place, 
says  the  author,  have  for  its  object  the  removal  of  the  cause.  That  an 
antrum  should  be  treated  by  syringing  it  out  while  the  carious  roots  of 
upper  molars  with  inflamed  root  meml>ranes  are  left  alone,  is  without 
reason.  The  extraction  of  teeth  proved  to  be  diseased  is  to  be  carried 
out,  unless  they  are  to  be  treated  conservatively,  even  if  they  only 
awaken  the  suspicion  that  they  are  engaged  in  the  causation  of  an  em- 
pyema of  the  antrum.  Also  stopped  teeth,  although  they  may  excite 
no  pain,  may  nevertheless  be  the  cause  of  a  circumscribed  apical  root- 
membrane  inflammation,  combined  with  proliferation  of  granulation  tis- 
sue, and  so  exercise  a  constant  irritation  on  the  neighboring  mucous 
membrane  of  the  antrum.  How  often  do  we  observe  perfectly  painless 
chronic  swellings  persisting  on  the  jaw  that  are  only  maintained  by  such 
granulation  proliferation  ! 

The  closest  examination  of  the  mouth  and  teeth  of  the  affected  half 
of  the  Jaw  must  precede  any  therapeutic  measure.  A  hasty  view  of  the 
teeth  does  not  suffice.  Often  carious  defects  are  concealed  on  the  ap- 
proximate surfaces  or  under  the  gums  by  the  necks  of  the  teeth,  and 
are  only  to  be  found  by  the  most  careful  examination  with  mirror  and 
probe.  Frequently  a  stream  of  cold  water  reveals  an  exposed  pulp  with 
but  a  small  concealed  cavity,  or  a  closer  examination  of  a  tooth  shows 
an  isolated  sensibility  of  the  root  to  pressure. 

The  least  suspicion  of  a  tooth  in  the  range  of  the  molars  and  bicus- 
pids being  affected  warrants  its  extraction  in  a  case  where  a  unilateral 
purulent  discharge  is  present.  Extraction  affords  also  an  opportunity 
for  opening  the  antrum.  If  the  antrum  is  not  already  opened  by  the 
extraction,  it  may  be  perforated  from  the  bottom  of  the  socket  with  a 
chisel  or  strong  trocar.  I  maintain  that  this  method  is  more  quickly 
carried  out  than  perforating  with  the  drilling  engine,  as  it  is  hardly  pos- 
sible with  the  usual  bin-ring  engine  to  bore  with  a  thick  drill  through 
the  hard  bone.  A  vigorous  thrust  with  chisel  or  trocar  opens  the  cavity 
and  provides,  by  a  species  of  rotation  movement,  with  the  instrument 
already  introduced,  for  a  sufficient  width  of  the  canal.  The  anaesthesia 
produced  by  bromide  of  ethyl  here  renders  excellent  service. 

I  introduce  at  once  into  the  passage  a  rubber  drainage-tube  which 
consists  of  a  rubber  plate  vulcanized  on  at  right  angles  to  a  drainage- 
tube.  No.  1  or  No.  2,  having  a  small  flap  covering  the  end  of  the  tube 
transversely.  A  drainage-tube,  being  drawn  over  a  bulbed  probe  nearly 
to  its  upper  end,  is  introduced  with  the  probe  into  the  canal.  It  lies 
close  to  the  wall  of  the  passage,  and  prevents  the  entrance  of  particles 
of  food.  Access  to  the  tube  is  closed  l)y  the  valve  to  substances  enter- 
ing from  the  mouth.  The  plate  may  be  so  cut  that  it  lies  well  on  the 
alveolar  process  and  between  the  teeth.  It  prevents  the  drainage-tube 
from  slipping  up  into  the  antrum  and  facilitates  its  removal  if  the  canal 
is  molded  round  it.  From  the  first  day  the  patient  is  able  to  syringe 
out  the  antrum,  for  he  only  needs  to  introduce  the  syringe  into  the 
drainage-tube  underneath  the  free  portion  of  the  small  valve  flap,  in 
order  with  ease  to  bring  the  stream  into  the  antrum.    On  the  with- 


drawal of  the  syringe  the  flap  places  itself,  in  virtue  of  its  elasticity,  be- 
fore the  opening  of  the  tube,  and  will  be  pressed  close  against  it  by 
every  bite. 

These  cannula;  have  rendered  me  better  service  than  ordinary  drain- 
age-tubes secured  to  the  teeth  with  threads  or  bands,  or  metal  tubes 
with  plates  for  fastening  to  the  teeth.  To  say  nothing  of  their  higher 
price  and  the  impossibility  of  applying  them  in  all  cases,  the  latter  have 
the  disadvantage  that  they  follow  the  mechanical  working  of  the  bite 
I)ressure  much  less  easily,  but  exercise  slight  pressure  in  the  bony  canal. 
In  using  my  rubber  drainage-tube  one  has  only  to  take  care  that  the 
tube  is  not  left  too  long,  as  otherwise  it  will  not  lie  with  its  upper  end 
on  the  floor  of  the  antrum,  but  will  reach  into  it. 

Should  the  canal  become  covered  with  granulations  the  drainage- 
tube  should  l)c  replaced  by  a  thinner  and  more  delicate  one,  which  in 
like  manner  lies  snugly  against  the  alveolar  process,  but  is  not  perfo- 
rated throughout.  I  use  for  this  purpose,  what  is  already  an  article  of 
commerce,  the  so-called  artificial  memhranatympani,  according  to  Lucae, 
which  is  formed  of  a  thin,  delicate  rubber  tube  carrying  a  plate  which 
by  virtue  of  its  delicacy  adheres  lightly  and  securely  to  the  mucous 
membrane  of  the  alveolar  process.  The  small  tube  is  to  be  removed 
at  each  syringing ;  the  syringing  being  accomplished,  and  after  antisep- 
tic cleansing,  the  tube  is  replaced.  Thus  the  treatment  may  be  carried 
on  without  inconvenience  to  the  patient  for  weeks  and  months,  as  long 
as  is  requisite.  It  remains  to  be  observed  that  the  drainage-tube  should 
not  be  allowed  to  remain  in  too  long,  as  it  is  capable  of  acting  as  a  for- 
eign body  and  exciting  the  formation  of  pus.  It  should  be  removed  as 
soon  as  the  flow  of  pus  is  reduced  to  a  minimum. 

Contrasted  with  the  opening  of  the  antrum  from  the  alveolar  pro- 
cess, that  from  the  nose  offers  the  great  advantage  that  particles  of  food 
can  not  lodge  in  the  antrum  ;  but  it  has  the  disadvantage  that  it  is  more 
difficult  to  perform,  and  the  after-treatment  is  more  complicated. 

Against  the  contention  of  Zuckerkandl,  based  on  anatomical  facts, 
that  the  nasal  opening  should  be  made  from  the  middle  naris,  since  here 
the  wall  of  the  antrum  may  be  most  easily  pierced,  must  be  placed  the 
clinical  fact  that  any  em|)yema,  when  possible,  is  to  be  opened  at  its 
lowest  point,  since  otherwise — some  secretion  being  always  retained — 
its  ultimate  cure  will  be  retarded,  if  not  rendered  impossible.  It  was 
this  reason,  perhaps,  in  addition  to  the  technical  difticulty,  that  caused 
Mikulicz  to  carry  it  out  from  the  lower  nasal  passage ;  to  him  we  are 
indebted  for  the  reinvestigation  of  the  opening  of  the  antrum  from  the 
nose,  which  had  been  known  to  Hunter  and  Jourdain,  and  had  then  sunk 
into  oblivion.  Mikulicz  bores  through  the  nasal  wall  of  the  antrum  in 
the  inferior  meatus  with  a  stilette  fitted  at  an  obtuse  angle  to  a  curved 
handle.  In  the  meatus  the  instrument  is  carried  first  with  its  point 
turned  forward  and  downward — if  it  is  kept  close  to  the  inferior  turbi- 
nated bone — then  the  point  is  turned  gradually  outward  so  as  to  come 
round  the  lower  border  of  the  turbinated  bone. 

If  by  turning  the  handle  outward  one  succeeds  in  passing  under 
the  turbinated  bone,  the  wall  of  the  antrum  is  at  once  perforated  with 
a  powerful  thrust.  Then  one  cuts  out  so  much  of  the  bony  wall  by 
planing  and  shaving  movements  that  the  instrument  can  move  freely 
in  and  out  in  the  opening  Just  formed.  An  abnormal  narrowing  of  the 
inferior  naris,  a  considerable  hypertrophy  of  the  inferior  turbinated 
bone,  or  an  unusual  thickening  of  the  bony  wall  between  the  antrum 
and  the  inferior  meatus,  may  render  the  operation  itself  difficult  or  im- 
possible (Michelson). 

From  the  opening  the  antrum  is  daily  syringed  out  w  ith  a  ball  syr- 
inge until  the  cure  of  the  catarrh  is  complete. 

The  circumstance  that  in  the  after-treatment  the  necessary  syring- 
ing of  the  antrum  must  always  be  carried  out  by  the  physician,  or  under 
the  direction  of  the  phy.-ician,  has  called  forth  various  changes  of  the 
method. 

Firstly,  Krause  has  modified  the  instrument  by  giving  it  the  form 
of  a  curved  trocar,  and  by  using  it  for  perforation,  after  the  withdrawal 
of  the  stilette,  the  cannula  can  remain,  and  at  once  the  syringing  of  the 
antrum  may  be  commenced.  The  search  for  the  opening  that  has  been 
made  by  Mikulicz's  method,  in  order  to  introduce  the  ball  syringe,  on 
account  of  the  certain  bleeding,  is  a  disadvantage. 

After  the  withdrawal  of  the  cannula,  in  order  that  the  troublesome 
introduction  of  the  catheter  for  syringing  tlirough  the  opening  formed 


April  29,  1893.] 


MISCELLANY. 


481 


by  perforation  may  be  dispensed  with,  I  have  introduced  at  once  a  full- 
sized  celhiloid  tube  through  the  cannula  itself,  pushed  as  far  as  the 
posterior  wall  of  the  antrum.  If  tlie  tube  selected  is  very  long  (the 
best  celhiloid  catheters  in  the  market  are  to  be  used  for  the  purpose), 
it  is  easy  while  the  tube  is  pressed  toward  the  antrum  to  draw  down 
the  cannula  over  the  tube,  the  celluloid  tube  being  cut  sufficiently 
short  to  be  concealed  in  the  outer  naris  in  the  corner  between  the  carti- 
laginous sa^ptum  and  the  ala  nasi.  So  the  patient  carries  it  without 
trouble  from  four  to  si.x  weeks,  so  long  as  treatment  is  necessary — the 
patient  being  in  the  position  to  perform  the  syringing  for  himself. 

Being  placed  in  front  of  tlie  mirror,  he  presses  the  point  of  the  nose 
upward,  and  by  dint  of  practice  causes  the  opening  of  the  little  tube  to 
become  visible,  which  usually  is  hidden  in  the  meatus  of  the  nose.  In 
it  he  fixes  the  cannula  of  his  syringing  apparatus.  Larger  sizes  can 
easily  be  introduced  for  any  desirable  dilatation  of  the  communicating 
passage.  My  colleague,  Schwartz,  to  whom  I  have  communicated  this 
method,  has  been  so  kind  as  to  adopt  it  and  recommend  it  warmly. 
He  has  also  decidedly  improved  Krause's  instrument.  The  old  instru- 
ment had  the  disadvantage  that,  particularly  where  a  strong  push  was 
necessary  to  bore  through  into  the  antrum,  the  tapering  trocar  stopped 
at  its  upper  end  and  the  opening  of  the  cannula  no  longer  closely  fitted 
it,  so  that  in  the  thrust  of  the  instrument  the  edge  of  the  cannula  was 
turned  up  if  the  stilette  pierced  the  wali  of  the  .jaw. 

Schwartz,  then,  has  removed  these  really  practical  drawbacks  to 
the  operation  by  making  the  trocar  completely  solid ;  and,  in  order  to 
turn  the  curved  cannula  over  the  firm  trocar,  at  present  the  cannula  is 
made  jointed,  like  Konig's  long  tracheal  cannula. 

This  modification  necessitated,  in  order  that  the  cannula  could  be 
easily  removed  and  drawn  back  over  the  celluloid  tube,  a  rigid  guide- 
rod  inside  the  jointed  segments  of  the  cannula.  This  instrument  is 
now  so  modified  as  to  prove  very  useful,  and  I  intend  to  use  it  exclu- 
sively. 

When  in  one  of  these  ways  the  passage  to  the  antrum  has  been 
formed,  then  comes  the  task  of  removing  the  purulent  contents  of  the 
antrum,  and  so  far  allaying  the  catarrhal  irritation  or  purulent  inflam- 
mation of  the  mucous  membrane  of  the  antrum  that  no  further  fluid 
will  be  secreted. 

The  first  task  is  that  most  easily  performed.  Then  the  cavity  at 
once  after  the  opening  may  be  washed  out  with  a  warm  antiseptic  .solu- 
tion as  unirritating  as  possible,  or  sterilized  Koch's  solution  of  salt 
water  0'6  per  cent.,  the  injection  requiring  a  greater  or  less  amount  of 
pressure  according  to  the  consistence  of  the  pus  and  the  capacity  of 
the  natural  opening  of  the  antrum,  which  generally  will  readily  be  per- 
ceived by  the  patient  himself. 

It  is  often  necessary,  owing  to  the  thickened  mass  of  pus  and  to  a 
considerable  narrowing  of  the  orifice,  for  a  long  time  to  elapse  before 
the  injection  runs  out  clear. 

An  offensive  odor  often  betrays  to  wliat  great  extent  decomposition 
has  taken  place  in  the  pus.  The  patient  perceives  after  the  removal  of 
this  substance  that  he  is  evidently  lighter — he  forgets,  in  the  disappear- 
ance of  the  heavy  pressure,  and  in  being  free  from  the  tormenting 
smell,  the  momentary  ]5ain  of  the  operation.  Generally  the  majoiity 
of  patients  present  a  lively  and  cheerful  appearance  on  the  day  suc- 
ceeding the  operation.  Then  comes  the  often  more  troublesome  task 
for  the  physician — to  bring  about  the  complete  cure  of  the  suppura- 
tion. Often  it  can  be  accomplished  by  blowing  out  through  the  antrum, 
but  only  if  the  pei-foration  has  been  made  from  the  alveolar  process. 
If  the  patient  is  told  to  drive  air  from  the  nose  while  compressing  both 
the  outer  nares,  then,  owing  to  the  free  communication  of  the  antriun 
with  the  nasal  cavity,  it  goes  through  the  canal  which  has  been  formed 
to  the  mouth,  and  it  carries  with  it  the  accumulated  pus. 

In  other  cases  syringing  must  be  employed  in  order  to  bring  about 
a  cessation  of  the  suppuration.  While  this  in  many  cases  succeeds 
very  quickly,  in  others  it  takes  an  endless  amount  of  trouble  and  severely 
tests  the  patience  of  the  sufferer  as  well  as  the  physician.  It  is  these 
cases  which  always  occasion  the  recommendation  of  new  remedies  that 
are  said  to  have  a  special  action  on  suppuration  m  the  antrum. 

Solutions  are  reconiiiiended  and  employed,  such  as  boric  acid, 
salicylic  acid,  permanganate  of  potassium,  sozoiodide  of  zinc,  nitrate  of 
silver,  pyoctanin,  peroxide  of  hydrogen,  corrosive  sublimate.  Rotter's 


solution — briefly,  every  newly  puffed  antiseptic.  As  a  washing-out  ajv 
paratus,  I  have  made  use  of  a  form  of  douche  which  has  a  rubber  ball 
and  pointed  injection  tube.  It  may  also  readily  be  employed  as  a  syr- 
inge by  compression  on  the  upper  part  of  the  ball  in  cases  where 
stronger  pressure  is  recjuisite.  That  in  obstinate  cases  the  treatment 
with  dry  antiseptics,  iodoform,  or  iodol — as  has  been  recommended  by 
Krause  and  Friedliinder — will  always  attain  its  object,  to  my  experience 
appears  questionable.  I  have  also  lately  used  the  dry  "dermatol" 
(subgallate  of  bismutli),  but  without  apparent  result.  The  powder 
treatment  of  suppuration  of  the  antrum,  which  has  also  its  advantages 
— principally  that  the  patient  is  saved  the  troublesome  syringing — is  to 
be  conducted  in  this  maimer.  The  antrum  having  been  perforated 
with  a  strong  trocar,  and  the  cavity  thoroughly  cleansed  of  its  purulent 
contents  by  means  of  Kabier's  insufflator,  with  which  is  combined  a 
special  close-fitting  moutlipiece,  a  large  quantity  of  iodoform  or  iodol  is 
introduced  into  the  antrum  and  distributed  over  it,  and  it  is  closed.  Ac- 
cording to  the  requirements  of  the  case,  after  a  delay  of  from  three  to 
four  days,  a  similar  insufflation  may  be  performed  again.  The  sozoio- 
dide of  zinc,  unfortunately,  is  said  to  form  into  a  mass,  and  therefore 
is  of  little  use  for  this  jjurpose.  It  would  be  desirable  to  find  a  substi- 
tute for  iodoform,  as  certain  persons  have  such  a  strong  idiosyncrasy 
with  regard  to  iodoform  that  they  begin  to  complain  of  headache,  gid- 
diness, vomiting,  and  loss  of  appetite,  besides  the  constant  unpleasant 
mixture  of  iodoform  with  the  breath,  and  the  fact  that  each  meal  tastes 
of  iodoform.  The  odorless  dermatol  has  in  this  instance  not  yet 
proved  a  substitute  for  iodoform. 

The  obstinacy  of  certain  cases  depends  probably  on  the  anatomical 
changes  of  the  mucous  membrane  of  the  antrum,  either  inflammatory 
or  of  the  nature  of  a  tumor.  For  their  cure  energetic  measures  will  be 
necessary.  They  possibly  may  be  treated  by  making  a  free  passage  to 
the  antrum  by  a  wide  opening  of  the  facial  wall.  This  method,  in- 
augurated by  Desault,  has  lately  been  warmly  advocated  by  Kiister. 
Kiister  has  improved  it  by  carrying  it  out  subperiosteally. 

After  a  previous  application  of  cocaine,  a  flap  of  mucous  membrane 
having  its  base  above  is  to  be  traced  out,  extending  from  the  first 
bicuspid  to  the  first  molar ;  the  periosteum  is  raised  with  an  elevator,  and 
while  the  flap  is  retracted  strongly  upward,  the  antrum  is  laid  open  with 
chisel  and  hammer.  The  opening  thus  punched  out  should  be  made  sulli- 
ciently  wide  that  the  finger  maybe  introduced  to  explore  the  antrum.  I 
prefer  to  illuminate  the  antrum  from  the  opening  with  tlie  usual  electric- 
light  apparatus  for  the  ear  or  urethra,  and  to  inspect  the  walls  closely. 
This  illumination  of  the  antrum  is  far  more  useful  than  its  transillumina- 
tion. Then  whatever  one  finds  as  the  cause  of  the  supjiuration  in  the  an- 
trum— necrosis,  roots  of  teeth,  unerupted  teeth,  foreign  bodies,  tumors 
of  various  kinds,  etc. — it  is  self-evident  must  be  removed.  Also  the  pus 
may  be  thoroughly  evacuated.  If  the  cavity  is  then  filled  with  a  loose 
plug  of  iodoform  gauze,  the  previous  severe  suppuration  seems  to  van- 
ish quickly  and  rapidly,  as  well  as  all  its  accompanying  complaints. 
For  the  after-treatment  I  have  used  the  drainage-tubes  already  in-evi- 
oiisly  mentioned,  but  with  the  difference  that  I  order  them  to  be  so 
manufactured  that  the  plate  is  not  fastened  horizontally,  but  obliquely 
on  the  rubber  tube,  in  order  that  they  can  be  easily  pushed  into  the 
cavity ;  only  the  upper  half  of  the  plate  must  be  entirely  cut  off,  there 
being  no  room  for  it  vertically,  since  the  opening  always  lies  high  on 
the  reflected  fold  of  the  oral  cavity. 

Gradually  the  opening  whicli  has  been  made  so  large  contracts  to 
the  extent  that  only  a  medium-sized  canal  remains,  through  which  the 
drainage-tulie  may  easily  be  pushed  in  and  out.  A  patient  has  already 
carried  a  cannula  without  inconvenience  over  a  year  and  a  day,  and 
can  not  be  induced  to  allow  it  to  be  removed,  as  she  fears  the  return  of 
her  old  complaint,  although  she  feels  perfectly  well. 

The  rubber  drainage-tube  remains  perfectly  steady  by  itself,  and  need 
neither  be  fixed  by  an  artificial  plate  nor  fastened  round  the  teeth  l>y 
threads. 

This  operation  must  be  reserved  far  the  severest  cases  of  supimra- 
tion  of  the  antrum  and  tor  the  removal  of  foreign  bodies  and  tumors. 
For  the  latter  cases  it  is  the  only  rational  one. 

The  Texas  State  Medical  Association  wi'l  hold  its  twenty-fifth  an- 
nual meeting  in  (iaiveston  on  Tuesday,  Wednesday,  Thursday,  and  Fii- 


482 


MISCELLANY. 


[N.  Y.  Med.  Jodr,, 


day,  May  2d,  3d,  4th,  and  5th,  under  the  presidency  of  Dr.  J.  D.  Osborn, 
of  Cleburne.    Tlie  preliminary  programme  is  as  follow.s : 

Section  in  General  Jl/cdinnc. — Report  of  the  chairman,  Dr.  J.  C- 
Loggins,  of  Ennis ;  The  Association  of  Di.-^eases  and  Morbid  Proces.ses, 
by  Dr.  H.  A.  West,  of  Galveston  ;  The  Action  and  Uses  of  Pental,  by 
Dr.  David  Cerna,  of  Galveston ;  Metastasis  in  Cancer  of  the  Ktoniach, 
by  Dr.  Allen  J.  Smith,  of  Galveston  ;  The  Continued  Fevers  of  Te.\as 
Classified,  by  Dr.  B.  F.  Brittain,  of  Baird ;  A  Study  of  the  Factors  con- 
cerned in  the  Reconversion  of  Peptone  into  Albumin,  and  their  Rela^ 
tion  to  Certain  Organic  Diseases,  by  Dr.  James  Kennedy,  of  San  An- 
tonio ;  Opium  Suicides,  their  Prevention  and  Treatment — Report  of  Fif- 
teen Cases,  by  Dr.  E.  W.  Capps,  of  Fort  Worth  ;  Report  of  Ten  Cases  of 
Membranous  Croup,  with  Remar  ks  on  Treatment,  by  Dr.  I.  E.  Clark,  of 
Schulenburg ;  Concussion  of  the  Spine,  by  Dr.  C.  H.  Wilkinson,  of 
Galveston. 

Section  in  Obstetrics  and  Diiyeaises  of  Children. — Report  of  the  chair- 
man. Dr.  Irvin  Pope,  of  Tyler;  The  Influence  of  Development  in  Dis- 
eases, by  Dr.  H.  P.  Cooke,  of  Galveston ;  Paracentesis  Capitis  in  Hydro- 
cephalus— Report  of  a  Case,  by  Dr.  N.  A.  Olive,  of  Waco ;  Placenta 
PriEvia,  with  New  Instruments  for  treating  the  Same,  by  Dr.  Q.  C. 
Smith,  of  Austin. 

Section  in  Surf/erif. — Report  of  the  chaiiinan.  Dr.  A.  B.  Gardner,  of 
Bellville ;  Whitehead's  Operation  for  Ha'uiorrhoids  considered  from  an 
Anatomical  and  Pathological  Standpoint,  by  Mr.  James  E.  Thompson, 
of  Galveston ;  Rapid  Operating  as  a  Factor  in  Surgical  Success,  by  Dr. 
A.  Morgan  Cartledge,  of  Louisville,  Ky. ;  A  Case  of  Splenectomy,  with 
Recovery,  by  Dr.  J.  F.  Y.  Paine,  of  Galveston ;  The  Treatment  of  De- 
pressed Fractures  of  the  Skull,  by  Dr.  P.  C.  Coleman,  of  Colorado ; 
Gunshot  Wound  of  the  Chest  and  Spine,  by  Dr.  J.  E.  Prince,  of  Big 
S])rings ;  The  Treatment  of  Tetanus,  by  Dr.  George  H.  Lee,  of  Galves- 
ton ;  The  Treatment  of  Perforating  Typhoid  Ulceration  by  Operative 
Measures,  by  Mr.  James  E.  Thompson,  of  Galveston  ;  A  Modified 
Whitehead's  Operation  for  Hseraorrhoids,  by  Dr.  A.  F.  Sampson,  of 
Galveston;  Bone  Excision  in  the  Forearm,  by  Dr.  W.  R.  Blailock, 
of  McGregor;  Incised  Wound  of  the  Abdomen — Removal  of  One 
Third  of  the  Omentum — Recovery,  by  Dr.  I.  E.  Clark,  of  Schulen- 
burg ;  Moist  Gangrene  with  Amputation,  by  Dr.  J.  D.  Osborn,  of 
Cleburne. 

Section  in  Medical  Jurinprudence. — Progress  made  in  the  Treatment 
of  the  Insane,  by  Dr.  John  Preston,  chairman ;  Hypnotism,  by  Dr.  Mat- 
thew M.  Smith,  of  Austin;  Transverse  Myelitis,  with  Cases,  by  Dr. 
Allen  J.  Smith,  of  Galveston. 

Section  in  State  Medicine,  etc. — Report  of  the  chairman,  Dr.  C.  M. 
Rosser,  of  Dallas  ;  Some  Thoughts  on  Higher  Medical  Education  and 
Medical  Ethics,  by  Dr.  David  Cerna,  of  Galveston. 

Section  in  Gynaecology. — Address  of  the  chairman.  Dr.  J.  F.  Y. 
Paine,  of  Galveston ;  The  Pathology  and  Treatment  of  lutrapelvic  In- 
flammation in  Women,  by  Dr.  Louis  McMurtry,  of  Louisville,  Ky. ;  A 
Contribution  to  the  Pathology  of  the  Fourchette,  by  Dr.  B.  E.  Hadra, 
of  Galveston  ;  Rupture  of  the  Perinaeum,  by  Dr.  B.  H.  Vaughan,  of 
Vaughan ;  Two  Cases  of  Unilateral  Oophorectomy,  with  Practical  De- 
ductions pertaining  thereto,  by  Dr.  J.  Cummings,  of  Austin ;  Cervical 
and  Corporeal  Endometritis,  by  Dr.  W.  M.  Cunningham,  of  Bastrop ; 
Preventive  Gynajcology — Important  Factors  in  the  Causation  of  Uterine 
Disorders  and  Neurasthenia,  by  Dr.  M.  S.  Scott,  of  Brownwood ;  The 
Use  of  Electrolysis  in  Stenosis  of  the  Cervix  Uteri,  by  Dr.  Arthur  S. 
Wolff,  of  Brownville;  Pelvic  Peritonitis  and  Cellulitis,  by  Mr.  W.  Keil- 
ler,  of  Galveston. 

Section  in  Ophthalmology  and  Otology. — A  Contribution  to  the  Study 
of  Insuflicieucics  of  the  Ocular  Muscles  and  the  Measures  directed  to 
their  Relief,  by  Dr.  G.  P.  Hall,  of  Galveston;  Trachoma,  or  Granular 
Conjunctivitis,  by  Dr.  R.  E.  Haughton,  of  Midland  ;  Paralysis  of  Ac- 
commodation as  a  Sequela,  by  Dr.  W.  Caston,  of  Corsicana  ;  Neurosis 
of  the  Eye  due  to  Stricture  of  the  Male  Urethra,  with  Cases,  by  Dr. 
John  V.  Spi'ing,  of  San  Antonio ;  Otitis  and  its  Treatment,  by  Dr.  W.  H. 
Monday,  of  Terrell ;  Aural  Catarrh,  the  Importance  of  Early  Recog- 
nition and  Treatment,  by  Dr.  W.  H.  Baldinger,  of  Galveston. 

Scctleyn  in  Dermatology,  etc. — Report  of  the  chairman.  Dr.  R.  W. 
Knox,  of  Houston  ;  Acne,  by  Dr.  ¥.  E.  Daniel,  of  Austin ;  Circumcision, 
by  Dr.  R.  W.  Knox,  of  Houston. 


Section  in  Microscopy  and  Pathology. — Histological  Demonstrations 
of  Malignant  Tumors,  by  Dr.  Allen  J.  Smith,  of  (ialveston. 

The  Pan-American  Medical  Congress. — The  Secticm  in  Marine  Hy- 
giene and  Quarantine  has  been  organized  as  follows :  Honorary  presi- 
dents :  Dr.  Lino  Alarco,  Lima,  Peru  ;  Dr.  Henry  B.  Baker,  Lansing, 
Mich.;  Dr.  Cardenas,  Managua,  Nicaragua;  Dr.  J.  J.  Corailliac,  St. 
Pierre,  Martinicpie,  F.  W.  I. ;  Dr.  Felix  Formento,  New  Orleans ;  Dr.  H. 
B.  Horlbeck,  Charleston ;  Lieutenant-Colonel  Araalio  Lorenz,  Sub-in- 
spector of  second  class  Spanish  Navy,  Havana ;  Dr.  F.  Monlizambert, 
Quebec,  Canada ;  Dr.  Francisco  Nunez,  St.  Tecla,  Salvador ;  Dr.  Juan 
Ortego,  Guatemala,  (iuatemala;  Dr.  Joseph  Y.  Porter,  Jacksonville, 
Fla.  ;  Dr.  John  Pringle,  Kingston,  Jamaica ;  Dr.  Juan  J.  Unoa,  San 
Jos6,  Costa  Rica  ;  Dr.  J.  Mills  Browne,  Surgeon  General,  United  States 
Navy.  Executive  president :  Dr.  Walter  Wyman,  Surgeon  General, 
United  States  Mai  ine-Hospital  Service,  Washington.  Secretaries :  Dr. 
S.  T.  Armstrong  (English-speaking),  166  West  Fifty-fourth  Street,  New 
York;  Dr.  G.  M.  Guit6ras  (Spanish  speaking).  United  States  Marine- 
Hospital  Service,  Washington.  Advisory  Council :  Dr.  H.  M.  Biggs, 
New  York  city  ;  Dr.  John  C.  Boyd,  United  States  Navy ;  Dr.  H.  R. 
Carter,  Norfolk,  Ya. ;  Dr.  W.  M.  L.  Coplin,  Philadelphia  ;  Dr.  A.  G. 
Clopton,  Galveston,  Texas ;  Dr.  C.  G.  Currier,  New  York ;  Dr.  S.  Dur- 
gin,  Boston:  Dr.  Seneca  p]gbert,  Boston  ;  Dr.  George  Homan,  St.  Louis; 
Dr.  W.  T.  Jenkins,  New  York;  Dr.  J.  F.  McShane,  Baltimore;  Dr.  G. 
H.  F.  Nuttall,  Baltimore  ;  Dr.  S.  R.  OUiphant,  New  Orleans ;  Dr.  Dab- 
ney  Scales,  Mobile;  Dr.  R.  M.  Swearingen,  Austin,  Tex. 

The  executive  president  desires  to  call  the  attention  of  all  members 
of  the  medical  profession  that  are  interested  in  the  topics  pertaining  to 
this  section  to  the  regulation  of  the  congress,  that  contributors  are  re- 
quired to  forward,  not  later  than  July  1st,  to  the  secretary  of  the  sec- 
tion, abstracts,  not  to  exceed  six  hundred  words  each,  of  the  papers 
they  propose  to  present  before  the  section. 

The  topics  that  will  be  considered  by  this  section  are  as  follows  :  1. 
The  hygiene  of  vessels,  commercial  or  naval,  including  the  questions  of 
ventilation,  heating,  sanitary  arrangements,  the  disposal  of  cargo  so  as 
to  facilitate  disinfection,  food  supply,  etc.  2.  The  medical  officers  of 
passenger  vessels ;  methods  for  their  selection,  duties,  etc.  3.  The 
vital  statistics  of  seamen  and  firemen.  The  question  of  the  medical  ex- 
amination of  crews  preparatory  to  .shipping.  4.  The  supervision  of 
vessels  by  government  medical  inspectors  at  ports  of  arrival  and  of 
departure.  Code  of  rules  for  handling  an  e^iidemic  disease  that  breaks 
out  on  shipboard.  Disinfection  of  passengers  and  crew  during  a  voy- 
age. Location  and  arrangement  of  ships'  hospitals.  5.  Epidemic  and 
exotic  diseases  propagated  by  shipping.  What  diseases  should  be 
quarantined.  Responsibility  of  nations  for  epidemics ;  India  for  chol- 
era. South  America  for  yellow  fever.  Can  a  feasible  plan  be  devised  to 
totally  exterminate  cholera?  International  intei-vention  to  prevent  the 
propagation  of  cholera  or  other  epidemic  diseases  by  pilgrimages  or 
immigration.  6.  International  uniformity  in  quarantine  regulations. 
Should  quarantine  officers  be  notaries  public  ?  7.  Arrangement  of  de- 
tail and  equipment  of  quarantine  stations :  a,  inspection  stations ;  6, 
local  quarantine  stations  ;  c,  refuge  stations.  Methods  for  handling  in- 
fected or  suspected  vessels.  Interstate  and  inland  quarantine :  sani- 
tary cordons ;  camps  of  refuge ;  camps  of  probation.  Recent  improve- 
ments in  hospitals  for  infectious  diseases.  Railroad  inspection  and 
quarantine.  Length  of  time  vessels  should  be  held  in  quarantine.  Con- 
ditions that  should  determine  proclamation  of  quarantine  against  a 
country.  Under  what  requirements  may  passenger  traffic  be  carried  on 
between  a  port  infected  with  yellow  fever  and  a  Southern  poit  of  the 
United  States  during  the  summer  with  the  least  obstruction  to  such 
traffic?  What  merchandise  should  be  considered  as  re(iuiring  treat- 
ment if  shipped  from  a  port  or  place  infected  with  cholera,  yellow 
fever,  or  small-pox  ?  8.  Methods  of  disinfection  :  a,  persons ;  6,  bag- 
gage ;  c,  cargoes ;  d,  vessels.  Recent  improvements  in  quarantine  ap- 
pliances ;  steam  chambers ;  sulphur  furnaces.  Liquid  sulphur  dioxide 
as  a  disinfectant.  Treatment  of  ballast :  water ;  solid.  What  time 
should  an  infected  vessel  be  detained  in  quarantine  ?  :  a,  for  cholera ; 
A,  for  small-pox  ;  c,  for  typhus  fever ;  d,  for  plague ;  e,  for  yellow  fever. 
Methods  of  disposal  of  the  bodies  of  those  that  die  while  in  quarantine. 

A  Proposed  Act  to  Amend  the  Coroner's  System  of  New  York  City. 
— At  the  meeting  of  the  Section  in  Public  Health,  Legal  Medicine,  and 


April  29,  1898.] 


MISCELLANY. 


483 


Medical  unci  Vital  Stiitistics  of  the  Academy  of  Medicine,  held  on  March 
1st,  a  committee,  consisting  of  Dr.  Stephen  Smith  (chairman),  Dr. 
John  Winters  Hrannan,  and  Dr.  F.  H.  Dillingham  (secretary),  was  ap- 
pointed to  make  certain  amendments  to  a  hill  introduced  into  the  New 
York  State  Assembly  by  Mr.  Kempner.  This  bill  provided  for  the 
transfer  of  certain  duties,  now  performed  by  the  coroners  of  the  city 
and  county  of  New  York,  to  the  board  of  health  of  that  city ;  but  the 
committee  found  that  certain  of  the  provisions  of  the  bill  were  uncon- 
stitutional, while  there  was  insufficient  detail  regarding  other  matters 
essential  to  accomplish  the  desired  end.  The  question  was  carefully 
considered  and  the  committee  made  its  report  on  April  19th,  in  the 
form  of  the  amended  bill  given  below.  This  report  was  unanimously 
adopted  by  the  section,  and  it  was  presented  to  the  academy  at  the 
general  meeting  held  on  April  20th,  with  the  recommendation  that  it 
be  received,  ordered  to  be  printed  so  as  to  be  presented  to  the  fellows 
of  the  academy  for  careful  consideration,  and  transmitted  to  other  local 
medical  societies  so  that  their  co-operation  might  be  asked  for  in  order 
to  accomplish  the  reform  evidently  demanded  in  the  administration  of 
the  office. 

An  Act  to  transfer  certain  Duties  now  performed  by  the  Coroners 
of  the  City  and  County  of  New  York  to  the  Board  of  Health,  and 
to  define  the  Method  of  Procedure  in  Cases  of  Sudden  or  Violent 
Deaths. 

The  people  of  the  State  of  New  York,  represented  in  Senate  and 
Assembly,  do  enact  as  follows : 

Sectio.v  1.  In  all  cases  in  which  a  coroner  of  the  city  and  county  of 
New  York,  or  a  coroner's  physician,  was  heretofore  required  by  law  to 
make  a  medical  examination,  and  in  all  cases  mentioned  in  section 
seven  hundred  and  seventy-three  of  the  Code  of  Criminal  Procedure, 
the  board  of  health  of  said  city  and  county  shall  have  complete  juris- 
diction and  authority.  Said  board,  by  one  or  more  of  its  physicians, 
appointed  as  hereinafter  provided,  shall  perform  the  duties  and  make 
the  examinations  required  by  said  section,  and  shall  proceed  without 
the  aid  or  assistance  of  jurors.  Said  physicians  shall  make  duplicate 
reports  of  their  examinations  and  all  of  their  proceedings,  stating 
therein  the  cause  of  injury  or  death,  and  file  one  copy  with  the  board 
of  health  and  the  other  with  the  district  attorney  of  said  city  and 
county. 

Sec.  2.  The  board  of  health  of  said  city  and  county  of  New  York  is 
hereby  authorized  to  create  a  bureau  to  be  known  as  the  "  Bureau  of  In- 
quest," and  to  appoint  five  competent  physicians,  to  be  kno\vn  as  "  In- 
quest Physicians,"  who  shall  receive  a  salary  not  exceeding  the  sum  of 
three  thousand  dollars  each,  and  a  clerk,  to  be  known  as  the  "  Inquest 
Clerk,"  who  shall  keep  a  complete  record  of  all  incjuests,  and  shall  re- 
ceive a  salary  not  exceeding  the  sum  of  two  thousand  dollars,  such 
salaries  to  be  appropriated  by  the  Board  of  Estimate  and  Apportion- 
ment when  fixing  their  provisional  and  final  estimates  for  the  board  of 
health. 

Sec  3.  All  the  duties  and  jurisdiction  heretofore  vested  in  a  coroner 
or  the  coroners  of  the  city  and  county  of  New  York,  affecting  civil  ac- 
tions, proceedings  and  writs,  and  the  service  and  execution  thereof,  shall 
be  performed  by  and  repose  in  the  "  collector  of  assessments  and  clerk 
of  arrears  "  of  said  city  and  county. 

Sec.  4.  It  shall  be  the  duty  of  any  citizen  in  the  city  and  county  of 
New  York,  who  may  become  aware  of  the  death  of  a  person  who  shall 
have  died  from  criminal  violence,  or  by  a  casualty,  or  suddenly  when  in 
apparent  health,  or  when  unattended  by  a  physician,  or  in  prison,  or  in 
any  suspicious  or  unusual  manner,  to  report  such  death  forthwith  to  the 
Bureau  of  Inquest,  or  to  any  police  officer,  who  shall  notify  the  Bureau 
of  Inquest  without  delay  of  such  death  ;  and  any  person  who  shall  will- 
fully neglect  or  refuse  to  report  such  death  as  above  required  shall, 
upon  conviction,  be  adjudged  guilty  of  a  misdemeanor,  and  shall  be  pun. 
ished  by  imprisonment  for  a  period  not  exceeding  one  year  or  by  a  fine 
not  exceeding  five  hundred  dollars,  or  by  both  such  fine  and  imprison- 
ment. 

Sec.  5.  Any  person  in  said  city  and  county,  except  an  inquest  physi. 
cian,  who  shall  willfully  touch,  remove,  or  disturb  the  body  of  any  one 
who  shall  have  died  in  the  manner  described  in  the  last  section,  or  who 
shall  willfully  touch,  remove,  or  disturb  the  clothing,  or  any  article  upon 
or  near  such  body,  without  a  written  order  from  an  inquest  physician, 


shall,  upon  conviction,  be  adjudged  guilty  of  a  misdemeanor,  and  shall 
be  punished  by  imprisonment  for  a  period  not  exceeding  one  year,  or  by 
a  fine  not  exceeding  five  hundred  dollars,  or  by  both  such  tine  and  im- 
prisonment. 

Sec.  6.  Whenever  information  is  given  at  the  Bureau  of  Inquests  of 
the  Board  of  Health  that  there  has  been  found,  or  is  lying,  within  the 
jurisdiction  of  said  board,  the  dead  body  of  a  person  who  is  supposed 
to  have  come  to  his  death  by  violence,  an  inquest  physician  shall  forth- 
with repair  to  the  place  where  such  body  lies  and  take  charge  of  the 
same,  and  if  on  view  thereof  and  personal  inquiry  into  the  cause  and 
manner  of  the  death,  he  deems  a  fui  ther  examination  necessary,  he  shall 
in  the  presence  of  two  or  more  discreet  persons,  whose  attendance  he 
may  compel  by  subpoena  if  necessary,  make  an  autopsy,  and  then  and 
there  reduce  to  writing  every  fact  and  circumstance  tending  to  show  the 
condition  of  the  body,  and  cause  and  manner  of  death,  together  with  the 
names  and  addresses  of  said  witnesses,  which  record  he  shall  subscribe. 
Before  making  such  autopsy,  he  shall  call  the  attention  of  said  witnesses 
to  the  position  and  appearance  of  the  body. 

Sec.  1.  If  upon  such  view,  personal  inquiry,  or  autopsy,  he  shall  be 
of  opinion  that  the  death  was  caused  by  violence,  he  shall  at  once  notify 
one  of  the  coroners  of  the  city  and  county  of  New  York,  and  shall  file 
a  duly  attested  copy  of  the  record  of  his  examination  and  autopsy  in  the 
office  of  said  coroners,  in  addition  to  the  reports  made  in  accordance 
with  section  first  of  this  act.  The  coroner  shall  thereupon  hold  an  in- 
quest which  shall  consist  of  the  testimony  of  the  inquest  physician,  and 
that  of  any  other  witnesses  that  the  coroner  may  find  necessary.  Said 
inquest  may  be  private,  in  which  case  any  or  all  persons  other  than  those 
required  to  be  present  by  the  provisions  of  this  act  may  be  excluded 
from  the  place  where  the  same  is  held,  and  said  coroner  may  also  direct 
the  witnesses  to  be  kept  separate  so  that  they  can  not  converse  with 
each  other  until  they  have  been  examined.  The  district  attorney,  or 
some  person  designated  by  him,  shall  attend  the  inquest,  and  may  ex- 
amine all  witnesses. 

Sec.  8.  The  coroner  shall  have  power  to  issue  subpoenas  for  wit- 
nesses, returnable  either  forthwith  or  at  such  time  and  place  as  he  shall 
appoint  therein,  and  it  shall  be  the  duty  of  the  coroner  to  give  due  no- 
tice of  the  time  and  place  of  the  inquest  to  the  inquest  physician  who 
examined  and  reported  on  the  case,  and  it  shall  be  the  duty  of  said 
physician  to  attend  said  inquest. 

Sec.  9.  The  coroner  shall,  after  hearing  the  testimony,  draw  up  and 
sign  a  report,  in  which  he  shall  find  and  certify  when,  where,  and  by 
what  means  the  person  deceased  came  to  his  death,  his  name,  if  known, 
and  all  material  circumstances  attending  his  death ;  and  if  it  appears 
that  his  death  resulted  wholly  or  in  part  from  the  unlawful  act  of  any 
person,  he  shall  further  state,  if  known  to  him,  the  name  of  such  per- 
son, and  of  any  person  whose  unlawful  act  contributed  to  such  death, 
which  report  shall  be  returned  by  him  to  the  office  of  the  District  At- 
torney of  the  City  and  County  of  New  York. 

Sec.  10.  Any  police  justice  in  the  city  and  county  of  New  York  is 
hereby  authorized  and  empowered,  in  case  the  attendance  of  a  coroner 
can  not  be  procured  within  twelve  hours  after  the  discovery  of  a  dead 
body,  upon  which  an  inquest  is  now  by  law  required  to  be  held,  to  hold 
an  inquest  thereon,  in  the  same  manner  and  with  the  like  force  and 
effect  as  coroners. 

Sec.  11.  From  and  after  th  e  passage  of  this  act  no  person  shall 
be  eligible  to  the  office  of  coroner  who  is  not  a  duly  qualified  lawyer. 

Sec.  12.  All  acts  or  parts  of  acts  inconsistent  with  the  provisions  of 
this  act  are  hereby  repealed. 

Sec.  13.  This  act  shall  take  effect  on  the  expiration  of  the  terms 
of  office  for  which  the  present  coroners  of  the  city  and  county  of  New 
York  were  respectively  elected. 

Important  Frizes  offered  by  the  Smithsonian  Institution. — The 

Scientific  Amei-ican  publishes  the  following :  "  In  October,  1891,  Thomas 
George  Hodgkins,  Esq.,  of  Setauket,  N.  Y.,  made  a  donation  to  the 
Smithsonian  Institution,  the  income  from  a  part  of  which  was  to  be  de- 
voted '  to  the  increase  and  diffusion  of  more  exact  knowledge  in  regard 
to  the  nature  and  properties  of  atmospheric  air  in  connection  with  the 
welfare  of  man.' 

"  With  the  intent  of  furthering  the  donor's  wishes,  the  Smithsonian 


484 


MISCELLANY. 


|N.  Y.  Med.  Jock. 


Institution  now  announces  the  rollowiug  prizes  to  he  awarded  on  or 
after  July  1,  1894,  sliould  satisfactory  papers  be  offered  in  competition: 
"  1.  A  prize  of  $10,000  for  a  treatise  embodying  some  new  and  im- 
portant discovery  in  refjjard  to  tlie  nature  or  properties  of  atmospheric 
air.  These  properties  may  be  considered  in  their  beai  ing  upon  any  or 
all  of  the  sciences — e.  g.,  not  only  in  regard  to  meteorology,  but  in  con- 
nection with  hygiene,  or  with  any  department  whatever  of  biological  or 
physical  knowledge. 

"  2.  A  prize  of  $2,000  for  the  most  .satisfactory  es.say  upon — 
"  (a)  The  known  properties  of  atmospheric  air  considered  in  their 
relationships  to  research  in  every  department  of  natural  science,  and  the 
imjiortonce  of  a  study  of  the  atmosphere  considered  in  view  of  these  re. 
lationships. 

"  [b)  The  proper  direction  of  future  research  in  connection  with  the 
imperfections  of  our  knowledge  of  atmospheric  air,  and  of  the  connec- 
tions of  that  knowledge  with  other  sciences. 

"  The  essay,  as  a  whole,  should  tend  to  indicate  the  path  best  calcu- 
lated to  lead  to  worthy  results  in  connection  with  the  future  administra- 
tion of  the  Hodgkins  foundation. 

"  3.  A  prize  of  $1,000  for  the  best  popular  treatise  upon  atmos- 
pheric air,  its  properties  and  relationships  (including  those  to  hygiene, 
physical  and  mental).  This  essay  need  not  exceed  20,000  words  in 
leni'th  ;  it  should  be  written  in  simple  language,  and  be  suitable  for 
publication  for  popular  instruction. 

"  -1.  A  medal  will  be  established,  under  the  name  of  The  Hodgkins 
Medal  of  the  Smithsonian  Institution,  which  will  be  awarded  annually 
or  biemiially,  for  important  contributions  to  our  knowledge  of  the  na- 
ture and  properties  of  atmospheric  air,  or  for  practical  applications  of 
our  existing  knowledge  of  them  to  the  welfare  of  mankind.  This 
medal  will  be  of  gold,  and  will  be  accompanied  by  a  duplicate  impres- 
sion in  silver  or  bronze. 

"  The  treatises  may  be  written  in  English,  French,  German,  or 
Italian,  and  should  be  sent  to  the  Secretary  of  the  Smithsonian  Institu- 
tion, Washington,  before  July  1,  18'J4,  except  those  in  competition  for 
the  first  prize,  the  sending  of  which  may  be  delayed  until  December  31, 
1894. 

"  The  papers  will  be  examined,  and  prizes  awarded,  by  a  committee 
to  be  appointed  as  follows :  One  member  by  the  secretary  of  the  Smith- 
sonian Institution,  one  member  by  the  president  of  the  National  Acad- 
emy of  Sciences,  one  by  the  president,  pro  tempore,  of  the  American 
Association  for  the  Advancement  of  Science ;  and  the  committee  w  ill 
act  together  with  the  secretary  of  the  Smithsonian  Institution  as  mem- 
ber ex  officio.  The  right  is  reserved  to  award  no  prize  if,  in  the  judg- 
ment of  the  committee,  no  contribution  is  offered  of  sufficient  merit  to 
warrant  an  award.  An  advisory  committee  of  not  more  than  three 
European  men  of  science  may  be  added  at  the  discretion  of  the  com- 
mittee of  award. 

"  If  no  disposition  be  made  of  the  first  prize  at  the  time  now  an- 
nounced, the  institution  may  continue  it  until  a  later  date,  should  it  be 
made  evident  that  important  investigations  relative  to  its  object  are  in 
progress,  the  results  of  which  it  is  intended  to  offer  in  competition  for 
the  prize.  The  Smithsonian  Institution  reserves  the  right  to  limit  or 
modify  the  conditions  for  this  prize  after  December  1,  1894,  should  it 
be  found  necessary.  Should  any  of  the  minor  prizes  not  be  awarded  to 
papers  sent  in  before  July  1,  1894,  the  said  prizes  will  be  withdrawn 
from  competition. 

"A  principal  motive  for  offering  these  prizes  is  to  call  attention  to 
the  Hodgkins  Fund  and  the  purposes  for  which  it  exists,  and  accord- 
ingly this  circular  is  sent  to  the  piincipal  universities  and  to  all  learned 
societies  known  to  the  institution,  as  well  as  to  representative  men  of 
science  in  every  nation.  Suggestions  and  recommendations  in  regard 
to  the  most  effective  application  of  this  fund  are  invited. 

"  It  is  probable  that  special  grants  of  money  may  be  made  to  spe- 
cialists engaged  in  original  investigation  upon  atmospheric  air  and  its 
properties.  Applications  for  grants  of  this  nature  should  have  the  in- 
dorsement of  some  recognized  academy  of  sciences,  or  other  institution 
of  learning,  and  should  be  accompanied  by  evidences  of  the  capacity  of 
the  applicant,  in  the  form  of  at  least  one  memoir  already  published  by 
him,  based  u[)on  oi  iginal  investigation. 

"  To  prevent  misapprehension  of  the  founder's  wishes  it  is  repeated 


that  the  discoveries  or  applications  proper  to  be  brought  to  the  Cf)n- 
sideration  of  the  committee  of  award  may  be  in  the  field  of  any  science 
or  any  part  without  restriction  ;  provided  only  that  they  have  to  do 
with  '  the  nature  and  properties  of  atmospheric  air  in  connection  w  ith 
the  welfare  of  man.' 

"  Information  of  any  kind  desired  by  persons  intending  to  become 
competitors  will  be  furnished  on  application.  All  conununications  in 
regard  to  the  Hodgkins  Fund,  the  Hodgkins  Prizes,  the  Hodgkins 
Medals,  and  the  Hodgkins  Fund  Publications,  or  applications  for  grants 
of  money  should  be  addressed  to  S.  P.  Langley,  Secretary  of  the  Smith- 
sonian Institution,  Washington." 

A  Prescription  for  Migraine.— The  Practitioner  gives  the  following 
formula  :  Butylchloral  hydrate,  fifteen  grains  ;  tincture  of  gelsemmm, 
thirty  minims  ;  tincture  of  cannabis  indica,  fifteen  minims  ;  glycerin, 
four  fluidrachms  ;  water,  enough  to  make  three  fluidounces.  Mix.  A 
third  part  to  be  taken  at  once,  and  the  dose  to  be  repeated  in  half  an 
hour. 


To  Contributors  and  Correspondents. —  The  attenlion  of  all  wJuo  purjme 
faporiug  us  with  loininiutiratiom  is  respectfully  called  to  llie  follow- 
ing : 

A".i/iors  of  articles  inicTided  for  pichlication  under  the  head  of  "  original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti- 
cles, we  always  do  so  witli  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  seiU  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  ai  the  time  the  article  is  sent  to  vs  ;  (S)  adapted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  icill  be 
published  CU1  promptly  as  our  other  enxjageuuiiU  tvill  admit  of — we 
Clin  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  a>iy 
londitions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  anompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  tJie  ?nanuscript  fteus  hern  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  Joumcd, -either  because  they  are 
too  Ion//,  or  are  loaded  with  tabular  rhatter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  proj'ess'ion 
ai  large.  We  can  not  enter  into  any  correspondence  ccmceming  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- 
responderUs  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 
i.t  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  7is  in- 
J'orrned  of  the  dates  of  their  societies'  regular  meetings.  Brief  notif- 
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  tts  information  of  matters  of  interest 
to  our  readei's  will  be  considered  as  doing  them  and  us  a  javor,  and, 
if  the  space  at  our  command  admits  of  it,  vje  shall  take  pleasure  in 
inserting  the  S7tbstance  of  such  communicatiom. 

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

All  communications  relatiiig  to  the  business  of  the  journal  should  be  ad- 
dressed to  the  publishers. 

Contributors  who  wish  to  order  REPRINTS  of  their  articles  should  do 
so  on  a  biank  prepared  for  that  purpose,  which  will  be  sent  to  them 
by  the  publishers  on  receipt  of  a  request  to  that  effect.  The  order 
should  be  sent  to  the  publishers,  and  not  to  the  editor. 


THE  ^EW  YORK  MEDICAL  JOURNAL,  May  6,  1893. 


ccturcs  nub  ^btrrcsscs. 


APPENDICITIS : 

A  CLINICAL  LECTURE  AT  THE  POHT-GKADUATE  MEDICAL  SCHOOI,, 
January  I4,  1893. 

By  ROBERT  T.  MORRIS,  A.M.,  M.  D. 

Gentlemen  :  Before  proceeding  to  remove  this  patient's 
appendix  vermiformis,  let  us  briefly  review  some  of  the 
salient  points  of  these  cases. 

First. — Acute  peritonitis  in  the  male  means  appendici- 
tis, no  matter  whether  there  is  tenderness  at  McBurney's 
Doint  or  not.  That  is  a  rule.  We  may  occasionally  find 
an  exception  in  a  case  of  acute  trichinosis,  or  in  some  equal- 
ly rare  complication  ;  but  the  more  one  sees  of  appendicitis 
the  less  he  sees  of  other  causes  for  acute  peritonitis. 

I  formerly  made  the  diagnosis  of  csecitis  and  perityphli- 
tis and  idiopathic  peritonitis,  but  whenever  opportunity 
came  for  real  observation  my  cases  all  proved  to  be  appen- 
dicitis in  pristine  purity  of  character.  A  physician  of  large 
practice  not  long  ago  told  me  that  he  did  not  have  cases  of 
true  appendicitis.  I  had  an  argument  with  him  upon  the 
subject,  and  since  that  time  have  removed  several  perfo- 
rated or  sloughing  appendices  at  his  request.  This  patient 
was  recently  treated  for  three  weeks  as  a  case  of  typhoid 
fever.  The  appendicitis  patient  who  formed  the  subject 
for  my  lecture  two  weeks  ago  was  thought  to  have  idio- 
pathic peritonitis  without  known  cause  by  a  council  of 
physicians,  but  you  saw  the  true  cause  here.  A  physician 
has  written  me  to-day  asking  if  I  will  remove  some  gall 
stones  for  his  wife ;  but  the  description  of  the  case  has  led 
me  to  prepare  for  removing  her  appendix. 

Second. — Appendicitis  is  apparently  less  common  in  the 
female  than  in  the  male,  but  there  are  many  excuses  for  an- 
other diagnosis  in  women. 

Third. — The  reason  why  the  symptom  of  local  tender- 
ness may  be  misleading  is  because  the  perforating  appendix 
tip  may  be  attached  to  the  liver,  or  it  may  be  in  a  hernial 
sac  down  in  the  patient's  scrotum,  or  it  may  be  rolled  all 
in  a  heap  with  the  left  ovary  and  tube. 

You  all  remember  one  of  my  recent  cases  in  which  the 
tip  of  the  appendix  was  attached  near  its  own  base  to  the 
caecum,  which  it  had  perforated,  completing  a  hollow  loop, 
like  the  handle  of  a  Peruvian  jug. 

Fourth. — Anything  that  causes  the  mucous  membrane 
of  the  appendix  to  swell  may  cause  necrosis.  The  mu- 
cous membrane  forms  a  soft,  distensible  tube  within  a  tube 
of  muscle  and  periton;Eum,  which  is  less  elastic.  A  simple 
catarrh  of  the  intestine  may  cause  this  mucous  tube  to  choke 
itself  to  death  within  the  inelastic  tube.  A  seed  or  a  fa-c-al 
concretion  may  start  the  swelling,  and  I  have  no  doubt  tliat 
many  cases  of  real  typhoid  and  of  dysentery  die  of  appen 
dicitis. 

Fifth. — Whenever  we  have  colicky  pains  in  an  attack 
of  appendicitis  I  believe  that  it  means  spasm  of  the  mus- 
cular sheath  of  the  tube  and  a  sympathizing  intestine 
Sloughs,  large  or  small,  are  usually  thrown  oil  from  the 


mucous  membrane  of  the  tube  in  an  attack  of  appendicitis. 
If  they  escape  into  the  bowel,  a  granulating  ulcer  is  left,  and 
the  patient  recovers  (temporarily).  If  the  slough  escapes 
through  the  walls  of  the  appendix,  the  patient  dies  unless 
adhesions  have  protected  liim.  If  lymph  exudate  walls  in 
the  site  of  the  perforation,  an  abscess  forms,  and  this  can 
be  absorbed  leisurely — lymph,  pus,  slough,  and  all — but  it 
is  so  risky  for  the  patient  that  we  must  not  allow  Nature 
to  have  her  way. 

Sixth. — The  reason  why  we  should  remove  the  appen- 
dix as  soon  as  the  diagnosis  of  appendicitis  is  made  is  be- 
cause we  never  can  tell  when  or  where  perforation  will  oc- 
cur, and  we  never  know  whether  the  products  of  inflamma- 
tion are  going  to  kill  or  not. 

Seventh. — The  reason  why  the  appendix  should  be  re- 
moved between  attacks  in  recurrent  cases  is  because  the 
death  rate  ought  not  to  be  above  one  per  cent,  at  such 
times,  and  the  mortality  rate  must  be  much  higher  when 
we  are  dealing  with  perforations  and  large  septic  abscesses. 

This  patient  wanted  an  operation  after  he  had  recovered 
from  his  typhoid  fever,  because  there  was  a  tender  spot  in 
the  right  groin  that  always  needed  protection.  Besides 
that,  he  did  not  want  to  be  constantly  in  dread  of  another 
attack  of  appendicitis.  Aside  from  the  danger  and  the 
dread  of  other  attacks,  he  did  not  want  to  lose  the  time 
necessary  for  recovery  from  subsequent  attacks. 

In  the  case  of  two  weeks  ago  the  patient  had  been  sent 
to  me  last  year  in  an  interval  between  attacks,  and  it  was 
left  to  my  judgment  to  decide  whether  to  operate  then  or 
not.  With  that  false  idea  of  conservatism  that  is  so  hard 
to  overcome,  I  decided  to  wait  until  the  patient  had  acute 
symptoms  again.  When  the  appendicitis  again  flared  up, 
and  after  I  had  removed  a  suppurating  mass  of  green 
lymph  exudate  and  a  rankly  poisonous  perforated  appendix, 
the  father  of  the  patient  came  to  me  and  asked  if  I  had 
really  used  good  judgment  in  deferring  operation  until  that 
time. 

In  proceeding  with  the  operation  upon  the  patient  who 
is  before  you,  I  hope  that  the  reason  for  each  step  will  be 
apparent  without  much  explanation.  In  the  first  place,  the 
patient  is  placed  in  Trendelenburg's  posture,  because  that 
will  allow  me  to  separate  adhesions  and  to  work  by  sight 
without  disturbing  the  intestines.  In  the  case  of  two  weeks 
ago,  in  which  there  was  green  fa>tid  pus  and  a  large  mass 
of  lymph  exudate,  Trendelenburg's  posture  allowed  me  to 
open  four  separate  abscesses  and  to  clean  out  the  abscess 
cavities  with  peroxide  of  hydrogen,  and  finally  to  skin  out 
the  "  area  of  dullness "  and  the  necrotic  appendix  in  one 
lump  without  endangering  the  general  peritoneal  cavity. 

The  usual  incision  over  the  normal  base  of  the  appen- 
dix having  been  made,  I  now  lift  the  appendix  out  of  the 
peritoneal  cavity,  and  you  will  observe  that  it  is  swollen 
and  red.  About  an  inch  of  the  tip  is  free,  and  about  two 
inches  and  a  half  of  the  tube  are  bound  to  the  ca'cum  in  a 
spiral  form  with  very  strong  adhesions.  The  mcsenterv  of 
the  protruding  tip  is  grasped  with  forceps,  and  adhesions 
are  stripped  away  until  the  appendix  is  entirely  free.  The 
mesentery  of  the  appendix  is  ligated  close  to  the  csecum, 


436 


ELHNER:  NEWER  METHODS  OF  STOMACH  EXAMINATION.  [N.  Y.  Med.  Jodk., 


and  I  now  snip  tlirougli  two  coats  of  tho  appendix  well 
down  into  the  cajcum.  If  any  appendix  tissue  were  left,  it 
would  very  likely  perforate  later  beneath  a  ligature.  The 

mucous  tube  now  being 
put  upon  the  stretch,  it  is 
ligated  fairly  down  to  the 
csecal  mucous  membrane, 
and  then  snipped  off  close 
to  the  ligature.  That  cuts 
off  danger  of  contamina- 
tion from  the  intestine. 

The  next  step  consists 
in  scarifying  the  perito- 
najum  all  about  the  vicin- 
ity of  the  knot  with  the 
point  of  a  needle  so  that 
we  are  sure  of  an  abun- 
dant exudation  of  cement 
after  the  sutures  are  in 
place.  Sutures  are  now 
passed  through  the  scari- 
\  '     .  i        fied  csecum  in  such  a  way 

*  ^''/  that  the  old  site  of  the 

appendix  is  deeply  and 
safely  buried  with  the 
Lembert  closure.  Aristol 
is  sprinkled  along  the  line 
of  sutures.  If  we  simply 
ligated  the  base  of  an  ap- 
pendix and  did  not  bury  the  stump,  you  can  readily  see 
that  that  point  would  be  the  weakest  part  of  the  intestine 
after  repair  was  complete.  A  sort  of  Eskimo  window  would 
be  left,  through  which  the  intestinal  microbes  could  peer 
out  into  the  peritoneal  cavity. 

In  closing  the  abdominal  wound  we  follow  a  surgical 
law^ which  demands  that  tissues  be  replaced  in  good  order, 
and  consequently  I  suture  the  cut  margins  of  each  structure 
separately,  giving  particular  attention  to  the  superficial  fas- 
cia— the  seamless  bag  which  holds  the  patient's  abdomen 
together. 

This  method  of  suturing  saves  time — not  to-day,  to  be 
sure,  for  it  has  required  more  time  than  all  of  the  rest  of 
the  operation.  It  saves  time  because  we  shall  not  have  to 
do  a  secondary  operation  next  year  for  the  relief  of  a  hernia 
at  the  site  of  the  incision. 

Our  work  having  been  completed,  I  now  split  open  the 
appendix  for  examination.  As  the  peritoneal  and  muscu- 
lar coats  are  divided,  the  mucous  tube  quickly  springs  into 


Via 


.  1. — Perforiili'vl  apixndix  and  "area 
of  dullness "  removed  in  one  mass 
and  showiug-the  openings  of  two  of 
the  abscess  cavities. 


Kio.  2.— Appendix  laid  open  to  show  contents  and  scar  strictures. 

the  incision,  showing  what  pressure  it  has  been  subjected 
to.  The  mucous  tube  being  split,  we  find  one  whole  seed 
and  part  of  another  covered  with  hard  fajcal  matter.  The 


seeds  are  evidently  those  of  a  small  melon.  Half  an  inch 
from  the  tip  of  the  appendix  there  is  a  stricture  which 
closes  the  canal  and  which  marks  the  point  from  which  a 
mucous  slough  separated  at  some  former  time.  Near  the 
Cffical  end  of  the  tube  another  stricture  similar  in  character 
effectually  prevented  the  expulsion  of  the  seeds.  The  mu- 
cous membrane  of  the  pouch  which  contained  the  seeds  is 
studded  with  red  dots,  showing  what  fires  were  smoldering 
there. 

Note. — Since  the  presentatioti  of  this  article  for  publication  the 
author  has  completed  a  .series  of  investigations  which  prove  that  ap- 
pendicitis is  an  infectious  exudative  inflammation,  commonly  terminat- 
ing in  connective-tissue  replacement  of  the  muco.sa  of  the  appendix  when 
the  accidents  of  rajiid  necrosis  do  not  cause  a  different  ending. 


Cfi^rigmal  Communitalions. 


ON  THE  PRACTICAL  VALUE  OF 
THE  NEWER   METHODS   OF  EXAMINATION  IN 
THE  DISEASES  OF  THE  STOMACH, 

WITH   A  CONSIDERATION  OK  TIIK 
INDICATIONS  GIVKN  FOR  DIET  AND  TREATMENT  BY  SUCH  EXAMINATIONS. 

Being  part  of  a  Discussion  on  the  Newer  Methods  of 
Diagnosis  and  Treatment  of  Stomarh  and  Intestinal  Di.wises.* 

By  henry  L.  ELSNER,  M.  D., 

PROFESSOR  OP  CLINICAL  MEDICINE,  STBACUSK  JTEDICAL  COLLEGE  ; 

PHYSICIAN  TO  ST.  JOSEPH'S  HOSPITAL  ; 
CONSULTrNG  PHYSICIAN  TO  ST.  ANN'S  HOSPITAL,  SYRACDSE,  N.  Y. 

The  subject  which  by  your  courtesy  it  is  my  privilege 
to  introduce  for  discussion  to-day  is  one  which  is  so  full  of 
interest  and  so  important  alike  to  the  physician  and  the 
surgeon  that  I  approach  it  with  fear  and  a  consciousness 
of  weakness,  which  increases  as  I  compare  my  feeble  efforts 
with  those  which  others  might  have  made  for  your  greater 
enlightenment.  Having  accepted  your  invitation,  I  shall 
discuss  the  practical  value  of  the  newer  methods  of  exami- 
nation in  diseases  of  the  stomach,  and  the  indications  given 
by  such  examinations  for  diet  and  treatment,  impartially, 
with  the  view  of  formulating  such  conclusions  as  may  ap- 
pear justified,  and  a  desire  to  stimulate  in  the  profession  a 
more  careful  and  scientific  study  of  the  available  methods 
of  diagnosis  in  stomach  diseases. 

The  great  aim  of  the  modern  scientific  physician  is  to 
understand  symptoms  so  thoroughly  that  it  becomes  possi- 
ble for  him  to  localize  lesions  exactly,  or  to  detect  faulty 
functions  with  equal  certainty. 

With  the  discovery  of  free  hydrochloric  acid  in  the  gas- 
tric mucus  by  Prout  in  1824,  and  the  demonstration  of 
pepsin  by  Schwann  in  1836,  the  first  data  for  an  ultimate 
and  more  thorough  understanding  of  the  physiological  and 
chemical  functions  of  the  stomach  were  given.  These  dis- 
coveries, with  those  of  Reaumur  and  Spallanzani,  formed 
the  foundation  upon  which  ultimate  gastric  pathology  was 
to  rest,  and  upon  which  a  structure  has  been  erected  to 
which  modern  medicine  points  with  just  pride. 


*  Read  before  the  Medical  Society  of  the  State  of  New  York  at  its 
eighty-seventh  annual  meeting. 


May  6,  1893.) 


ELSNER:  NEWER  METHODS 


OF  STOMACH  EXAMINATION. 


4«7 


"  The  way  to  pathology  is  througli  physiology,"  says 
Ewald  (1)  in  his  well-known  work,  and  the  more  we  deal 
with  this  subject  the  firmer  is  the  truth  of  that  statement 
impressed  upon  our  minds.  It  is  not  the  study  of  the  pep- 
tonizing function  alone  which  claims  our  attention,  but  it  is 
the  proper  understanding  of  the  entire  work  which  is  per- 
formed in  this  human  laboratory,  including  a  large  part  of 
the  alimentary  canal,  and  a  thorough  appreciation  of  the 
relations  which  each  function  bears  to  the  others,  that  makes 
a  rational  anatomical  diagnosis  and  indications  for  treat- 
ment possible  and  in  many  cases  positive. 

While  we  may  not  be  able  from  this  discussion  to  draw- 
positive  conclusions,  it  will  be  the  endeavor  of  all  who  take 
part  in  it  to  treat  the  subject  without  prejudice,  for  the  bet- 
ter understanding  of  the  profession  generally,  which  has 
not  yet  given  it  sufficient  thought  or  the  study  which  is 
needed  to  estimate  the  relative  values  of  these  newer  meth- 
ods of  examination  to  the  diagnostician  of  internal  dis- 
eases. 

History, — Though  it  is  a  fact  established  beyond  con- 
troversy that  the  stomach  tube  had  been  used  for  various 
purposes  before  1869,  it  was  Kussmaul(2)  who  during  that 
year  became  the  pioneer  in  the  treatment  of  stomach  dis- 
eases by  the  use  of  the  stomach  pump  and  tube.  He  took 
advantage  of  the  instrument  which  had  for  some  time  been 
used  in  America  for  emptying  the  thoracic  cavity  in  cases 
of  empyema  (Kussmaul  (2),  Martius  (3)). 

Liebermeister  (4),  in  commenting  on  this  subject, 
prophesied  that  the  manoeuvre  of  Kussmaul  would  proba- 
bly mark  an  epoch  in  the  treatment  of  chronic  diseases  of 
the  stomach. 

In  1871  Leube  first  recommended  the  stomach  tube  for 
purposes  of  diagnosis,  since  which  time  a  band  of  earnest 
workers  in  Europe,  headed  by  Leube,  Kussmaul,  and  Rie- 
gel,  with  recruits  such  as  Ewald,  van  den  Velden,  v.  Noor- 
den.  Sticker,  Honigman,  Boas,  Leo,  and  others  in  Germany, 
Hayem  and  Winter  in  France,  and  in  our  own  country  such 
men  as  Kinnicut,  Einhorn,  and  Stockton  have  done  much  to 
clear  the  way  for  a  thorough  discussion  of  the  questions 
with  which  we  are  to-day  dealing. 

A  genuine  impulse  was  given  when,  in  1874,  Ewald  sub- 
stituted the  soft,  flexible  tube  for  the  stifEer,  less  elastic  one 
which  until  that  time  had  been  used. 

Physiological  Data. — For  the  better  understanding  of 
this  discussion  you  will  bear  with  me  if  I  hurriedly  rehearse 
a  few  physiological  data  which  must  serve  to  make  clear  the 
digestive  activity  of  the  stomach. 

L  The  fact  may  be  accepted  as  proved  by  Miller  (5) 
that  the  saliva  is  brought  in  contact  with  micro-organisms 
in  the  food,  and  others  which  find  a  habitat  in  the  mouth. 
It  is  supposed  that  there  are  two  groups  of  these  organisms, 
which,  both  in  the  mouth  and  in  the  stomach,  give  rise  to 
actual  fermentation.  The  one  group,  in  the  presence  of  the 
saliva,  decomposes  carbohydrates  with  the  formation  of  an 
acid  ;  the  other  causes  a  disorganization  of  albuminoids  with 
alkaline  products.  The  first  class  is  said  to  give  rise  to  the 
production  of  lactic  and  fat  acids,  which  in  turn,  according 
to  Bokai  (6),  even  in  small  (juantities,  particularly  the  for- 
mer, have  a  salutary  effect  in  stimulating  intestinal  peristal- 


sis. Whether  the  presence  of  lactic  acid  in  the  secretions 
after  leaving  the  buccal  cavity  is  ever  normal  we  will  con- 
sider later  in  this  chapter.  I  mention  the  matter  here  to 
remind  you  that  modern  physiologists  and  pathologists  are 
attributing  more  than  a  simple  amylolytic  action  to  the 
saliva. 

II.  The  amylolytic  action  continues,  as  a  rule,  for  some 
time  after  the  changed  starch  is  infi'oduced  into  the  stomach, 
particularly  if  accompanied  by  albuminoids.  The  further 
conversion  should  cease  in  the  normal  stomach  with  the  in- 
crease of  hydrochloric  acid  secretion,  and  after  the  forma- 
tion of  syntonin  or  acid-albumin  (Wesner  (7),  Wille  (8), 
Boas  (9)). 

III.  The  introduction  of  saliva  into  the  stomach  has  a 
direct  stimulating  effect  on  the  gastric  mucous  membrane 
(Sticker  (10)). 

IV.  It  may  be  stated  almost  with  certainty  that,  as  a  rule, 
the  normal  stomach  is  empty  during  the  fasting  period,  its 
membrane  is  pale,  covered  with  a  layer  of  mucus,  either 
neutral  or  alkaline.  It  contains  no  gastric  juice.  If  hydro- 
chloric acid  is  present,  it  is  a  remnant  of  a  former  digestive 
process,  or  the  passage  or  presence  of  the  tube  has  caused 
it  (Wille  (11),  Ewald  (12),  Foster  (13),  Kinnicut  ( 1 4)). 

V.  Variation  in  the  functional  activity  of  the  stomach 
must  be  expected  according  to  the  character  of  the  food  ingest- 
ed. (This  is  one  of  the  fundamental  rules  of  modern  gastric 
physiology,  and  must  always  be  considered  when  engaged 
in  the  diagnosis  of  stomach  diseases.) 

VI.  Direct  irritation  of  the  mucous  membrane  of  the  stom- 
ach is  necessary  for  the  secretion  of  the  gastric  juice.  Nor- 
mally, it  is  the  food  which  causes  activity  immediately  upon 
its  entrance  into  the  stomach. 

VII.  Lactic  acid  is  never  present  in  the  stomach  after  the 
first  period  of  digestion ;  upon  this  conclusion  all  writers 
seem  to  agree.  There  is  said  to  be  an  intermediate  stage 
during  which  it  is  held  that  lactic  acid  is  present  with  hy- 
drochloric acid  (Ewald  (16)). 

This  lactic  acid  is  not  to  be  considered  as  a  result  of 
glandular  secretion,  but  it  is  due  to  a  process  of  fermen- 
tation already  described,  accompanying  the  digestion  of 
carbohydrates  or  the  ingestion  of  meat  (Pasteur  (16), 
Iluppe  (17)).  Lactic  acid  is  not  present  when  pure  egg 
albumin  alone  is  taken. 

With  the  establishment  of  an  abundant  hydrochloric- 
acid  secretion,  and  ultimate  free  hydrochloric  acid  in  the 
stomach,  lactic  acid  disappears  (Miller  (18),  F.  Cohn  (19)). 
As  the  result  of  experiment  with  a  pure  meat  diet  I  have 
been  able  to  verify  the  truth  of  Boas's  statement  that  lactic 
acid  is  occasionally  present  shortly  after  the  beginning  of 
digestion  in  very  small  proportion.  In  contradistinction  to 
what  is  taught  in  all  the  newer  text-books,  Martius  (20),  in  a 
recently  published  work  dealing  alone  with  the  gastric  juice, 
holds  that  in  "the  normal  process  of  digestion  other  acids 
than  IICl  are  not  to  be  taken  into  consideration  " — in  other 
words,  are  not  present ;  that  lactic-acid  fermentation  to  any 
discoverable  extent  is  always  pathological.  He  opposes  the 
division  of  the  digestive  process  into  three  periods,  as  made 
by  Ewald  and  Boas  (21)  : 

1.  Period  in  which  lactic  acid  is  found. 


488 


ELSNER:  NEWER  METHODS  OF  STOMACH  EXAMINATION.         [N.  Y.  Med.  Jouh., 


2.  Period  in  which  lactic  acid  and  IICl  are  found. 

3.  Period  in  wliich  HCl  alone  is  present. 

The  safest  conclusion  for  us  to  accept  with  our  present 
knowledge  is  that  lactic  acid  is  not  normally  present  in  the 
stomach  during  the  digestive  period,  unless  the  ingested 
food  contains  carbohydrates  in  a  process  of  fermentation — 
i.  e.,  the  fermentation  lactic  acid  or  the  sarcolactic  acid  as 
introduced  by  meat. 

VIII.  It  may  be  taken  for  granted  that  the  most  important 
constituent  of  the  (jastric  juice  which  the  physician  is  called 
upon  to  take  into  consideration  in  conjunction  with  the  chem- 
ical analyses  of  the  stomach  contents  for  purposes  of  diayno- 
sis  is  hydrochloric  acid.  While  the  chemical  analysis  is 
usually  confined  to  the  detection  of  the  presence  or  absence 
of  free  IICl,  it  must  not  be  forgotten  that  the  free  acid  found 
in  the  later  stages  of  digestion  is  but  a  remnant  left  after 
the  thorough  combination  of  HCl  with  the  albuminoid  ele- 
ments of  the  food  and  other  bases  (Martius  (22)). 

IX.  IICl  is  secreted  free,  molecule  for  molecule,  by  the 
glandular  structures  of  the  stomach.  It  is  quickly  brought 
in  contact  with  the  food  and  other  secretions  in  the  stom- 
ach, when  the  period  of  its  utility  begins  without  delay 
(Bidder  and  Schmidt  (23),  Martius  (24)). 

This  statement  is  made  in  contradiction  of  the  opinion 
of  the  French  school,  as  represented  by  Hayem  and  Winter, 
which  holds  that  absolutely  no  HCl  is  secreted  as  such,  but 
that  it  results  from  a  combination  ultimately  formed  by  a 
chemical  change  of  the  chlorides,  more  particularly  the 
chloride  of  sodium,  during  the  process  of  digestion. 

X.  HCl  with  the  pepsin  secreted  by  the  peptic  glands 
forms  the  agent  vjhich  is  instrumental  in  the  ultimate  pepto- 
nization of  the  albuminoids,  and  this  is  the  most  important 
function  of  the  gastric  juice. 

XI.  It  may  be  taken  for  granted  that  the  average  time 
when  free  HCl  can  be  detected  in  the  stomach  contents  after  the 
ingestion  of  food  is  about  one  hour.  With  large  meals  and 
coarse  food  it  may  be  considerably  later,  depending  largely 
upon  the  quantity  and  quality  of  the  food  ingested  (Rie- 
gel  (25)).  The  largest  amount  of  free  HCl  is  present  two 
hours  after  the  ingestion  of  the  ordinary  trial  meal,  when  it 
comprises,  as  it  does  at  the  height  of  the  digestive  process, 
the  largest  part  of  the  acid  constituent  of  the  gastric  juice 
(Lowenthal  (26)). 

This  fact  has  been  emphasized  by  me  for  some  time 
past,  and  we  now  find  that  Lowenthal's  (27)  experience 
verifies  the  truth  of  the  statement  made  above.  He  found 
that  with  the  trial  meal  of  Riegel,  with  the  total  acidity  of 
56"5,  there  was  present  35'5  free  HCl  one  hundred  and 
twenty  minutes  after  the  taking  of  the  meal. 

(This  physiological  fact  leads  me,  in  practice,  to  express 
the  stomach  contents  somewhat  earlier  than  has  ordinarily 
been  recommended,  and  taken  in  conjunction  with  the  fact 
that  the  amount  of  free  IICl,  as  well  as  the  total  acidity, 
are  subject  to  variations,  it  would  lead  to  repeated  ex- 
aminations at  corresponding  periods  of  digestion,  on  dif- 
ferent days,  to  determine  the  working  condition  of  the 
stomach.) 

XII.  The  peptogenic  function  of  the  stomach  may  be  di- 
vided into  three  stages,  in  each  of  which  the  changed  albumi- 


noid can  be  studied,  and  gives  characteristic  reaction.  The 
first  combination  resulting  gives  rise  to  an  acid  albumin  or 
syntonin,  simply  a  more  thorough  combination  of  albumin 
with  the  acid.  The  second  is  the  stage  in  which  propeptone 
is  found  ;  this  leads  to  a  third  stage,  when  normally  the 
process  of  peptonization  is  ended  and  peptone  has  become 
the  final  product  of  albumin  digestion,  ready  to  be  absorbed 
or  pushed  onward  to  meet  its  fate  in  the  duodenum. 

XIII.  The  percentage  of  free  IICl  present  in  normal  gas- 
tric juice  averages  between  0'L5  and  0'22  per  cent.  Any 
considerable  deviation  from  these  figures  may  be  consid- 
ered abnormal. 

XIV.  Rennet  is  present  in  the  gastric  juices  and,  like  pep- 
sin, is  a  constant  constituent  (Ilaudnitz  (28),  Boas  (29), 
Johnson  (30),  Klemperer  (31),  Rosenthal  (32)). 

XV.  The  presence  of  bile  in  the  stomach  interferes  with 
the  free  performance  of  gastric  digestion. 

XVI.  The  normal  digestion  of  starch  precludes  the  possi- 
bility of  the  presence  of  achroodextrin,  maltose,  or  dextrose, 
after  one  hour  of  stomach  activity  (Ewald  (33)). 

XVII.  Normally,  evidences  of  absorption  from  the  mu- 
cous membrane  of  the  stomach  should  be  found  on  chemical 
analysis  to  have  taken  place  in  from,  fifteen  to  twenty  minutes 
after  the  ingestion  of  food  or  drugs  (Penzoldt  and  Faber 
(34),  Ewald  (35),  Wesener  (36)). 

XVIII.  Normally,  the  stomach  is  empty,  the  changed 
food  having  passed  the  pylorus  between  six  and  seven  hours 
after  the  beginning  of  its  digestion  (Leube  (37),  Riegel  (38), 
Wesener  (39)).  The  motor  function  normally  ought  to 
force  a  bolus,  which  is  not  digested  in  the  stomach,  into 
the  small  intestine  before  the  end  of  seventy-five  minutes 
after  taking  it,  as  has  been  demonstrated  by  Ewald  (40), 
also  Klemperer  (41). 

The  following  chart  shows  the  changes  which  are  dem- 
onstrated by  the  newer  methods  of  examination  in  the  se- 
cretory, motor,  and  absorptive  functions  of  the  stomach, 
with  a  tabulation  of  the  diseases  with  which  such  changQg 
are  often  associated. 

1.  The  qualitative  changes  are  usually  dependent  upon  a 
process  of  abnormal  fermentation.  These  are  accompani- 
ments of  the  various  forms  of  indigestion  which  have  also 
well-marked  quantitative  changes  in  the  gastric  juice,  more 
particularly  associated  with  a  deficiency  of  the  acid  of  the 
secretion. 

2.  Quantitative  changes. 

a,  1  and  2.  The  deficient  secretion  of  the  gastric  juice 
is,  as  a  rule,  attended  with  a  greater  lack  of  free  IICl  than 
of  the  pepsin  element.  With  this  lack  of  sufl[icient  free 
HCl  it  may  be  taken  for  granted  that  the  period  of  diges- 
tion is  materially  prolonged,  that  fermentation  is  likely  to 
take  place,  and  that  the  albuminoids  are  tardily  and  faultily 
digested.  In  the  fluid  taken  from  a  stomach  in  which 
there  is  deficient  HCl  after  a  trial  meal  we  find  the  meat 
undigested,  its  fibers  slightly  swollen,  but  little  changed. 
Lactic  acid  and  other  organic  acids  are  present  after  we 
have  reason  to  expect  an  active  digestive  period. 

There  may  be  either  reduced  HCl,  or  the  quantitative 
change  may  show  anacidity. 

b.  Hyperacidity  with  normal  quantity  of  gastric  juice. 


Miiy  1893.] 


ELSNER:  NEWER  METHODS  OF  STOMACH  EXAMINATION. 


489 


1.  Secretory 
changes. 


Motor 
changes. 


Absorptive 
chanf^es. 


1.  Qualitative, 


1. 
2. 

(I,  1.  Deficiency  of  the 
secretion  nu(l  free 
HCl  production. 


2.  Quantitative.  > 


'/,  2.  Anacidity. 


h.  Hyperacidity,  with 
normal  quantity  of 
gastric  juice. 

c.  Hyperacidity  and  hy-  j 


persecretion. 
d.  Hypersecretion. 


a.  Increa.sed  motor  activity. 


h.  Diminished  motor  activity. 


a.  Tardy  alworption. 

h.  Complete  absorptive  failure. 


With  abnormal  fermentation — usually  associated  with  quantitative  changes. 
1.  Anaimia,  general  and  local  neuroses. 

^  Tuberculosis, 
Constitutional  diseases.  \  S\'philis, 
(  Diabetes. 

Beginning  chronic  gastritis,  mental  diseases,  acute  febrile  diseases,  disease.s  of 
the  heart,  lungs  (emphy.sema,  bronchitis),  chronic  nephritis, 
a,  2.  Physiological  in  early  stages  of  digestion. 

Cancer  of  stomach,  chronic  catarrh  of  stomach,  atrophy  of  gastric  follicles,  re- 
gurgitation of  bile,  secondary  changes  due  to  impeded  circulation. 

i.  Tuberculosis,     Amyloid  diseases.     Diabetes  mellitus. 
Constitutional  diseases.  -|  Syphilis,  Addison's  disease,  Leucocytosis. 

(  Cancer  (?),        Pernicious  anasmia. 
Uterine  disorders  and  those  of  annexa. 

Cancerous  disease  of  liver,  pancreas,  duodenum,  and  colon  [Boas  (42)].  (Denied 
by  Leube  (43)  and  by  the  author  as  result  of  clinical  experience.) 

Alkaline  and  caustic  poisons — also  with  large  doses  of  alkalies  not  poisonous 
[Boas  (44)]. 

h.  (Jastric  neurosis,  ulcer  of  stomach  and  duodenum,  polypoid  gastritis,  cicatricial 
base  with  central  ulceration  (stomach). 
Gastric  ulceration  resting  on  a  cai-einomatom  base,  without  far-reaching  infil- 
tration. 

<■.  Netiroses  (gastric),  ulcer  of  stomach,  gastroxynsis  [Rossbach,  Reichman  (45)]. 

Gastrorrhoea  acida  simplex  (Jaworski),  non-cancerous  gastrectasia. 
d.  Rarely  found  alone,  occasionally  with  alcoholic  gastritis. 

Usually  accompanies  hyperacidity. 
a.  Hysteria,  neurasthenia,  idiopathic  form  of  nervous  vomiting  [Leyden  (46)], 
tormina  ventriculi  [Kussmaul  (47)]  (peristaltic  unrest),  rapid  emptying  {i.  e., 
hypermotility)  of  ingesta  into  the  duodenum  [Leo  (48)].  Spastic  closure  of 
cardia  [Poensgen  (49),  pylorismus,  spastic  closure  of  pylorus  [Ziemssen  (50), 
Kussmaul  (51)]. 

'  Anaemia,  chlorosis,  improper  diet,  phthisis,  leukaemia, 
alcoholism,  diabetes  mellitus,  amyloid  degeneration, 
syphilis,  acute  infection  (typhoid,  etc.),  cholera,  puer- 
peral fever,  chronic  catarrh  of  the  stomach. 
Obstruction  (usually  at  pylorus,  carcinomatous,  cicatri- 
cial, non-malignant  tumor). 
Gastrectasia. 

Ulcer,  cancerous  degeneration  of  stomach  wall. 
Hypertrophy  of  muscular  coat  with  congenital  narrowing 

of  pylorus. 
Tumors  pressing  on  pylorus. 

Adhesions  to  neighboring  organs  (gall  bladder),  liver, 

pancreas,  duodenum. 
Ligamentous  bands. 
[  Hernia  [Boas  (52)]. 

a.  and  b. 

Diseased  gastric  mucous  membrane  (often  accompanied  with  atrophy  of  the 

gastric  follicles). 
Connective-tissue  overgrowth  in  stomach  wall. 
Cancerous  infiltration. 
Amyloid  disease. 

Impeded  circulation  from  whatever  cause. 


i,  1. 


Weakened  motor 
force.  Atony. 


Changes 
stomach. 


Extra 
pressure. 


the 


gastric 


This  change  we  often  find  in  both  acute  and  chronic 
diseases  of  the  stomach.  With  Reigel,  we  consider  these 
cases  as  inckiding  only  those  in  which  the  hyperacidity  can 
he  demonstrated  during  the  digestive  period.  Any  excess 
of  HCl  above  0-3  per  cent,  may  be  considered  as  belong- 
ing to  this  class.  In  contradistinction  to  the  anacid  or 
deficient  IICl  gastric  secretion,  we  find  with  hyperacidity 
the  albuminoids  well  and  rapidly  digested  in  the  majority 
of  cases.  In  some  cases,  and  these  have  been  carefully  de- 
.scribed  by  Sticker,  we  find  the  meat  digestion  tardy,  owing 
to  the  disproportion  between  the  pepsin  and  HCl. 

c.  Ilijperacidity  and  supersecretion. 

We  classify  under  this  division  such  cases  as  are  sup- 
plied with  a  gastric  juice  of  good  digestive  quality,  but  in 
which  there  is  an  overactivity  of  the  secretory  glands,  giv- 
ing rise  to  an  almost  continuous  acid  secretion  independent  of 
the  digestive  period. 

It  is  possible,  therefore,  to  express  from  the  stomachs 
of  these  patients,  long  after  digestion  has  ceased,  a  fluid 
which  is  free  from  all  remnants  of  ingested  foods,  but  on 
examination  is  found  to  be  sufficient  to  digest  albuminoids. 
This  condition  can  only  be  diagnosed  after  emptying  the 


stomach  thoroughly,  and  allowing  a  period  to  lapse  with- 
out the  ingestion  of  food,  when  the  tube  is  introduced 
and  a  fluid  extracted  with  the  characteristics  already  men- 
tioned. As  a  rule,  the  motor  function  of  the  stomach  in 
these  cases  is  faulty ;  there  remain  in  the  stomach  undi- 
gested starch  and  undivided  bread  particles ;  but,  as  a  rule, 
the  meat  has  been  thoroughly  and  completely  digested, 
and  fermentation  is  not  likely  to  occur. 
d.  Supersecretion. 

It  is  a  question  whether  there  is  a  simple  supersecretion 
which  is  unattended  by  hyperacidity.  Riegel's  'experience 
emphasizes  the  statement  that  hyperacidity  can  occur  alone, 
while  supersecretion,  in  its  most  pronounced  forms,  is,  as  a 
rule,  which  is  almost  without  exception,  accompanied  with 
hyperacidity. 

2.  a  and  b.  Motor  disturbances  may  be  considered  to 
be  due  to  secondary  changes.  There  may  be  overactivity 
or  motor  weakness.  The  more  severe  cases  of  the  latter 
are  found  with  some  impediment  to  the  free  emptying  of 
the  stomach  at  the  pylorus,  when  there  may  be  simple  dimi- 
nution of  the  motor  function,  or  it  may  be  almost  com- 
pletely abolished.    Believing,  as  I  do,  that  a  disturbance  of 


490 


ELSNER:  NEWER  METHODS  OF  STOMACH  EXAMINATION.  [N.  Y.  Med.  Jodk., 


the  motor  function  is  rarely  found  without  some  fault  in 
the  gastric  chemical  function,  I  am  anxious  to  impress 
upon  you  the  importance  of  gaining  positive  evidence  of 
the  motor  strength,  and  giving  to  each  abnormity  of  mo- 
tion its  proper  significance.  The  clinical  evidences  which 
this  paper  is  to  furnish  will,  I  think,  in  conjunction  with 
what  Professor  Stockton  shall  offer  in  detail,  on  this  sub- 
ject, prove  the  value  of  a  thorough  understanding  of  the 
motor  function  of  the  stomach.  In  very  many  doubtful 
cases,  indeed,  I  hold  that,  when  coupled  with  absorptive 
disturbances,  it  furnishes  data  of  equal  if  not  greater  im- 
port than  are  supplied  by  a  study  of  the  secretory  function 
alone ;  for  if  the  latter  be  at  fault,  we  may  still  hope,  with 
a  sufficient  motor  function,  to  advance  the  food  into  the 
duodenum,  for  its  ultimate  digestion  and  absorption  there. 
3.  a  and  b.    Absorptive  changes. 

Tardy  or  complete  failure  of  the  stomach  to  absorb 
must  be  taken  into  account  for  the  better  understanding  of 
the  condition  of  the  mucous  membrane  of  that  organ. 

If  the  accompanying  chart  is  carefully  studied  it  will 
be  found  that  here,  as  in  most  diseases  which  require  thor- 
ough physical  examination  for  their  accurate  diagnosis, 
there  is  no  one  change  in  either  secretion,  motion,  or  ab- 
sorption which  is  pathognomonic  or  which  justifies  a  j)Osi- 
tive  diagnosis. 

The  practical  value  of  the  newer  methods  of  examina- 
tion of  the  stomach  and  its  contents  lies  in  the  knowledge 
which  we  gain  of  the  changes  in  the  functional  activity  of 
that  organ,  as  epitomized  above,  and  the  addition  of  such 
information  to  our  other  subjective  and  objective  symptoms. 
Our  fondest  hope  can  not  make  the  results  more  than  con- 
firmatory, while  the  study  of  these  methods  emphasizes  the 
importance  of  adding  every  detail  which  all  cases  present. 

Absence  of  Free  HCl. — Within  the  past  few  years  the  di- 
agnostic value  which  had  been  accorded  to  the  absence  of 
free  HCl  from  the  stomach  during  the  height  of  digestion 
has  been  materially  modified,  and  we  are  daily  leaning  more 
toward  the  conclusion  that  it  points  more  directly  to  a  dis- 
turbed function  and  less  to  any  one  diseased  condition  of 
the  stomach. 

The  diagnostic  value  of  the  absence  or  diminution  of 
free  HCl  in  the  stomach  secretion,  associated  more  particu- 
larly with  pyloric  cancer  and  ultimate  dilatation,  was  first 
systematically  investigated  by  R.  von  den  Velden  at  the 
clinic  of  Kussmaul  in  Strassburg. 

It  seems  strange  that  the  knowledge  of  this  fact,  which 
was  given  to  the  profession  as  long  ago  as  1842  byGolding 
Bird  (53),  did  not  lead  to  its  application  for  diagnostic  pur- 
poses. Bird's  patient  was  a  man,  aged  forty-two,  with  py- 
loric cancer  and  dilatation.  The  diagnosis  was  verified  by 
autopsy.  Bird  made  three  chemical  analyses  in  about  three 
weeks,  and  concluded  that  "  during  the  more  irritative  stage 
of  the  disease  free  HCl  is  present  in  the  vomit  in  consider- 
able quantities;  but  it  gradually  diminishes  in  proportion  to 
the  patient's  loss  of  strength,  and  the  organic  acids  increase 
proportionally  as  the  free  HCi  diminishes." 

It  has  been  held  that  the  absence  or  diminution  of  HCl 
from  the  gastric  secretion  is  an  almost  constant  attendant 
of  all  forms  of  cancers,  regardless  of  their  location  or  histo- 


logical structure.  That  this  is  not  true  I  am  able  to  state 
positively  as  the  result  of  experimentation  during  the  past 
two  years  in  eight  cases  of  cancer  —  three  uterine,  two 
omental,  with  ultimate  secondary  nodules  in  the  liver,  two 
recurring  cancers  of  the  breast,  and  one  medullary  cancer 
probably  of  the  right  kidney  after  removal  of  the  right  tes- 
ticle for  the  same  disease  about  one  year  previous.  In  all 
of  these  eight  cases  Leube-Riegel  test  meals  were  given  and 
repeated  chemical  examinations  were  made  with  positive  re- 
sults. HCl  was  present,  both  combined  and  free,  in  over 
ninety  per  cent,  of  the  tests.  In  the  case  of  cancer  of  the 
right  kidney  HCl  was  absent  at  times,  owing  to  the  regur- 
gitation into  the  stomach  of  the  bile,  due  to  extra-intestinal 
pressure  and  constriction. 

In  conjunction  with  the  study  of  the  importance  of  free 
HCl  as  a  diagnostic  sign,  we  must  remember  that  in  not  a 
few  cases  a  feeble  digestive  process  has  progressed  without 
the  characteristic  color  reaction  at  the  height  of  digestion. 
It  must  not  be  taken  for  granted  that  digestion  begins  at 
the  moment  when  the  secretion  is  expected  to  react  to  these 
tests ;  but  let  the  clinician  note  that  at  that  time  a  large  part 
of  the  stomach  work  has  been  done  and  digestion  is  almost 
ended  (Martius  (54)).  "Free  HCl"  might  then  more  prop- 
erly be  spoken  of  as  "  surplus  HCl."  It  is,  in  fact,  the  rem- 
nant left  after  all  affinities  have  been  satisfied. 

Cancer  of  the  Stomach. — The  pathological  condition  with 
which  absence  or  diminution  of  HCl  has  been  most  frequent- 
ly associated  by  clinicians  is  cancer  of  the  stomach.  With 
your  permission  I  will  spend  a  few  minutes  in  considering 
the  diagnosis  of  this  condition,  with  special  reference  to  the 
newer  methods  of  examination  of  the  stomach  contents. 

The  positive  statement  is  made  by  Riegel  (55)  (after 
emphasizing  the  fact  that  our  examinations  must  be  oft-re- 
peated and  made  with  accuracy  and  reliable  reagents  before 
formulating  conclusions)  "  that  the  constant  presence  in  a 
gastric  juice  of  free  HCl  and  a  normal  peptic  strength  al- 
lows the  exclusion  of  cancer  of  the  stomach  with  certainty, 
regardless  of  the  other  symptoms,  however  strongly  they 
point  to  that  disorder." 

If  we  accept  the  statement  of  Riegel,  we  are  forced  to 
determine  the  factor  which  causes  the  changed  secretion  and 
functional  inactivity.  That  there  is  nothing  in  the  cancer 
per  se  to  check  the  HCl  secretion  is  shown  by  innumerable 
cases  of  cancerous  diseases  of  other  organs,  as  already  men- 
tioned, in  which  free  HCl  is  almost  always  present  in  the 
gastric  juice.  It  has  been  the  experience  of  others  that  in 
a  few  cases  of  cancer  of  the  stomach  free  HCl  continues  in 
the  gastric  secretion,  and  within  the  past  three  years  the 
writer  has  had  a  similar  experience  in  two  cases  in  which 
free  HCl  could  always  be  demonstrated  at  the  height  of  di- 
gestion. In  all  of  these  cases  there  has  been  a  functionally 
active  gastric  juice.  In  both  of  my  cases  the  autopsies  re- 
vealed the  presence  of  cancer  of  the  stomach,  but  without 
the  usual  accompaniment  of  far-reaching  atrophy  or  degen- 
eration of  the  gastric  follicles.  The  writer  has  notes  of  an 
autopsy  made  during  the  winter  of  1890  in  a  case  of  pneu- 
monia ending  in  three  days  where  the  patient  was  also  in 
the  early  stages  of  cancer  of  the  stomach.  In  this  case 
there  was  always  presence  of  free  HCl.    The  post-mortem 


May  G,  1898.] 


ELSNER:  NEWER  METHOD fil  OF  STOMACH  EXAMINATION. 


491 


showed  a  small  scirrhous  nodule  at  the  pylorus ;  the  mucous 
membrane  of  the  stomach  was  but  little  changed  ;  the  mi- 
croscope gave  evidences  of  unchanged  peptic  glands. 

Without  dilating  too  long  on  the  causes  of  anacidity  in 
cancer  of  the  stomacli,  it  may  be  assumed  with  great  cer- 
tainty that  the  prime  factor  in  its  causation  is  the  intiltrat- 
ing  character  of  carcinoma,  involving  the  glandular  elements 
of  the  stomach  in  a  process  of  atrophy  with  more  or  less  ad- 
ditional gastritis. 

Jaworski  and  Gluczinski  (56)  held  that  in  cancer  of  the 
stomach  there  was  no  free  HCl,  little  pepsin,  and  no  pep- 
tones. Their  study  of  the  subject  seemed  to  them  sufficient 
to  justify  the  conclusion  that  with  free  HCl  and  normal  di- 
gestive faculty  carcinoma  should  be  excluded.  To  this  view 
Ewald  (57)  also  subscribes.  How  contradictory  are  the 
statements  of  Cahn  and  v.  Mering  (58),  who  conclude  that 
with  cancer  of  the  pylorus  the  presence  of  HCl  is  the  rule, 
its  absence  the  exception  "  ! 

The  largest  number  of  examinations  have  been  made  by 
Kiegel  (59),  who  reports  two  hundred  and  seventy-four 
analyses  in  thirteen  cases.  Free  HCl  was  never  detected. 
He  (Riegel  (60))  reported  three  cases  of  cancer  of  the  stom- 
ach in  which  a  feeble  HCl  reaction  took  place  early  in  the 
disease. 

Rosenheim  (61)  reports  sixteen  cases,  in  fourteen  of 
which  there  was  an  absence  of  free  HCl ;  in  the  other  two 
there  was  a  transitory  presence  of  free  HCl  and  hyperacid- 
ity, respectively. 

Kinnicut  (62)  reports  eight  cases  with  one  hundred  and 
thirty-two  analyses.  Free  HCl  was  demonstrable  only  in 
two  cases,  in  one  of  which  a  trace  was  detected  in  two  ex- 
aminations out  of  twelve  ;  in  the  second  a  feeble  HCl  reac- 
tion was  once  obtained. 

In  ten  cases  under  my  own  observation  with  one  hun- 
dred and  twenty  tests,  free  HCl  was  absent  in  92 '7  per 
cent,  of  the  tests,  and  present,  as  a  rule  feebly,  in  7"3  per 
cent. 

Thiersch  (63),  in  an  interesting  article  On  the  Presence 
of  Free  HCl  in  the  Gastric  Juice  in  Beginning  Cancer  of  the 
Stomach,  reports  a  case  in  which  HCl  was  present,  and 
Krause  (64)  has  established  beyond  doubt  the  fact  that  HCl 
may  persist  in  cases  of  ulcerating  carcinomata  of  the  py- 
lorus. A  continuous  absence  of  HCl  is  found  in  all  cases 
in  which  there  is  atrophy  or  amyloid  degeneration  of  the 
mucous  membrane  of  the  stomach  accompanying  cancer 
(Levy  (65),  Edinger  (66)). 

In  considering  the  diagnosis  of  gastric  cancer  from  the 
chemical  analysis  of  the  stomach  contents,  it  must  be  re- 
membered that  in  most  forms  of  gastritis  (Boas  (67),  Ja- 
worski (68))  HCl  is  reduced  (from  0-22  per  cent.,  0-28  per 
cent.,  to  0-1217  per  cent.). 

Boas  has  found  that  in  marasmus,  Riegel  (69)  in  fever, 
Ilonigman  in  regurgitated  bile  (a  fact  to  which  I  have  al- 
ready referred  in  my  own  statistics)  free  IK'I  is  absent,  and 
Grundzach  (70)  has  shown  that  in  perfectly  healthy  indi- 
viduals with  normal  digestion  there  may  be  a  transitory 
deficiency  of  free  HCl. 

With  such  data  before  us  no  one  will  assert  that  we  are 
justified  in  diagnosticating  cancer  of  the  stomach  from  the 


absence  or  presence  of  free  HCl  alone,  while  in  the  majority 
of  cases  of  cancer  of  the  stomach,  as  shown  by  the  results 
of  the  tests  made  by  Riegel,  Rosenheim,  Kinnicut,  and  my- 
self, absence  of  HCl  has  been  demonstrated;  "the diagnos- 
tic value  of  this  circumstance  is  materially  lessened  by  the 
occurrence  of  this  same  deficiency  in  other  diseases  with 
similar  symptoms."  Ewald  (71)  concludes:  "But  granting 
this,  the  proposition  which  I  was  the  first  to  announce  is 
still  true,  that  the  demonstration  of  the  presence  of  HCl 
points  with  very  great  probability  against  the  existence  of 
cancer  of  the  stomach,  for  the  cases  of  this  disease  in  which 
there  is  a  positive  reaction  to  the  carefully  applied  tests 
are  so  rare  that  they  have  very  little  bearing  on  the  ques- 
tion." 

1.  Latency  of  Gastric  Cancer. — The  frequent  examina- 
tion of  the  stomach  contents  has  demonstrated,  to  my  mind, 
at  least,  the  fact  that  in  a  large  number  of  cases  there  are 
periods  of  latency  during  which  there  remains  a  certain 
amount  of  functional  inactivity,  but  in  properly  managed 
cases  immunity  from  many  of  the  painful  and  depressing 
symptoms  of  the  original  disease. 

Latent  gastric  cancer  has  not  been  generally  recognized 
and  in  many  cases  the  first  and  correct  diagnosis  has  been 
changed  by  the  unsuspecting  physician,  owing  to  this 
period  of  latency  with  evident  improvement  and  deviation 
from  the  ordinary  course  of  the  disease.  I  have  in  mind 
at  this  time  a  number  of  cases,  and  in  most  of  them,  if 
seen  sufficiently  early,  there  is  decreasing  HCl  in  the  secre- 
tion, a  tardy  absorption,  with  more  or  less  motor  involve- 
ment, according  to  the  location  of  the  tumor  and  the 
amount  of  secondary  dilatation  with  the  period  of  latency. 
The  examination  of  the  stomach  contents  shows  no  im- 
provement, neither  does  the  amount  of  HCl  vary  materially 
from  that  found  at  the  beginning  of  the  period  of  latency. 

In  many  of  these  cases  the  olive-oil  and  salol  tests 
prove  increasing  motor  strength,  and  in  those  patients  who 
have  accompanying  glandular  atrophy  and  yet  show  general 
improvement  it  may  be  assumed  that  constriction  does  not 
exist  to  any  great  degree,  and  that  the  duodenum  and  in- 
testines are  performing  their  functions  with  sufficient  ac- 
tivity to  nourish  the  patient.  It  follows,  therefore,  that 
the  cases  in  which  we  most  frequently  find  latent  gastric 
cancer  are  either  those  with  localized  tumor  without  much 
constriction  and  ultimate  gastrectasia,  or  the  infiltrating 
variety,  with  only  moderate  thickening  at  the  pylorus. 

It  is  surprising  to  note  the  length  of  time  during  which 
the  disease  remains  latent  and  the  long  duration  of  the  dis- 
ease as  a  result  of  these  periods  of  latency. 

I  have  at  the  present  time  a  case  under  observation 
which  has  continued  for  almost  six  years — that  of  a  woman, 
now  sixty  years  old,  which,  seven  years  ago,  commenced  with 
vague  symptoms  of  indigestion  and  anorexia.  For  two 
yfears  there  was  an  increase  of  these  symptoms,  with  the 
characteristic  changes  in  tlie  blood  found  in  cancerous  dis- 
eases, as  shown  by  microscopic  examination.  Four  years 
ago  she  had  coffee-ground  vomit,  and  later  considerable 
luematemesis.  Three  years  ago  there  was  almost  complete 
absence  of  II CI,  with  tardy  absorption  and  weakened  motor 
strength.    With  these  symptoms  no  tumor  could  bo  felt, 


492 


ELSNER:  NEWER  METHODS 


OF  STOMACH  EXAMINATION. 


[N.  Y.  Mkd.  Jout., 


neither  was  tliere  gastrectasia.  At  that  time  she  com- 
menced to  improve ;  trial  meals  showed  absence  of  IICl, 
but  the  motor  function  had  improved  so  that  gradually  the 
stomach  learned  to  empty  itself,  to  allow  of  the  more  thor- 
ough digestion  in  the  small  intestine.  The  subsequent 
history  shows  periods  of  exacerbation  and  latency  until 
now,  when  we  find  a  well-marked  tumor  in  the  anterior 
stomach  wall,  as  shown  by  distending  that  organ,  and  sec- 
ondary nodules  in  the  groin,  and  probably  in  the  liver. 

Some  may  say  that  this  was  originally  a  case  of  ulcer 
which  now  has  a  carcinomatous  base.  This  is  not  pro])a- 
ble,  for  there  has  been  no  time  wlien  there  was  hyperacid- 
ity or  supersecretion,  always  deficient  HCl ;  at  no  time  was 
the  secretion  of  the  stomach  competent  to  digest  albumi- 
noid foods,  while  the  seat  of  the  tumor,  with  the  early 
cachexia  and  blood  changes,  preclude  the  presence  of  an 
original  ulcus  ventriculi.  In  these  cases  of  latent  cancer 
without  tumor  formation  the  disease  strongly  resembles 
pernicious  anaemia  ;  but  here  the  microscope  comes  to  our 
aid  and  the  experienced  haimatologist  will  have  no  trouble 
in  distinguishing. 

Henry  (72),  in  a  clinical  lecture  on  diagnosis  of  cancer 
of  the  stomach,  says :  "  I  had  under  my  care  at  the  same 
time  two  cases — one  with  pernicious  anaemia,  the  other  with 
cancer  of  the  stomach.  The  latter  was  far  more  emaciated, 
far  more  feeble  than  the  former,  while  the  red  blood-cor- 
puscles were  four  or  five  times  as  numerous.  Surely  nothing 
in  the  whole  field  of  clinical  medicine  can  be  more  diag- 
nostic than  such  facts.  In  carcinoma  of  the  stomach  the 
reduction  of  the  number  of  red  blood-corpuscles  does  not 
keep  pace  with  the  cachexia;  in  pernicious  ana'mia  the 
cachexia  does  not  keep  pace  with  the  reduction  of  the  red 
blood- corpuscles." 

2.  Infiltrating  cancer  of  the  stomach  without  distinct 
tumor  formation  is  not  of  infrequent  occurrence.  Unless 
the  infiltration  or  new  tissue  formation  in  the  neighbor- 
hood of  the  pylorus  is  sufficient  to  cause  constriction  with 
more  or  less  dilatation,  the  diagnosis  between  this  con- 
dition and  atrophy  of  the  gastric  follicles  becomes  very 
difficuh. 

Here  again  our  tests  will  come  to  our  assistance  if 
made,  for  physical  signs  will  not  avail  until  secondary 
changes  have  taken  place.  Tn  both,  IlCl,  pepsin,  and  ren- 
net may  be  absent.  In  atrophy  there  is  never  haemateme- 
sis,  while  the  presence  of  altered  blood  and  pigment  gives 
the  stomach  contents  a  characteristic  color  in  carcinoma 
(Ewald  (73)). 

With  infiltrating  cancer  we  find — 

a.  During  fasting,  the  presence  of  the  food  taken  the 
day  before  in  the  stomach. 

b.  With  trial  meal,  absence  of  free  HCl. 

c.  Lactic  acid  present. 

d.  Progression  of  disease,  never  an  improvement  of 
functional  activity  of  the  stomach. 

3.  Pyloric  Carcinoma,  Stenosis,  and  Gastrectasia. — In 
these  cases  the  symptoms  gradually  appear.  If  the  patient 
presents  early,  there  is  complaint  of  occasional  vomiting, 
with  more  or  less  sternal  and  epigastric  distress.  As  the 
disease  advances,  even  before  the  tumor  is  palpable,  per- 


cussion elicits  a  changed  note  over  or  near  the  normal  loca- 
tion of  the  pylorus. 

The  examination  of  the  stomach  contents  after  a  test 
meal  sliows  acidity  due  to  the  organic  acids,  lactic  mainly. 
The  food  taken  during  the  previous  day  is  found  in  the 
stomach.  As  a  rule,  free  HCl  is  absent ;  if  not  entirely 
absent,  is  reduced  in  quantity.  As  the  disease  advances 
there  may  still  be  presence  of  pepsin  in  a  reduced  quantity, 
while  rennet  may  or  may  not  be  present,  also  peptone  and 
propeptone. 

It  may  be  taken  for  granted  that  if,  on  repeated  exami- 
nation with  the  tube  and  with  a  proper  diet,  composed  in 
part  of  albuminous  food,  the  stomach  retains  the  ingesta, 
but  slightly  changed  and  undigested  for  more  than  seven 
hours,  a  constriction  is  present  at  the  pylorus ;  and  if  free 
HCl  is  absent,  with  the  absorptive  function  of  the  stomach 
deranged,  the  chances  are  decidedly  in  favor  of  carcinoma. 
Dilatation  is  usually  present  under  such  circumstances;  if 
not,  it  will  not  be  long  in  showing  itself.  The  amount  of 
fluid  expressed  through  the  tube  gives  an  approximate  idea 
of  the  degree  of  the  constriction  and  the  amount  of  gas- 
trectasia. 

4.  Carcinomatous  Infiltration  of  the  Base  of  Old  Ulcers 
(particularly  at  the  Pylorus). — From  seven  to  nine  per  cent, 
of  all  gastric  cancers  are  located  in  and  take  their  origin 
from  ulcers  (Haberlin  (74),  Rosenheim  (75)). 

In  a  private  communication  from  Professor  Billroth,  to 
which  I  will  again  refer,  he  writes:  "I  consider  the  differ- 
ential diagnosis  of  an  ulcer  of  the  stomach  with  cicatriza- 
tion and  beginning  carcinomatous  infiltration  from  primary 
cancer  as  very  difficult  and  usually  impossible — ofttimes 
impossible  when  the  fresh  specimen  is  before  us  and  cut 
into,  only  possible  after  many  and  large  sections  have  been 
microscopically  examined."  It  may  be  said  at  this  junc- 
ture that  given  a  case  (Rosenheim  (76))  in  which  there  is 
tumor  formation,  pain,  anorexia,  and  rapid  emaciation, 
with  the  characteristic  blood  changes  of  cancer,  free  HCl 
constantly  present  at  the  height  of  digestion,  with  possibly 
hyperacidity  and  ultimate  gastrectasia,  we  may  conclude 
with  a  considerable  degree  of  certainty  that  we  are  dealing 
with  a  cancerous  infiltration  of  the  base  of  an  old  gastric 
ulcer.  Here,  too,  we  must  be  careful  to  exclude  extra- 
gastric  growths,  which  cause  compression  of  the  pylorus 
and  dilatation  in  consequence,  and  may  at  the  same  time 
have  accompanying  hyperacidity.  Such  cases  have  been 
reported  by  Plawski  (77),  who  dilates  very  fully  on  this 
subject  in  his  article. 

5.  Localized  cancers  without  constriction  and  with  but 
little  rjlandular  atrophy  occasionally  occur,  and  HCl  may 
continue  to  be  present  in  the  secretion  until  within  a  short 
time  before  death. 

Here  the  diagnosis  requires  a  thorough  physical  exami- 
nation. The  stomach  must  be  outlined  after  the  method 
of  Piorry  and  allowance  must  be  made  for  absorptive  and 
motor  functions  according  to  the  location  of  the  neoplasm 
and  the  extent  of  the  change  in  the  mucous  membrane  as 
the  disease  progresses. 

6.  Non-malignant  and  Fibrous  Stenoses  of  the  Pylorus. — 
In  this  connection  it  must  not  be  forgotten  that  there  are 


May  6,  1893.] 


ELSNER:  NEWER  METHODS 


OF  STOMACH  EXAMIKATION. 


493 


cases  of  non-malignant  and  fibrous  stenoses  of  the  pylorus. 
In  many  of  these  cases  we  have  a  previous  history  of  ulcer, 
with  attending  hyperacidity,  characteristic  pain,  and  hiemor- 
rhage.  In  other  cases  the  stenosis  is  gradually  formed, 
the  aetiology  remains  obscure,  and  a  differentiation  from 
cancerous  obstruction  becomes  necessary. 

In  fibrous  stricture  we  find  IICl  present,  in  some  cases 
in  excess,  peptic  action  slow,  but  ultimately  satisfactory. 
In  thirty-three  cases  studied  by  Riegel  (Y8),  he  found  0-10 
to  0-46  per  cent,  of  HCl,  and  in  twenty  cases  titrated  by 
Ewald  (79)  he  found  0'17  to  0-30  per  cent,  of  the  acid. 

As  a  rule,  after  the  Ewald  test  meal,  I  have  found 
hyperacidity,  similar  to  the  experience  of  Einhorn,  as  re- 
lated to  me  in  a  personal  communication  of  great  value. 
Free  HCl  is  present,  food  is  held  in  the  stomach  longer 
than  normal,  while  albuminoids  are  changed  and  partially 
digested,  while  the  organic  acids,  particularly  lactic  acid 
and  butyric  acid,  are  present  and  in  the  ascendency,  dis- 
placing in  some  cases  the  free  HCl,  which  is  again  found 
after  thorough  disinfection  and  washing  out  of  the  stomach. 

In  most  of  the  modern  works  on  carcinomatous  diseases 
of  the  stomach  it  appears  to  the  writer  that  too  little  im- 
portance has  been  placed  on  a  more  careful  study  of  the 
motor  and  absorptive  function  of  the  stomach,  while  the 
HCl  estimation  has  been  constantly  placed  in  the  fore- 
ground. 

The  newer  methods  of  diagnosis  must  include  in  the 
diagnosis  of  gastric  cancer  the  frequent  examination  of  the 
blood  for  hajmoglobin  as  dwelt  upon  by  Ilaberlin  (80)  in 
his  monograph,  and  the  examination  of  the  urine  for 
indican  (Rosenheim  (81)),  in  order  to  give  valuable  in- 
formation. 

In  association  with  the  subject  of  cancer  of  the  stom- 
ach, with  your  kind  permission  I  will  report  two  cases 
which  show  the  value  of  examination  of  the  stomach  con- 
tents as  an  aid  in  differential  diagnosis : 

Case  I. — On  the  27th  of  May,  1891,  I  was  called  to  see 
Ellen  R.,  aged  forty-two,  unmarried,  with  a  negative  family 
history.  For  several  months  she  had  been  complaining  of  a 
feeling  of  distress  after  taking  food,  pains  radiating  through  the 
upper  half  of  the  abdomen,  progressive  but  gradual  emaciation, 
with  increasing  muscular  enfeeblement  and  considerable  anaemia. 
The  pains  bore  no  relation  to  the  ingestion  of  food,  though 
she  complained  of  flatulence  about  two  hours  after  her  meals. 
6he  had  vomited  at  various  times  during  the  preceding  two 
montlis,  never  blood,  usually  a  light-yellow,  sour-tasting,  but 
not  foul-smelling  fluid. 

At  times  the  vomited  matter  had  been  of  a  darker,  almost 
brown  color.  There  were  no  other  subjective  symptoms  save 
a  chronic  constipation.  Ovarian  and  uterine  functions  were  nor- 
mal, though  she  gave  a  vague  history  of  a  |)elvic  peritonitis,  for 
which  she  had  been  treated  about  two  years  before  the  begin- 
ning of  the  symptoms  of  which  she  now  complained.  There  was 
also  a  slight  accentuation  of  the  mitral  sounds  over  that  area. 
With  these  symptoms,  the  character  of  the  pain,  the  vomiting, 
more  particularly  the  occasional  ejection  of  a  brownish,  almost 
coffee- colored  fluid,  malignant  disease  of  the  stomach  or  duo- 
denum was  strongly  suspected. 

Physical  examination  of  the  abdomen  at  the  first  visit  failed 
to  give  satisfactory  evidence  of  the  existence  of  such  a  lesion. 
On  pressure  over  the  epigastrium  there  was  increased  tender- 


ness, while  percussion  was  normal  all  over  the  abdomen.  The 
size  of  the  stomach  was  tested  after  the  method  of  Piorry  and 
Penzoldt,  and  was  found  to  be  normal.  After  this  she  refused 
the  trial  meal,  preferring  treatment  for  a  number  of  days  before 
the  reintroduction  of  the  tube.  An  examination  of  the  urine 
at  this  time  showed  it  to  be  normal,  with  a  specific  gravity  of 
1-024.  During  the  week  following,  the  patient's  condition  did 
not  change  materially.  On  the  5th  of  June,  about  nine  days 
after  my  first  visit,  the  patient  was  given  a  Leube-Riegel  test 
meal,  which  was  expressed  after  five  hours  by  means  of  a  soft 
tube,  when  it  was  found  that  most  of  the  albuminoid  food  had 
been  digested.  The  extracted  remnant  contained  neither  starch 
nor  any  of  its  products,  gave  positive  evidence  of  the  presence  of 
nCl  with  Congo  paper  and  ihe  Gunzburg  test,  as  well  as 
that  of  Boas.  The  amount  of  HCl  was  0"2.5  per  cent.  The 
Cflfelmann  test  failed  to  show  the  presence  of  organic  acids. 
The  test  for  pepsin  and  rennet  showed  a  good  digestive  fluid. 

The  result  of  this  examination,  after  the  strong  suspicion  of 
gastric  cancer,  was  surprising  and  puzzling.  The  test  of  the 
motor  function  with  salol,  and  the  absorptive  function  also, 
showed  normal  motor  and  absorptive  activity.  Gastric  cancer 
was  at  once  excluded,  though  I  now  leaned  very  strongly, 
strengthened  by  the  increasing  emaciation  and  ansemia  of  the 
patient,  to  the  diagnosis  of  malignant  disease  of  some  one  of 
the  abdominal  viscera  other  than  the  stomach.  No  positive 
diagnosis  was  made. 

The  subsequent  course  of  the  case  proved  the  correctness  of 
that  view.  During  the  following  month  a  distinct  nodule  could 
be  felt  in  the  epigastric  region,  near  the  normal  position  of  the 
pylorus.  To  localize  this  nodule  more  exactly  the  stomnch  was 
inflated,  when  it  was  found  that  the  nodule  was  situated  behind 
its  posterior  wall.  The  diagnosis  of  retroperitoneal  or  pan- 
creatic cancer  seemed  justified.  In  the  course  of  the  next  few 
weeks  it  became  evident  that  there  were  cancer  nodules  in  the 
omentum  and  in  the  retroperitoneal  folds  and  the  pancreas. 

The  addition  of  glycosuria  to  her  other  symptoms  several 
weeks  before  her  death  led  me  to  conclude  that  the  nodule  felt 
in  her  epigastrium  was  connected  with  the  pancreas,  though 
there  was  no  fat  in  her  stools  at  any  time. 

On  the  31st  of  Jidy,  1891,  she  was  suddenly  taken  with  a 
profuse  diarrhoea,  and  died  in  collapse  during  the  following 
night. 

The  post-mortem  examination,  made  by  Dr.  Curtiu,  showed 
cancer  nodules  involving  the  retroperitoneal  glands  and  omen- 
tum, with  a  large  cancerous  mass  occupying  the  normal  seat  of 
the  head  of  the  pancreas.  This  organ  was  adherent  to  the 
stomach,  and  the  latter  organ  was  found  entirely  free  from 
disease. 

In  this  case  it  may  be  said  that  the  chemical  analysis 
was  of  great  value  in  distinguishing  and  in  a  measure  locat- 
ing the  seat  of  the  disease.  Without  the  examination,  but 
with  the  presence  of  a  tumor  ultimately  in  the  epigastric  re- 
gion, palpable,  with  the  symptoms  already  given  during  the 
period  preceding  the  glycosuria,  no  physician  would  have 
leaned  as  strongly  to  any  other  diagnosis  as  to  that  of  gas- 
tric cancer. 

The  absence  of  fat  from  the  stools,  in  spite  of  the 
persistence  of  glycosuria,  would  have  had  no  material  bear- 
ing in  the  diagnosing  of  the  case  without  the  positive  evi- 
dences of  a  normally  acting  stomach,  such  as  we  obtained 
from  our  chemical  analysis. 

This  case  is  one  of  many  which  might  be  related  to 
convince  the  most  skeptical  of  the  truth  of  the  statement 


494 


MANLEY:  HOM(EO-OSTEOPLASTY. 


[N.  Y.  Med.  Jodr., 


that  we  possess  in  the  newer  methods  of  examination  aids 
of  practical  value  for  the  differential  diagnosis  of  diseases 
which  have  a  great  similarity  to  the  organic  stomach  dis- 
turbances. The  cases  which  have  given  me  the  greatest 
satisfaction  have  been  those  in  which  I  have  been  able  by 
these  methods  to  exclude  almost  positively  the  existence  of 
organic  disease  of  the  alimentary  tract  when  there  were 
present  well-marked  evidences  of  some  serious  organic  dis- 
sease.  In  such  cases,  in  spite  of  the  fact  that  there  are 
symptoms  referable  to  the  stomach,  it  may  be  said,  indeed 
we  may  be  almost  justified  in  formulating  the  rule,  that  with- 
out marked  change  in  the  contour  of  the  stomach,  without  a 
tumor  which  can  with  certainty  be  located  in  the  stomach 
wall,  without  unequivocal  signs  of  organic  disease  of  the 
stomach,  with,  on  chemical  analysis,  the  evidences  of  normal 
secretory,  motor,  and  absorptive  functions,  organic  disease  of 
the  stomach  can  be  excluded  with  certainty.  The  cases  in 
which  nodules  in  the  epigastrium  or  its  immediate  neigh- 
borhood connected  with  the  liver,  gall  bladder,  pancreas,  or 
omentum  require  accurate  differentiation  are  constantly 
coming  to  us,  and  require  all  of  the  skill  and  acumen  of  the 
careful  and  painstaking  diagnostician.  In  a  recent  per- 
sonal communication  from  Boas  I  was  pleased  to  note  that 
he  expressed  his  belief  in  the  fact  that  one  of  the  most  im- 
portant achievements  of  the  chemical  analyses  of  the  stom- 
ach contents  was  the  certainty  with  which  they  permit  of 
the  exclusion  of  the  diseases  of  the  stomach. 

Case  11. — In  a  case  which  recently  came  to  my  notice  there 
was  a  small  nodule  in  the  lower  right  corner  of  the  epigastrium, 
which  tblloweil  in  about  ten  months  after  the  removal  of  the 
right  testicle  for  medullary  cancer  in  a  man  aged  thirty-seven. 
There  were  some  symptoms  which  made  the  exact  localization 
of  the  tumor  impossible.  There  was  repeated  vomiting  at  first 
of  an  acid  mucus.  As  the  nodule  increased  in  size  it  was  found 
that  the  stomach  symptoms  grew  worse.  An  examination  of 
the  stomach  contents  after  a  trial  meal  failed  to  show  any 
change  in  the  functional  activity  of  that  organ  ;  as  a  result,  gas- 
tric cancer  was  excluded. 

In  the  course  of  a  few  weeks,  as  the  tumor  enlarged,  it  was 
found  that  at  times  so  much  bile  was  present  in  the  stomach, 
regardless  of  the  digestive  period,  that  a  constriction  of  the  in- 
testine below  the  entrance  of  the  common  duct  was  strongly 
suspected,  thus  causing  a  regurgitatiDU  of  the  bile  into  the  stom- 
ach. When  the  stomach  was  thoroughly  emptied  and  all  bile 
removed,  the  reactions  were  normal  after  a  test  meal  at  the 
height  of  digestion.  The  subsequent  hi.-tory,  I  think,  justified 
the  diagnosis  of  a  growth  connected  with  the  right  kidney,  by 
pressure  almost  occluding  the  duodenum  at  a  point  below  the 
entrance  of  the  ductus  choledochus.  Unfortunately,  no  post- 
mortem was  allowed. 

i^To  he  conclnded .) 


Changes  of  Address. — Dr.  Louis  A.  Bull,  to  No.  619  Main  Street 
(32  and  :U  Market  Arcade),  Buffalo,  N.  Y.  ;  Dr.  George  H.  Coclss,  to 
No.  19SC)  Madison  Avenue;  Dr.  Jolin  G.  Curtis,  to  No.  327  West  Fifty- 
eighth  Street ;  Dr.  Z.  Taylor  Emery,  to  No.  481  Washington  Avenue, 
Brooklyn  ;  Dr.  P'rancis  Foerster,  to  No.  39  We.st  Fifty-second  Street ; 
Dr.  L.  Le  Bnin,  to  No.  78  South  Ferry  Street,  Albany,  N.  Y.  ;  Dr. 
Maurice  J.  Lewi,  from  Albany  to  No.  78  West  Eiglity-second  Street, 
New  York ;  Dr.  Emmett  D.  Page,  to  No.  297  De  Kalb  Avenue,  Brook- 
lyn;  Dr.  H.  W.  Rand,  to  No.  172  Clinton  Street,  Brooklyn;  Dr.  Cyrus 
S.  Siegfiied,  to  No.  149  Franklin  Street,  fJuffalo,  N.  Y. ;  Dr.  Irving 
Townsend,  to  No.  56  West  Forty-sixth  Street. 


NOTES  ON 

CASES  OF  IIOMCEO-OSTEOPLASTY 

IN  THE  SHATTERING  DISORGANIZATION  OF 
COMPOUND  FRACTURE  OF  THE  LEG,  THIGH,  AND  HAND. 

By  THOMAS  H.  MANLEY,  M.  I). 
/ 

In  serious  cases  of  compound  fracture  of  a  limb  at- 
tended with  loss  of  bone  substance  we  are  often  required 
to  promptly  decide  on  the  adoption  of  such  measures  as 
will  save  life  and  afford  us  the  best  prospect  of  saving  the 
limb.  In  the  main,  under  these  circumstances,  there  are 
but  two  procedures  open  to  us — first,  immediate  amputa- 
tion ;  and  second,  delay  and  the  application  of  such  a  ten- 
tative therapy  as  will  enable  us  to  spare  every  particle  of 
such  tissues  as  may  later  serve  a  useful  purpose. 

After  considerable  experience  with  many  very  extensive 
mangling  fractures  of  the  extremities  of  every  description, 
I  am  led  to  conclude  that  in  the  present  advanced  state  of 
modern  surgery  a  primary  amputation  in  civil  life  is  never 
a  justifiable  procedure  unless  the  initial  vulnerant  force  ap- 
plied has  been  so  great  as  to  totalhj  destroy  the  vitality  of 
tissues  beyond  the  line  of  injury — in  other  words,  unless 
the  physical  force  has  in  itself  effected  practically  a  trau- 
matic amputation.  In  other  recent  contributions  *  I  have 
fully  and  in  detail  endeavored  to  clearly  set  forth  my  posi- 
tion in  this  particular ;  to  define  the  class  of  cases  in  which 
the  greatest  success  may  be  attained,  with  a  varied  technique 
and  therapy,  which,  when  instituted,  is  attended  with  good 
results ;  and  demonstrated,  both  by  an  appeal  to  the  most 
noted  recent  authorities  and  the  citation  of  a  large  number 
of  cases,  that  we  must  under  all  circumstances  practice 
extreme  conservatism  in  all  cases  of  serious  fractures  ac- 
companied by  extensive  disorganization  of  substance. 

The  cases  here  described  were  attended  by  me  within 
the  past  six  months. 

The  most  interesting  of  the  group  I  will  present  first. 

Case  I.  Compound  Fracture  of  Left  Tibia;  Removal  of  Three 
Inches  and  a  Quarter  of  Shattered  Shaft  with  a  Corresponding 
Segment  of  the  Unbroken  Fibula. — I^atieiit,  Mr.  C.  B.,  aged  thir- 
ty-nine years,  of  medium  height  and  good  general  health,  on  the 
30th  of  June,  1892,  while  descending  a  staircase,  slipped  and  fell 
to  the  bottom.  As  he  was  unable  to  rise  after  the  accident 
without  assistance,  he  was  lifted  up,  placed  in  a  conveyance, 
and  sent  to  bis  home.  Here  he  was  attended  by  Iiis  family 
physician.  Not  having  very  good  success  in  the  management 
of  the  case,  and  finding  that  the  patient's  general  condition  was 
becoming  seriously  disturbed,  the  doctor  sent  him  to  the  Har- 
lem Hospital. 

When  the  case  was  seen  by  me  (July  4th)  in  hospital  and  I 
discovered  the  extremely  serious  nature  of  the  injury,  before 
instituting  any  special  line  of  treatment  other  than  securing 
the  i)arts  in  u  comfortable  temporary  adjustment,  I  sent  for  the 
family  physician  to  again  see  the  rather  hopeless  sort  of  case 
we  had  in  our  hands— as  far,  at  lea.^t.  as  the  saving  of  the  limb 


*  Resection  as  a  Substitute  for  Primary  Amputation  {Xoi;  Enghtnd 
Medical  MonfMi),  'May,  1891);  A  Study  of  Osteogenesis  from  a  Patho- 
logical Standpoint  (J/<(/i<'(// ajirf  Sjtrffirid.  Kcportrr,  J>d\,  1891);  Osteo- 
genesis and  Osteoplasty  in  Crushing  Lesions  of  the  Extremities  {Buffalo 
Medical  and  Siirriiral  Journal.^  November,  1H92). 


May  6,  1893. J 


MANLEY:  HOM(EO-OSTEOPLASTY. 


495 


went — before  we  should  undertake  any  sort  of  serious  operation 
•on  hitn. 

Tiie  tibia  had  been  broken  about  four  inches  from  the  ankle 
joint.  Botli  the  proximal  and  distal  ends  of  the  frafjint-nts  were 
cointninuted,  and  were  projecting  through  a  large  breach  in  the 
integument  along  the  inner  aspect  of  the  leg.  More  than  three 
inches  of  the  tibial  shaft  protruding  was  of  a  lusterless,  charred 
appearance,  completely  denuded  of  its  periosteum.  The  foot 
and  leg  were  greatly  swollen,  and  the  appearance  of  the  wound 
was  most  unpromising.  Its  surface  was  bloodless,  of  a  gray 
hue,  abundantly  discharging  an  ichorous,  foul  smelling  fluid  on 
the  least  pressure. 

His  general  condition  was  not  good.  Already  symptoms  of 
inci])ient  wound  infection  and  constitutional  irritation  were 
manifested  by  the  quick  |>ulse.  Hushed  cheek,  and  high  tempera- 
ture. He  had  a  good  heart,  however,  with  plenty  of  "nerve" 
and  will  power,  and  was  ready  to  submit  to  anything  that 
might  be  done  which  would  preserve  the  leg. 

Now  the  question  arose,  What  was  to  be  done  that  would 
secure  the  best  prospect  of  future  locomotion  and  save  his 
life? 

Well,  if  we  were  to  institute  that  measure  which  would  the 
most  promptly  rid  him  of  the  mas-*  of  irritable  tissue  and  etiect 
prompt  union,  the  answer  would  be.  Amputation  and  an  artifi- 
cial limb.  But  bow  lew  ever  secure  a  stump  that  will  bear  an 
artificial  limb  with  any  degree  of  comfort ;  and,  even  though 
they  do  about  once  in  ten  cases  after  amputation  through  con- 
tiguity of  tissue  in  the  leg,  what  a  miserable  substitute  tlie  most 
perfect  prothetic  apparatus  is  con)pared  even  with  an  ankylosed 
ankle! 

After  careful  deliberation  and  anticipating  many  of  the  dan- 
gers in  the  way  of  resection,  it  was  decided  to  utilize  modern 
osteoplastic  procedures  and  endeavor  to  preserve  the  limb. 

It  must  be  remembered  that  the  fibula  was  yet  whole  and 
unbroken.  We  might,  it  is  true,  have  removed  the  debris  of 
the  broken  tibia  and  left  a  gap  in  the  tissues,  but  the  limb  would 
have  been  useless  for  either  motion  or  pressure.  So  we  might 
have  plugged  the  breach  with  decalcified  bone  chips;  but, 
(though  these  might  be  covered  in  in  time  by  a  temporary  cica- 
trix, yet  they  are  as 
much  a  foreign  sub- 
stance as  the  bone 
about  to  be  removed. 

Heteroplastic  bone 
grafts  were  quite  out 
of  the  question,  for 
the  bone  elements  of 
man  will  not  mingle 
and  assimilate  with 
those  of  a  lower  ani- 
mal. 

It  was  decided  then 
to  cut  away  all  the 
disorganized  bone  of 
the  tibia  and  remove 
sufficient  of  the  fibular 
shaft   to    permit  the 
transverse  surfaces  to 
come   evenly  togeth- 
er ;  in  that  manner  to 
secure    solid  union, 
though  at  the  exjiense 
of  the  length  of  the  leg. 
Operation. — On  the  afternoon  of  July  .5th,  after  having  had 
the  patient  prepared  and  the  limb  in  readiness,  I  commenced  by 
pushing  out  the  lower  fragment  to  its  uttermost,  in  order  that 


Fio.  1.— Anterior  internal  aspcot.  1.  Segment 
correeponding  in  eize  and  situation  with  that 
removed.  2.  Scar  of  internal  incision.  ,3. 
Horizontal  patella  line.  4.  Line  correspond- 
ing with  heel-surface  raised. 


the  chain  saw  might  engage  at  the  broad,  unbroken  surface  of 
the  distal  fragment,  just  above  the  epiphyseal  line,  when  it  was 
cut  through,  leaving  a  wide,  vascular  bone  surface.  The  proxi- 
mal fragment  was  treated  in  a  similar  manner.  Now  the  fibu- 
lar shaft  was  sought  for,  and  it  was  intended  to  reduce  its 
length  by  such  an  excis-ion  as  would  permit  us  to  opi)ose  the 
tibial  surfaces.  But,  as  seen  in  the  cut,  we  had  to  remove  a 
second  piece  before  this  end  was  secured. 

After  the  sawn  surfaces  of  the  bone  shafts  were  brought 
together,  one  heavy  silver  wire  suture  was  introduced  deeply 
into  the  free  ends  of  the  tibia,  which  secured  them  firmly  to- 
gether, after  its  ends  were  twisted. 

The  periosteal  coverings  of  the  divided  tibia  and  fibula  were 
now  carefully  sewn  together  around  the  hiatus,  in  the  tibia  and 
fibula,  and  then  the  tissues  were,  each  layer  homologously, 
apposed  and  sutured  until  the  integuments  were  reached. 
Through  all,  down  to  the  bone,  an  ample  drain-vent  was  left. 
At  this  stage  a  plaster  dressing  was  applied.  Fearing  the 
troublesome  secondary,  excessive  oozing  so  common  after 
permanent  dressings  are' applied  when  Esmarch's  constrictor  is 
u'ed,  we  did  not  employ  it. 

Our  man  was  on  the  table,  under  ether,  a  little  more  than 
an  hour.  He  reacted  well,  and,  though  his  complete  recovery 
and  the  return  of  the  full  use  of  his  leg  had  been  tedious,  he 
has  been  rewarded  for  the  time  lost  and  expense  entailed  there- 
by by  the  preservation  of  his  leg. 

Ultimate  Results  as  to  Locomotion  and  Strength  of  the  Limb. 
— The  bones  now  are  solidly  united,  and  he  is  able  to  attend 
his  place  of  business  and  stand  unsupported  on  his  limbs  from 
morning  until  night. 

In  the  beginning  of  November  he  had  a  shoe  specially  made 
for  the  injured  leg.  This  was  so  constructed  as  to  give  firm 
support  to  the  ankle;  and,  by  extending  the  broad,  strong, 
lateral  welts  up  to  the  knee  on  firm  lacing,  some  of  tlie  weight 
of  the  body  was  in  this  manner  borne  by  the  knee  joint  direc.ly. 
As  there  were  removed  just  three  inches  and  a  fifth  ot  bone 
shafts  in  their  vertical  diameters,  hence,  in  making  the  shoe,  a 
cork-sole  lift,  corresponding  to  this  loss,  was  built  up  trom 
below. 

He  now  has  no  pain  or  discomfort  of  any  kind. 
Under  date  of  February  2,  1893,  he  writes  to  me  that  at  the 
time  he  was  injured  he  was  crippled  with  rheumatism  in  the 


Fig.  2.— Showing  asymmetry  in  length.  1.  Line  through  the  horizont  1  plane 
c.f  the  lower  limbs,  in  the  sitting  posture.  2.  Cork-sole  shoe  with  a  three- 
and-one-llfth-inch  lift. 

joints  of  both  of  his  legs,  and  had  been  a  victim  to  this  malady 
for  many  years;  but  that  since  he  was  injured  his  rheumatism 
has  entirely  left  him.  Accordingly  he  inquires,  "Do  yon  think 
that  the  operation  on  my  leg  cured  me  of  my  rheumatism  ? " 
And  he  adds:  "  If  any  one  doubts  the  present  strength  and  use 


496 


MANLEY:  HOMCEO-OSTEOPLASTY. 


[N.  Y.  Med.  Jodr., 


of  my  leg  let  him  coine  forward  ;  and  as  I  can  now  give  him  a 
good  kicking  with  it,  he  will  soon  change  his  mind." 

"The  little  bone,"  he  says,  "which  you  expected,  came  out 
yesterday,  much  to  our  relief;  and  let  me  assure  you  that  we 

gave  it  a  right  royal  wel- 
come, as  it  no  doubt  is 
tlie  last  of  his  race." 

It  must  be  confessed 
that  for  the  remarkable 
result  and  the  preserva- 
tion of  Mr.  B.'s  leg  we 
are  largely  indebted  to 
our  nurse,  his  excellent 
wife,  through  whose 
faitliful  care  and  un- 
remitting attention  very 
much  of  our  success  is 
attributable. 

I  may  add  in  con- 
clusion that  this  case 
was  one  which  has  de- 
monstrated   the  enor- 
mous advantage  of  homoeo  osteoplasty  in  those  serious, 
complicated,  compound  fractures  in  which  heretofore  the 
usual  procedure  has  been  immediate  amputation.    I  can 


Fig.  3. — Standing  position.  !.  Horizontal 
line  through  center  of  patella;.  2.  Hori- 
zontal line  under  one  ankle  joint  and 
over  the  other. 


Fio.  4. — 1.  Proximal  fragment  of  tibia  sawn  i.tf.  2.  Distal  fragment  of  tibia 
Bawn  off  cloHe  to  ankle  joint.  3.  Section  of  fibula  (sound)  sawn  through. 
4.  Section  additional  rendered  necessary.  .5,  6,  7,  8,  9.  Shattered  fragments 
removed  from  hiatus. 

find  no  parallel  case  in  the  annals  of  American  surgery. 
In  Ollier's  great  work,  among  the  many  cases  of  osteoplasty 


there  cited  are  many  similar  ones;  but  they  were  all  of  a 
constitutional  or  pathological  origin,  and  do  not  belong  to 
the  category  of  traumatisms. 

It  may  be  added  that  in  any  other  case  of  a  similar  de- 
scription in  a  healthy  child  or  adult,  in  whom  there  is  a 
"  cushion  joint "  (a  pseudarthrosis)  with  loss  of  bone  sub- 
stance following  a  bone  injury  of  the  leg,  it  may  be  as  safely 
dealt  with,  with  as  good  prospects  of  satisfactory  results,  a 
month,  a  year,  or  more  after  the  primary  injury  as  immedi- 
ately after  the  accident,  when  osteoplasty  is  resorted  to  and 
skillfully  employed. 

Case  II.  Compound  Comminuted  Fracture  of  the  Tibia  with 
Simple  Fracture  of  Fibula,  besides  a  Cranial  Fracture ;  Pri- 
mary Resection  of  Bone  with  Adjustment;  Acute  Gangrene; 
Preparation  for  Amputation  ;  Death  under  Ether. — Patient, 
aged  thirty-one,  a  heavx -built,  swarthy,  vigorous  man,  wliile  on 
a  "  bender  "  during  tiie  Oliristmas  holidays  fell  through  a  bulk- 
head, sustaining  the  injuries  above  stated.  He  was  admitted  to 
Harlem  Hospital  December  26th.  There  were  evidences  of 
fracture  of  the  base  of  the  skull,  though  he  was  rational.  On 
examining  the  leg  (right),  it  was  found  that  he  had  a  compound 
fracture  of  tlie  tibia  with  extensive  shattering,  besides  a  simple 
fracture  of  the  fibula  which  was  not  displaced.  The  parts  were 
treated  immediately  on  admission,  as  the  preceding  case. 

He  came  out  of  the  antesthesia  well  and  passed  a  good  night. 
There  was  nothing  of  special  note  through  the  day  succeeding, 
except  an  incoherency  of  speech  and  mixed  symptoms  of  de- 
lirium a  potu  and  cerebral  injury. 

On  the  evening  after  admission,  on  looking  closely  at  the 
toes  of  the  injured  leg,  which  were  cold,  it  was  seen  that  they 
were  of  a  deep  purple  and  bloodless.  In  other  words,  gangrene 
had  set  in.  Removing  all  the  dressings,  it  was  ai)parent  that 
mortification  had  extended  up  as  far  as  the  knee,  and  that  there 
remained  no  alternative  but  an  amputation. 

But  his  general  condition  was  at  this  time  very  unfavorable 
to  a  capital  operation.  There  was  a  high  temperature  and  his 
pulse  was  very  quick.  Indeed,  his  case  presented  a  most  serious 
aspect.  Nevertheless,  if  the  cerebral  lesion  was  not  extensive, 
with  the  dead  limb  off  there  was  a  glimmer  of  hope  of  saving 
his  life.  Therefore,  after  carefull}'  considering  the  case  from 
all  sides,  it  was  finally  decided  to  moderately  etherize  and  do 
a  quick  circular  amputation  through  the  lower  third  of  the 
femur. 

With  this  object  in  view  he  was  brought  into  the  operating 
room.  Scarcely  an  ounce  of  ether  was  given,  however,  when 
he  suddenly  ceased  to  breathe  and  was  dead. 

In  reviewing  this  case  in  my  mind,  and  its  sudden  ter- 
mination, my  only  regrets  have  been  that  I  deviated  from 
my  usual  course  and  did  the  resection  with  the  primary 
dressing  while  my  patient  was  in  shock.  This  was  done 
because  it  was  thought  that  while  there  were  so  many  ves- 
sels to  ligate  and  so  much  shattered  bone  to  remove,  it  would 
add  but  little  if  any  to  the  collapse  to  do  the  resection  and 
make  the  adjustment.  But  this,  I  am  convinced,  was  a  seri- 
ous mistake.  Although  a  post-mortem  was  denied,  as  he 
had  free  haunorrhage  from  both  ears  with  symmetrical  ec- 
chymosis,  there  is  little  doubt  of  a  skull  fracture. 

Case  III.  Compound  Comminuted  Fracture  of  the  Femur, 
Upper  Third;  Reposition  of  Fragments ;  Recovery. — Patient, 
a  young  man  nineteen  years  old,  was  injured  by  a  fragment  of 
board  rebounding  from  a  circular  saw,  hitting  with  great  vio- 


May  6,  1893.] 


McGUIRE:  EXCISION  OF  CHANCRE. 


497 


lence  in  the  left  groin.  He  was  admitted  July  22d  to  the  Har- 
lem Hospital. 

Ho  was  in  considerable  shock  when  admitted.  The  left 
lower  limb  was  in  the  position  of  typicial  femoral  shaft  fracture. 
At  seat  of  injury,  projecting  through  integument  at  inner  bor- 
der of  rectus  muscle,  was  a  S[)iculum  of  the  shattered  bone  i)ro- 
jecting.  As  the  fracture  was  within  but  about  three  inches 
of  the  upper  epiphyseid  line,  the  iinraen-e  number  of  powerful 
muscles  inserted  into  the  trochanters  had  full  play  on  the  supe- 
rior fragments.  In  this  case  the  temptation  to  enlarge  the 
opening  and  do  an  osteoplasty  on  the  displaced  fragments  and 
spike  them  together  was  very  great.  But  aformei'  ac<iuaintancc 
with  traumatic  lesions  of  the  femoral  shaft  had  taught  me  the 
important  lesson  that  the  femur,  of  all  the  bones  in  the  liuman 
body,  is  the  one  in  the  skeleton  which  will  not  bear  manipula- 
tion with  impunity  after  fracture. 

Dr.  James  R.  Wood  used  to  say  that  "  he  took  off  his 
hat  to  the  peritonaeum  "  ;  and  my  experience  has  led  me  to 
have  a  very  respectful  regard  for  the  fragments  of  a  broken 
femur.  I  have  seen  one  case  in  which  on  non-union  the 
fracture  was  cut  down  upon  by  the  surgeon,  when  the  ends 
of  the  fragments  were  chiseled  and  wired.  The  patient 
narrowly  escaped  with  his  life,  remained  eighteen  montlis 
in  bed,  and  got  up  with  an  ankylosed  knee  joint  and  non- 
union of  the  fragments  again.  Another  eminent  surgeon 
whom  I  saw  refracture  a  distortion  of  the  femur  after 
vicious  union  informed  me  that  a  sort  of  union  followed 
after  considerable  time,  but  that  the  limb  was  no  better 
than  before  operation.  Hence  in  this  case,  with  the  excep- 
tion of  replacing  the  fragments  and  adjusting  of  the  limb, 
nothing  was  done.  The  usual  attitude  was  maintained,  and 
the  young  fellow  made  an  uneventful  recover}',  leaving  the 
hospital  October  ;3d  with  two  inches  of  shortening  in  the 
injured  limb. 

Case  IV.  Compound  Fracture  of  the  Three  External  Meta- 
carpal Bones  of  the  Left  Hand,  with  Complete  Shattering  of  all 
the  Phalanges  of  the  Little  Finger ;  Railroad  Accident. — Pa- 
tient, aged  twenty-one  years,  a  brakeman,  came  under  my  care 
November  21st.  While  coupling  cars  at  White  Plains,  N.  Y., 
his  left  iiand  was  crushed  between  the  buffers.  Immediately 
after  the  accident  there  was  considerable  haemorrhage,  but  by 
tight  bandaging  it  was  efficiently  subdued,  and  he  was  at  once 
sent  to  this  city.  When  he  came  under  my  notice,  six  hours 
after  the  accident,  he  was  suffering  from  severe  shock,  and  the 
mangled  hand,  with  the  many  fractured  ends  of  bones  ])rqject- 
irig  through  its  dorsal  surface,  at  first  sight  seemed  hojielessly 
de-tr  lyed. 

The  little  tinger  was  reduced  to  a  mass  of  pul|).  Its  meta- 
carpal bone  was  fractured  in  its  center.  The  fourth  metacarpal 
was  torn  completely  out  of  its  socket  at  the  metacarpo-i)halan- 
geal  articulation.  The  third  metacarpal  bone  in  its  distal  third 
was  fractured  and  shattered  into  the  articulation  with  the  first 
phalanx  of  the  middle  finger.  The  entire  p;dmar  cutaneous 
surface  of  the  hand  was  imbroken. 

In  this  case,  after  a  careful  examination,  I  felt  justitied  in 
promising  to  be  able  to  save  sufficient  of  the  hand  to  serve  as  a 
useful  mend)er,  provided  there  was  not  an  exttiiisive  loss  of  in- 
tegumental  covering  in  the  event  of  an  extensive  slough.  It  was 
evident  on  inspection  that  though  there  was  considerable  disor- 
ganizatii)n  and  displacement  of  bone,  yet,  with  few  exceptions, 
all  the  fragments  maintained  intimate  attachments  with  the 
loose  adjacent  tissues.  Hence  it  was  assumed  that  with  ro|)osi- 
tion  their  vascular  feeders  would  preserve  their  vitality  and  aid 


in  the  processes  of  repair.  The  crushed  finger,  traumatically 
amputated,  was  removed,  with  its  stump  left  to  heal  by  granu- 
lations. The  fragments  of  the  third  metacarpal  bone  were  re- 
sected, but  great  care  was  observed  to  preserve  its  periosteum. 
All  the  other  fragments  were  replaced  and  the  parts  aseptically 
dressed  and  s|)linted.  In  this  and  none  of  the  other  cases  were 
any  antiseptic  solutions  employed. 

Our  patient,  thougli  not  quite  well  yet,  promises  in  the 
near  future  to  have  a  fairly  useful  hand.  There  will  re- 
main some  stiffness  and  impairment  of  strength,  but  it  will 
be  a  hundiedfold  more  useful  than  would  be  any  sort  of  an 
artificial  substitute. 


EXCISION  OF  THE  CHANCRE 
AS  A  MEANS  OF  ABORTING  SYPHILIS.* 
By  JAMES  C.  McGUIRE,  A.M.,  M.  D., 

WASHINGTON,  D.  C. 

Excision  of  the  chancre  as  a  means  of  aborting  syphi- 
lis was  long  ago  abandoned  by  the  majority  of  syphilog- 
raphers,  but  of  late  it  has  been  again  revived.  The  latest 
discussion  on  the  subject  took  place  at  the  Society  of 
Dermatology  and  Syphilograjjhy  in  Paris  {Journal  of  Cu- 
taneous and  Genito-urinarf/  Diseases,  January,  1892).  The 
most  interesting  case  referred  to  was  that  of  Dr.  Mauriac. 
He  excised  a  chancre  on  the  third  day.  On  the  following 
day  a  new  chancre,  and  one  more  indurated  than  the  origi- 
nal, developed  at  some  distance  beneath  the  prepuce ;  this 
was  also  cut  out.  The  wounds  cicatrized  rapidly,  but  be- 
neath them  specific  induration  again  occurred.  Syphilis 
followed  in  due  course.  "  The  general  infection  was  thus 
neither  prevented  nor  retarded  by  the  operation." 

The  question  of  the  advisability  of  removing  the  initial 
lesion  depends  on  whether  we  regard  it  as  a  local  lesion 
which  is  always  followed  by  constitutional  infection,  or  be- 
lieve the  system  is  already  under  the  influence  of  the  poison 
when  the  chancre  first  appears.  Those  who  believe  the 
systsm  at  large  is  only  affected  by  the  gradual  absorption 
of  the  virus,  after  induration  in  the  chancre  has  taken  place, 
of  course  advocate  early  excision. 

Judging  from  analogy,  the  poison  does  not  lie  quiescent 
in  the  system ;  it  may  be  very  active,  but  not  in  a  way  to 
make  itself  manifest ;  it  takes  an  appreciable  length  of 
time  for  the  virus  to  develop  itself  into  a  higher  and  more 
poisonous  element — in  other  words,  preparing  itself  for  its 
future  career  of  destruction.  Surely  if  this  is  true  we  can 
not  think  of  it  as  an  inert  mass  localized  at  a  single  point. 
To  me  it  is  as  absurd  to  suppose  the  syphilitic  virus  re- 
mains inactive  at  the  point  of  inoculation  for  the  space  of 
several  weeks,  as  it  would  be  to  suppose  the  poison  of  the 
rattlesnake  would  remain  dormant  at  the  point  of  inocula- 
tion for  days. 

Is  there  anything  in  the  poison  of  syphilis,  in  regard  to 
its  absorption,  to  cause  it  to  act  differently  from  any  other 
virus  ?  If  there  is,  how  did  we  discover  it  I  Not,  surely, 
from  practical  experience,  nor  yet  from  analogy.  Remault 
inoculated  horses  with  acute  glanders,  excised  the  parts, 

*  Head  before  the  District  of  Columbia  Medical  Society,  1893. 


498 


McGUIRE:  EXCISION  OF  CHANCRE. 


[N.  Y.  Med.  Joue., 


and  applied  the  actual  cautery  an  hour  afterward,  yet  the 
animals  died  of  the  disease. 

A  short  resume  of  the  opinions  of  those  in  authority 
who  have  written  upon  this  subject  during  the  last  few 
years  may  be  of  interest. 

Von' Zeissl,  of  the  Vienna  University,  operated  in  thir- 
teen cases,  and  "not  in  a  single  case  did  the  excision 
weaken  the  course  of  the  constitutional  symptoms." 

Dr.  Taylor  declares  the  abortive  treatment  never  could 
have  been  entertained  had  it  not  been  for  confounding  the 
chancroid  with  syphilis.  He  further  says  :  "  In  the  discus- 
sion of  Dr.  Morrow's  paper  before  the  Academy  of  Medi- 
cine, New  York,  in  1882,  participated  in  by  almost  every 
surgeon  in  New  York  who  had  made  venereal  diseases  a 
study,  the  opinion  was  unanimous  that  this  method  of 
aborting  syphilis  is  a  faikirc." 

Humbert,  of  Paris,  believes  the  operation  is  useless ;  he 
has  had  eleven  failures  out  of  twelve.  Barthelemy,  of 
Paris,  expresses  the  same  views. 

At  the  International  Medical  Congress,  Copenhagen, 
"  Wilkes  states  that  the  results  obtained  by  a  commission 
appointed  to  study  the  subject  of  excision  showed  that 
such  a  plan  is  useless.  He  mentions  that  in  the  Dread- 
naught  Marine  Hospital  there  could  long  be  seen  a  jugful 
of  chancres  collected  by  one  of  the  surgeons  and  then  ex- 
hibited as  proof  of  the  uselessness  of  excision "  (Treat- 
ment of.  Syphilis  at  the  Present  Time,  by  Dr.  von  Zeissl). 

Ricord  declared  that  destruction  at  any  time  was  abso- 
lutely useless. 

Fournier,  Lewin,  Martineau,  Newman,  and  many  others 
have  declared  themselves  opposed  to  ihe  operation.  Cor- 
nil  collected  405  cases.  Of  these,  339  were  unsuccessful,  105 
successful.  "  Of  these  successes,  some  must  be  accepted 
with  the  greatest  reserve ;  others  can  not  withstand  criti- 
cism." 

On  the  other  hand,  Neisser  believes  the  symptoms  of 
syphilis  may  be  modified  and  the  disease  itself  many  times 
prevented  if  the  enlarged  lymphatic  glands  are  included  in 
the  operation.  It  is  well  here  to  remember  Fournier's 
statement  that  tlie  iliac  and  pelvic  glands  ai'e  also  affected 
at  this  time. 

Zarewicz  believed  it  would  Tnodify  but  not  prevent  the 
disease.  He  operated  in  fourteen  cases  without  success, 
the  time  of  operation  varying  from  twelve  hours  to  twenty- 
two  days. 

Auspitz  operates,  even  after  the  glands  are  affected,  with 
favorable  results. 

Jullien,  of  Paris,  though  advocating  the  operation,  con- 
siders it  should  be  performed  before  the  glands  are  in- 
volved. Unna,  Pick,  llueter,  and  others  favor  the  operation. 

In  regard  to  my  personal  experience  in  this  operation,  I 
will  here  report  two  cases. 

Mr.  M.,  aged  twenty-five  years,  married,  consulted  me  in 
regard  to  a  sore  situated  on  the  prepuce,  lie  said  tliat  while  on 
a  drunken  spree  he  had  liad  sexual  intercourse  with  a  prostitute 
just  eighteen  days  previous  to  tins  visit.  lie  first  noticed  a  pimple 
on  his  penis  the  night  before  coining  to  me.  He  was  in  a  very 
nervous,  excited  condition,  and  begged  me  to  cut  away  the  sore 
if  there  was  the  slightest  danger  of  constitutional  infection. 


Explaining  tlie  matter  to  the  patient  thiit  many  sjphilographers 
believed  in  tlie  efficacy  of  excision,  and  that  this  would  be  a 
|)articularly  favorable  cass,  considering  tlie  sliort  time  tliat  liad 
intervened  since  the  appearance  of  the  sore,  and  as  the  inguinal 
glands  were  ni)t  yet  enlarged,  the  operation  was  performed  at 
this  time — that  is,  twelve  hours  after  the  appearance  of  the  sore. 
In  seven  weeks,  or,  to  be  exact,  in  forty-seven  days,  lje  returned 
to  me  witli  a  typical  erythematous  rasli  upon  the  chest  and  al)- 
domen,  the  inguinal  glands  enlarged,  and  some  induration  where 
the  initial  lesion  had  been  removed.  After  this,  though  amen- 
able to  treatment,  the  disease  took  its  usual  course,  not  appre- 
ciably modified  in  any  way.  He  re|)orted  that  liis  wife  also  had 
a  rash  upon  lier  chest  which  tlie  attending  physician  declared 
to  be  syphilitic. 

Mr.  C,  aged  thirty-six,  commercial  traveler,  showed  nie  an 
abrasion  upon  the  frenum  that  had  occurred  only  two  honrs  pre- 
viously while  having  intercourse  with  a  prostitute.  He  had 
noticed  that  the  woman's  mouth  was  sore.  He  came  to  me  to 
have  the  abrasion  treated.  I  cauterized  it  thoroughly  with  pure 
carbolic  add.  In  twenty  days  the  patient  returned  showing  an 
indurated  chancre  at  the  point  that  had  been  burned,  the  ingui- 
nal glands  enlarged.  Tiie  chancre  was  removed  as  in  the  pre- 
vious case.  In  six  weeks  an  erythematous  rash  appeared  upon 
the  abdomen,  with  the  usual  symptoms  of  the  constitutional 
disease. 

P>en  if  no  constitutional  symptoms  had  occurred  in 
these  cases  I  should  not  have  considered  it  sufficient  proof 
that  the  immunity  was  due  to  the  operation,  as  there  is 
difficulty  in  making  a  positive  diagnosis  before  induration 
of  the  sore  and  the  glands  takes  place.  Even  after  this 
occurs  we  can  not  be  positive  till  the  appearance  of  the 
secondary  symptoms,  when,  of  course,  it  would  be  too  late 
to  operate. 

Instantaneous  absorption  is  a  physical  impossibility. 
Therefore,  for  a  time  the  poison  of  syphilis  is  confined  to 
the  point  of  inoculation.  Granting  this  proposition,  it  fol- 
lows that,  if  the  virus  is  removed  or  destroyed  within  this 
time,  the  constitution  will  not  be  affected.  This  is  a  self- 
evident  proposition,  and  it  only  remains  for  practical  expe- 
rience to  show  that  the  poison  is  localized  for  an  appreciable 
time.  It  is  my  belief  that  if  within  a  few  hours  the  point 
of  inoculation  is  thoroughly  cauterized,  syphilis  will  many 
times  be  prevented.  In  conclusion,  I  can  not  do  better 
than  to  quote  Dr.  L.  Brocq,  who  says  (in  the  Journal  oj 
Cutaneous  and  Genito-urinari/  Diseases,  Januarj-,  1892): 
"  For  us  there  exists  but  one  legitimate  and  logical  excis- 
ion of  the  syphilitic  chancre — the  one  which  could  be  made 
immediately  after  the  infecting  coitus,  just  as  we  cauterize 
with  a  red-hot  iron  the  bite  of  a  mad  animal.  We  should 
then  have  to  do  with  a  lesion  probably  still  local  if  we  in- 
tervened quickly  enough.  This  brings  us  back  practically 
to  the  common  precept,  '  After  a  suspected  coitus  wash 
with  an  alcoholic  solution  of  bichloride  of  mercury  and 
cauterize  vigorously  your  excoriation,  if  you  have  any.' " 

1527  Sixteenth  Street. 


The  Death  of  Dr.  Milton  Josiah  Roberts  occurred  last  week.  He 
was  a  graduate  of  the  Medical  Department  of  the  UDiversity  of  the 
City  of  New  York,  of  the  class  of  1818.  In  the  field  of  orthopaedics  he 
had  done  some  very  creditable  work  and  shown  exceptional  powers  of 
invention. 


May  6,  1893.J 


LEADING  ARTICLES— MINOR  PARAGRAPHS. 


499 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  Sc  Co.  Frank  P.  Foster,  M.  I). 

JTEW  YORK,  SATURDAY,  MAY  6,  1893. 


A  SUCCESSFUL  SECONDARY  OPEEATJON  FOR  VOLVULUS. 

Dr.  Finney,  of  Baltimore,  reports  in  the  Johns  Moplcins 
Hospital  Bulletin  for  Marcli  a  case  of  volvulu.s  of  tlie  sigmoid 
flexure  in  which  detorsion  was  followed  by  success.  The  pa- 
tient was  first  at  the  hospital  in  January,  1890,  when  he  came 
under  the  care  of  Dr.  llalsted,  by  whom  an  operation  was  per- 
formed for  the  relief  of  intestinal  occlusion.  Tlie  incision 
through  the  peritonamm  liberated  an  enormously  distended 
colon,  which  was  found  to  have  described  a  complete  volvuhis, 
making  a  constriction  at  the  sigmoid  flexure  and  at  the  ileo- 
•caecal  valve.  The  patient  was  relieved  and  made  a  good  recov- 
«ry.  He  was  taken  with  his  second  attack  of  occlusion  late  in 
December,  1892,  or  after  an  interval  of  thirty-five  months.  At 
the  time  of  his  second  entrance  into  the  hospital  he  had  suf- 
fered considerably  from  pain,  distention,  and  vomiting,  but  his 
condition  was  so  good  that  an  operation  did  not  seem  to  be 
called  for  at  once,  and  by  the  advice  of  Dr.  Osier  treatment  by 
enemata,  with  the  hips  elevated,  was  resorted  to,  as  had  been 
■done  before  with  good  palliative  effect.  At  the  end  of  a  week, 
however,  it  was  seen  that  the  patient  was  los'ng  ground,  and  it 
was  decided  to  defer  the  operation  no  longer.  Under  ether 
anaesthesia  an  abdominal  section  was  made,  avoiding  the  line  of 
the  old  cicatrix.  The  intra-abdominal  pressure  was  so  great 
that  the  colon  escaped  from  the  cavity  before  the  surgeons 
could  acquaint  themselves  with  the  true  position  of  the  parts, 
but  the  colon  was  judged  to  make  a  complete  turn  upon  itself 
as  it  came  out  through  the  incision  ;  a  loud  gurgling  sound  was 
heard  at  the  same  time.  The  man  was  relieved  by  the  opera- 
tion and  had  continued  to  improve  in  respect  to  his  intestinal 
functions  down  to  the  time  when  the  case  was  reported  before 
the  hospital  medical  society,  which  was  eighteen  days  after  the 
operation.  There  is,  of  course,  a  liability  to  recurrence  of  the 
volvulus,  and  at  the  time  of  the  operation  the  feasibility  of 
adding  a  step  to  the  procedure,  to  prevent  this  return,  was  dis- 
cussed. The  desirability  of  shortening  the  mesocolon,  a  step 
advocated  by  Dr.  Senn,  was  not  apparent,  on  account  of  the 
great  length  of  the  mesocolon,  for  to  shorten  the  mesocolon  in 
such  cases,  the  surgeons  argued,  would  bo  to  produce  a  danger- 
ously sharp  bend  in  the  intestine  and  to  reduce  the  circulation 
to  an  embarrassing  extent. 

In  the  discussion  tliat  followed.  Dr.  Halsted  quoted  from  a 
recent  paper  by  13raun,  of  Konigsberg,  to  show  that  tliis  case  of 
Dr.  Finney's  was  probably  the  first  in  which  a  successful  second 
operation  for  volvulus  has  been  recorded.  There  had  been 
other  second  operations  for  recurrent  vf)lvulus,  but  it  was  not 
known  that  there  had  been  any  survivals.  According  to 
Braun,  there  have  been  seventeen  cases  of  volvulus  of  the  sig- 


moid flexure  wherein  detorsion  has  been  effected,  with  six 
recoveries.  Of  the  eleven  fatal  cases,  two  were  marked  by  re- 
turn of  the  occlusion  ;  one  patient  bad  a  recurrence  immediately 
after  the  operation,  the  other  four  months  after.  Both  of 
them  died.  One  had  no  second  operation ;  the  other  was 
operated  on,  but  died  three  days  later,  presumably  of  typhoid 
fever. 


MINOR  PARAGRAPHS. 

PUBIC  SYMPHYSEOTOMY  AS  A  STEP  IN   OPERATIONS  ON 
THE  BLADDER. 

AoooKDiNG  to  the  Semaine  medicale,  Dr.  Albarran  presented 
to  the  French  Academy  of  Medicine  on  January  17th  a  man, 
aged  thirty-one  J  ears,  on  whom  this  procedure  had  been  done 
as  part  of  an  operation  for  the  removal  of  an  epithelioma  of  the 
bladder.  This  patient  bad  undergone  an  ojjeration  for  the  re- 
moval of  a  vesical  tumor  in  April,  1890,  by  a  suprapubic  incision. 
That  growth  was  pediculate,  but  about  a  year  later  it  was  suc- 
ceeded by  a  sessile  epithelioma  which  proved  the  source  of  con- 
siderable hasmaturia.  The  growth  was  situated  close  to  the  neck 
of  the  bladder  and  extended  on  to  the  left  lateral  wall.  In  per- 
forming the  section  it  was  first  necessary  to  make  a  /^-shaped 
incision  through  the  superficial  tissues  in  order  to  get  the  penis 
moved  to  one  side.  The  symphysis  was  divided  with  the  knife, 
followed  up  by  chisel  and  inallet,  and  then,  by  fiexion  and  ab- 
duction of  the  thighs,  the  pubic  bones  were  separated  about  two 
inches.  This  afforded  the  room  required  to  exercise  a  suitable 
portion  of  the  inferior  and  left  lateral  portions  of  the  bladder- 
The  wound  in  the  bladder  was  closed  by  a  double  row  of  su- 
tures, and  a  catheter  was  introduced  and  left  in  position.  The 
patient  was  placed  in  a  Bonnet's  splint  and  kept  there  for  sev- 
enteen days.  An  obstruction  of  the  catheter  caused  a  perineal 
fistula  at  about  the  end  of  the  third  week;  otherwise  the  pa- 
tient's convalescence  was  uneventful.  The  patient  had  gained 
in  weight  and  was  able  to  retain  his  urine  for  three  hours  or 
longer ;  he  walked  without  discomfort  and  had  resumed  his 
former  employment.  There  was  no  longer  any  perineal  fistula, 
and  the  scar  left  by  the  wound  was  small.  Wickhoff,  of  Vienna, 
has  lately  made  known  the  results  of  experiments  on  the  cadaver 
made  to  test  the  advantages  of  symphyseotomy  over  epicystoto- 
my  in  operations  on  the  prostate  and  for  the  removal  of  neo- 
plasms. He  recommends  the  operation  in  such  cases  as  b^ing 
both  easy  and  safe.  He  believes  it  may  also  be  serviceable  in 
certain  cases  of  vesico-vaginal  fistula. 


"PEACH  FEVER,"  AN  OCCUPATIONAL  DISEASE. 

This  name  has  been  given  to  a  cutaneous  irritation,  with 
fever,  not  infrequently  seen  among  the  employees  in  the  fruit- 
packing  and  canning  establishments  of  Maryland  and  Delaware. 
A  paper  by  Dr.  C.  L.  Anderson,  of  Hagerstown,  Maryland,  is 
published  on  this  subject  in  a  recent  number  of  the  Maryland 
Medical  Journal.  Dr.  Anderson  divides  the  cases  into  two  va- 
rieties: First,  the  psychotic  variety,  marked  by  mental  exalta- 
tion, ideas  of  grandeur,  seen  in  persons  having  a  lively  imagi- 
native faculty  ;  second,  the  true  peach  fever,  caused  by  contact 
with  the  fruit  in  the  course  of  its  being  picked  and  packed  for 
market.  This  variety  is  defined  as  "a  morbid  condition  of  the 
respiratory  and  cutaneous  surfaces,  with  some  consequent  sys- 
temic disturbances,  due  to  irritation  from  the  pubescence  of 
the  skin  of  the  conunon  i)each — the  Ami/gdahis  persica.''^  Tiio 
Schneiderian  membrane  first  becomes  irritated  and  tumefied, 
and  yields  a  large  flow  of  serum  and  mucus.    The  frontal 


500 


MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Joob., 


sinuses,  tlie  conjiinctivse,  and  the  larger  bronchi  may  take  on, 
by  extension,  the  same  kind  of  disiiirbaiice ;  cougii  and  asthma 
may  be  excited  in  susceptible  subjects.  On  the  skin,  the  chief 
display  of  tliis  amygdaline  intlanimation  will  be  found  about 
the  wrists,  forearms,  neck,  and  forehead.  It  commonly  begins 
and  end-4  in  a  macular  or  papular  eruption,  but  it  may  go  on  to 
a  true  dermatitis  and  to  f)Ustulation.  The  febrile  rise  may  be 
as  high  as  two  degrees,  wliich  may  be  taken  to  indicate  the 
amount  of  systemic  discomfort  induced  by  the  respiratory  and 
cutaneous  irritation.  Thin-skinned  and  neurotic  young  women 
anfi'er  more  and  longer  than  the  pachydermatous  men  and  the 
older  women.  The  more  experienced  workers  seem  to  become 
proof  against  the  irritant  after  some  years  in  the  business. 
There  is  no  evidence  to  show  that  the  disorder  is  contagious. 


THE  POST-GRADUATE  MEDICAL  RCHOOL  OF  CHICAGO. 

This  energetic  institution  is  going  to  turn  to  account  the 
prospective  attendance  of  distingui.«hed  medical  men  on  the 
Columbian  Fair.  It  announces  special  courses,  extending  from 
May  to  October,  in  which  its  faculty  will  have  the  co  o])eratiiin 
of  Dr.  Herman  Knapp,  Dr.  Henry  D.  Noyes.  Dr.  Robert  T. 
Morris,  Dr.  Emmons  Lamphier,  Dr.  B.  Farquliar  Curtis,  and 
Dr.  Robert  Newman,  of  New  York;  Dr.  -Jonathan  Wright,  of 
Brooklyn ;  Dr.  Joseph  Price  and  Dr.  Hobart  Amory  Hare,  of 
Philadelphia;  Dr.  Henry  O.  Marcy,  of  Boston;  Dr.  Howard 
Kelly,  of  Baltimore;  Dr.  J.  C.  Mulhall,  of  St.  Louis;  Dr.  Jo- 
seph Matthews,  of  Louisville;  Dr.  Joim  O.  Roe,  of  Rochester; 
Dr.  Thaddeus  A.  Reamy,  of  Cincinnati;  Dr.  Rudolph  Matas,  of 
New  Orleans;  Dr.  Joseph  Eastman,  of  Indianapolis;  Dr.  Ros- 
well  Park,  of  Buffalo;  Dr.  D.  J.  Hayes,  of  Milwaukee;  Mr. 
Reginald  Harrison  and  Dr.  H.  RadclifTe  Crocker,  of  London  ; 
Mr.  Lawson  Tait  and  Mr.  W.  Savage,  of  Birmingham;  Dr. 
Thomas  Moore  Madden,  of  Dublin;  Dr.  Auvard  and  Dr.  Char- 
teris,  of  Paris;  Dr.  H.  Krause,  of  Berlin;  Di-.  F.  Schauta,  of 
Vienna;  Dr.  T.  Heryng,  of  Warsaw;  and  Dr.  Massei,  of 
Naples. 

CARDIAC  IRREGULARITY  AND  PALPITATION. 

Dr.  Jamrs  Tyson,  professor  of  clinical  medicine  in  the  Uni- 
versity of  Pennsylvania,  closes  a  valuable  article  on  The  Treat- 
ment of  Chronic  Valvular  Disease  of  the  Heart,  in  the  April 
number  of  the  Therapeutic  Gazette,  by  calling  attention  anew  to 
the  beneficial  action  of  belladonna  in  the  irregularity  and  j>al- 
pitaiion  of  the  heart  that  are  common  accompaniments  of  mitral 
disease.  His  observation  leads  him  to  conclude  that  a  bella- 
donna plaster  placed  over  the  palpitating  heart  is  one  of  the 
most  efficient  agents  in  subduing  it.  Nitroglycerin  also  he 
finds  often  very  useful  for  the  same  purpose,  and  sometimes 
for  the  relief  of  cardiac  pain.  The  proper  dose,  he  thinks,  is  a 
hundredth  of  a  grain,  ra])idly  increaseil  to  a  fiftieth  of  a  grain, 
three  times  a  day. 


ICUTHYOL  IN  THE  TREATMENT  OF  GONORRHOEA. 

Dr.  Manganetti  (Annales  de  la  Soeiete  medico-chirurgieale 
de  Liege,  February,  1893;  Annales  des  maladiei  des  orgnues 
genito-urinaires,  April,  1893)  has  used  injections  of  solutions 
of  ichthyol  of  varying  degrees  of  strength,  ranging  frotn  one 
per  cent,  to  four  per  cent.,  from  three  to  five  times  a  day. 
When  the  strength  of  the  solution  is  not  greater  than  two  {)er 
cent,  there  is  no  pain  from  the  injections,  and  he  has  never 
known  them  to  produce  any  complication.  In  many  patients 
excellent  results  iiave  followed,  whether  the  disease  was  acute 
or  lingering.  The  only  inconveniences  noted  were  tlie  odor  of 
the  drug  and  the  fact  that  it  stained  the  linen. 


McGILL  UNIVERSITY. 

The  Maritime  il/e<?icflZ.M?ws  has  information  that  the  McCiill 
University  Medical  School  has  made  an  efl'ort  to  draw  Dr.  Wil- 
liam Osier  away  from  the  J<jhns  Hopkins  Hospital  back  to  his 
alma  mater.  The  Neics  j)redictsthat  he  will  not  go,  for  to  do  so 
would  be  to  abandon  resources  and  opportunities  that  he  him- 
self has  done  much  to  bring  into  their  present  admirable  form. 
The  resources  of  the  McGill  school  are  great  and  growing,  but 
they  can  hardly  yet  be  termed  magnificent,  except  in  their  prom- 
ise. Much  has  been  done  to  improve  the  Canadian  seat  of  learn- 
ing, but  it  falls  short  of  being  an  active  rival  of  the  Baltimore 
institution. 


THE  PREDOMINANCE   OF   FALLOPPIAN-TUBE  DISEASE  ON 
THE  LEFT  SIDE. 

Dr.  F.  Byron  Robinson,  of  Chicago,  finds  that  the  lumen 
of  the  left  Falloppian  tube  is  larger  than  that  of  the  right. 
This  fact,  he  thinks,  together  with  a  restless  rectum,  a  loaded 
sigmoid  Hexure  resting  on  the  left  ovarian  vein,  the  opening  of 
the  vein  at  right  angles  into  the  left  renal  vein,  and  the  greater 
size  of  the  left  pampiniform  plexus,  accounts  for  the  greater 
frequency  of  pelvic  disease  on  the  left  side  in  women.  He  finds 
valves  in  the  left  ovarian  vein  in  about  two  thirds  of  the  bodies 
he  examines.  The  size  of  the  lumen  of  the  left  tube,  he  thinks, 
facilitates  the  admission  of  septic  material. 


CANTHARIDES  IN  EPITHELIAL  NEPHRITIS. 

The  second  number  of  the  New  York  Therapeutic  Review 
contains  an  article  by  Dr.  E.  Lancereaux,  of  Paris,  in  which  the 
author  expresses  his  conviction  that  tincture  of  cantharidcs  is  a 
valuable  agent  in  the  treatment  of  epithelial  nephritis.  He 
gives  notes  of  two  cases  in  which  it  was  used  in  daily  amounts 
of  six  drops  to  begin  with,  increased  to  ten  or  twelve.  He 
thinks  the  drug  acts  by  controlling  the  tendency  to  tumefaction 
^of  the  epithelium  of  the  tubuli  contorti  and  thus  obviating 
anuria. 


THE  TESTICLE-JUICE  TREATMENT. 

Dr.  Pilatte  (Semaine  medicale,  1893,  No.  14;  Revue  gene- 
rale  de  medecine,  de  chirurgie  et  d''ohstetrique,  April  5,  1893) 
combats  the  notion  that  the  amelioration  following  the  use  of 
the  Brown-Sequard  injections  in  locomotor  ataxia  and  paralysis 
of  long  standing  is  due  either  to  the  glycerin  contained  in  the 
liquid  or  to  suggestion.  Whenever  he  has  substituted  injections 
of  glycerin  for  those  of  testicle  juice,  without  the  patient's 
knowing  it,  he  has  observed  the  amelioration  disappear. 


QUININE  AS  AN  APPLICATION  TO  WOUNDS. 

In  Nouvemtx  remedes  for  April  8th  there  is  mentioned  an 
article  by  Dr.  Alfoldi,  published  in  the  Pester  medicinisch- 
chirurgitsche  Presse  and  sunmiarized  in  the  February  number  of 
the  Therwperitische  Monatshefte,  who  is  convinced  that  a  one-per- 
cent, solution  of  quinine  sulphate  is  a  more  rapid  detergent  and 
cicatrizant  in  cases  of  infected  wounds  than  either  corrosive 
subhmate  or  iodoform.  He  adds  that  wounds  that  are  free 
from  infection  also  heal  with  astonishing  rapidity  under  the 
use  of  quinine  applications. 


A  MEDICAL  CENTENARIAN. 

Progres  medical  says  that  the  medical  profession  of  Havre 
recently  gave  a  banquet  in  honor  of  a  physician  who  was  born 
on  the  4th  of  April,  1793.    The  old  gentleman  presided  at  the 


May  6,  1893.] 


ITEMS. 


501 


dinner  and  showed  a  good  appetite.  A  coinmeniorativo  medal 
was  presented  to  him,  and  he  responded  in  a  charming  speech 
in  wiiich  lie  said  that  his  own  father  had  lived  to  the  age  of  a 
hundred  and  eight  years,  and  that  he  himself  was  going  to  do 
his  best  to  prolong  his  life  to  the  utmost. 


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  May  2,  1893  : 


DISEASES. 

Week  ending  Apr.  5J5. 

Week  ending  May  2 

Cases. 

Deaths. 

Cases. 

Deaths. 

12 

8 

10 

10 

14 

1 

.') 

169 

18 

19() 

18 

Cerebro-spinal  meningitis. . . 

16 

10 

11 

7 

102 

0 

i;55 

10 

115 

&8 

lot) 

31 

8 

4 

4 

2 

The  American  Association  of  Obstetricians  and  Gynaecologists  will 
hold  it.-<  sixth  annual  meeting  at  the  Russell  House,  Detroit,  on  Thurs- 
day, Friday,  and  Saturday,  .June  1,  2,  and  3,  1893,  under  the  presidency 
of  Dr.  Lewis  S.  McMurtry,  of  Louisville.  The  following  is  the  prelinu- 
nary  programme  so  far  as  titles  are  annoimced  :  The  president's  address 
(The  Present  Position  of  Pelvic  Surgery),  by  Dr.  L.  S.  McMurtry,  of 
Louisville  ;  Abdominal  Fixation,  by  Dr.  F'lorian  Krug,  of  New  York  ; 
Endoscopic  Tubes  for  Direct  Examination  of  the  Interior  of  the  Uterus 
and  Bladder,  by  Dr.  Robert  T.  Morris,  of  New  York;  Placenta  PrsBvia, 
by  Dr.  William  H.  Wenning,  of  Cincinnati ;  What  are  the  Indications 
for  Abdominal  Section  in  Intrapelvic  Ha'morrhage  ?  by  Dr.  M.  Rosen- 
wasser,  of  Cleveland ;  The  Treatment  of  Metritis,  by  Dr.  E.  Pielranera, 
of  Cordova,  A.  R. ;  A  Plea  for  Better  Surgery  in  the  Closm-e  of  the  Ab- 
dominal Incision,  by  Dr.  H.  W.  Longyear,  of  Detroit ;  Remarks  on  the 
Treatment  after  Abdominal  Section,  by  Dr.  C.  C.  Frederick,  of  Buffalo  ; 
The  Management  of  the  Abdominal  Incision,  by  Dr.  Charles  A.  L.  Reed, 
of  Cincinnati ;  Dilatation  of  the  Cervix  for  Dysmenorrhoea,  by  Dr.  E.  M. 
Pond,  of  Rutland ;  Intra-uterine  [sic]  Pregnancy,  with  Report  of  Cases, 
by  Dr.  George  S.  Peck,  of  Youngstown ;  A  Contribution  to  the  Study 
of  Ectopi3  Gestation,  by  Dr.  E.  Arnold  Praeger,  of  Nanaimo;  A  Few 
Practical  Notes  on  the  Establishment  of  Anastomosis  between  the  Gall- 
bladder and  Intestine  for  Obstruction  of  the  Common  Duet,  with  the 
Relation  of  a  Case  of  Obstruction  of  the  Common  Duct  by  a  Small 
Growth,  by  Dr.  James  F.  W.  Ross,  of  Toronto;  Vaginal  Hysterectomy 
for  Malignant  Disease,  by  Dr.  Rufus  B.  Hall,  of  Cincinnati;  The  Care 
of  Pregnant  Women,  by  Dr.  John  Milton  Duff,  of  Pittsburgh ;  A  Con- 
tribution to  the  Pathology  of  Surgical  Disease  of  the  Gall-bladder,  by 
Dr.  \V'alter  P.  Manton,  of  Detroit ;  The  Legal  Questions  in  Gyna;cologi- 
cal  Operations  on  the  Insane,  by  Dr.  Walter  P.  Manton,  of  Detroit ;  Pel- 
vic Abscess,  by  Dr.  I.  S.  Stone,  of  Washington ;  Central  Rupture  of  the 
Periuieum  ;  its  Causation  and  Prevention,  by  Dr.  John  C.  Sexton,  of 
Rushville  ;  A  Case  of  Myomectomy  with  Extrapei  itoneal  Treatment  of 
the  Pedicle,  followed  by  Pregnancy  and  complicated  by  HicnKU'rhages 
through  the  Abdominal  Cicatrix,  by  Dr.  X.  0.  Werder,  of  Pittsbingh  ; 
The  Anatomy  and  Surgical  Importance  of  the  Perirenal  Cellulo  adiposc 
Tissue,  by  Dr.  L.  H.  Dunning,  of  Indianapolis ;  Report  of  Cases  from 
Practice,  with  Remarks  on  the  Same,  by  Dr.  A.  Vander  Veer,  of  Al- 
bany ;  Further  Observations  on  the  Relation  of  Pelvic  Disease  and 
P.sychical  Disturbances  in  Women,  by  Dr.  George  H.  Roh(5,  of  Catons- 
ville. 

Mount  Sinai  Hospital. — The  following  ajipointments  were  made  on 
April  23d :  Dr.  B.  Sachs,  consulting  neurologist ;  Dr.  S.  Lustgarten, 
consulting  dermatologist ;  Dr.  Morris  Manges  and  Dr.  N.  E.  Brill,  as- 
sistant visiting  physicians ;  Dr.  H.  Lilienthal  and  Dr.  W.  W.  Van 
Arsdale,  assistant  visiting  surgeons ;  Dr.  J.  Brettauer,  assistant  visiting 
gynajcologist ;  Dr.  C.  H.  May,  assistant  visiting  ophthalmologist;  Dr. 
H.  Koplik,  assistant  visiting  physician  for  children. 


The  New  York  Infirmary  for  Women  and  Children. — On  Wednes- 
day afternoon,  the  3d  inst.,  new  wards  were  thrown  open  for  inspection,, 
also  the  nurses'  home  and  the  laboratories  of  the  Woman's  Medical 
College. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department^  United  States 
Army,  from  April  23  to  April  £9,  1893: 

Byrne,  Charles  C,  Lieutenant-Colonel  and  Deputy  Surgeon  General. 
The  leave  of  absence  granted  is  hereby  extended  one  month. 

Kkndall,  William  P.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  Fort  Douglas,  Utah,  and  ordered  to  Willett's  Point,  N.  Y., 
for  duty.    Par.  14,  S.  0.  89,  A.  G.  O.,  April  21,  1893. 

Carter,  William  V.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  Willet's  Point,  N.  Y.,  and  ordered  to  Fort  Sill,  Oklahoma 
Territory,  for  duty.    Par.  14,  S.  0.  89,  A.  G.  0.,  April  21,  1893. 

Taylor,  B.  D.,  Captain  and  Assistant  Surgeon,  is  relieved  from  duty  at 
Fort  Sill,  Oklahoma  Territory,  and  oi-dered  to  Fort  Bliss,  Texas. 
Par.  14,  S.  0.  89,  A.  G.  0.,  April  21,  1893. 

Owen,  William  0.,  Jr.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  Jefferson  Barracks,  Missouri,  and  ordered  to  Fort  Bayard, 
New  Mexico,  for  duty.    Par.  14,  S.  0.  89,  A.  G.  0.,  April  21,  1893. 

CoMEGYS,  EnwARD  T.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  Fort  Bayard,  New  Mexico,  and  ordered  to  Fort  Wadsworth, 
New  York,  for  duty.    Par.  14,  S.  0.  89,  A.  G.  0.,  April  21,  1893. 

PoLHEMUS,  A.  S.,  Captain  and  Assistant  Surgeon,  is  relieved  from  duty 
at  Fort  Monroe,  Virginia,  and  ordered  to  report  at  Fort  Douglas, 
Utah,  for  duty.    Par.  14,  S.  0.  89,  A.  G.  0.,  April  21,  1893. 

Banister,  William  B.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  Washington  Barracks,  District  of  Columbia,  and  ordered  to 
Fort  Mcintosh,  Texas,  for  duty.  Par.  14,  S.  0.  89,  A.  G.  0.,  April 
21,  1893. 

McCreery,  George,  Captain  and  Assistant  Surgeon,  is  relieved  from  duty 
at  his  present  station,  and  ordered  to  F'ort  Sidney,  Nebraska,  for  duty. 
Par.  14,  S.  0.  89,  A.  G.  0.,  April  21,  1893. 

Tesso.v,  Louis  S.,  Captain  and  Assistant  Surgeon,  is  relieved  from  duty 
at  Fort  Sidney,  Nebraska,  and  ordered  to  Jefferson  Barracks,  Mis- 
souri, for  duty.    Par.  14,  S.  0.  89,  A.  G.  0.,  April  21,  1893. 

Wyeth,  Marlborough  C,  Captain  and  Assistant  Surgeon,  is  granted 
leave  of  absence  for  one  month  on  surgeon's  certificate  of  disability, 
with  permission  to  leave  the  limits  of  the  department ;  to  take  effect 
when  Assistant  Surgeon  Ware  shall  have  returned  to  Fort  Supply, 
Indian  Territory. 

Woodruff,  Ezra,  Major  and  Surgeon,  is  hereby  granted  leave  of  ab- 
sence for  twenty  days,  to  take  effect  after  May  1,  1893. 

Winter,  Francis  A.,  First  Lieutenant  and  Assistant  Surgeon,  is  re- 
lieved from  duty  at  Fort  Wingate,  New  Mexico,  and  will  report  in 
person  to  the  senior  commissioner  of  the  International  Boundary 
Survey  Commission  at  Yuma,  Arizona  Territory,  for  duty,  relieving 
McVay,  Harlan  E.,  First  Lieutenant  and  Assistant  Surgeon.  First 
Lieutenant  McVay,  on  being  relieved  by  First  Lieutenant  Winter, 
will  report  in  person  to  the  commanding  officer,  San  Carlos,  Arizona 
Territory,  for  duty  at  that  station,  relieving  Shillock,  Paul,  Cap- 
tain and  Assistant  Surgeon.  Captain  Shillock,  on  being  relieved  by 
First  Lieutenant  McVay,  will  report  in  person  to  the  commanding 
officer.  Fort  Wingate,  New  Mexico,  for  duty  at  that  post. 

Promotion. 

Rafferty,  Ogden,  First  Lieutenant  and  Assistant  Surgeon,  to  be  Assist- 
ant Surgeon,  with  the  rank  of  Captain,  from  March  26,  1893,  after 
five  years'  service,  in  conformity  with  the  act  of  June  23,  1874. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  Slates  Navy  for  the  week  ending  April  29.  1893  : 
Clark,  J.  H.,  Medical  Director.    Ordered  as  President  of  Naval  Jlcdical 

Examining  Board. 
HoEiiLiNG,  A.  A.,  Medical  Director.    Detached  as  President  of  Naval 

Medical  Examining  Board  and  placed  on  waiting  orders. 
WEDEKiNn,  L.  L.  voN,  Passed  Assistant  Surgeon.    Detached  from  the 

U.  S.  Steamer  Wabash  and  ordered  to  the  U.  S.  Steamer  Alliance. 


502 


LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Meu.  Jouu., 


Society  Meetings  for  the  Coming  Week : 

Monday,  May  8th  :  New  York  Academy  of  Medicine  (i^ectioii  in  Gen- 
eral Surgery)  ;  Lenox  Medical  and  Surgical  Society  (New  York, 
private);  Xew  York  Ophthalniological  Society  (private);  New  York 
Medico-historical  Society  (private);  New  York  Academy  of  Sciences 
(Section  in  Chemistry  and  Technology) ;  Boston  Society  lor  Medical 
Improvement ;  Gyniccological  Society  of  Boston ;  Burlington,  Vt., 
Medical  and  Surgical  Club ;  Norwalk,  Conn.,  Medical  Society  (pri- 
vate) ;  Baltimore  Medical  Association ;  Shelby  County,  Indiana, 
Medical  Society  (Shelbyville). 

Tuesday,  Ma}/  9th :  New  York  Academy  of  Medicine  (Section  in  Genito- 
urinary Surgery) ;  New  York  Medical  Union  (private) ;  Kings  County, 
N.  Y.,  Medical  Association ;  Medical  Societies  of  the  Counties  of  Al- 
bany (semi-annual),  (ireene  (annual — Cairo),  and  Rensselaer,  N.  Y.  ; 
Newark,  N.  J.,  and  Trenton  (private),  N.  J.,  Medical  Associations; 
Camden  (annual — Camden),  Morris  (annual),  and  Sussex  (annual), 
N.  J.,  County  Medical  Societies  ;  Norfolk,  Mass.,  District  Medical 
Society  (election— Hyde  Park) ;  Franklin,  Vt.,  County  Medical  Asso- 
ciation (annual);  Northwestern  Medical  Society  of  Philadelphia; 
Baltimore  Gynaecological  and  Obstetrical  Society. 

Wednesday,  May  10th :  New  York  Surgical  Society  ;  New  York  Patho- 
logical Society;  Metropolitan  Medical  Society  (New  York,  private); 
American  Microscopical  Society  of  the  City  of  New  York ;  Medical 
Society  of  the  County  of  Albany,  N.  Y.  ;  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  11th:  New  York  Academy  of  Medicine  (Section  in 
Paediatrics) ;  Society  of  Medical  Jurisprudence  and  State  Medicine 
(New  York) ;  Brooklyn  Pathological  Society;  Medical  Society  of  the 
County  ot  Cayuga,  N.  Y. ;  South  Boston,  Mass.,  Medical  Club  (pri- 
vate) ;  Pathological  Society  of  Philadelphia. 

Friday,  May  12th :  Yorkville  Medical  Association  (private) ;  German 
Medical  Society  of  Brooklyn  ;  Brooklyn  Dermatological  and  Genito- 
urinary Society  (private) ;  Medical  Society  of  the  Town  of  Sauger- 
ties,  N.  Y. 

Saturday,  May  13th  :  Obstetrical  Society  of  Boston  (private). 
Answers  to  Correspondents : 

iVo.  4^01. — We  believe  that  you  would  have  to  submit  to  the  exami- 
nation. 

No.  40£. — Lauder  Brunton's  work  on  Digestion  and  its  Derange- 
ments (or  some  cipiivalent  title). 

No.  JfOS. — The  instrument  is  of  considerable  value. 


'%t\\n%  to  tijc  (^bitor. 


CRANIECTOMY. 
1729  Chestnut  Street,  Philadelphia,  April  27,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  In  your  issue  for  April  22(],  page  454,  I  observe  that 
Dr.  Starr  stated  ''that  the  operation  of  craniectomy  had  been 
performed  apparently  without  regard  to  the  age  of  the  patient. 
Keen  liad  operated  on  one  patient  nineteen  years  old ;  Ham- 
mond, Sr.,  had  operated  on  one  aged  twenty  two  years;  Weir 
had  operated  on  one  aged  eighteen  years."  I  beg  leave  to  say 
that  the  oldest  patient  I  have  ever  ojierated  on  was  six  years 
and  a  lialf  old,  and  tliat  I  have  uniformly  declined  to  operate 
on  any  child  past  seven  years  of  age.  Whether  the  statement 
that  Dr.  Hammond  operated  on  one  at  twenty-two  and  Weir  at 
-eighteen  is  correct  I  do  not  know,  but  it  has  always  seemed  un- 
wise to  me  to  operate  on  any  patient  except  in  early  childhood. 

W.  W.  Keen,  M.  D. 


|]roccebino[S  of  .^onetics. 

PHILADELPHIA  COUNTY  MEDICAL  SOCIETY. 
Meeting  of  March  22,  1893. 
{Concluded  from  page  478.) 

A  Discussion  of  the  Legal  Aspect  of  Criminal  Abortion. 

— Mr.  William  W.  Pukter  read  the  following:  It  is  with  liesi- 
tation  that  I  participate  in  the  discussion  of  this  subject,  because 
the  topic  is  somewhat  remote  from  the  matters  which  daily 
engross  those  of  us  of  the  legal  profession  who  devote  our 
attention  to  questions  of  a  so-called  civil  character.  When, 
however,  we  go  down  to  the  foundation  of  the  matter,  there  is 
little  difference  in  kind  between  proceedings  for  the  punishment 
of  crime  and  the  settlement  of  civil  disputes.  A  crime  is  simply 
a  wrong,  a  deflection  from  moral  rectitude;  but  a  wrong  of  so 
heinous  or  grievous  a  character  as  to  affect  the  public  as  well  as 
the  individual  upon  whom  the  direct  injury  is  inflicted. 

The  great  commentator  on  the  common  law  has  said :  "  In  all 
cases  the  crime  includes  an  injury.  Every  public  ofl'ense  is 
always  a  private  wrong  and  somewhat  more.  It  affects  the 
individual,  and  it  likewise  affects  the  community." 

The  crime  of  abortion,  or  attempting  to  procure  abortion,  is 
a  wrong  committed  by  one  individual  upon  another,  but  it  is 
of  so  horrible  a  character  that  a  punishment  for  its  commission 
has  been  inflicted  by  legislation  in  order  to  prevent  its  frequent 
occurrence. 

The  legislation  in  Pennsylvania  upon  the  subject  of  criminal 
abortion  is  contained  in  two  sections  of  the  Act  of  March  31, 
1860,  known  as  the  Penal  Code.  It  is  applicable  to  the  case  of 
death  following  an  attempt  to  procure  abortion.  The  full  text 
of  the  section  is  as  follows : 

"Section  87.  If  any  person  sliall  unlawfully  administer  to  any 
woman,  pregnant  or  quick  with  child,  or  supposed  and  believed 
to  be  pregnant  or  quick  with  child,  any  drug,  poison,  or  other 
substance  whatsoever,  or  shall  unlawfully  use  any  instrument 
or  other  means  whatsoever,  with  the  intent  to  procure  the  mis- 
carriage of  such  woman,  and  such  woman,  or  any  child  with 
which  she  may  be  quick,  shall  die  in  consequence  of  either  of 
said  unlawful  acts,  the  person  so  offending  shall  be  guilty  of 
felony,  and  shall  be  sentenced  to  pay  a  fine  not  exceeding  five 
hundred  dollars,  and  to  undergo  an  imprisonment  by  separate 
or  solitary  confinement  at  labor  not  exceeding  seven  years." 

Section  88  of  the  same  act  provides  for  the  penalty  to  be 
imposed  for  procuring  or  attempting  to  procure  abortion  where 
death  does  not  ensue.  Tlie  full  text  of  the  section  is  as  fol- 
lows : 

"  If  any  person,  with  intent  to  procure  the  miscarriage  of  any 
woman,  shall  unlawfully  administer  to  her  any  poison,  drug, 
or  substance  whatsoever,  or  shall  unlawfully  use  any  instrument, 
or  other  means  whatsoever,  with  the  like  intent,  such  person 
shall  be  guilty  of  felony,  and  being  thereof  convicted,  shall  be 
sentenced  to  pay  a  fine  not  exceeding  five  hundred  dollars,  and 
undergo  an  imprisonment  by  separate  or  solitary  confinement 
at  labor  not  exceeding  three  years." 

fn  so  distinguished  an  assembly  of  the  medical  profession 
little  interest  can  be  felt  in  any  attempt  to  interpret  the  mean- 
ing of  these  legislative  enactments.  No  reputable  member  of 
the  medical  profession  would  consent  to  participate  in  the  com- 
mission of  so  heinous  a  crime  as  attempting  criminal  abortion. 
Were  the  statute  book  barren  of  any  enactment  tliere  would  be 
no  danger  from  such  a  source  of  any  transgression  of  what  a 
true  moral  sense  imjjosed.  I  did  not  therefore  propose  to 
enter  upon  any  discussion  of  the  direct  provisions  of  this  act. 


May  6,  1893.] 


PROCEEDINGS 


OF  SOCIETIES. 


503 


It  may  be  well,  however,  to  learn  wliat  the  Supreme  Court  said 
in  an  opinion  rendered  ten  years  before  tlie  adoption  of  the 
•present  existing  lef?islation,  in  the  case  of  Mills  vs.  Common- 
wealth, 13  Pa.  St.,  633,  defining  in  what  the  crime  consists. 
The  opinion  of  the  Court  was  delivered  by  Mr.  Justice  Coulter. 
He  says:  "The  error  assigned  is  that  the  indictment  charges 
the  defendant  with  intent  to  cause  and  procure  the  miscarriage 
and  abortion  of  the  said  Mary  Elizabeth  L.,  instead  of  charging 
the  intent  to  cause  and  produce  miscarriage  and  abortion  of  tlie 
child.  But  it  is  a  misconception  of  the  learned  counsel  that  no 
abortion  can  be  predicated  of  the  act  of  untimely  birth  by  foul 
means. 

"Miscarriage,  both  in  law  and  philology,  means  the  bringing 
forth  the  toetus  before  it  is  perfectly  formed  and  capable  of 
living;  and  is  rightfully  predicated  of  the  woman,  because  it 
refers  to  the  act  of  premature  delivery.  The  word  abortion  is 
synonymous  and  equivalent  to  miscarriage  in  its  primary  mean- 
ing. It  has  a  secondary  meaning,  in  which  it  is  used  to  denote 
the  offspring.  But  it  was  not  used  in  that  sense  here,  and  ought 
not  to  have  been.  It  is  a  flagrant  crime  at  common  law  to 
attempt  to  procure  the  miscarriage  or  abortion  of  the  woman, 
because  it  interferes  with  and  violates  the  mysteries  of  Nature  in 
that  process  by  which  the  human  race  is  propagated  and  con- 
tinued. It  is  a  ci'ime  against  Nature  which  obstructs  the 
fountain  of  life,  and  therefore  it  is  punished.  The  next  error 
assigned  is  that  it  ought  to  have  been  charged  in  the  count  that 
the  woman  had  become  quick.  But,  although  it  has  been  so 
held  in  Massachusetts  and  some  other  States,  it  is  not.  I  appre- 
hend, the  law  in  Pennsylvania,  and  never  ought  to  have  been 
the  law  anywhere.  It  is  not  murder  of  a  living  child  which 
constitutes  the  offense,  but  the  destruction  of  gestation  by 
wicked  means  and  against  Nature.  The  moment  the  womb  is 
instinct  with  embryo  life,  and  gestation  has  begun,  the  crime 
may  be  perpetrated.  The  allegation  in  this  indictment  was 
therefore  sufficient,  to  wit:  'that  she  was  then  and  there  preg- 
nant and  big  with  child.'  By  the  well-settled  and  established 
doctrine  of  the  common  law,  the  civil  rights  of  an  infant  in  ven- 
tre sa  mere  are  fully  protected  at  all  periods  after  conception." 

The  only  interest  which  the  reputable  practitioner  can  have 
in  the  subject  of  criminal  abortion  may  be  discussed  in  answer 
to  two  questions,  both  arising  out  of  a  professional  call  to  attend 
a  patient  upon  whom  an  abortion  has  been  attempted.  In  such 
a  case  the  medical  attendant  is  interested  to  know — 

I.  What  personal  risk  he  assumes  in  attending  upon  such  a 
case,  and 

II.  What  moral  or  legal  obligation  he  mcurs  in  connection 
therewith. 

I.  He  does  incur  some  risk  in  such  a  case. 

1.  He  may,  unless  he  steers  his  course  carefully,  be  involved 
as  an  accessory  after  the  fact. 

The  Act  of  March  31,  1860,  also  contains  in  Section  180  the 
following  provision  : 

"Every  principal  in  the  second  degree,  or  accessory  before 
the  fact,  to  any  felony  [)unishable  under  this  act,  for  whom  no 
punishment  has  been  hereinbefore  provided,  shall  be  punisha- 
ble in  the  same  manner  as  the  principal  in  the  first  degree  is  by 
this  act  punishable.  Every  accessory  after  the  fact  to  any 
felony  punishable  under  this  act,  for  whom  no  punishment  has 
been  hereinbefore  provided,  shall,  on  conviction,  be  sentenced 
to  a  fine  not  excieeding  five  hundred  dollars,  and  to  undergo  an 
imprisonment,  with  or  without  labor,  at  the  discretion  of  the 
Court,  not  exceeding  two  years.  And  every  person  who  shall 
counsel,  aid,  or  abet  the  commission  of  uny  misdemeanor,  pun- 
ishable under  this  act,  for  whom  no  punishment  has  been  here- 
inbefore provided,  sliall  be  liable  to  be  proceeded  against  and 
punished  as  the  principal  offender." 


What  an  accessory  means  in  the  case  of  an  abortion  it  is 
difficult  to  say,  inasmuch  as  the  books  seem  to  contain  no  pre- 
cedent, and  the  courts  have  given  no  expression  of  opinion^ 
While  this  fact  adds  to  the  difficulties  of  discussion  and  deter- 
mination, it  also  may  he  looked  upon  as  an  evidence  that  tlie 
danger  to  the  physician  in  such  a  connection  is  small,  inasmuch 
as  none  seem  to  have  been  pursued  by  litigation. 

It  practically  means  that  the  physician  must  be  careful  when 
called  in  to  treat  a  patient  upon  whom  such  an  operation  has. 
been  peiformed,  that  he  shall  do  nothing  to  assist  in  the  pur- 
pose of  the  perpetrator  of  the  operation,  except  that  which  is 
necessitated  by  the  condition  of  the  patient,  to  save  life  or 
restore  health.  The  best  safeguard  in  a  case  where  the  physi- 
cian is  compelled  to  complete  the  operation  (if  such  a  case  ever 
arises)  is  to  have  another  reputable  ])ractitioner  in  consultation 
and  present  at  the  time  of  treatment. 

2.  One  who  has  committed  an  abortion  resulting  in  death 
can  not  be  convicted  of  murder.  In  the  case  of  Commonwealth 
rs.  Railing,  113  Pa.  St.,  37,  decided  in  1886,  it  was  held  tliat  the 
87lh  Section  of  Criminal  Code  took  the  crime  therein  specified^ 
namely,  procuring  miscarriage  resulting  in  the  death  of  the 
child  or  woman,  out  of  the  class  designated  as  murder,  and 
made  it  a  felony  of  lesser  grade,  and  prescribed  the  punish- 
ment therefor;  hence,  if  one  cause  the  death  of  a  woman  in 
attempting  to  procure  miscarriage,  he  can  not  be  indicted  for 
murder. 

3.  The  physician  in  cases  of  abortion  may,  by  the  action  of 
evilly-disposed  persons,  be  involved  in  the  commission  of  a  crime 
perpetrated  wholly  by  another.  When  a  physician  is  charged 
with  such  a  crime,  the  evidence  of  one  who  is  charged  as  a  co-. 
defendant  may  be  used  against  him. 

A  somewhat  recent  case  which  has  appeared  in  the  reported 
decisions  of  the  Supreme  Court  of  Pennsylvania  is  that  of  Cox 
vs.  Commonwealth,  125  Pa.  St.,  94.  The  decision  was  filed  in 
March,  1889.  This  was  the  case  of  a  Dr.  Cox,  of  Easton,  Pa., 
who  was  accused  of  having  procured  an  abortion  upon  the 
person  of  a  young  unmarried  woman  who  was  taken  to  Easton 
for  the  purpose  of  having  the  operation  performed.  There  was 
little  to  connect  the  physician  with  the  commission  of  the  act 
(except  the  fact  that  he  had  engaged  a  nurse  for  the  patient  in 
advance  of  her  arrival  in  Easton)  beside  the  testimony  of  one 
Evans,  who  was  indicted  with  the  physician  as  a  party  to  the 
crime.  Evans  was  called  as  a  witness  by  the  Commonwealth, 
and  testified  that  he  had  made  arrangements  with  Dr.  Cox  to 
perform  tlie  operation  at  Easton,  and  that  he  subsequently  ac- 
companied the  young  woman  to  Easton  to  a  hotel.  He  knew 
nothing  of  the  actual  operation.  Upon  this  testimony,  in  large 
measure,  the  doctor  was  convicted  of  the  offense,  the  Supreme 
Court,  by  Mr.  Chief-Justice  Paxson,  conceding  that  juries  may 
convict  upon  the  uncorroborated  testimony  of  an  accomplice. 

A  physician  might  thus  be  convicted  on  the  uncorroborated 
testimony  of  a  self  confessed  accomplice,  provided  such  accom- 
plice was  able  or  willing  to  testify  to  all  of  the  facts  leading 
up  to  a  commission  of  the  act  and  to  the  act  itself.  In  the 
case  cited  the  commission  of  the  act  itself  was  independently 
proved. 

An  ill-disposed  man  might,  in  order  to  trouble  and  perhaps 
blackmail  a  physician,  falsely  confess  himself  an  accomplice, 
and  thus,  practically  unsupported,  secure  a  verdict  of  guilty 
against  a  physician  whose  only  connection  with  the  case  might 
have  been  treatment  of  a  patient  who  had  committed  the  crime 
upon  herself.  Again,  the  patient  herself  might  be  a  confed- 
erate and  ex[)ect  to  bo  a  participant  in  the  rcw.'ii-d  which  the 
blackmailer  hoped  to  force  from  the  i)hysiciaii  for  silence.  It 
is  true  that  an  alleged  ac(^omi)lico  must  i)ersuade  the  jury  by 
whom  the  ca?o  is  tried  that  he  is  telling  the  truth,  and  it  is 


504 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


difficult  to  so  persuade  a  jury  without  some  corroborating  evi- 
dence. I  speak  here  not  of  what  is  liicely,  but  what  is  possible 
to  happen.  There  may  be  blackmailers  wlio  would  go  so  far. 
The  method  to  avoid  the  danger  is  the  association  of  a  consult- 
ing physician  immediately  on  being  called  to  treat  the  case,  or, 
if  it  shall  seem  to  the  physician  an  aggravated  case  of  wrong- 
doing by  a  person  other  than  the  sufferer,  to  report  the  case  to 
the  police  authorities. 

4.  A  most  important  question  w.is  for  some  time  an  open 
one — namely,  whether  the  dying  declarations  of  a  person  upon 
wliom  an  abortidn  has  been  committed  are  admissible  in  evi- 
dence. It  was  supposed  to  be  set  at  rest  by  the  case  of  Railing 
vs.  Commonwealth,  110  Pa.  St.,  100,  decided  in  1885,  where  it 
was  distinctly  held  that  such  declarations  could  not  be  accepted 
in  evidence  on  the  trial  of  one  charged  with  tlie  crime. 

I  observed  by  the  Philudel|)liia  I'uh lie  Ledger  this  morning 
that  an  act  has  been  introduced  in  the  Senate  of  Pennsylvania 
making  dying  declarations  admissible  as  evidence.  I  have  been 
unable  to  secure  a  copy  of  the  proposed  act. 

In  view  of  tlie  fact  that  such  a  bill  is,  or  soon  will  be,  under 
discussion,  a  (juotiitiou  of  some  length  fr(>m  the  ojiinion  of  Mr. 
Justice  Green,  of  the  Supreme  Court  of  Pennsylvania,  delivered 
in  the  case  above  referred  to,  showing  the  reasoning  by  whicii 
the  result  was  reached  by  the  Court,  may  be  permissible,  lie 
says: 

"The  principal  question  in  this  case  is  that  which  relates  to 
the  admissibility  of  the  dying  declarations  of  Annie  F.  The  de- 
fendant was  charged  with  administering  to  her  a  drug  with  intent 
to  procure  a  miscarriage,  and  it  was  also  charged  that  her  death 
resulted  as  a  consequence.  There  were  four  counts  in  the  in- 
dictment, and  all  of  them  charged  the  death  of  tlie  woman  as  a 
result  of  the  defendant's  unlawful  act.  It  is  entirely  unques- 
tioned that  dying  declarations  are  admissible  only  in  homicide 
cases,  as  a  rule,  and  that  the  death  of  the  deceased  must  be  the 
subject  of  the  charge,  and  the  circumstances  of  the  death  the 
subject  of  the  declaration:  1  Greenl.  Ev.,  Sec.  156,  13th  ed.; 
Whart.  Or.  Ev.,  Sec.  276;  Whart.  Am.  Cr.  Law,  Sec.  669  et  seq. 
It  is  equally  unfjuestioned  that  there  is  no  grade  of  homicide 
involved  in  this  case,  the  offense  charged  being  the  one  com- 
monly known  as  abortion.  It  is  argued,  however,  with  much 
force,  that  the  death  of  the  woman,  when  it  occurs,  is  a  neces- 
sary ingredient  of  the  offense  under  our  statute,  and  therefore 
brings  the  case  within  the  rule  above  stated.  It  is  claimed  that 
the  death  is  in  part,  at  least,  the  subje(;t  of  the  charge.  In  one 
sense  this  is  true.  But  the  question  is.  Is  it  so  in  the  real  sense 
of  the  rule  which  controls  the  subject?  That  inquiry  involves 
the  necessity  of  an  examination  of  our  criminal  statute  against 
abortion.  It  consists  of  two  sections,  the  87th  and  88th  of  the 
Criminal  Code  of  1800."  Here  the  learned  judge  states  the 
substance  of  the  two  sections.  He  then  continues:  "In  the 
last  case  the  offense  is  complete  without  the  death  of  the 
woman  or  child.    In  both  cases  the  grade  of  the  offense  is  the 

gj^fjje  felony.    In  both,  the  acts  done  by  the  prisoner  are  the 

same.  In  the  first,  if  those  acts  are  followed  by  the  death  of 
the  mother  or  child  as  a  consequence— -that  is,  in  the  relation  of 
effect  to  a  cause — a  difference  results  in  one  of  the  penalties  im- 
posed ;  the  possible  fine  is  the  same,  but  the  possible  imprison- 
ment is  longer — seven  years,  instead  of  three.  The  facts  which 
constitute  the  crime  are  precisely  the  same  in  both  cases,  to 
wit,  the  administering  the  drug,  or  using  the  instrument,  with 
intent  to  procure  a  miscarriage.  It  follows  that  the  death  is  no 
part  of  the  facts  which  go  to  make  up  or  constitute  the  crime. 
It  is  complete  with  the  death  or  without  it.  The  death,  there- 
fore considered  in  and  of  itself  is  not  a  constituent  element  of 
the  offense.  It  may  happen  or  it  may  not.  If  it  does  not  hap- 
pen, a  certain  possibility  of  penalty  follows.    If  it  does  happen, 


the  same  character  of  penalty  results,  but  with  a  larger  possi- 
bility, not  a  certainty,  in  one  of  the  items.  This  seems  to  be  a 
precise  expression  of  the  difference  between  the  cases  provided 
for  in  the  two  sections.  This  being  so,  the  ijuestion  rec'urs.  Is 
the  difference  between  the  two  of  such  a  character  as  to  change 
the  application  of  the  rule  of  law  relating  to  the  admissibility 
of  dying  declarations?  Of  course  they  are  not  admissible  if 
death  d(jes  not  result  as  a  conse<iuence  from  the  unlawful  acts. 
Therefore,  if  the  woman  should  subsequently  die  from  some 
entirely  different  and  independent  cause,  her  d)ing  declarations 
in  relation  to  a  prior  miscarriage  would  be  clearly  incompetent. 
In  case  she  does  die  in  consecpience  of  the  unlawful  acts,  the 
crime  charged  and  tried  is  not  homicide  in  any  of  its  forms,  but 
the  felony  of  administering  a  drug  or  using  an  instrument  with 
intent  to  produce  a  miscarriage.  In  its  facts  and  in  its  essence 
it  is  the  same  crime  that  is  charged  and  tried  if  no  death  results. 
The  death,  when  it  occurs,  is  an  incident,  the  sole  purpose  of 
which  is  to  determine  whether  the  imprisonment  of  the  defend- 
ant may  be  longer  than  when  death  does  not  occur.  The  facts 
which  constitute  the  crime  may  not  be  jiroved  by  any  declarations 
of  the  woman  when  death  does  not  follow,  or  when  it  follows 
frotn  some  other  cause.  Why,  then,  should  the  very  san  e  facts 
be  proved  by  such  declaration  when  death  does  result?  Not 
because  it  is  a  homicide,  and  the  rule  as  to  dying  de<darations 
admits  them  in  such  cases,  because  it  is  not  a  case  of  homicide 
in  a,ny  point  of  view.  Not  because  the  death  is  the  subject  of  the 
charge,  for  the  charge  is  the  attempted  or  accomplished  miscar- 
riage by  means  of  a  drug  or  in.strument.  That  crime  is  as  fully 
completed  without  the  death  as  with  it.  The  death,  therefore, 
is  not  an  essential  ingredient  of  it.  Its  function  under  the 
statute,  when  it  occurs  as  a  consequence,  is  not  to  determine 
the  Jactum,  or  the  character,  or  the  grade  of  the  crime,  but  the 
character  of  the  penalty  that  should  be  endured  by  the  criminal. 
Of  course,  if  the  statute  had  declared  that  when  death  resulted 
the  offense  should  be  manslaughter  or  any  other  grade  of  homi- 
cide, the  case  would  be  entirely  different.  Then  the  death 
would  be  an  essential  ingredient  of  the  offense,  and  would  be 
the  subject  of  the  charge,  and  the  rule  as  to  dying  declarations 
would  apply.  But  such  is  not  this  case,  and  we  do  not  think  it 
wise  to  enlarge  the  operation  of  the  rule  so  as  to  embrace  cases 
other  than  homicide  strictly.  The  objections  to  the  admission  of 
such  testimony  are  of  the  gravest  character.  It  is  hearsay,  it  is 
not  under  the  sanctity  of  an  oath,  and  there  is  no  opportunity 
for  cross-examination.  It  is  also  subject  to  the  special  objection 
that  it  generally  comes  from  persons  in  the  last  stage  of  physi- 
cal exhaustion,  with  mental  powers  necessarily  impaired  to  a 
greater  or  less  extent,  and  at  the  best  represents  the  declar- 
ant's percefitions,  conclusions,  inferences,  and  o[)inions,  which 
may  be,  and  often  are,  based  upon  imperfect  and  inadequate 
grounds.  Nor  is  the  reason  ordinarily  given  for  tlieir  admission 
at  all  satisfactory.  It  is  that  the  declarant  in  the  immediate 
presence  of  death  is  so  conscious  of  the  great  responsibility 
awaiting  him  in  the  near  future  if  he  utters  a  faNehood.  that  he 
will,  in  all  probability,  utter  only  the  truth.  The  fallacy  of  this 
reasoning  has  been  many  times  demonstrated.  It  leaves  en- 
tirely out  of  accoimt  the  influence  of  the  passions  of  hatred  and 
revenge  which  almost  all  human  beings  naturally  feel  against 
their  murderers,  and  it  ignores  the  well-known  fact  that  persons 
guilty  of  murder,  beyond  all  question,  very  frequently  deny 
their  guilt  up  to  the  last  moment  upon  the  scaft'old." 

II.  Wo  come  now  to  the  second  grand  division  of  the  sub- 
ject— namely,  the  obligations  resting  ujxm  the  physician  or  sur- 
geon who  is  called  upon  to  attend  in  a  case  of  criminal  abortion. 
Having  satisfied  himself  that  the  injury  to  the  patient  has  not 
been  self-inflicted,  should  the  physician  conceal  the  truth  or 
make  it  known  ? 


May  6,  1893.] 


PROCEEDINGS 


OF  SOCIETIES. 


505 


In  answering  this  question  lie  must  consider — 

1.  11  is  duty  to  his  patient. 

2.  His  duty  to  his  jjrofession. 

3.  His  duty  to  the  public  at  large. 

In  discussing  these  matters  we  are  met  with  ethical  rather 
than  legal  considerations.  I  have  been  able  to  find  nothing  as 
a  guide,  either  in  legislative  enactments  or  in  cases  decided  by 
the  courts. 

Therefore  what  is  here  said  is  only  by  way  of  suggestion 
and  discussion.  The  determination  of  the  questions  of  duty  in 
each  case  must  be  relegated  to  the  fonim  of  individual  con- 
science. 

1.  The  duty  to  the  patient. 

Take  the  following  as  an  illustration  :  A  reputable  head  of  a 
family  has  called  in  the  services  of  the  family  doctor  to  attend 
a  sick  daughter.  The  physician  has  soon  evidence  sufficient  to 
indicate  a  case  of  criminal  abortion.  He  learns  from  the  pa- 
tient in  confidence  that  a  certain  physician,  or  her  lover,  or 
both,  have  assis'ed  in  [)r()diicing  her  serious  condition. 

There  is  a  plain  duty  to  the  girl  and  to  her  father,  to  pre- 
vent scandal,  and  yet  an  act  has  been  committed  which  has 
been  pronounced  by  the  State  law  a  felony.  Silence  means 
that  the  criminal  must  go  unpunished.  It  is  a  condition  that, 
unfortunately,  men  of  the  medical  profession  have  sometimes 
to  face. 

There  is  no  statutory  penalty  imposed  for  silence.  Can  it 
be  doubted  that  the  physician  in  such  a  case  is  justified  in  hold- 
ing his  peace  so  long  as  a  fatal  termination  of  the  ilbiess  is 
not  impending  ? 

Information  received  by  counsel  from  his  client  is  regarded 
by  the  law  as  a  privileged  communication,  and  he  can  not  he 
compelled  to  divulge  the  information  so  received.  In  the  case 
of  a  phvsician,  however,  the  rule  of  the  common  law  seems  to 
be  that  he  can  be  compelled  to  divulge  communications  re- 
ceived from  his  patient.  There  is  to  my  mind,  in  this  distinc- 
tion between  the  professions,  an  illogical  discrimination,  and  I 
believe  that  in  most  cases  a  physician  would  rather  undergo 
the  punishment  imposed  by  a  court  for  silence  than  violate  the 
professional  C'  nfidence.  Some  of  the  States  (for  example,  New 
York)  have  adopted  legislation  making  confidential  communica- 
tions between  patient  and  physician  privileged,  and  I  would  re- 
spectfully sugge.-t  that  measures  to  secure  such  legislation  in 
Pennsylvania  might  well  be  taken,  both  for  the  protection  of  the 
medical  practitioner  and  the  sanctity  of  the  professional  rela- 
tion. 

2.  The  duty  to  the  profession. 

A  loyal  physician  holds  bis  profession  in  high  honor.  To 
have  men  within  its  ranks  who  will  lend  themselves  to  the 
coramis-ion  of  crime  is  a  disgrace.  Not  to  punish  them  will 
only  lead  them  to  greater  confidence  in  their  ability  to  escape 
punishment  and  encourage  them  in  their  infamous  behavior. 

This  consideration  has  weight  in  determining  the  ct)urse  of 
duty.  The  conclusion  therefore  reached  is  that  where  the  pro- 
fessional obligation  to  the  patient  will  permit,  duty  to  the  pro- 
fession must  impel  disclosure  (at  least  to  the  profession,  and 
better,  to  the  police  authorities)  of  the  name  of  the  wrongdoer. 

3.  What  of  the  public  generally  ? 

The  j)hysician  is  a  citizen.  He  owes  a  citizen's  duty  to  the 
community  at  large.  If  he  or  any  other  citizen  knows  that  a 
crime  has  been  committed  by  a  particular  person,  and  fails  to 
bring  the  criminal  to  justice,  he  falls  short  of  his  obligation. 
It  is  true  that  in  the  smaller  otienses  (especially  those  involving 
property)  we  can  hardly  be  expected  in  all  cases  coming  under 
our  knowledge  to  see  that  each  wrongdoer  is  puniohed. 

When  the  urchin,  with  our  eyes  upon  him,  pilfers  an  apple 
from  the  corner  stand,  we  do  not  feel  that  we  have  committed 


a  grievous  sin  of  omission  if  we  do  not  personally  inform  the 
first  policeman,  or  if  we  do  not  ourselves  pursue  the  little  cul- 
prit to  his  capture,  in  order  to  insure  his  punishment. 

If,  however,  we  see  serious  bodily  injury  inflicted,  or  mur- 
der impending,  who  of  us  would  not,  at  personal  inconven- 
ience or  peril,  see  to  the  capture  and  pimishment  of  the  per- 
petrator ? 

If  the  patient  is  to  recover  from  the  effects  of  the  crime 
per|)etrated  on  her,  and  the  injury  is  slight,  by  analogy,  there 
is  some  justification  tor  silence. 

If  she  is  to  die,  and  the  injury  is  thus  greater,  silence  is  not 
only  dangerous,  but  it  is  without  justification.  It  is  not  easy, 
certainly,  to  justify  this  conclusion,  since,  under  the  act,  the 
criminal  intent  is  the  same  in  both  cases,  the  only  difference 
being  in  the  result.  Death  from  criminal  abortion  entails  upon 
the  attending  physicinn  who  conceals  it  the  necessity  for  a 
written  lie  in  the  certificate  which  he  is  required  to  give  by  the 
registrati(m  acts.  Should  he  certify  the  true  cause  of  death  he 
can  not  avoid  publicity,  and  may  be  subjected  to  censure  for 
failing  to  rej)ort  the  case  sooner  to  the  authorities.  If  he  cer- 
tifies falsely  and  is  discovered,  he  runs  the  risk  of  being  charged 
with  the  commission  of  the  crime  itself. 

Fit  ally,  the  rules  of  conduct  may  he  summarized  thus: 

1.  When  called  to  such  a  case,  immediately,  on  suspicion  of 
criminality  being  aroused,  call  in  another  physician  to  your  aid. 

2.  If  consistent  with  your  ])rimary  duty  to  the  patient,  re- 
port the  case  (even  though  not  likely  to  he  fntal)  to  the  district 
attorney. 

3.  As  soon  as  a  fatal  result  appears  likeh,  report  the  case  to 
the  district  attorney,  who  (if  requested)  will  doubtless  never  let 
you  be  known  as  his  informant,  but  who  will  be  enabled  by 
other  means  of  proof  to  bring  a  criminal  to  justice. 

4.  If  you  have  not  reported  the  case,  and  the  end  is  death, 
do  not  be  led  into  the  giving  of  a  false  certificate  of  death. 

In  conclusion,  it  will  be  seen  that  what  has  been  said  is  al- 
most wholly  discursive.  It  would  ill  become  a  member  of  our 
profession  to  assume  to  instruct  in  the  ethics  of  the  sister  pro- 
fession. It  can  not  truthfully  be  said  that  the  legal  profession 
has  a  higher  moral  standard  than  the  medical,  and  to  each  con- 
scientious member  of  both  must  it  be  left  to  do  the  right  as  to 
conscience  and  good  morals  it  shall  appear. 

The  Hon.  Geokge  S.  Graham  said :  I  should  hesitate  to  add 
anything  to  this  discussion  were  it  not  for  the  fact  that  there 
are  one  or  two  points  on  which  I  differ  with  those  who  have 
preceded  me.  I  have  nothing  to  say  about  the  definition  and 
the  law  ;  both  have  been  thoroughly  and  amply  stated.  1  want 
to  call  attention,  first,  to  the  question  of  dying  declarations; 
and,  second,  to  the  attitude  of  the  physician  with  relation  to 
this  offense.  I  wish  to  call  the  attention  of  this  organization  to 
the  bill  that  is  now  pending  in  the  Legislature  of  Pennsylvania, 
intended  to  cover  a  gap  in  the  criminal  law  through  which 
more  men  escape  conviction,  who  justly  deserve  it,  than  through 
any  other.  I  am  not  here  to  criticise  the  ruling  of  the  Supreme 
Court,  but  the  effect  of  that  ruling  which  excludes  the  dying 
declaration  from  admissibility  as  a  piece  of  evidence.  In  con- 
versation with  a  gentlemen,  a  member  of  this  society,  he  sug- 
gested to  me  the  desirability  of  some  such  law,  and  in  pursu- 
ance of  that  suggestion  I  prepared  the  bill  which  was  intro- 
duced yesterday,  and  therefore  the  objurgations  of  my  friend 
fall  upon  my  head.  The  bill  is  plain,  simple,  and  to  the  point; 
it  provides  that  in  all  cases  of  prosecution  for  abortion  where 
death  resulis  the  dying  declaration  may  be  admitted  as  evi- 
dence. It  does  not  change  the  rules  under  which  that  declara- 
tion is  admissible.  It  simply  remedies  what  was  disturbed  and 
broken  by  the  decision  in  Commonwealth  r«.  Rauck.  The  ques- 
tion was  discussed  in  that  case  wliether  or  not  such  doclara- 


506 


PROCEEDINGS  OF  SOCIETIES. 


[)^.  Y.  Med.  Jode., 


tions  were  admissible  in  prosecutions  fur  abortion  wliere  the 
person  died.  In  our  county  we  liad  talien  the  ground  that  this 
crime  involved  an  inquiry  into  the  question  of  a  death,  and 
that,  therefore,  the  dying  declaration  was  admissible.  We  were 
able  to  convince  the  judges  of  our  courts  of  Quarter  Sessions 
that  that  was  the  true  view,  and  there  were  three  decisions  sus- 
taining that  view.  The  case  referred  to  went  up  from  Dauphin 
County,  and  the  Supreme  Court  reversed  the  decisions  in  the 
county  courts  and  held  that  because  of  the  passage  of  the  Act 
of  Assembly  which  called  abortion  a  felony  and  defined  it  as 
the  crime  of  abortion,  it  was  withdrawn  from  tiie  list  of  homi- 
cides, and  that  dying  declarations  were  only  admissible  in  cases 
of  homicide.  It  is  conceded  by  all  lawyers  that  abortion  did, 
at  common  law,  come  under  the  classification  of  homicide;  a 
person  might  have  been  convicted  at  common  law,  according 
to  the  circumstances,  of  murder  in  the  second  degree  or  of  man- 
slaughter. It  was  owing  to  the  passage  of  that  act,  wliich  lifted 
criminal  al)ortion  out  of  the  category  of  homicide  and  ])laced  it 
in  a  new  relation  to  the  criminal  code,  that  the  Court  held  that 
dying  declarations  in  this  kind  of  a  case  were  not  admissible. 
My  friend  quoted  the  obiter  dicta  of  the  judge.  That  is  no  part 
of  the  decision  and  no  part  of  the  authority  of  the  case  itself. 
Speaking  of  dying  declarations  on  the  broad  ground  whether 
they  should  be  admitted  or  not,  the  judge  said  that  they  are  the 
merest  hearsays,  and  should  not  be  permitted  to  appear  in  evi 
dence  to  fnsten  crime.  Here  is  an  anomaly  to  which  I  direct 
your  attention.  While  the  judge  reasoned  that  they  should  be 
excluded  in  a  crime  which  had  been  lessened  and  made  of 
smaller  magnitude  in  the  eye  of  the  law,  he  admitted  that  in 
the  higher  and  graver  crimes,  such  as  murder  and  manslaughter, 
the  necessity  of  society  demanded  that  dying  declarations  should 
be  admitted.  Mark  the  ground  on  which  they  are  to  be  ad- 
mitted—to wit,  tlie  necessity  of  society.  If  there  is  a  single  in- 
stance of  criminality  in  which  the  necessity  of  society  demands 
the  admission  of  dying  declarations  as  a  piece  of  evidence,  it  is 
in  that  most  secret  of  all  oifenses,  the  crime  of  abortion.  Now, 
surely  the  reasoning  of  that  learned  judge  is  utterly  fallacious 
in  another  i)oint.  Said  he:  "The  argument  usually  employed 
that  the  solemnization  of  the  thoughts  at  the  idea  of  dissolution 
will  cause  the  person  to  speak  the  truth,  is  not  applii^able,  for 
we  leave  out  the  element  of  the  passions  of  hatred  and  re- 
venge.'' Why,  gentlemen,  by  a  parity  of  reasoning  you  would 
destroy  all  te>timony,  for  the  same  line  of  argument,  logically 
pursued,  would  make  you  exclude  the  evidence  of  every  wit- 
ness. I  submit  that  the  reason  upon  which  dying  declarations 
are  admitted  has  a  good  foundation.  It  is  well  known  that  the 
approach  of  dea'h  solemnizes  the  thoughts  of  every  man  or 
woman.  They  may  laugh  and  scoff  at  death  in  health,  but  I 
tell  you  when  they  come  face  to  face  with  the  hour  of  dissolu- 
tion, it  must  be  the  rare  exception  indeed,  in  which  the  storm 
of  passion  can  dominate  the  soul  and  make  one  commit  perjury 
of  the  worst  kiml,  standing  on  the  threshold  of  the  future.  I 
say,  therefore,  that  dying  declarations,  if  admissible  in  homicide 
of  the  higher  grades,  should  be  admitted  in  this  offense  of  abor- 
tion, and  I  come  to  ask  your  body  to  pass  some  resolution  ask- 
ing for  such  a  law. 

I  want  to  say  a  word  about  tlie  duty  of  the  physicinn.  I 
appreciate  what  has  been  said  by  Dr.  Parish  and  Mr.  Porter 
with  regard  to  the  sentiment  that  gathers  about  the  relation- 
ship of  physician  to  patient.  The  i)icture  drawn  by  Mr.  Porter 
appeals  to  the  sentiments  of  us  all,  bur  there  is  only  one  test, 
and  it  is  not  the  test  of  sentiment.  It  is.  Is  the  thing  intrin- 
sically right,  or  is  it  wrong?  We  are  not  considering  what  the 
law  ought  to  be,  but  what  it  is.  It  is  the  duty  of  every  citizen, 
if  he  knows  that  a  crime  has  been  (committed,  to  make  it 
known.    If  an  ott'ense  is  grave  enough  for  the  law  to  recognize 


and  fix  a  penalty  on,  you  have  no  right  to  set  that  law  aside  and 
say  that  it  is  too  insignificant  for  you  to  notice.  The  physician 
can  only  es?ape  censure  or  prosecution  by  revealing  the  fact 
that  an  offense  has  been  committed.  It  would  be  no  defense 
in  a  court  of  justice  for  a  [)hysician  to  say  that  he  ke[)t  it  quiet 
because  he  wished  to  be  a  shield  between  a  suffering  female 
and  the  disgrace  that  might  ensue.  Of  course,  in  the  graver 
cases  where  death  ensues,  it  is  imperative  that  the  matter  should 
be  reported.  I  ask  you.  laying  aside  sentiment,  to  point  out  a 
single  reason  why  there  should  be  a  distinction  between  the 
cases  where  death  follows  and  those  where  death  does  not  fol- 
low. The  distinction  is  attempted  to  be  drawn  because  one  is 
of  less  importance,  but  my  answer  to  that  is  that  the  law  does 
not  say  that  it  is  the  duty  of  the  citizen  to  report  only  impor- 
tant criminal  cases.  Besides,  both  are  felonies.  It  is  his  duty 
to  report  every  criminal  case,  and  the  physician  who  learns  of 
such  a  crime  and  conceals  it  becomes  an  aider  and  abettor  in 
the  crime.  Surely  no  man  can  rise  and  say  that  on  the  basis  of 
sentiment  he  has  a  right  to  become  a  criminal.  That  is  the  re- 
sult, for  if  by  concealment  he  becomes  a  particeps  criminis^ 
surely  the  duty  to  speak  must  be  regarded  as  absolute. 

Coroner  Samuel  H.  Asiibkidge  said  :  I  shall  not  enter  into 
this  discussion  from  a  medical  or  a  legal  standpoint,  but  merely 
from  that  of  practical  observation  and  with  reference  to  the 
rules  that  we  lay  down  in  our  office  for  the  purjjose  of  conduct- 
ing cases  of  the  character  under  consideration.  The  question 
has  been  raised  whether  or  not  these  cases  should  be  reported. 
During  the  year  we  have  hundreds  of  cases  reported  to  our 
office  by  physicians,  who  state  that  the  patient  is  suffering  from 
peritonitis  which  they  believe  to  be  the  result  of  operation  for 
the  induction  of  abortion.  Such  information  is  always  treated' 
as  confidential,  and  the  name  or  residence  of  the  patient  is  not 
asked.  I  say  to  the  physician  that  if  the  patient  dies  and  he- 
believes  that  the  death  is  due  to  criminal  abortion,  it  is  his  duty 
to  report  it.  I  am  glad  to  state  that  there  are  few  deaths  in 
comparison  to  the  nun.ber  of  cases  reported. 

Abortions  are  prevalent  in  all  communities;  but  I  want  to 
say,  to  the  credit  of  our  city,  that  there  are  fewer  abortions  in 
Philadelphia  than  in  any  other  great  city  on  this  continent. 
One  reason  of  this  is  the  high  moral  chariictcr  of  the  medical 
profession  of  this  city.  It  is  rare  that  you  find  a  graduate  of  a 
regular  reputable  medical  college  who  will  stoop  to  the  crime 
of  abortion. 

I  agree  with  the  district  attorney  in  regard  to  the  enactment 
of  a  law  making  dying  declarations  admissible.  It  is  very 
difficult  for  us  to  procure  unmistakable  evidence  unless  from 
the  victim  herself.  Crimes  of  this  character  are  of  such  a  secret 
nature  that  often  they  are  only  known  to  the  victim  and  the 
perpetrator.  In  Philadelphia,  at  the  present  time,  detection  of 
this  crime  is  less  frequent  than  at  any  other  period,  according 
to  my  knowledge.  I  can  not  say  that  it  is  because  more  skill 
is  used,  but  there  does  not  seem  to  be  any  lessening  of  the  of- 
fense. We  have  the  opportunity  of  learning  many  things  that 
are  never  published  to  the  world — in  fact,  it  is  not  our  duty  as 
public  officials  to  reveal  scandals  that  may  come  to  our  knowl- 
edge. If  the  majesty  of  the  law  has  been  maintained  we  feel 
that  we  have  done  all  that  is  incumbent  upon  us. 

Dr.  H.\ERis  A.  Sloclm  said:  I  agree  with  Dr.  Parish  that 
the  diagnosis  of  criminal  abortion  is  a  difficult  matter  except  in 
cases  of  puncture,  or  where  there  are  evidences  of  laceration 
where  accident  can  be  excluded. 

The  responsibility  of  the  physician  in  treating  these  cases  is 
a  matter  that  has  been  brouiiht  to  my  mind  a  number  of  times. 
The  district  attorney  has  said  that  it  is  the  duty  of  the  physi- 
cian to  report  these  cases;  but  if  the  names  of  the  patients 
are  insisted  upon  I  think  that  there  are  few  physicians  who 


May  6,  1893.] 


PROCEEDINGS 


OF  SOCIETIES. 


607 


would  not  object.  We  know  that  the  counsel  for  a  criminal  is 
permitted  to  retain  the  facts  given  to  him  by  his  client.  Would 
a  lawyer  who  was  not  counsel  for  the  prisoner,  but  who  was 
told  the  facts,  be  permitted  to  retain  them  ? 

Mr.  Gkaham  said:  He  would  have  to  tell  them.  The  law 
says  that  the  counsel  shall  not  divulge  the  facts  told  him  by  his 
client,  but  it  says  that  the  physician  shall  tell  those  given  him 
by  his  patient. 

Dr.  Slooum  said :  I  have  always  been  under  the  impression 
that  facts  of  this  kind  communicated  to  a  physician  were  to  be 
held  sacred  and  not  divulged,  and  I  think  the  majority  of  phy- 
sicians hold  the  same  opinion.  Surely  the  law  is  unjustly  dis- 
criminating when  it  extorts  such  evidence  from  a  man  whose 
whole  duty  is  to  relieve  suffering  or  save  life,  and  who  is  called 
in  an  emergency  for  that  purpose,  and  that  alone ;  yet  the  very 
one  whose  duty  it  should  be  to  contribute  to  the  administration 
of  justice,  and  who  is  officially  stamped  for  that  purpose,  is 
permitted  to  have  knowledge  of  incriminating  facts  and  to  keep 
silent  about  them,  even  during  the  crucial  trial  in  court,  when 
eve^  effort  is  apparently  being  made  to  know  the  truth  and 
the  whole  truth. 

I  am  glad,  however,  to  get  this  official  information  respect- 
ing our  duty  in  these  cases  in  the  sight  of  the  law.  It  is  a 
point  that  many  of  us  have  wished  to  be  certain  about.  We 
now  know  that  we  are  confronted  by  the  unpleasant  alterna- 
tives of  breaking  the  law  or  of  ^betraying  the  trust  reposed  in 
us  by  becoming  informers,  and  it  is  probable  that  every  physi- 
cian in  Philadelphia,  even  those  of  the  highest  reputation  and 
of  the  greatest  integrity,  will  fall  into  one  line  or  the  other 
It  seems  to  me  that  in  the  cause  of  right  and  justice  that  por- 
tion of  the  law  which  relates  to  this  subject  should  be  so  modi- 
fied as  to  leave  some  latitude  to  the  discretion  of  the  physician. 
No  class  of  men  at  the  present  day  is  doing  so  much  to  prevent 
this  crime  as  is  that  of  medicine,  and  yet  a  representative  of  that 
class  is  liable,  at  any  time,  and  against  his  inclination,  to  be- 
come either  a  criminal,  in  the  eyes  of  the  law,  in  being  an 
"  accessory  after  the  fact,"  or  a  betrayer  in  the  eyes  of  a  patient. 

Dr.  Eugene  P.  Bernardt  said :  No  matter  at  what  stage  or 
period  of  pregnancy  the  operation  for  criminal  abortion  is  per- 
formed, it  is  murder.  I  know  many  will  differ  with  me;  the 
theologian  and  lawyer,  more  especially  the  layman.  With  what 
insignificance  the  idea  of  animate  existence  of  the  foetus  in  its 
early  stages  is  held  by  them,  we,  as  physicians,  know — from 
the  poor,  ignorant,  hard-working  women  in  our  courts  and 
alleys,  to  whom  another  child  means  more  care  and  harder 
work,  to  our  society  woman  of  the  highest  mental  attainments, 
to  whom  a  child  is  a  bother  in  the  way  of  her  social  duties- 
Women  who  would  not  cause  the  least  unnecessary  pain  to  be 
inflicted  upon  any  human  being  or  beast  will,  without  the 
slightest  hesitation  or  shame,  ask  that  they  be  relieved  of  their 
(to  them)  troublesome  burden,  and,  when  refused,  are  surprised 
and  become  indignant,  and  reply:  "Why,  it  is  only  a  month 
old,  and  it  certainly  is  not  alive."  If  not  alive,  could  it  con- 
tinue its  growth,  until  eventually,  from  the  seemingly  micro- 
scopic inert  mass,  springs  forth  that  wonderful  creation — man  j 
I  ask  again,  Could  a  dead  mass  perform  such  an  act?  To 
grow,  we  must  be  animate ;  to  be  animate,  we  must  have  vital- 
ity. Life  means  a  soul.  At  what  time  of  pregnancy  does  this 
mystical  union  of  the  animal  and  spiritual  natures  of  the  human 
being  occur?  At  the  moment  of  conceptiou,  quickening,  or 
birth?  On  this  point  theologians  are  divided.  Many  believe 
that  the  soul  enters  the  body  at  the  moment  of  quickening,  and 
previous  to  that  moment  the  fcetus  was  soulless.  Others  believe 
that  the  soul  is  imparted  to  the  child  at  the  moment  of  its 
birth.  I  can  not  believe  that  God  performs  such  imperfect 
work.    I  believe  that  the  embryonic  mass,  surrounded  by  the 


decidua,  vera,  and  reflexa,  has  as  much  a  soul  as  the  child  on 
the  day  of  its  birth,  and  on  this  conviction  have  I  always  prac- 
ticed, looking  upon  the  performance  of  a  criminal  abortion  as 
being  nothing  less  than  murder. 

Quickening  is  a  mere  circumstance  in  the  physiological  his- 
tory of  the  foetus.  It  is  uncertain  in  its  periods,  sometimes 
making  itself  sensible  at  three  months,  at  other  times  four  or 
five  months,  and  in  a  large  percentage  of  cases  not  at  all. 
Many  women  have  been  delivered  of  children  that  have  never 
quickened.    Are  these  children  to  be  considered  as  soulless? 

On  this  very  point  were  laws  made  in  England  under 
George  III,  in  1803,  when  it  was  ordained  that  the  procuring 
of  an  abortion  of  a  female  not  quick  with  child  is  felony,  to  be 
punished  by  fine,  imprisonment,  or  exposure  in  the  pillory,  or 
that  the  criminal  may  be  publicly  or  privately  whipped,  or 
transported  beyond  the  sea  for  any  term  not  exceeding  four- 
teen years.  The  same  act  also  declares  that  to  procure  abor- 
tion after  quickening  is  murder,  to  be  punishable  with  death. 
This  law  has  of  recent  years  been  somewhat  modified,  and  at 
present  the  law  in  England  is  that  the  procuring  of  an  abortion 
at  any  period  of  pregnancy  is  a  felony,  to  be  punished  by 
transportation  for  fifteen  years  or  for  life,  or  by  imprisonment 
for  three  years. 

The  laws  with  regard  to  the  punishment  for  this  crime  vary 
in  the  different  countries,  some  imposing  punishment  more  or 
less  severe,  according  to  the  stage  of  pregnancy.  The  laws  of 
Pennsylvania  look  upon  the  act  as  criminal  in  all  its  stages. 
On  the  trial  of  a  murderer  for  performing  a  criminal  abortion 
which  resulted  in  the  death  of  the  mother,  the  judge,  in  charg- 
ing the  jury,  declared  that  "at  common  law  the  crime  is  mur- 
der. Every  act  of  procuring  an  abortion  is  murder,  whether 
the  person  perpetrating  the  crime  intended  to  kill  the  woman 
or  merely  feloniously  to  destroy  the  fruit  of  her  womb."  The 
procuring  of  an  abortion  is  "  a  base  and  unmanly  act";  it  is  a 
crime  against  the  natural  feelings  of  man,  against  the  welfare 
and  safety  of  woman,  against  the  peace  and  prosperity  of  so- 
ciety, and  against  the  Divine  command,  "Thou  shalt  not  kill." 
It  is  murder. 

Mr.  Porter  said :  I  have  not  had  an  opportunity  of  reading 
the  bill  to  which  reference  has  been  made.  I  am  not  here  to 
oppose  it ;  but  I  would  caution  the  medical  profession  to  think 
twice,  or  at  least  once,  before  it  indorses  it.  The  adoption  of 
such  a  law  amounts  to  this :  that  when  you  are  attending  a  case 
of  this  kind,  where  death  seems  to  be  approaching,  you  must 
metamorphose  yourself,  change  from  the  medical  practitioner 
to  the  practiced  detective,  or  run  to  a  public  officer,  in  order 
that  the  dying  declaration  may  be  obtained  from  one  who  has 
intrusted  to  your  care  body,  health,  and  even  that  which  is 
more  sacred — the  secret  of  her  vanished  honor.  I  throw  this 
out  as  a  suggestion.  I  should  like  to  see  the  act  before  I  say 
anything  directly  concerning  it. 

The  district  attorney  has  dwelt  upon  the  duty  of  the  physi- 
cian in  regard  to  reporting  these  cases.  I  have  listened  to  hear 
what  punishment  is  to  be  inflicted  for  silence,  and  I  have 
listened  in  vain.  Is  silence  criminal?  God  forbid!  It  is 
golden.  There  is  in  the  criminal  code  no  penalty  for  silence, 
impelled  by  a  sense  of  honor,  in  such  cases. 

Mr.  Grauam  said :  1  would  suggest  to  my  friend  that  there 
is  such  a  thing  as  misprision  of  felony  or  the  concealment  of  a 
felony.  There  is  a  duty  upon  the  citizen  to  disclose  a  felony 
that  comes  to  his  knowledge.  The  question  is  one  of  abstract 
duty;  sentiment  can  not  overcome  it.  I  have  not  discussed 
the  question  whether  the  lawyer  and  physician  should  be  put 
on  the  same  basis.  The  present  position  of  the  physician  under 
the  law  is  different  from  that  of  the  lawyer.  The  law  has  said 
that  the  lawyer's  relation  with  his  client  is  confidential,  while 


508 


BOOK  K0TIGE8. 


[N.  Y.  Med.  Jodb., 


the  physician  is  not  protected.  So  long  as  this  is  the  case,  the 
duty  of  the  physician  to  report  a  felony  is  absolute. 

Mr.  Porter  said:  When  we  talii  about  the  right  of  the  law- 
yer to  keep  silence  it  means  that  if,  on  the  witness  stand,  he  is 
asked  a  question,  he  may  decline  to  reply  on  the  ground  that 
the  communication  was  confidential  from  a  client.  If  the  phy- 
sician, on  the  stand,  det^lines  to  reply,  the  Court  may  punish 
bim.  This,  however,  is  totally  different  from  saying  that  a 
physician,  not  on  the  witness  stand,  who  is  the  repository  of  a 
secret,  is  bound  to  divulge  it.  Even  if  he  knows  of  the  crime 
as  a  citizen,  there  may  be  strong  grounds  of  Justification  in 
withholding  such  knowledge,  but  when  the  knowledge  is 
gained  through  the  professional  relation,  if  you  can  discriminate 
in  good  morals  between  the  rights  of  the  lawyer  and  those  of 
the  physician,  I  can  not. 


The  Diseases  and  Deformities  of  the  Foetus :  an  Attempt  toward 
a  System  of  Antenatal  Pathology.  By  J.  W.  Ballantyne, 
M.  D.,  F.  R.  C.  P.,  F.  Pv.  S.  E.,  Lecturer  on  Diseases  of  In- 
fancy and  Childhood,  Minto  House  School  of  Medicine,  Ed- 
inburgh, etc.  With  Plate  and  other  Illustrations.  Volume 
I.  Edinburgh:  Oliver  &  Boyd,  1892.  Pp.  xiii-252.  [Price, 
\0s.  U.] 

The  author  has  taken  up  the  consideration  of  a  subject  that, 
while  of  considerable  scientific  interest,  is  likely  to  be  regarded 
as  of  slight  practical  importance,  because  it  is  not  possible  to 
make  a  diagnosis  of  a  disease  of  a  foetus  in  utero,  and  it  is  con- 
sequently impossible  to  adopt  any  method  of  treatment.  It  is 
for  this  reason  more  than  any  other  that  the  nomenclature  of 
foetal  maladies  is,  with  few  exceptions,  symptomatological ; 
and,  if  it  is  almost  impossible,  as  the  author  says,  to  distinguish 
foetal  dropsy  due  to  anomalies  of  the  blood  or  lymphatic  system 
from  that  produced  by  cardiac  or  renal  disease,  it  is  not  difficult 
to  understand  the  reason  for  the  retention  of  the  symptomato- 
logical term.  We  fully  agree  with  the  author  that  it  is  impos- 
sible to  predict  what  results  may  flow  from  discoveries  in  this 
field  of  research,  though  we  do  not  look  forward  to  an  early 
arrangement  of  a  system  of  prophylactic  and  curative  ante- 
natal therapeutics  that  will  abolish  foetal  and  congenital  disease 
altogether. 

It  seems  that  in  this  method  of  approaching  his  topic  the 
author  has  been  enthusiastic  rather  than  visionary,  being  desir- 
ous of  collecting  and  arranging  his  scientific  facts  and,  with 
these  in  his  possession,  to  turn  them  to  practical  use.  He  has 
prepared  a  careful  synopsis  of  the  methods  of  investigation  that 
should  be  employed  in  studying  foetal  maladies,  and  summarizes 
a  scheme  of  case-taking  that  would,  if  adopted,  serve  to  en- 
hance our  knowledge  of  this  subject. 

There  is  an  interesting  historical  sketch  of  the  diseases  of 
the  foetus  as  observed  or  recorded  among  primitive  peoples,  the 
earliest  civilizations,  those  of  the  Greeks  and  the  Romans,  as 
well  as  in  the  middle  ages  and  during  the  sixteenth,  seven- 
teenth, eighteenth,  and  nineteenth  centuries. 

The  various  classifications  of  diseases  of  the  foetus  that  have 
been  published  are  presented  for  consideration,  and  the  author 
calls  attention  to  the  fact  that  neither  the  {etiological,  nor  the 
pathological,  nor  the  systemic,  nor  the  regional  method  has 
been  altogether  satisfactory.  A  scheme  of  classification  that 
should  combine  these  different  plans  would,  ho  says,  be  most 
desirable.    The  scheme  that  he  presents  seems  satisfactory,  in- 


cluding, as  major  headings,  the  subjects  of — (1)  idiopathic  dis- 
eases; (2)  transmitted  diseases;  (3)  traumatic  morbid  states; 
(4)  toxicological  conditions;  (5)  death  of  the  foetus  and  post- 
mortem appearances. 

The  first  disease  considered  in  this  volume  is  general  dropsy 
of  the  foetus,  the  varieties  of  which  and  the  frequency  with 
which  they  occur  being  mentioned,  many  cases  and  specimens 
being  described,  and  the  conclusion  being  reached  that  while  in 
some  cases  of  the  disease  there  has  existed  an  adequate  cause 
in  the  foetus  itself,  in  most  instances  it  has  been  due  to  a  chain 
of  factors  having  a  cachectic  state  of  the  mother  at  one  end 
and  a  blood  disease  of  the  foetus  at  the  other,  with  a  morbid 
state  of  the  uterine  mucosa  and  placenta  intervening.  The  au- 
thor states  that  it  is  well-nigh  impossible  to  diagnosticate  the 
disease  during  pregnancy,  and  the  treatment  is  one  resting 
upon  an  unknown  condition  due  to  an  unknown  cause.  All 
these  features  of  uncertainty  of  diagnosis,  aetiology,  and  treat- 
ment are  involved  in  the  subject  of  general  dropsy  in  the  twin 
foetus,  as  well  as  in  that  of  general  cystic  elephantiasis  of  the 
foetus;  and  a  study  of  these  two  conditions,  as  observed  id  the 
lower  animals,  throws  little  light  on  the  questions  involved. 
There  is  a  chapter  on  general  foetal  obesity  with  dropsy,  based 
on  a  specimen  observed  by  the  author. 

It  is  the  author's  intention  to  present  the  subjects  of  the  re- 
maining idiopathic  and  some  of  the  transmitted  morbid  states 
of  the  foetus  in  a  second  volume,  and  to  complete  the  considera- 
tion of  the  subject  in  a  third  volume. 

The  increasing  interest  in  the  subject  of  embryology  makes 
this  volume  timely,  and  in  no  single  work  is  it  possible  for  any 
one  studying  this  subject  to  obtain  the  information  presented 
by  Dr.  Ballantyne.  We  trust  the  recei)tion  accorded  the  vol- 
ume will  be  commensurate  with  the  earnest  work  that  has 
been  given  to  its  preparation. 


Manual  of  Chemistry.    A  Guide  to  Lectures  and  Laboratory 
Work  for  Beginners  in  Chemistry.    A  Text-book  especially 
adapted  for  Students  of  Pharmacy  and  Medicine.    By  W. 
Simon,  Ph.  D.,  M.  D.,  Professor  of  Chemistry  and  Toxicology 
in  the  College  of  Physicians  and  Surgeons,  Professor  of 
Chemistry  and  Analytical  Chemistry  in  the  Maryland  Col- 
lege of  Pharmacy,  Baltimore.    Third  Edition,  thoroughly 
revised.    With  Forty-four  Illustrations  and  Seven  Colored 
Plates,  representing  Fifty-six  Chemical  Reactions.  Philadel- 
phia: Lea  Brothers  &  Co.,  1891.    Pp.  479. 
It  will  probably  be  unnecessary  to  recall  the  distinctive 
traits  of  a  work  the  third  edition  of  which  can  not  fail  to  in- 
crease the  popularity  so  deservedly  enjoyed  by  the  first  two, 
but  as  there  may  be  among  our  readers  some  who,  taking  up 
chemistry  for  the  first  time,  are  unacquainted  with  the  litera- 
ture of  the  subject  and  will  be  glad  to  learn  why  this  particular 
treatise  should  be  preferred  to  so  many  others,  we  take  pleas- 
ure in  enumerating  some  of  its  many  qualities.    Although  the 
volume  is  not  large  and  the  type  is,  there  is  an  unusual  amount 
of  material  to  be  found  between  its  covers,  thanks  to  the  co- 
ordinated form  in  which  it  is  presented.    The  seven  divisions 
of  the  work  are  in  a  gradual  progression,  so  that  each  conquered 
difficulty  aids  in  the  comprehension  of  the  successive  one,  and 
a  fundamental  grasp  of  the  whole  subject  can  be  obtained. 
Physical  principles  are  treated  of  before  the  chemical  ones, 
inorganic  substances  before  the  organic,  concrete  and  easily  in- 
telligible forms  before  the  complex  grouping  of  the  hydrocar- 
bons, etc.    As  an  assistance  in  the  laboratory,  a  description  of 
many  experiments  is  given,  and  whenever  a  color  reaction 
takes  place  an  accompanying  plate  portrays  its  nature.  An- 
nexed to  each  chapter  are  many  clearly  put  questions,  which 


May  6,  1893.] 


BOOK  NOTICES.—MISGELLANY. 


509 


will  necessarily  define  the  limits  of  the  student's  acquirements. 
The  niiraerona  illustrations,  the  excellent  typographical  work, 
all  combine  to  make  the  work  pre-eminently  a  good  one  and 
worthy  of  its  continued  success. 


A  Manual  of  Physics :  being  an  Introduction  to  the  Study  of 
Physical  Science.    Designed  for  the  use  of  University  Stu- 
dents.   By  William  Peddie,  D.  Sc.,  F.  R.  S.  E.,  Assistant  to 
the  Professor  of  Natural  Philosophy  in  the  University  of 
Edinburgh.    New  'York:  G.  P.  Putnam's  Sons  (London: 
Bailli^re,  Tindall,  &  Cox),  1892.    Pp.  xii-501. 
The  author  of  this  volume  has  placed  his  work  among  the 
most  valuable  of  college  text-books  by  his  clear  and  thorough 
treatment  of  the  subject,  which  should  enable  the  student  to 
acquire  such  a  mastery  of  the  principles  as  to  materially  facili- 
tate efforts  made  in  any  of  the  branches  of  technology. 


The  International  Medical  Annual  and  Practitioner^ s  Index. 
A  Work  of  Reference  for  Medical  Practitioners.  By  Vari- 
ous Authors.  1893.  Eleventh  Year.  New  York:  E.  B. 
Treat.    Pp.  ix-626. 

In  our  issue  of  April  loth  we  gave  extended  notice  of  the 
Medical  Annual  for  1893,  and  called  attention  to  its  valuable 
features  and  many  advantages.  It  only  remains  for  ns  to  say 
that  the  International  Medical  Annual  is  the  American  edition 
of  this  work,  and  that  its  contents  and  arrangement  are  the 
same  as  those  of  its  English  predecessor.  The  very  favorable 
impression  produced  by  the  Medical  Annual  for  1898  therefore 
applies  to  the  International  Medical  Annual  for  1893  as  well. 

BOOKS,  ETC.,  RECEIVED. 

Investigations  into  the  Nature,  Causation,  and  Prevention 
of  Texas  or  Southern  Cattle  Fever,  made  under  the  Direction 
of  Dr.  D.  E.  Salmon,  Chief  of  the  Bureau  of  Animal  Industry. 
By  Theobald  Smith,  Ph.  B.,  M.  D.,  and.  F.  L.  Kilborne,  B.  Agr., 
B.  V.  S.  Published  by  Authority  of  the  Secretary  of  Agricul- 
ture. Washington  :  Government  Printing  Office,  1893.  Pp. 
x-11  to  301. 

Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory 
Work  for  Beginners  in  Chemistry.  A  Text-book  specially 
adapted  for  Students  of  Medicine  and  Pharmacy.  By  W.  Simon, 
Ph.  D.,  M.  D.,  Professor  of  Chemistry  and  Toxicology  in  the 
College  of  Physicians  and  Surgeons,  etc.,  Baltimore,  Md.  Fourth 
Edition,  thoroughly  revised.  With  Forty-four  Illustrations  and 
Seven  Colored  Plates,  representing  Fifty-six  Chemical  Reactions. 
Philadeli)hia:  Lea  Brothers  &  Co.,  1893.  Pp.  xiv-17  to  493. 
[Price,  $3.25.] 

Clinical  Lectures  on  Abdominal  Hernia,  chiefly  in  Relation 
to  Treatment,  including  the  Radical  Cure.  By  William  H.  Ben- 
nett, F.  R.  C.  S.,  Surgeon  to  St.  George's  Hospital,  etc.  With 
Twelve  Diagrams.  London  and  New  York :  Longmans,  Green, 
&  Co.,  1893.    Pp.  ix-225.    [Price,  $2.50.! 

Diseases  of  the  Eye.  A  Practical  Treatise  for  Students  of 
Ophthalmology.  By  George  A.  Berry,  M.  B.,  F.  R.  C.  S.  Edin., 
Ophthalmic  Surgeon,  Edinburgh  Royal  Infirmary,  etc.  Second 
Edition,  revised  and  enlarged.  With  Colored  Illustrations 
from  Original  Drawings.  Philadel])liia :  Lea  Brothers  &  Co., 
1893.    Pp.  xxii-TaT. 

Case  of  Suprapubic  Cystotomy  jjcrformed  to  secure  Con- 
tinuous Drainage  of  the  Bladder.  By  Cephas  L.  Bard,  M.  D., 
Ventura,  California.  [Reprinted  from  the  Southern  California 
Practitioner.  \ 

Two  Cases  illustrating  the  Therapeutic  Uses  of  the  Nitrites. 
By  Solomon  Solis-Cohon,  M.  D.  [Reprinted  from  the  Philadel- 
phia Hospital  Reports.] 


Hospitals,  their  Work  and  their  Obligations.  The  Valedic- 
tory Address  delivered  at  the  Commencement  Exercises  of  the 
Miami  Medical  College,  Cincinnati,  March  30,  1893.  By  N.  P. 
Dandridge,  M.  D.  Cincinnati :  Robert  Clarke  &  Co.,  1893.  Pp. 
5  to  23.    [Price,  25  cents.) 

A  Case  of  Akromegaly.  By  Solomon  Solis-Cohen,  M.  D. 
[Reprinted  from  the  Medical  News.] 

A  Study  of  Seventeen  Cases  of  Empyema.  By  James  P. 
Warbasse,  M.  D.,  of  Brooklyn.  [Reprinted  from  the  Annals  of 
Surgery.] 

Sixth  Annual  Report  of  St.  Margaret's  Hospital,  of  Kansas 
City,  Kansas.    For  the  Year  ending  December  31,  1892. 

Sulla  origine  dei  corpuscoli  del  sangue.  Ricerche  del  Dott. 
Vincenzo  Allara.  Milano :  C.  chiesa  e  F.  Guindani,  1893. 
Pp.  155. 

The  One  Hundred  and  Twenty-second  Annual  Report  of  the 
State  of  the  New  York  Hospital  and  Bloomingdale  Asylum. 


SI  i  s  t  c  1 1  a  tt  5 . 


The  American  GynBecological  Society  will  hold  its  eighteenth  an- 
nual meeting  in  Philadelphia,  in  the  ljuilding  of  the  College  of  Physi- 
cians, on  Tuesday,  Wednesday,  and  Thursday,  the  16th,  I7th,  and  18th 
inst.,  under  the  presidency  of  Dr.  Theophilus  Parvin,  of  Philadelphia. 
The  announcement  includes  the  following  titles : 

An  Address  of  Welcome,  by  the  president ;  Abdominal  Fistula  after 
Coeliotomy ;  its  Prevention  and  Treatment,  by  Dr.  Paul  F.  Munde,  of 
New  York ;  A  New  Operation  for  Uterine  Fibroids,  with  Report  of 
Cases,  by  Dr.  Franklin  H.  Martin,  of  Chicago ;  A  Further  Report  upon 
Supravaginal  Hysterectomy  by  the  New  Method,  by  Dr.  B.  F.  Baer,  of 
Philadelphia ;  Two  Cases  of  Supravaginal  Hysterectomy  by  Baer's 
Method,  by  Dr.  Archibald  MacLaren,  of  St.  Paul  ;  Congenital  Dilatation 
of  the  Urethra,  by  Dr.  William  H.  Baker,  of  Boston  ;  Operations  upon 
the  Uterine  Appendages  with  a  View  to  preserving  the  Functions  of 
Menstruation  and  Ovulation,  by  Dr.  William  H.  Polk,  of  New  York  ; 
The  Treatment  of  Septicaemia  with  Oxygen,  by  Dr.  Andrew  F.  Currier, 
of  New  York ;  Puerperal  Eclampsia ;  the  Experience  of  the  Boston 
Lying-m  Hospital  during  the  last  Seven  Years,  by  Dr.  Charles  M.  Green, 
of  Boston ;  A  Case  of  Inversion  of  the  Uterus,  by  Dr.  Edward  P.  Davis, 
of  Philadelphia  ;  Ovarian  Tumors  obstructing  Pregnancy,  by  Dr.  A.  F. 
A.  King,  of  Washington  ;  the  president's  address ;  Membranous  Dys- 
menorrhcea,  by  Dr.  Thaddeus  A.  Reamy,  of  Cincinnati ;  The  Operative 
Treatment  of  Uterine  Fibro-myomata,  by  Dr.  Hermann  J.  Boldt,  of  New 
York ;  The  Dangers  and  Complications  of  Uterine  Fibroids,  by  Dr.  S.  C. 
Gordon,  of  Portland,  Maine ;  Internal  Crossing  of  the  Ovum,  by  Dr.  Henry 
C.  Coe,  of  New  York ;  Hystero-epilepsy ;  Report  of  Seven  Cases  cured 
by  Cfleliotomy,  by  Dr.  H.  Marion  Sims,  of  New  York ;  The  Operative 
Treatment  of  Prolapsus  Uteri  et  Vaginas,  by  Dr.  George  M.  Edebohls, 
of  New  York ;  The  Origin  of  Dermoid  Tumors  of  the  Ovary,  by  Dr. 
Arthur  W.  Johnstone,  of  Cincinnati ;  The  Pathology  and  Treatment  of 
Injuries  of  the  Pelvic  P'loor,  by  Dr.  Alexander  J.  C.  Skene,  of  Brooklyn ; 
The  Elastic  Ligature  versus  the  Wire  Serre-nceud  in  Supravaginal  Hys- 
terectomy, by  Dr.  R.  Stansbury  Sutton,  of  Pittsburgh ;  The  Surgical 
Treatment  of  Abortion,  by  Dr.  Egbert  H.  Grandin,  of  New  York ;  Clini- 
cal Report  of  Cases  of  Pyosalpinx  treated  by  Uterine  Drainage,  with 
Subsequent  Conception,  by  Dr.  Robert  A.  Murray,  of  New  York ;  Va- 
ginal Enterocele  in  Pregnancy  and  Labor,  by  Dr.  Barton  C.  Hirst,  of 
Philadelphia ;  Calcified  Tumors  of  the  Ovary,  by  Dr.  J.  Whitridge 
Williams,  of  Baltimore ;  The  Results  of  Aseptic  Ccvliotomy,  by  Dr. 
William  H.  Wathen,  of  Louisville;  The  Uterine  Curette,  by  Dr.  Wil- 
liam U.  Parish,  of  Philadelphia ;  Retention  of  Menstrual  Fluid  in  Cases 
of  Bicornate  Uterus,  l)y  Dr.  Charles  .}.  CuUingworth,  of  London,  Eng. ; 
Some  Elements  of  Success  in  Cirliotomy,  by  Dr.  A.  Laptliorn  Smith,  of 
Montreal,  Can. ;  Practical  Methods  in  Dress  Reform,  by  Dr.  Robert  L. 
Dickinson,  of  Brooklyn  ;  lu  Menioriam — Dr.  A.  Reeves  Jackson,  by  Dr. 


510 


MISCELLANY. 


N.  Y.  MSD.  JoiTB., 


Henry  T.  Byford,  of  Chicago ;  In  Memoriam — Dr.  Charles  V.  Strong, 
by  Dr.  Egbert  H.  (Jranilin,  of  New  York. 

The  American  Electro-therapeutic  Association. — The  next  annual 
meeting  will  be  held  in  Chicago  on  Septenjl)er  12th,  1.3th,  and  14th. 

At  a  meeting  of  the  executive  council  held  on  March  2d  the  follow- 
ing resolution  was  adopted : 

"  Resolved,  That  the  secretary  be  instructed  to  prepare  a  circular  to 
send  to  fellows  of  the  association,  to  members  of  the  medical  profes- 
sion, to  electrical  experts,  and  to  manufacturers  of  electrical  appliances 
for  medical  work,  containing  titles  of  all  the  committees,  the  niembera 
serving  on  them,  with  their  addresses,  and  the  matter  prepared  for  dis- 
cussion and  investigation  by  each  committee. 

"  And  that  manufacturers  be  asked  to  communicate  with  the  mem- 
bers of  the  different  committees,  if  they  desire  to  have  their  instruments 
examined  and  tested,  stating  their  claims  and  merits. 

"  And  that  physicians,  electrical  experts,  and  manufacturers  be  asked 
to  co-operate  in  making  suggestions  and  in  relating  their  experience  and 
preference  for  instruments,  with  reasons  and  data. 

"  And  to  mail  this  circular  to  all  members  of  the  association,  to 
manufacturers,  to  medical  journals,  and  to  others  who  are  known  to  use 
electricity  extensively,  asking  for  a  speedy  reply  either  to  the  secretary 
or  to  the  members  of  the  respective  committee  whom  it  concerns." 

In  accordance  with  this  resolution  the  following  has  been  prepared : 

Committee  on  Standard  Coils  :  Dr.  W.  J.  Morton,  19  East  Twenty- 
eighth  Street,  New  York  ;  Dr.  A.  H.  Goelet,  351  West  Fifty-seventh 
Street,  New  York  ;  Dr.  W.  F.  Hutchinson,  Providence,  R.  I.  ;  Dr.  G. 
Betton  Massey,  212  South  Fifteenth  Street,  Philadelphia  ;  Mr.  A.  E. 
Keimelly,  Chief  Electrician,  Edison  Laboratory,  Orange,  N.  J. 

Points  to  he  consiilered :  I.  Portability.  II.  Practical  mechanism  of 
machines  as  adapted  to  physicians'  use.  III.  Range  and  rate  of  vibra- 
tion. IV.  Electro-motive  force  and  its  range  in  relation  to  resistances 
to  be  overcome.  V.  The  resistance  of  the  coil  producing  these  electro- 
motive forces.  VI.  The  battery  power  required  for  individual  coils. 
VII.  Shape  of  the  generated  wave  of  electro-motive  force. 

CoMMiTTEK  ON  STANDARD  METERS :  Dr.  Margaret  A.  Cleaves,  68 
Madison  Avenue,  New  York  ;  Dr.  H.  E.  Hayd,  78  Niagara  Street,  Buffa- 
lo;  Dr.  Wellington  Adams,  2741  Olive  Street,  St.  Louis;  Dr.  W.  F. 
Robinson,  214  State  Street,  Albany. 

Points  to  be  considered :  I.  A  good  meter  should  have  a  clear,  legi- 
ble scale,  fairly  uniform  over  the  range,  and  not  crowded  at  different 
points.  II.  It  should  be  capable  of  being  noted  or  observed  at  a  dis- 
tance. III.  The  resistance  should  be  low.  IV.  There  should  be  no 
tendency  to  overheat  with  the  strongest  current  employed.  V.  It  would 
be  advantageous  to  avoid  a  shunt,  if  one  milliampere  can  be  read 
throughout  the  scale.  VI.  The  instrument  should  be  capable  of  indi- 
cating in  all  positions.  VII.  Any  instrument  whose  indications  depend 
directly  upon  the  local  magnatic  force  is  objectionable,  for  the  reason 
that  its  indications  are  liable  to  be  affected  by  iron  in  the  vicinity. 
Vin.  The  suspended  system  should  require  as  little  attention  as  possi- 
ble, either  for  adjustment  or  shipment.  IX.  It  is  an  advantage  for  the 
instrument  to  indicate  with  either  direction  of  the  current.  X.  Porta- 
bility.   XI.  Liability  to  fracture. 

Committee  on  Standard  Electro-static  or  Influence  Machines  : 
Dr.  W.  J.  Morton,  19  East  Twenty-eighth  Street,  New  York;  Dr.  J.  H. 
Kellogg,  Battle  Creek,  Mich.;  Dr.  G.  Betton  Massey,  212  South  Fif- 
teenth  Street,  Philadelphia ;  Dr.  Margaret  A.  Cleaves,  68  Madison  Ave- 
nue, New  York. 

Points  to  be  considered :  I.  Electro-static  machine  best  adapted  to 
medical  work,  to  be  determined  by  its  "  output."  Its  output  to  be  de- 
termined as  follows:  (a)  At,  respectively,  100  and  at  150  revolutions 
per  minute,  (b)  With  two  Leyden  jars,  each  of  whose  outer  metallic 
surfaces  has  the  area  of  4J  X  1 A  inches  =  5-]%  square  inches,  (c)  With 
discharging-rods  having  ball  terminals  one  inch  in  diameter  and  ar- 
ranged respectively  six  inches  and  ten  inches  apart,  (rf)  Give  the  num- 
ber of  sparks  per  minute  which  will  pass  between  the  discharging- 
rods.  II.  Give  the  greatest  inaximum  length  of  spark  with  machine 
arranged  as  in  Section  I,  except  as  to  distance  apart  of  the  discharging- 
rods.  III.  (Jive  the  maximum  length  of  the  brush  discharge  between 
the  diecharging-rods  with  machine  airauged  as  in  Section  I,  except  that 


no  Leyden  jars  are  used.  FV.  Give  the  maximum  length  of  spark  that 
may  be  obtained  by  a  brass-ball  electrode,  two  inches  in  diameter,  from 
a  pei-son's  back,  seated  in  the  usual  mamicr  upon  an  insulated  platform 
— the  platform  connected  to  one  prime  conductor  of  the  machine,  the 
other  being  connected  to  the  ground,  (a)  With  above  Leyden  jars.  (6) 
Without  Leyden  jars.  V.  Kind  of  electro-static  machine  best  adapted 
to  medical  wor  k,  whether  a  Holtz,  Wirashui'st,  Toepler,  Voss,  Carr6, 
Lewandowski,  Toepler-Holtz,  Wimshurst-IIoltz,  or  machine  not  here 
named,  provided  the  type  as  constructed  successfully  fulfills  require- 
ments outlined  in  Section  1.  VI.  Does  the  machine  preferred  easily  re- 
ver-se  its  charge  ?  Does  it  maintain  its  charge  successfully VII. 
Facility  and  means  of  charging  machine  under  all  atmo.spheric  condi- 
tions. VIII.  Can  a  good  meter  to  measure  the  output  of  the  raachiue 
be  suggested  ?  IX.  Mechanical  construction  of  machine,  (a)  Ease  of 
actuating  machine  by  motive  power-,  (b)  Dur'ability  of  the  mechanism 
causing  the  revolution  of  its  plates,  (c)  Dirrability  of  its  construction. 
(d)  Is  a  glass  case  necessary  ?  X.  The  best  means  for  drying  the  air 
within  an  inclosing  glass  case.  XI.  The  best  means  for  absorbing  the 
ozone  and  nitrogen  compounds  for-med  within  a  glass  case.  XII.  Is  it  not 
advisable  to  decide  in  a  general  way  that  no  machine,  the  diameter  of 
whose  revolving  discs  is  less  than  twenty-six  inches,  and  the  number  of 
whose  discs  is  less  than  six,  should  be  recommended  by  this  committee 
for  medical  work  ? 

Committee  on  Constant-current  Generators  and  Controllers  : 
Dr.  W.  J.  Herdman,  48  East  Huron  Street,  Ann  Arbor,  Mich.,  Rheo- 
stats and  Dynamo  Current-controllers ;  Dr.  Robert  Newman,  68  West 
Thirty-sixth  Street,  New  York,  Primary  Stationary  Batteries ;  Dr. 
Frederick  Peterson,  201  West  Fifty-fourth  Street,  New  York,  Secondare 
Batteries  and  Primary  Portable  Batteries. 

Points  to  be  considered:  I.  Primary  batteries.  Express  preference 
and  reasons  therefor  for  a  battery,  voltage,  modification,  and  control  of 
current-strength,  current-generator,  etc.  II.  As  to  cells  and  secondary 
batteries.  What  are  the  defects  and  inconveniences  ?  What  the  ad- 
vantages over  other  forms  ?  What  the  ampere  hours,  what  the  con- 
stancy, voltage,  and  action  ?  III.  As  to  dynamo  currents.  What  the 
nature  of  the  current,  what  its  voltage,  how  is  it  modified  by  the  form 
of  controller  under  consideration  ?  IV.  Report  new  forms  of  batteries 
and  improvements,  with  claims  as  to  superiority  over  those  now  in  use. 
V.  Rheostats.  Tests,  various  forms  and  devices  to  modify  and  con- 
trol currents ;  difference  in  effect  produced  by  each,  mechanically, 
chemically,  or  physiologically. 

Committee  on  Standard  Electrodes  :  Dr.  A.  Lapthom  Smith,  248 
Bishop  Street,  Montreal,  Canada;  Dr.  R.  J.  Nunn,  119  York  Street, 
Savannah,  Ga. ;  Dr.  Charles  R.  Dickson,  263  Victoria  Street,  Toronto, 
Ontario. 

Points  to  be  considered:  I.  Inactive  electrodes.  1.  What  is  the 
best  material  in  general  for  the  ground-work  of  the  electrode  and  what 
in  special  cases  ?  2.  How  may  it  best  be  connected  with  its  rheophore? 
3.  What  is  the  best  material  to  cover  its  conducting  surface  ?  4.  When 
neeessai'y,  how  may  it  liest  be  insulated  ?  5.  In  what  way  may  it  be 
kept  warm  and  moist  when  not  in  use,  should  this  be  necessary  ?  6. 
What  should  be  accepted  as  standard  sizes  and  shapes,  and  how  best 
designated  ?  7.  What  other  points  require  to  be  considered  ?  II.  Ac- 
tive electrodes  1.  What  is  the  best  material  in  general  and  in  special 
for  the  ground-work  of  the  electrode  ?  (a)  When  used  at  the  positive 
pole  ?  (6)  When  used  at  the  negative  pole  ?  2.  How  may  it  best  be 
connected  with  its  rheophore  ?  3.  What  is  the  best  material  to  cover 
its  conducting  surface  when  necessary,  in  general  and  special  ?  4. 
How  may  it  be  insulated  when  necessary  ?  5.  What  is  the  best  form 
of  construction  where  flexibility  is  required  for  tortuous  canals  ?  6. 
What  shall  be  considered  the  standard  shapes  and  sizes  ;  what  scale 
shall  be  adhered  to  in  considering  the  latter ;  how  may  their  surface 
area  be  estimated  when  they  are  of  irregular  shape  ?  7.  When  desig- 
nated by  numerals  as  to  size  and  surface,  how  may  such  best  be  ex- 
pressed when  stamped  or  otherwise  marked  on  them  ?  8.  How  may 
simplicity  of  construction  be  best  obtained  and  cost  of  manufacture 
reduced  without  impairing  efficiency  ?  9.  How  may  facility  of  cleans- 
ing and  rendering  aseptic  best  be  achieved?  10.  What  other  points 
to  be  considered?  III.  Active  and  inactive  electrodes.  1.  Are  the 
terms  "  active  "  and  "  inactive  "  the  best  standard  terms  we  can  eni- 


May  6,  1893.J 


MISCELLANY. 


511 


ploy  ?  2.  In  the  case  of  both  active  and  inactive  electrodes,  should 
not  the  threads  of  all  screws  used  in  construction  as  a  means  of  at- 
tachment, also  all  plugs  and  sockets,  etc.,  he  of  a  standard  gauge,  that 
electrodes  might  be  used  with  attachments  of  all  makes,  etc.,  and  to 
facilitate  repair  ? 

Replies  may  be  sent  to  Margaret  A.  (.'leaves,  M.  D.,  secretary,  *i8 
Madison  Avenue,  New  York. 

Organic  Extracts  and  their  Therapeutic  Effects. — In  an  article  with 
this  title  the  Indian  Medico-ckirurgical  Review,  of  Bombay,  quotes  from 
an  article  by  Dr.  William  A.  Hammond  recently  published  in  this  jour, 
nal,  and  adds : 

"  We  have  (juoted  the  ipsissima  vn-ba  of  the  author  in  order  to  en- 
able our  readers  the  better  to  understand  the  system  on  which  the  treat- 
ment is  based.  Acting  upon  these  bases.  Dr.  Hammond  experimented 
at  first  with  the  fresh  juice  of  the  organs ;  but,  as  its  use  was  not  unat- 
tended with  danger,  he  modified  his  experiments  and  used  extracts  made 
by  a  somewhat  elaborate  process.  He  describes  the  process  of  making 
cerebrine  from  the  brain  of  the  ox,  and  the  same  process  is  applicable  to 
making  extracts  from  the  organs  as  the  heart,  liver,  kidneys,  testicles, 
etc.  Five  minims  of  the  extract  diluted  with  an  equal  quantity  of  dis- 
tilled water  constitutes  a  hypodermic  dose.  The  local  result  of  the  hy- 
podermic injection  is  a  slight  smarting  at  the  time  of  injection,  followed 
by  itching  and  erythema.  The  physiological  effects  produced  by  a  single 
injection  of  cerebrine  are  acceleration  of  the  pulse  with  feeling  of  full- 
ness and  distention  in  the  head,  exhilaration  of  spirits,  increased  urinary 
excretion,  augTuentation  of  the  expulsive  force  of  the  bladder  and  peri- 
staltic action  of  the  intestines,  increase  in  muscular  strength  and  endur- 
ance, increased  power  of  vision  in  elderly  people,  and  increased  appetite 
and  digestive  power.  Injections  of  cerebrine  have  been  used  by  the 
author  in  neurasthenia,  insomnia,  migraine,  hysteria,  epilepsy,  etc.,  and 
he  has  also  obtained  excellent  results  from  treating  appropriate  cases 
by  the  extract  of  the  testicles  of  the  bull  and  also  that  of  the  pancreas 
of  the  ox. 

"  Dr.  Hammond  controverts  the  assertion  of  some  that  there  is  no 
difference  between  the  action  of  medicines  taken  into  the  stomach  and 
injected  into  the  blood  by  hypodermic  injections  and  says  that  all  those 
substances  that  are  acted  upon  (and  they  are  almost  all)  by  the  gastric 
juice  and  then  absorbed  into  the  system,  become  altered  and  hence  their 
effects  on  the  system  could  not  be  the  same.  He  finds,  however,  that 
if  some  of  the  organic  extracts  are  put  upon  the  tongue  in  double  the  dose 
used  for  injection  and  allowed  to  remain  in  the  mouth  without  being 
swallowed,  they  are  absorbed  and  exert  a  slower  but  still  decided  effect. 

"  Dr.  Hammond  believes  that  the  theory  on  which  he  has  based  his 
treatment  is  physiological  and  plausible,  and  he  thinks  it  probable  that 
the  beneficial  effects  observed  may  be  due  to  a  ferment  resulting  from 
a  mixture  of  boric  acid,  alcohol,  and  glycerin,  which  may  have  the  power 
of  restoring  to  the  weakened  brain  or  other  viscus  the  lost  or  impaired 
power  of  assimilation. 

"  This  leads  us  to  the  consideration  of  the  treatment  of  myxcedema, 
which  fits  in  to  a  certain  extent  with  Dr.  Hammond's  theory,  as  well  as 
that  of  diabetes  by  pancreatic  juice. 

"  We  join  issue  with  our  contemporary  the  Lancet  when  it  says  that 
the  use  of  cerebrine,  nephrine,  etc.,  suggests  as  if  the  limits  of  rational 
medicine  were  being  overstepped,  and  that  there  were  very  few  diseases 
where  the  pathological  entity  was  an  absence  of  a  particular  organ  as 
in  myxnedema.  But  if  the  treatment  of  myxwdema  and  diabetes  is 
analyzed  in  the  light  of  the  theory  propounded  by  Dr.  Hammond,  it 
seems  to  be  nothing  more  than  an  application  of  the  physiological  prin- 
ciples laid  down  by  him.  Although  the  organs  may  not  be  totally  ab- 
sent, as  indeed  they  are  always  not,  still  they  are  physiologically  so,  as 
their  normal  secretions  become  altered  or  defective  on  account  of  dis- 
ease. Hence  the  use  of  these  extracts  supplements  the  deficiency  to  a 
certain  extent  of  their  products  and  thus  allows  of  normal  physiological 
processes  being  carried  on  in  the  system  just  as  if  tiie  organs  were  sound 
and  not  diseased.  In  fact.  Dr.  Hector  Mackenzie  gives  some  such  ex- 
planation of  the  action  of  pancreatic  juice  in  diabetes.  This,  then,  must 
be  the  rational  explanation  of  the  plienomenal  success  of  the  thyreoid 
treatment,  and  as  such  it  marks  a  distinct  advance  in  rational  thera- 
peutics.   There  are  yet  several  points  to  be  cleared  up  as  to  why  the 


internal  administration  of  the  fried  or  raw  thyreoid  or  the  dry  extract 
should  give  better  results  than  grafting  or  hypodermic  injection,  and  to 
Dr.  Hammond  belongs  the  credit  of  fornmlating  a  rational  working  hy- 
pothesis for  the  new  treatment." 

Mineral  Waters. — An  article  entitled  Mineral  Waters,  Crude  and 
Refined,  by  Dr.  H.  D.  Didama,  of  Syracuse,  N.  Y.,  published  in  the 
Journal  of  the  American  Medical  Association  for  April  22d,  concludes 
as  follows : 

"  Vaimted  springs  which,  like  the  Poland  and  others,  contain  hardly 
an  appreciable  amount  of  any  mineral  (the  Poland  having  a  total  of 
about  three  grains  to  the  gallon,  two  thirds  of  this  being  lime  and  silica), 
may  still  be  beneficial  if  used  in  the  enormously  large  quantities  di- 
rected and  urged  by  their  proprietors. 

"  Their  location  may  be  where  the  air  is  invigorating  and  germless  ; 
where  the  weary  invalid  is  liberated  from  the  care  of  business,  relieved 
to  some  extent  of  the  deceitfulness — certainly  of  the  plethora — of 
riches,  and  flushed  out  every  few  hours  with  an  amount  of  fluid  for 
which  he  never  dreamed  he  had  a  capacity. 

"  Divesting  himself  of  prejudice,  he  would  probably  find  that  an 
equal  quantity  of  pure  water  at  home  would  (so  far  as  the  water  is  con- 
cerned) be  equally  beneficial.  And  (it  is  well  to  consider)  the  pecuniary 
condition  of  the  average  patient  will  not  allow  the  luxury  of  a  distant 
journey  and  a  board  bill  of  five  dollars  a  day. 

"  The  notion  that  the  natural  heat  of  the  earth  imparts  to  water  any 
virtue  which  could  not  be  derived  from  solar  or  stove  heat  has  no  sci- 
entific or  experimental  foundation.  Natrium  iodidum  is  known  to  be 
a  potent  weapon  in  the  armamentarium  of  the  Hot  Springs  medicine 
man. 

"  The  writer  has  never  sent  a  patient  to  the  National  Calidarium, 
but  he  has  treated  with  satisfaction  several  who  have  returned  unbene- 
fited  from  that  popular  but  somewhat  compromising  resort." 

The  late  Dr.  Charles  D.  Scudder.— At  the  last  annual  meeting  of  the 
medical  board  of  the  New  York  Lying-in  Asylum  the  following  resolu- 
tion was  adopted : 

That,  in  the  death  of  Dr.  Charles  D.  Scudder,  the  board  has  lost 
one  of  its  most  earnest,  enthusiastic,  and  valued  members.  Singularly 
qualified  for  the  great  task  to  which  his  rare  gifts  were  consecrated — 
the  amelioration  of  the  sufferings  of  his  fellow-beings — he  devoted  him- 
self to  it  with  an  unselfishness  of  purpose  which  won  for  him  the  deep- 
est admiration  of  his  associates.  He  was  a  profound  student,  an  ac- 
complished physician,  a  sincere  friend.    His  loss  is  irreparable. 

Resolved,  That  a  copy  of  this  resolution  be  sent  to  the  family  of  Dr. 
Scudder,  to  the  medical  journals  of  this  city,  and  to  the  board  of  mana- 
gers of  the  Lying-in  Asylum,  and  that  it  be  inscribed  on  the  records  of 
the  medical  board. 

[Signed]  L.  L.  Seaman,  M.  D.,  Chairman. 

The  American  Paediatric  Society  will  hold  its  fifth  annual  meeting 
at  Cranston's  Hotel,  West  Point,  N.  Y.,  on  May  24th,  25th,  and  26th,  un- 
der the  presidency  of  Dr.  A.  D.  Blackader,  of  Montreal,  besides  whose 
annual  address  the  preliminary  programme  announces  the  following : 
This  Year's  Failures  in  Diphtheria,  by  Dr.  M.  P.  Hatfield,  of  Chi- 
cago ;  The  Value  of  Peroxide  of  Hydrogen  in  Diphtheria,  by  Dr.  J. 
Lewis  Smith,  of  New  York ;  Brief  Notes  on  the  Use  of  Antipyretic 
Drugs  in  the  Febrile  Affections  of  Children,  by  Dr.  J.  P.  Crozier  Grif- 
fith, of  Philadelphia ;  A  Case  of  Laryngeal  Diphtheria,  by  Dr.  W.  D. 
Booker,  of  Baltimore  ;  Concerning  the  Care  of  the  Throat  and  Ears  of 
Children,  by  Dr.  W.  P.  Northrup,  of  New  York ;  Intestinal  Fever,  by 
Dr.  A.  Jacobi,  of  New  York ;  Report  on  a  Revisionary  Nomenclature  of 
Gastro-intestinal  Diseases,  by  Dr.  T.  M.  Rotch,  of  Boston  ;  Proctitis  in 
Early  Infancy,  by  Dr.  Louis  Starr,  of  Philadelphia ;  Studies  of  Milk 
from  Large  Western  Dairies,  by  Dr.  J.  M.  Keating,  of  Colorado 
Springs;  Pulmonary  Tuberculosis,  by  Dr.  William  Osier,  of  Baltimore; 
Report  on  the  Nomenclature  of  Diseases  of  the  Mouth,  by  Dr.  T.  M. 
Rotch,  of  Boston ;  A  Case  of  False  Meningocele,  by  Dr.  Irving  M. 
Snow,  of  Buffalo ;  Discussion  on  the  Treatment  of  Pertussis  (Local,  by 
Dr.  J.  P.  Crozier  Griffith ;  Constitutional,  by  Dr.  F.  Forchheimer ;  Cli- 
matic, by  Dr.  William  Osier;  (.'omplications,  by  Dr.  Henry  D.  Cha- 
pin);  Discussion  on  the  Treatment  of  Constipation  iu  Early  Infancy 


512 


MISCELLANY. 


(N.  Y.  Med.  Joie. 


(Dietetic,  by  Dr.  L.  Emmett  Holt ;  Medicinal,  by  Dr.  C.  P.  Putnam ; 
Local,  by  Dr.  Leroy  M.  Yale) ;  The  v^itiology  of  Incontinence  of  Urine, 
by  Dr.  B.  K.  Racliford,  of  Newport,  Ky. ;  Meningitis  complicating 
Pneumonia,  by  Dr.  L.  Emmett  Holt,  of  New  York ;  a  paper  (subject  to 
be  announced),  by  Dr.  Henry  D.  Chapin,  of  New  York ;  The  Treatment 
of  Certain  Forms  of  Autemia  in  Children,  by  Dr.  F.  Forchheimer,  of 
Cincinnati;  Some  Points  in  Connection  with  the  yKtiology  of  Rhachiti.«, 
by  Dr.  J.  Lewis  Smith,  of  New  York ;  The  Treatment  of  Rhachitis  with 
the  Lactophosphate  of  Lime,  by  Dr.  J.  Henry  Fruitnight,  of  New 
York ;  A  Report  of  Five  Cases  of  Tetany,  by  Dr.  J.  P.  Crozier  Griffith, 
of  Philadelphia ;  Acute  Scleroderma,  by  Dr.  William  Osier  and  Dr. 
Barker,  of  Baltimore ;  A  Case  of  Erysipelas  of  the  Scalp  and  Face  in 
an  Infant,  aged  Six  Weeks,  by  Dr.  Samuel  S.  Adams,  of  Washington; 
Description  of  a  New  Incubator,  by  Dr.  T.  M.  Rotch,  of  Boston ;  A 
Case,  by  Dr.  W.  P.  Northrup,  of  New  York ;  A  Gastric  Neurosis  in 
Childhood,  by  Dr.  Irving  M.  Snow,  of  Buffalo. 

Newspaper  Reports  as  to  Deaths  from  Ether. — With  some  reserva- 
tion as  to  the  cause  of  death  conjectured  by  the  Medical  News,  we  cor- 
dially indorse  the  following,  that  appeared  in  that  journal  for  April 
29th :  "  Few  misfortunes  arc  more  distressing  to  a  surgeon  than  the 
death  of  a  patient  on  the  operating-table.  Notwithstanding  every  pre- 
caution, this  will  sometimes  happen,  from  circumstances  not  to  be  fore- 
seen or  controlled.  It  has  taken  place  in  the  practice  of  some  of  the 
most  eminent,  skillful,  and  careful  men  that  ever  held  a  knife.  When 
the  patient  is  well  known  in  the  community  such  a  mishap  becomes 
widely  reported,  and  is  likely  to  be  damaging  to  the  reputation  of  the 
surgeon,  even  although  his  fellow-practitioners  are  fully  aware,  and 
freely  testify,  that  he  can  not  in  any  way  be  held  responsible  for  the 
unfortunate  result. 

"  In  the  case  of  the  late  Colonel  Shcpard  the  attendants  were  men  of 
deservedly  high  reputation,  and  there  is  absolutely  no  blame  whatever 
to  be  attached  to  them.  From  the  reports  published  in  the  newspapers, 
it  would  seem  that  the  cause  assigned  for  the  death  was  oedema  of  the 
lungs.  In  the  absence  of  evidence  of  this  from  an  autopsy,  we  should 
be  inclined  rather  to  suspect  some  lesion  of  the  cerebral  respiratory 
centers,  either  occurring  primarily  as  the  effect  of  ether  inhalation,  or 
previously  existing,  and  only  aggravated  thereby.  But  whatever  may 
have  been  the  pathologic  condition,  we  see  no  evidence  of  want  of  care 
or  of  skill  in  the  management  of  the  case. 

"  Such,  we  think,  will  be  the  unanimous  verdict  of  the  profe.ssion. 
It  is  therefore  with  indignation  that  we  find  the  following  paragraph 
going  the  rounds  of  the  newspapers  : 

" '  Dwight  A.  Lawrence,  the  New  York  politician,  has  recently  un- 
dergone an  operation  similar  to  the  one  the  doctors  tried  to  perform  on 
Colonel  Shepard.  "  I  was  quite  nervous  about  the  operation,"  he  said. 
"  Colonel  Shepard  was  in  my  mind,  as  his  case  occurred  a  week  before 
the  time  set  for  mine.  However,  I  resolved  to  stick  it  out.  I  went 
through  the  ordeal  all  right,  and  now  feel  like  a  new  man.  I  am  satis- 
fied that  if  Colonel  Shepard  had  had  more  careful  treatment  he  would 
be  alive  to-day." ' 

"  To  the  lay  mind  this  oracular  statement  of  a  layman  may  have 
weight,  to  the  prejudice  of  those  who  had  charge  of  Colonel  Shepard's  case. 
Very  possibly  no  such  remark  was  ever  made ;  it  may  have  emanated 
from  the  fertile  brain  of  a  reporter.  Yet  there  it  is,  published ;  and 
we  feel  bound  to  protest  against  such  a  gratuitous  reflection  upon  the 
professional  conduct  of  our  brethren.  We  do  not  know  whether  under 
the  law  of  libel  they  would  have  any  chance  of  redress  by  legal  pro- 
cess. The  damage  sustained  by  them  would  be  difficult  to  estimate, 
and  no  doubt  there  would  be  plenty  of  technicalities  under  cover  of 
which  the  slanderer  would  escape  responsibility.  But  we  think  the 
medical  press  and  profession  should  extend  their  moral  support  and 
their  sympathy  to  Dr.  McBurney  and  his  associates." 

The  Shelhy  County,  Indiana,  Medical  Society. — The  programme  for 
the  next  meeting,  on  Monday,  the  8th  inst.,  includes  a  paper  on  Ty- 
phoid P'ever,  by  Dr.  H.  M.  Connelly,  and  one  on  Cholera  Infantum,  by 
Dr.  Joseph  Bowlby. 

The  Kew  York  Academy  of  Medicine. — The  special  order  for  the 
meeting  of  Thursday  evening,  the  4th  inst.,  held  under  the  auspices  of. 


the  Section  in  Obstetrics  and  Gyna3cology,  was  a  discussion  on  Symphy- 
seotomy, to  be  opened  by  Dr.  Henry  J.  Garrigues  and  continued  by  Dr. 
Egbert  H.  Grandin,  Dr.  C.  A.  von  Ramdohr,  Dr.  William  M.  Polk,  Dr. 
Charles  Jewett,  Dr.  Henry  C.  Coe,  Dr.  William  T.  Lusk,  Dr.  J.  Clifton 
Edgar,  and  others. 

At  the  next  meeting  of  the  Section  in  Genito-urinary  Surgery,  on 
Tuesday  evening,  the  9tli  inst..  Dr.  E.  Fuller  will  read  a  paper  on 
Gonecystitis ;  Dr.  R.  (luitoras,  a  paper  on  Gonorrlujejil  Rheumatism ; 
and  Dr.  II.  Klotz,  one  on  The  Occurrence  of  Syphilitic  Tertiary  Lesions 
the  Result  of  Direct  Local  Infection,  with  Remarks  on  Syphilis  as  an 
Infectious  Disease. 

At  the  next  meeting  of  the  Section  in  Ui>hthalmology  and  Otology,  on 
Monday  evening,  the  15th  inst.,  there  will  be  a  discussion  on  the  sub- 
ject of  Dr.  Noyes's  paper.  The  Mode  of  Management  of  Partial  Cataract; 
Dr.  W.  B.  Marple  will  read  a  paper  on  The  Pathology  of  Hypopyon 
Keratitis;  and  Dr.  S.  A.  Payne  will  read  one  on  Insufficiency  of  Ocular 
Muscles  due  to  Errors  of  Refraction. 


To  Contributors  and  Correspondents. — The  attention  of  all  wluo  purpose 
favoring  us  with  communications  is  respect/idly  called  to  the  follow- 
ing: 

Authors  of  articles  intended  for  publication  under  the  hecul  of  "  orif/inal 
contributions  "  are  respectfully  informed  that,  in  avcepting  such  arti- 
cles, we  ahoays  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  se7it  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  u  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  specif  ed  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinclli/ 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters^  haiuls.  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  i/ie  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  Ao  at- 
tention will  be  paid  to  anonymous  communications.  Hereafter,  cor- 
respondents asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor- 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  Jor  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  viill  confer  a  favor  by  keeping  us  in- 
formed o  f  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. 

Neivspapers  and  other  publications  containing  matter  which  the  pei-son 
.iendi?u/  them  desires  to  bring  to  our  notice  should  be  marked.  Mem- 
bers of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and., 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  sub.stance  o  f  such  communicatiojis. 

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. 

Contributors  who  wish  to  order  REPRINTS  of  their  articles  should  do 
so  on  a  blank  prepared  for  that  purpose,  which  will  be  sent  to  tJierii 
by  the  j/ubhshcrs  on  receipt  of  a  request  to  that  effect.  The  order 
thovM  be  sent  to  the  publishers,  and  not  to  ilie  editor. 


THE  J^EW  YORK  MEDICAL  JOURNAL,  May  13,  1893. 


(Driginal  Commnnicntions. 


ON  THE  SELF-REGULATION 
OF  THE  BEAT  OF  THE  HEART.* 

By  S.  J.  MELTZER,  M.  D. 

In  a  heart  beating  seventy-five  times  in  a  minute  each 
cardiac  cycle  lasts  eight  tenths  of  a  second.  Of  this  time, 
three  tenths  of  a  second  is  taken  up  by  the  systole  and  the 
remaining  five  tenths  is  left  to  the  diastole.  Within  the 
systole  we  may  distinguish  the  period  in  which  the  ventri- 
cle contracts  ad  maximum,  and  the  maintenance  of  this 
maximal  contraction  for  some  time  before  relaxation  takes 
place.  The  time  for  this  latter  period  may  be  estimated 
one  tenth  of  a  second.  Upon  the  punctiVal  keeping  of  these 
minute  fractions  of  time  depends  the  stability  of  the  car- 
diac beats.  By  what  a  wonderful  mechanism  the  heart 
must  be  governed ! 

What  is  this  mechanism  ?  What  causes  the  muscle  of 
the  heart  to  contract,  and  what  makes  this  contraction  oc- 
cur rhythmically  ?  A  skeletal  muscle  can  be  made  to  con- 
tract either  by  a  stimulus  artificially  applied  to  the  muscle 
or  its  motoric  nerve,  or  by  an  impulse  issued  from  the  cen- 
tral nervous  system.  The  plain  muscle  tissue  can  besides 
be  brought  to  contraction  by  the  contents  of  the  cavities 
which  they  surround.  The  contractions  of  the  muscle  of 
the  heart  can  not  have  their  origin  in  impulses  emanating 
from  the  central  nervous  system,  since  the  heart  continues 
to  beat  for  some  time  after  its  isolation  and  removal  from 
the  body.  But  we  may  well  think  of  the  contents  of  the 
heart — the  blood — as  a  sufficient  cause  for  its  contraction. 
The  blood  may  stimulate  the  heart  mechanically  as  well  as 
chemically.  We  should  then  not  only  understand  the  cause 
of  the  contraction,  but  we  should  even  have  a  sufficient 
explanation  for  the  rhythm  of  the  beats  of  the  heart.  The 
accumulation  of  blood  in  the  heart,  we  may  think,  provokes 
its  contraction  ;  but  the  contraction,  on  the  other  hand,  re- 
moves the  blood,  which  means  the  removal  of  the  cause  for  the 
contraction  ;  therefore  relaxation  of  the  heart  follows,  and  it 
remains  relaxed  until  a  sufficient  quantity  of  blood  is  again 
accumulated  in  the  cavity  of  the  heart.  The  simplicity  of 
this  theory  has  indeed  captivated  the  minds  of  nearly  all 
the  physiologists  for  a  long  period — a  period  beginning 
with  Albert  von  Haller  and  ending  with  Johannes  Miiller. 
But  the  latter  has  done  away  with  this  theory  by  the  short 
remark  that  a  perfectly  bloodless  heart  continues  to  beat ; 
the  blood,  therefore,  can  not  be  the  cause  of  the  beat.  In 
the  half  century  which  passed  since  only  very  few  could  be 
found  who  seriously  entertained  the  opinion  that  the  blood 
is  the  stimulating  cause  for  the  contraction  of  the  heart. 
The  frog  manometer,  now  nearly  a  (juarter  of  a  centurj'  in 
use,  destroyed  the  last  chances  that  were  left  for  the  theory. 
Through  a  considerable  number  of  investigations  accom- 
plished by  Ludwig,  Kronecker,  and  their  pupils  with  this 
instrument,  it  became  evident  that  the  blood  and  its  gases 

*  Read  before  the  New  York  Neurolopcal  Society,  May  2,  1 893. 


were  important  to  the  movements  of  the  heart  only  as  a; 
condition,  but  not  as  a  cause.  The  blood  is  the  carrier  of 
the  nutrition  for  all  the  organs  of  the  body,  and  as  such  it 
is  indispensable  for  the  maintenance  of  the  movements  of 
the  heart,  but  it  is  not  the  cause  of  those  movements. 

Now,  if  it  is  not  the  blood,  what  else  is  the  cause  of  the 
rhythmic  movements  of  the  heart  ?    At  present  it  seems  to- 
be  the  unanimous  opinion  that  the  cardiac  beat  is  of  auto- 
matic origin.    This  theory  is  as  old  as  the  beautiful  word 
automatism  itself.    We  find  this  theory  put  forward  as  far 
back  as  in  the  first  edition  of  the  classic  Handbook  of 
Physiology  by  Johannes  Miiller.    I  mention  this  fact  es- 
pecially as  in  those  days  no  nerve  cells  or  ganglia  had 
yet  been  discovered  in  the  heart.    Now  we  have  at  our  dis- 
posal Remak's,  Bidder's,  and  others'  ganglia  or  single  nerve 
cells.    With  the  discoveries  of  the  several  ganglia  the  be- 
fore homeless  automatism  seemed  to  have  obtained  a  suit- 
able shelter.    The  nerve  cells  of  the  heart,  so  it  was  as^ 
suraed,  were  similar  to  the  nerve  cells  of  the  general  nervous 
system.    And  there  seems  to  be  no  doubt  as  to  the  right  of 
the  latter  cells  to  exercise  automatic  powers.    But  at  pres- 
ent we  meet  serious  doubts  as  to  the  localization  of  the 
automatism  of  the  heart  in  the  nerve  cells.    The  tip  of  the- 
frog's  ventricle — Bowditch's  Herzspitze — and  even  a  still! 
greater  part  of  the  ventricle  of  the  tortoise,  are  said  to  be 
free  from  nerve  cells,  and  still  those  parts  continue  to  beat 
regularly  even  after  severing  the  connection  with  the  rest 
of  the  ventricle.    And  recent  investigations  by  Romberg 
and  His  have  brought  to  light  the  interesting  fact  that  at 
an  early  period  of  embryonic  life  the  heart  accomplishes  its- 
movements  without  the  aid  of  the  nervous  elements.  There^ 
fore  many  investigators  transfer  the  government  of  the 
heart  to  its  muscular  tissue.    But,  after  all,  the  dispute  re- 
fers only  to  the  site  of  the  automatic  government,  while 
nobody  seems  to  doubt  its  presence  and  its  right  to  rule. 
Permit  me  to  ask,  What  does  it  signify  when  we  say  the- 
heart  beats  automatically  ?    We  want  to  know  what  is  the- 
stimulus  which  makes  the  muscle  of  the  heart  contract 
and  why  this  contraction  occurs  rhytlimically.    To  this  we 
get  the  answer,  The  nerve  cells  or  the  muscle  fibers  of  the 
heart  possess  the  capacity  to  generate  stimuli  and  to  dis- 
charge the  effects  of  them  rhythmically.    But  this  means, 
in  other  words,  the  heart  beats  rhythmically  because  it  has 
the  capacity  to  do  so.    Would  it  not  be  more  to  the  point 
if  we  plainly  confessed  that  we  did  not  know  the  real  cause 
of  the  beat  of  the  heart  ?    However,  in  the  discussions  upon 
the  automatic  movements  of  the  heart  we  find  certain  state- 
ments which  may  produce  the  impression  that  after  all  wt- 
have  succeeded  in  penetrating  the  mystery  of  the  mechan- 
ism, at  least  as  far  as  the  rhythmicity  of  the  beat  is  con- 
cerned.   Let  us  now  examine  those  statements. 

Johannes  Miiller  already  attempted  to  explain  the  rhyth- 
micity by  supposing  that  two  antagonistic  forces  are  en- 
gaged in  regulating  the  heart's  beat— viz.,  the  general  nerve 
impulse  striving  to  reach  the  muscle,  and  a  certain  resist- 
ance coming  from  the  ganglionic  parts  of  the  sympathetic- 
nerve.  Such  an  antagonistic  strife,  Miiller  thinks,  is  capa- 
ble of  converting  a  constant  stimulus  into  a  rhythmic  effects 


514 


MELTZER:  SELF-REOULATION  OF  TEE  BEAT  OF  THE  HEART.      [N.  Y.  Mkd.  Jodb., 


As  an  illustrative  instance  he  refers  to  the  rhythmic  dis- 
charge of  electric  sparks  from  a  machine  with  a  constant 
electric  source.  The  struggle  between  the  electric  current 
and  the  resistance  of  the  air  is,  according  to  M tiller,  the 
cause  of  the  rhythmic  discharge.  Miiller  confines  his  theory 
to  the  rhythm  of  the  heart  only ;  for  certain  reasons  he  ab- 
stains from  applying  it  to  the  respiratory  rhythm.  Twenty 
years  later  I.  Rosenthal  devised  another  ingenious  con- 
struction to  exemplify  the  rhythmic  working  of  two  oppos- 
ing forces.  Into  a  vertical  tube,  the  bottom  of  which  is 
kept  in  place  by  a  spring,  water  flows  continually.  When 
the  water  within  the  tube  reaches  a  certain  height  the 
spring  gets  overpowered  and  a  certain  quantity  of  water 
leaves  the  tube  at  once ;  then  the  spring  closes  up  until  the 
water  is  again  accumulated  to  the  effectual  height.  In  op- 
j)Osition  to  Miiller,  Rosenthal  applies  the  theory  of  the 
opposing  forces  to  the  rhythm  of  the  respiration.  A  few 
years  later  v.  Bezold,  following  Rosenthal's  steps,  applied 
the  said  theory  anew  to  the  rhythm  of  the  heart,  only  with 
a  new  illustrating  example — the  steam  which  is  under  con- 
stant pressure  in  the  engine  leaves  it  through  the  valve 
rhythmically.  L.  Hermann  refers  to  another  well-known 
instance  :  when  gas  is  brought  in  a  continual  stream  under 
water  it  escapes  in  bubbles.  A.  Fick  and  others  speak, 
again,  of  how  the  constant  electricity  in  a  Leyden  jar  is 
converted  into  a  periodical  discharge  of  sparks.  There 
would  be  no  difficulty  in  adding  some  more  similar  in- 
stances, but  I  do  not  see  how  all  these  illustrations  add 
anything  new  or  any  more  strength  to  the  original  theory 
as  it  was  first  put  forth  by  Johannes  Muller,  and  which  is, 
to  repeat  it  briefly,  as  follows : 

The  automatic  mechanism  generates,  nobody  knows  how, 
a  continual  stimulus,  which  has  to  overcome  a  certain  re- 
sistance before  reaching  the  muscle  of  the  heart ;  the  result 
of  this  struggle  is  a  rhythmic  contraction. 

You  all  know  that  if  two  forces  are  opposing  one  an- 
other, in  most  cases  the  result  is,  according  to  the  law  of 
the  parallelogram  of  two  forces,  not  a  rhythm,  but  a  con- 
stant resultant.  Now,  if  there  are  in  the  heart  two  oppos- 
ing forces,  why  is  the  result  a  rhythm  and  not  a  steady 
tonic  contraction  ?  But,  assuming  even  that  the  result  of 
two  opposing  forces  would  always  be  a  rhythm,  can  we 
maintain  that  we  understand  the  mechanism  of  the  rhythm 
of  the  heart  better  because  there  are  instances  showing  the 
conversion  of  constant  forces  into  rhythmic  effects  ?  If 
somebody  who  hears  the  rattle  of  your  faradaic  battery  asks 
you  for  the  explanation  of  the  mechanism  of  the  current, 
interrupter,  you  would  not  disclose  the  nature  of  the  mech- 
anism in  the  least  by  answering:  Such  rhythmic  rattle  is 
a  daily  occurrence  ;  hear  the  rattle  of  the  sewing  machine, 
the  ticking  of  the  watch,  the  rhythmic  dripping  of  the 
loosely-closed  faucet.  He  who  knew  the  physical  cause 
why  the  scanty  water  from  the  roof  was  not  streaming,  but 
rhythmically  dripping,  did  not  yet  know  how  to  invent  a 
timepiece,  and  many  a  good  watchmaker  does  not  under- 
stand the  ingenious  mechanism  of  the  self-interrupting 
hammer  in  the  faradaic  battery.  Thus  the  knowledge  of 
the  facts  that  the  electricity  of  a  Leyden  jar  is  discharged 
in  sparks,  that  gas  escapes  from  water  in  bubbles,  and  so 


on,  does  not  help  us  in  the  least  to  understand  the  special 
mechanism  of  the  heart's  rhythm. 

Accordingly  we  must  admit  that  we  do  not  know  what 
the  stimulus  is  which  makes  the  heart  contract,  and  where 
and  how  this  stimulus  is  generated ;  we  also  do  not  know 
why  the  heart,  by  virtue  of  the  continuity  of  the  stimulus, 
is  not  contracted  tonically ;  and  we  have  not  the  slightest 
knowledge  of  the  mechanism  which  regulates  the  steady 
and  stable  rhythm.  Then  what  do  we  know  of  the  mech- 
anism of  the  heart's  beat  ?  What  knowledge  do  we  gain 
of  this  mechanism  by  the  pretentious  allegation  that  it  is  of 
an  automatic  nature  ?  Certainly  none,  and  so  I  repeat  that 
a  simple  confession  of  our  ignorance  would  be  more  to  the 
point. 

To  sum  up  our  analysis  briefly,  the  blood  is  not  the 
cause  of  the  heart's  movements,  and  automatism  is  a  trans- 
parent cover  to  hide  our  ignorance.  Thus,  after  centuries 
of  labor  and  research,  we  stand  to-day  with  the  same  ap- 
parent helplessness  as  centuries  ago  before  the  puzzling 
problem.  What  makes  the  heart  beat  ? 

You  see  that  a  new  attempt  to  solve  our  problem  can 
not  be  considered  as  a  luxury.  And  as  the  search  for 
truth  is  everybody's  right,  I  hope  it  will  not  be  considered 
immodest  if  I  venture  now  to  lay  before  you  my  own  con- 
ception of  the  mechanism  under  discussion.  However,  be- 
fore entering  into  the  details  of  my  own  theory,  I  wish  to 
show  that,  in  accordance  with  our  present  knowledge,  our 
problem  might  appear  even  more  complicated.  We  were 
used  to  the  conception  that  a  stimulus  was  necessary  only 
for  the  production  of  a  contraction,  but  not  for  the  relaxa- 
tion of  a  muscle ;  the  relaxation  was  considered  as  a  passive 
condition  which  appeared  as  soon  as  the  cause  for  the  con- 
traction disappeared.  Therefore  the  question  concerning  the 
beat  of  the  heart  could  only  be.  What  is  the  stimulus  which 
produces  the  systole,  and  what  interrupts  the  stimulus  or 
its  effects  so  as  to  allow  the  heart  to  relax  ?  Now,  it  is 
nearly  half  a  century  since  Eduard  Weber  discovered  the 
far-reaching  fact  that  by  stimulation  of  the  vagus  the  heart 
could  be  brought  to  rest  in  a  diastolic  state.  Consequently, 
at  least  this  relaxation  of  the  heart  is  not  a  passive  one, 
due  to  the  disappearance  of  a  stimulus,  but  certainly  an 
active  one,  brought  on  by  a  stimulation  of  the  vagus.  The 
relaxation  is  therefore  not  always  a  passive  condition.  Now 
a  new  question  must  arise.  Is  the  natural  diastole  really 
only  a  passive  condition,  or  is  it  brought  about  in  a  similar 
way  as  the  effect  of  the  artificial  stimulation  of  the  vagus  ? 
In  other  words,  should  we  not  suppose  that  the  normal 
diastole  is  an  active  state,  an  inhibitory  phenomenon  ?  It 
seems  to  me  surprising  that  half  a  century  should  have  passed 
without  any  one  taking  this  possibility  under  serious  con- 
sideration.   Or  can  I  have  overlooked  such  an  attempt  ? 

Accordingly  our  problem  is  now  complicated  by  new 
questions.  Is  the  diastole  also  an  active  state,  and,  if  so, 
what  is  the  stimulus  for  the  diastolic  state  ?  Is  there  a 
separate  stimulus  for  the  systole  and  for  the  diastole,  or 
could  both  states  be  produced  by  one  and  the  same  stimulus  ? 

My  own  answer  to  these  questions  would  be,  briefly 
stated,  this :  The  diastole  is  indeed  an  active  state — a  state 
of  inhibition  produced  by  a  direct  stimulus  ;  but  both  states, 


May  ly,  1893.J 


MELTZER:  SELF-REOULATION 


515 


systole  and  diastole,  are  brought  about  by  one  and  the 
same  stimulus.  Aud  now  I  shall  ask  your  permission  to 
bring  before  you  a  more  comprehensive  account  of  my  view 
of  the  mechanism  of  the  cardiac  beat. 

The  heart  harbors  in  some  of  its  anatomical  substrata 
two  antagonistic  functions — viz.,  the  contractibility  and  the 
inhibitory  function.  If  we  were  to  recognize  the  muscular 
tissue  as  the  ultimate  carrier  of  the  heart's  mechanism, 
then  I  should  simply  say  that  the  muscular  fibres  of  the  heart 
were  capable  of  answering  to  a  stimulus  by  contraction  as 
well  as  by  relaxation.  And  it  will  remain  an  open  question 
if  the  muscle  of  the  heart  differs  in  the  respect  mentioned 
from  the  skeletal  muscle,  since  there  are  abundant  proofs 
of  the  presence  of  inhibitory  phenomena  in  the  skeletal 
muscle  also.  Here  I  may  refer  to  the  experiments  of 
Biederman,  Kaiser,  Wedenski,  and  Piotrowski.  My  theory, 
however,  is  independent  of  the  question  of  localization.  I 
shall  not  object  to  have  the  antagonistic  functions  localized 
in  separate  ganglia  or  even  in  one  and  the  same  nerve  cell. 
The  nerve  cells  will  then  possess  two  opposing  functions — 
one  to  bring  the  muscle  fibers  of  the  heart  to  contraction, 
and  the  other  for  the  inhibition  of  the  contraction.  This 
assumption  is,  of  course,  not  new..  We  have  seen  that 
most  authors  entertain  the  view  that  the  heart  is  governed 
by  two  opposing  forces.  Then,  again,  we  often  find  the  as- 
sumption that  there  are  a  motoric  and  an  inhibitory  mechan- 
ism in  the  heart.  My  presupposed  functions  have  the  ad- 
vantage inasmuch  as  they  are  less  complicated  ;  each  func- 
tion for  itself  does  not  form  a  mechanism ;  it  is  only  a 
simple  quality  of  some  anatomical  substratum  of  the  heart. 
What  I  expressly  wish  to  insist  upon  is  that  these  func- 
tions belong  to  the  heart  itself  and  not  to  the  endings  of 
the  peripheral  nerves.  The  embryonic  heart  beats  rhyth- 
mically even  before  the  peripheral  nerves  join^it.  Thus  I 
believe  that  the  inhibition  which  appears  after  stimulating 
the  vagus  belongs  not  to  this  nerve  or  its  endings,  but  to 
the  inhibitory  function  of  the  heart  which  is  specifically 
connected  with  the  vagus.  Both  peripheral  nerves  are  the 
pathways  leading  to  each  function  separately.  And  it  is 
only  by  those  peripheral  nerves  that  we  may  gain  separate 
access  to  each  of  the  functions.  By  any  other  stimulus 
which  we  may  apply  to  the  heart  directly  or  otherwise  we 
affect  both  functions  simultaneously.  By  these  stimuli  we 
are  therefore  unable  to  study  the  peculiarities  of  each 
function.  But  since  the  two  kinds  of  peripheral  nerves 
leading  to  both  functions  of  the  heart  are  their  separate 
pathways,  we  may  attempt  to  study  the  functions  by 
studying  their  corresponding  nerves.  And  here  we  find 
highly  interesting  facts  which  are  fitted  to  throw  a  bright 
light  on  the  peculiarities  of  the  antagonistic  functions  and 
on  the  mechanism  of  the  rhythmic  beat  of  the  heart.  To 
these  facts,  gentlemen,  I  now  invite  your  special  attention. 

By  the  cardiac  peripheral  nerves  I  mean,  of  course,  the 
pneumogastric  and  the  accelerator  nerves.  By  moderate 
stimulation  of  the  vagus  the  beats  of  the  heart  are  slackened 
and  weakened ;  stronger  stimulation  brings  the  heart  to  a 
standstill  in  diastole.  The  effect  of  the  stimulation  does 
not  appear  instantaneously  ;  there  is  always  a  latent  period 
of  about  one  fifth  of  a  second  between  the  stimulation  and 


the  inhibitory  effect.  After  cessation  of  stimulation  the 
inhibitory  effect  does  not  disappear  immediately,  but 
rather  continues  for  two  or  three  seconds — in  other  words, 
the  inhibitory  after- effect  of  the  stimulation  of  the  vagus 
lasts  from  two  to  three  seconds.  By  the  accelerator  nerve 
are  meant  cardiac  nerve  fibers  which  come  from  the  sympa- 
thetic nerve  and  which  have  a  different  course  in  different 
animals.  Isolated  stimulation  of  these  nerve  fibers  quickens 
and  augments  the  beat  of  the  heart.  The  latent  period  of 
the  accelerator  nerve  lasts  a  few  seconds,  and  still  more 
pronounced  is  its  after-effect ;  it  continues  for  several  min- 
utes— i.  e.,  for  several  minutes  after  the  stimulation  of  tlie 
accelerator  nerve  has  been  stopped  the  heart  continues  to 
beat  quicker  and  sti'onger.  Thus  we  see  that  tliere  is  a 
marked  difference  between  the  pneumogastric  and  the  ac- 
celerator nerves  concerning  the  length  and  strength  of 
their  latent  and  after-effect  periods.  There  are  still  other 
differences.  For  the  excitation  of  the  accelerator  nerve  a 
stronger  stimulus  is  required  than  for  the  excitation  of  the 
cardiac  vagus.  Then  the  vagus  exhausts  sooner  than  the 
accelerator  nerve.  Both  nerves  show  a  different  behavior 
in  relation  to  the  effects  of  temperature  aud  some  poisons. 
When  both  nerves — the  pneumogastric  and  the  accelerator 
— are  stimulated  simultaneously,  we  see  during  the  stimu- 
lation only  the  inhibitory  effect,  and  nearly  to  such  a  de- 
gree as  if  the  accelerator  nerve  would  not  have  been  co- 
stimulated  at  all.  The  effect  remains  about  the  same  even 
if  the  vagus  were  stimulated  by  a  weak  and  the  accelerator 
by  a  strong  current;  the  inhibitory  effect  prevails  under  all 
circumstances.  On  the  other  hand,  if  the  simultaneous 
stimulation  was  interrupted  simultaneously,  we  see  after 
the  expiration  of  the  inhibitory  after- effect  the  long  after- 
effect of  the  accelerator  nerve  making  its  appearance  in 
such  an  undisturbed  manner  as  to  make  us  believe  that 
the  effect  of  the  accelerator  nerve  was  developed  to  its  full 
extent  even  during  the  simultaneous  stimulation.  Indeed, 
it  is  now  a  generally  accepted  conclusion  that  during  the, 
simultaneous  stimulation  the  accelerating  effect  is  not  anni- 
hilated, but  only  covered  by  the  more  powerful  inhibitory 
effect  of  the  vagus.  I  shall  especially  point  out  that  after 
the  cessation  of  the  simultaneous  stimulation  the  inhibitory- 
after-effect  of  the  vagus  is  visibly  shortened;  here  the 
stronger  after-effect  of  the  accelerator  nerve  shortens  the 
weaker  after-effect  of  the  vagus.  xVll  these  principles  have 
been  studied  and  carefully  laid  down,  especially  by  the 
very  valuable  researches  of  Schmiedeberg,  Bowditch,  and 
N.  Baxt.  I  wish  to  add  here  only  one  point.  According 
to  the  statements  of  Baxt,  the  effect  of  the  simultaneous 
stimulation  is  exactly  the  same  as  of  the  solitary  stimula- 
tion of  the  vagus — i.  e.,  the  co-stimulation  of  the  accelerator 
nerve  does  not  in  the  least  affect  the  inhibitory  result  of 
the  stimulation  of  the  vagus.  In  an  article  published  last 
year  in  Du  Bois-Reymond's  Archiv  fur  Physiologie  I  dealt 
extensively  with  this  question.  I  have  shown  that  the 
effect  of  the  co-stimulated  accelerator  is  always  more  or 
less  distinctly  recognizable  even  during  the  simultaneous 
stimulation.  The  result  of  this  stimulation  is  always  a  re- 
sultant of  both  opposing  components  ;  only  that  the  in- 
hibitory component  is  prevailing  to  such  an  overwhelming 


516 


MELTZER:  SELF-REGULATION  OF  THE  BEAT  OF  THE  HEART.     [N.  Y.  Med.  Joub., 


4egree  that  the  influence  of  its  opponent  is  hardly  notice- 
able. The  effect  of  the  participating  accelerator  is  the 
more  distinct  the  stronger  the  accelerator  nerve  and  the 
weaker  the  vagus  were  stimulated. 

Ou  account  of  the  importance  of  some  of  the  stated 
points,  I  wish  to  repeat  them  briefly.  The  inhibitory  effect 
•of  the  vagus  possesses  a  short  after-effect  of  about  two  sec- 
onds' duration ;  the  after-effect  of  the  accelerator  nerve  lasts 
several  minutes.  When  both  nerves  are  stimulated  at  the 
same  time,  then  the  inhibition  prevails  during  the  stimula- 
tion; after  cessation  of  the  stimulation  first  comes  the  short- 
ened inhibitory  after-effect,  and  then  the  long  after-effect  of 
the  accelerating  nerve  makes  its  appearance. 

We  have  assumed  above  that  the  peripheral  nerves  are 
only  the  paths  leading  to  the  functions  within  the  heart. 
Thus  the  vagus  is  leading  to  the  inhibitory  function,  and 
the  accelerator  nerve  is  the  special  road  to  the  function  su- 
perintending the  contractions  of  the  heart.  But  since  the 
nerve  fibers  as  such  probably  differ  very  little,  we  may  right- 
ly assume  further  that  the  above-stated  differences  of  the 
peripheral  nerves  are  in  fact  differences  in  the  characters  of 
the  functions.  Or  there  is  at  least  no  objection  to  the  as- 
sumption that  the  characters  and  the  mutual  relations  of  the 
functions  are  about  the  same  as  of  their  respective  peripheral 
nerves.  Thus  we  may  assume  that  the  inhibitory  function 
possesses  a  short  latent  period  and  also  a  comparatively 
short  period  for  its  after-effect.  On  the  other  hand,  the 
Jifter-effect  of  the  function  for  the  contraction  may  last  sev- 
eral minutes.  If,  furthermore,  both  functions  are  stimulated 
simultaneously,  we  may  expect  a  distinct  prevalence  of  the 
inhibitory  function  during  the  stimulation;  but  after  cessa- 
tion of  stimulation  we  should  see  the  short  after-effect  of 
the  inhibition  still  more  reduced  by  the  following  long  and 
strong  after-effect  of  the  antagonistic  function  for  the  con- 
traction. 

Now,  if  we  further  suppose  that  with  each  systole  a 
.■stimulus  is  generated  which  affects  both  functions  simul- 
•taneously,  we  should  have  before  us  a  good  working  mech- 
anism which  is  capable  of  regulating  the  beat  of  the  heart 
in  the  following  manner  :  The  stimulus  accompanying  the 
rsystole  affects  the  functions  for  inhibition  and  contraction 
simultaneously.  But  as  the  inhibition  prevails  during  the 
stimulation,  a  relaxation  must  ensue  ;  the  relaxation,  how- 
ever, means  cessation  of  the  stimulus  ;  therefore  we  now 
have  before  us  the  period  of  the  after-effects — that  means, 
first,  the  expiration  of  the  short  period  of  the  inhibitory 
after-effect,  which  corresponds  to  the  diastolic  pause  ;  and 
then  the  after-effect  of  the  function  for  contraction  follows — 
that  means  that  a  long-lasting  contraction  of  the  heart  is  to 
appear.  But  since  this  means  a  new  systole  with  its  stimu- 
lus, therefore  the  result  is  not  a  long  contraction  but  a  new 
cardiac  cycle  with  relaxation,  pause,  and  contraction,  and  so 
on  ad  infinitum. 

But  what  sort  of  a  stimulus  could  it  be  which  should  ac- 
company each  and  every  systole  ?  Gentlemen,  we  might 
think,  in  the  first  [)lace,  of  the  negative  variation  of  the  mus- 
ele  current  which  accompanies  each  contraction  of  the  heart. 
This  negative  variation  is  sufficient  to  produce  a  muscular 
contraction,  as  is  shown  by  the  so-called  rhcoscopic  frog. 


If  the  nerve  of  an  irritable  muscle-nerve  preparation  is  laid 
over  a  pulsating  ventricle,  each  beat  is  responded  to  by 
a  contraction  of  the  muscle  of  the  preparation.  We  could 
think  then  that  the  negative  variation  might  be  sufficient 
also  to  stimulate  efficiently  both  functions  within  the  heart. 
Indeed,  I  do  not  think  that  this  assumption  is  inadmissible- 
But  I  confess  that  I  am  rather  inclined  to  consider  another 
incident  occurring  during  each  systole  as  the  effectual  stimu- 
lus. During  each  systole  the  heart  contracts  firmly ;  it  be- 
comes dense  and  hard.  Owing  to  the  spiral  arrangement 
of  the  muscle  fibers  of  the  heart,  with  each  energetic  con- 
traction a  strong  pressure  must  arise  which  is  capable  of 
mechanically  stimulating  all  that  is  exposed  to  this  pressure 
— that  is,  the  muscle  fibers  themselves  by  their  mutual  com- 
pression, and  all  that  is  imbedded  between  them.  And  I 
think  it  is  this  pressure  which  stimulates  mechanically  both 
functions  during  each  systole.  Even  when  the  heart  is  di- 
vided into  small  pieces,  there  still  remains  sufficient  pressure 
between  the  contracted  muscle  fibers  to  serve  as  a  stimulus. 
But  the  pressure  is  apparently  at  its  best  in  the  normal  heart, 
as  there  the  inner  surface  of  the  cavity  of  the  heart  is  sub- 
jected to  the  great  pressui'e  coming  from  the  opposite  wall ; 
this  corresponds  to  the  old  known  experience  that  stimuli 
which  are  applied  on  the  inner  surface  of  the  heart  are  most 
efficient. 

After  the  preceding  statements,  my  theory  of  the  mech- 
anism of  the  heart  may  be  briefly  presented  as  follows  : 

There  are  within  the  heart  two  opposing  functions,  for 
inhibition  and  for  contraction.  During  each  systole  a  de- 
gree of  pressure  is  developed  sufficient  to  stimulate  mechan- 
ically both  functions  at  once.  But  during  the  stimulation 
the  inhibitory  effect  prevails  and  therefore  the  heart  is  bound 
to  relax.  With  the  relaxation,  however,  the  stimulation  sub- 
sides, and  we  then  have  before  us  the  period  of  the  after- 
effects. Here  we  first  see  the  short  period  of  the  inhibitory 
after-effect,  winding  up  as  a  diastolic  pause,  after  which  the 
after-effect  of  the  function  for  contraction  makes  its  appear- 
ance, which  means  that  a  contraction  of  the  heart  is  bound 
to  appear.  This  contraction  would  last  many  minutes  if 
the  whole  after-effect  were  allowed  to  wind  up.  But  since 
this  contraction  means  a  new  systole  and  a  new  stimulation, 
it  is  then  cut  off  by  the  newly  aroused  inhibitory  effect ; 
therefore,  instead  of  a  prolonged  contraction,  a  new  cycle  of 
relaxation,  diastolic  pause,  and  subsequent  contraction  takes 
place.  In  other  words,  the  consequence  of  each  contraction 
is  a  circle  of  relaxation,  diastolic  pause,  and  contraction. 
Thus  each  heart  beat  generates  its  subsequent  diastole  and 
systole.  And  we  may  therefore  say  that  the  beats  of  the 
heart  are  regulating  their  own  rhythm. 

I  have  stated  above  that  after  the  heart  contracts  ad 
maximum  it  continues  to  be  contracted  for  some  time 
(about  one  tenth  of  a  second)  before  relaxation  takes  place. 
That  means,  according  to  my  theory,  that  the  stimulus  does 
not  immediately  bring  on  the  inhibitory  effect ;  or,  in  other 
words,  the  phase  of  the  continuation  of  the  contraction 
means  the  latent  period  of  inhibition. 

On  the  basis  of  my  theory  we  can  well  understand  why 
we  can  never  produce  a  tetanic  contraction  of  the  muscle 
of  the  heart.    It  is  because  each  contraction  produces  its 


May  18,  1893.J 


BECK:   SURGICAL  DISEASES  OF  THE  NECK. 


51t 


owu  inliibition,  thus  preventing  the  further  continuation  of 
the  contraction.  In  a  similar  way  the  theory  explains  why 
the  stimulation  of  the  accelerator  nerve  brings  on  only  an 
acceleration  and  augmentation  of  the  beat  of  the  heart,  and 
never  a  continued  contraction  of  the  heart.  It  is  again  be- 
cause each  contraction  cuts  ofE  its  own  continuation.  Other- 
wise I  am  indeed  of  the  opinion  that  the  relation  of  the 
accelerator  nerve  to  the  function  for  contraction  is  exactly 
the  same  as  the  relation  of  the  vagus  to  the  inhibitory  func- 
tion— i.  e.,  by  stimulation  of  the  accelerator  nerve  we  could 
indeed  bring  the  heart  to  a  continued  contraction  if  we 
•!ould  only  succeed  in  destroying  the  inhibitory  function,  or 
at  least  in  removing  its  prevalence  during  stimulation. 

I  shall  not  go  into  further  details  showing  the  adapta- 
bility of  many  facts  to  my  new  theory.  Only  concerning 
the  effect  of  atropine,  I  wish  to  say  briefly  that,  in  my  opin- 
ion, atropine  affects  only  the  connections  of  the  inhibitory 
function  with  the  peripheral  nerve  or  with  the  artificial 
stimuli ;  the  connection  of  the  natural  stimuli  with  the  in- 
hibitory function  remains  unaffected.  This  will  satisfacto- 
rily explain  all  facts  concerning  the  effect  of  atropine  on 
the  cardial  inhibition. 

I  have  to  appeal  to  your  indulgence  for  one  or  two  more 
remarks.  I  have  stated  above  that  no  effect  is  annihilated ; 
that  if  the  inhibitory  effect  prevails  during  a  simultaneous 
stimulation,  the  effect  of  the  co- stimulated  accelerator  nerve 
is  nevertheless  present,  ready  to  appear  at  any  offered  op- 
portunity. The  same  applies,  as  I  uow  wish  to  add,  to  the 
now  and  then  apparently  destroyed  inhibitory  effect — i.  e., 
the  inhibitory  effects  are  covered  and  not  destroyed.  Now 
this  fact  has  an  important  bearing  upon  my  theory.  Ac- 
cording to  it,  the  diastolic  pause  corresponds  to  the  after- 
effect of  the  inhibitory  function.  This  pause  lasts  only 
about  half  a  second,  while  the  after-effect  of  the  stimula- 
tion of  the  vagus  lasts  about  two  or  three  seconds.  We 
see,  indeed,  the  same  shortening  of  the  inhibitory  after- 
effect, as  it  was  stated  above,  when  the  stimulation  of  the 
vagus  and  accelerator  is  simultaneously  interrupted.  But 
as  the  rest  of  the  after-effect  can  not  be  annihilated,  it  must 
remain  present  and  exert  some  kind  of  influence.  And 
as  each  beat  leaves  such  a  rest  and  the  duration  of  each 
rest  comprises  nearly  two  beats,  we  may  well  assume  that 
all  the  rests  add  themselves  together  to  an  influential  in- 
hibitory tonus.  These  considerations  have  still  more  weight 
with  the  after-effect  of  the  function  for  contraction.  The 
after-effect  of  the  accelerator  nerve  lasts  many  minutes,  and 
we  accepted  the  view  that  we  might  expect  the  same  from 
the  function  for  contraction.  Now,  according  to  my  theo- 
ry, the  after-effect  of  the  co-stimulated  function  for  con- 
traction from  each  heart  beat  is  represented  in  the  next  fol- 
lowing systole,  and  is  cut  off  from  further  continuation  by 
tlie  new  stimulus.  And  as  the  systole  lasts  only  one  third 
of  a  second,  the  hidden  rest  of  the  after-effect  must  last 
many  minutes,  or  for  a  period  of  many  hundred  beats. 
That  means  from  each  beat  remains  a  potential  rest  of  the 
function  for  contraction  extending  over  many  hundreds  of 
beats  of  the  heart.  Consequently  we  have  the  sura  of 
many  hundreds  of  these  potential  rests  all  the  time  present. 
What  a  very  powerful  tonus  all  these  rests  of  the  function 


for  contraction  must  build  up  !  TTiis  strong  tonus  will  cer- 
tainly suffice  to  call  forth  a  strong  contraction  as  soon  as 
the  diminished  inhibitory  effect  or  after-effect  will  permit 
it.  Indeed,  it  is  my  opinion  that  the  systole  which  appears 
after  the  diastolic  pause  (shortened  inhibitory  after-effect) 
is  brought  on  by  the  said  strong  tonus  of  the  function  for 
contraction,  and  not  merely  by  the  after-effect  of  the  last 
systolic  stimulus.  I  rather  believe  that  the  after-effect  be- 
longing to  the  function  for  contraction  just  stimulated  by 
the  last  systole  ought  to  come  after  a  much  longer  period 
than  the  diastolic  pause,  on  account  of  the  long  latent  pe- 
riod peculiar  to  the  fimction  for  contraction,  as  seen  in  the 
stimulation  of  the  accelerator  nerve. 

It  is  probable  that  the  tonus  of  the  function  for  con- 
traction interferes  with  the  diastole  so  much  as  to  prevent 
a  full  relaxation  of  the  heart  at  each  diastole.  On  the 
other  hand,  the  inhibitory  tonus  probably  also  interferes 
with  the  systole  so  much  as  to  prevent  every  contraction 
from  being  the  strongest  possible. 

In  conclusion,  I  wish  to  remark  that  my  theory  of  the 
self-regulation  of  the  beat  of  the  heart  is  similar  in  the 
main  points  with  my  theory  of  the  self- regulation  of  respi- 
ration, which  I  have  described  elsewhere.  Here  as  well  as 
there  we  have  the  antagonism  between  inhibition  and  con- 
traction ;  here  as  well  as  there  the  inhibition  prevails  dur- 
ing the  stimulation,  while  the  contraction  overlasts  in  the 
period  of  the  after-effects.  Here  as  well  as  there  the  pause 
corresponds  to  the  shortened  inhibitory  after-effect.  And 
here  as  well  as  there  the  stimulus  is  a  mechanical  one,  pro- 
duced  by  the  natural  function  of  the  acting  organ ;  here  it 
is  the  contraction  of  the  heart,  there  it  is  the  expansion  of 
the  lungs.  Certainly  neither  of  these  theories  suffers  by 
their  mutual  resemblance. 
66  East  124th  Street. 


ON  SURGICAL  DISEASES  OF  THE  NECK, 

INCLUDING  THE  FIRST  ANNUAL  REPORT  OF 
THE  SPECIAL  DEPARTMENT  OF  SURGICAL  DISEASES  OP  THE  NECK 
AT  THE  GERMAN  POLIKLINIK  OF  THE  CITY  OP  NEW  YORK. 

By  CARL  BECK,  M.D. 
(Concluded  from  page  466.) 
Sarcoma. 

Case  I.  Lymphosarcoma. — Mrs.  Lizzie  F.,  housewife,  aged 
sixty-five,  born  in  Austria ;  family  history  good.  Six  months 
ago  she  noticed  a  small  lump  in  the  right  snbinasillary  re- 
gion, which  since  has  grown  to  the  size  of  a  goose  egg  and 
caused  considerable  interference  in  swallowing.  On  June  17, 
1892,  when  first  seen,  the  tumor  filled  out  the  whole  space  be- 
tween the  processus  mastoideus  and  the  oshyoidenm  and  pushed 
the  soft  palate  forward.  In  it  there  existed  a  cavity  of  peanut 
size  covered  with  detritus.  No  mobility ;  great  weakness.  The 
axillary  and  inguinal  glands  were  swollen;  also  some  small  hard 
tumors  on  both  forearms  were  noticed.  An  operation  did  not 
seem  to  bo  advisable  any  more. 

Case  II.— Cliristof  B.,  aged  sixty- one,  born  in  Germany; 
family  history  good.  Six  months  ago  ho  noticed  a  sharp  pain 
in  his  left  arm  down  to  his  fingers,  also  a  feeling  of  weakness 
and  heaviness  in  his  shoulder  and  arm ;  three  months  later  he 
first  found  a  hard  lump  in  the  left  supraclavicular  region.  On 


518 


BECK:  SURGICAL  DISEASES  OF  THE  NECK. 


[N.  Y.  Med.  Jode., 


March  29th,  when  he  was  seen  first,  his  tamor,  of  lien's-egt;  size, 
was  very  painful  to  touch.  Specific  treatment  was  unsuccesafal, 
wherefoi'e  the  diagnosis  lynipliosarcoma  was  made.  On  May 
20th  removal  of  the  growth.  Union  took  place  by  first  inten- 
tion. The  microscopical  examination  corroborated  the  diag- 
nosis. The  pain,  however,  disappeared  for  only  four  weeks. 
Three  weeks  after  the  operation  a  relapse  could  already  be 
noticed.  On  July  29th  the  tumor  was  extirpated  again.  This 
time  it  reached  as  far  back  as  the  cervical  vertebrsB  and  was  so 
mncli  attached  to  the  neighboring  tisane  that  the  internal  jugu- 
lar vein  had  to  be  ligated  twice.  This  time  union  by  first  in- 
tention was  obtained  again,  but  the  pain  remained  just  as  be- 
fore and  could  only  temporarily  be  stopped  by  morphine.  On 
August  10th  he  showed  symptoms  of  pleuritis  and  died  three 
days  after.  The  autopsy  revealed  pleuritis,  suppurative  bron- 
chitis, and  no  metastasis  in  internal  organs. 

Case  III. — Max  W.,  aged  eight,  born  in  New  York  city ; 
family  history  good.  Eight  weeks  ago  his  nose  became  obstruct- 
ed. The  family  physician  first  diagnosticated  a  severe  catarrh. 
Later  on,  when  the  symptoms  became  aggravated  by  interfer- 
ence with  pronunciation  and  deglutition,  he  observed  a  swell- 
ing of  the  right  tonsil  and  a  protrusion  of  the  palate.  Assum- 
ing that  an  abscess  was  forming,  he  incised  and  found  blood. 
Repeated  puncture  revealed  the  same.  On  November  13,  1892, 
when  first  seen  by  me,  I  found  the  right  tonsil  enlarged  to 
nearly  hen's-egg  size  and  the  soft  palate  pushing  toward  the 
base  of  the  tongue.  My  first  impression  was  that  adenoid  vege- 
tations had  reached  an  exorbitant  extent,  but  closer  examina- 
tion taught  me  soon  that  I  had  to  deal  with  a  malignant 
growth.  Four  days  later,  after  the  temporary  resection  of 
the  inferior  maxilla,  I  removed  the  growth,  which  was  ex- 
tending up  to  the  fossa  sphenopalatina  without  interfering 
with  large  blood-vessels.  The  operation  was  partially  per- 
formed leaving  the  head  hanging  down  and  only  under  tem- 
porary anfesthesia.  After  a  considerable  improvement  I  was 
very  much  disappointed  to  see  a  relapse  already  four  weeks 
after  the  operation.  Six  weeks  after  operation  dyspnoea  set  in, 
which  was  checked  by  tracheotomy.  After  a  short  period  of 
improvement  the  patient  died  from  marasmus.  Autopsy  de- 
clined. 

Case  IV. — Wenzel  L.,  aged  thirty-nine,  Bohemian;  family 
history  good.  Three  months  ago,  noticing  a  hard  lump  in  his 
pharynx  and  at  the  same  time  interference  with  deglutition,  he 
went  to  a  dispensary,  where  he  was  attended  for  chronic  catarrh 
without  relief.  One  month  ago  he,  at  the  German  Poliklinik, 
was  examined  by  Dr.  Freudenthal  also,  who,  after  an  unsuccess- 
ful specific  treatment,  suspected  a  malignant  growth.  On  Oc- 
tober 10th,  when  first  seen  by  me,  the  patient  showed  a  very 
hard  tumor  inclosing  the  whole  left  tonsil  and  the  neighboring 
portion  of  the  palate  and  was  extending  toward  the  base  of  the 
skull.  The  growth,  being  of  hen's-egg  size,  was  painful ;  it 
could  be  felt  from  the  outside  and  showed  evidence  of  ulcera- 
tion on  the  inside.  Several  submaxillary  glands  were  swollen. 
The  operation  was  preceded  by  tracheotomy.  A  Trendelenburg's 
tampon  cannula  was  introduced,  as  profuse  bleeding  had  to 
be  expected.  The  temporary  resection  of  the  inferior  maxilla 
was  done  and  immediately  followed  by  the  extirpation  of  the 
very  hard  fibrosarcoma,  which  had  reached  the  fossa  spheno- 
palatina. Uninterrujited  recovery  followed  until  three  months 
later  a  relapse,  setting  in  under  cerebral  symptoms,  produced 
septic  infiltration,  which,  two  weeks  after  the  new  process  had 
been  noticed,  ended  the  patient's  misery. 

Case  I.  Carcinoma. — Rosa  F.,  forty  years  of  age,  born  in 
(Jermany;  housewife;  sterile.  Family  history  good.  In  Feb- 
ruary, 1890,  total  vaginal  extirpation  of  the  uterus  for  carcino- 
ma was  performed  by  me.    She  had  been  doing  very  well  until 


afterward — on  .January  7,  1892,  when  I  saw  her  again — she  re- 
ported that  she,  for  the  last  few  weeks,  had  noticed  a  small 
lump  on  her  neck  which  did  not  cause  any  pain. 

On  examination.  I  found  in  the  sui)raclavicular  region  a  hard 
tumor  of  peanut  size.  Mobility  was  perfect.  Although  the 
patient  was  in  excellent  health,  my  suspicion  of  carcinoma  was 
very  natural.  But  my  advice  to  have  an  immediate  extirpation 
performed  was  not  accepted. 

Three  months  later  the  tumor  was  of  more  than  goose-egj: 
size,  softer,  non-movable,  and  especially  adherent  to  the  skin, 
where  the  so-called  cancer  navel  could  be  obserred.  As  great 
pain  liad  been  present  for  the  last  few  weeks,  the  patient  now 
demanded  extirpation  herself. 

The  operation  was  performed  successfully  on  April  5,  1892. 

Union  by  first  intention  was  obtained.  The  condition  of 
the  patient  was  excellent  until  November,  1892,  when  a  relapse 
made  its  appearance  in  the  scar.  Shortly  after,  icterus  and 
anasarca  set  in,  undoubtedly  due  to  carcinoma  of  the  liver,  to 
which,  in  the  course  of  four  weeks,  she  succumbed.  No  autopsy. 

Case  II. — -Henry  W.,  forty-nine  years  of  age,  born  in  New 
York  city.  Healthy  appearance.  Father  had  died  from  cancer 
of  the  stomach.  Since  four  months  he  suffers  from  a  snp])U- 
rating  and  painless  tumor  on  the  left  upper  trigonum.  The 
patient  declined  operation  and  left  our  department. 

Case  III. — Caspar  B.,  sixty  years  of  age,  born  in  Germany. 
Family  history  good.  Patient  has  always  been  well  until  in 
December,  1891,  he  noticed  a  painless  swelling  under  the  left 
side  of  his  lower  jaw.  He  did  not  consult  his  house  physician 
until,  two  months  later,  the  slowly  growing  tumor  became 
sensitive.  Poulticing  was  done  and  iodide  of  potassium  given 
internally  for  about  four  weeks,  when  the  skin  above  the  tumor 
became  red  and  soft. 

A  distinguished  surgeon,  who  was  called  in  consultation, 
incised  and  scraped,  assuming  that  the  disease  was  a  suppurat- 
ing gland. 

But  soon  after  this  operation  neighboring  glands  swelled, 
the  pain  increased,  and  the  patient's  general  condition  became 
worse.  On  May  7,  1892,  on  seeing  the  case  first,  I  found  a 
hard  tumor  of  peanut  size  in  the  submaxillary  region. 

On  the  anterior  margin  of  the  sterno-cleido-mastoid  four 
glands  were  found  to  be  enlarged.  Extirpation  was  done  by 
dissecting  the  sterno-cleido- mastoid.  The  recovery  was  com- 
plete already  three  weeks  after  the  operation,  when  he,  having 
had  frequent  previous  attacks  of  delirium  tremens,  became  a 
maniac.  Two  days  later  he  suffered  an  apoplectic  spell,  during 
which  he  died. 

Case  IV. — Hippolyte  L.,  sixty-seven  years  of  age,  born  in 
Austria.  Family  history  good.  For  three  months  he  com- 
plains about  difficulty  in  deglutition  and  of  a  burning  sensation 
in  his  pharynx.  His  house  physician  treated  him  with  a  gar- 
gle. On  March  11,  1892,  when  first  seen  by  me,  he  appeared 
sick  and  showed  great  debility.  The  inspection  of  the  pharynx 
revealed  a  tumor  which  was  of  hen's-egg  size  and  involved  the 
right  ton,sil.  The  removal  of  the  soft  tumor  was  not  very  diffi- 
cult and  could  be  done  without  any  preliminary  operation.  The 
patient  was  doing  very  well  until  January,  1893,  when  he  was 
reported  to  me  as  having  died  from  pneumonia. 

Case  V.  Carcinoma  of  the  Larynx. — L.  M.,  forty-three 
years  of  age,  saloon  keeper,  born  in  Germany.  Family  history 
good.  Patient  gives  a  specific  history.  For  six  months  hoarse- 
ness and  increasing  interference  with  deglutition.  Loss  of 
strength  and  appetite.  His  house  physician,  under  whose  care 
he  was  for  nearly  fifteen  years,  reported  that  he  repeatedly  has 
suffered  from  laryngeal  symptoms  and  swelling  of  the  glands 
of  the  neck.  Iodide  of  potassium  always  had  given  instant  re- 
lief, but  this  time  had  failed  to  do  so. 


May  13,  1893.] 


BECK:  SURGICAL  DISEASES  OF  THE  NECK. 


519 


As  the  dyspncea  assumed  a  dangerous  cliaracter,  tracheotomy 
was  performed  successfully  by  a  prominent  surgeon  of  this 
city,  who  put  him  under  specific  treatment  afterward. 

Temporary  relief,  especially  improvement  of  the  general 
condition,  was  gained,  but  on  both  sides  the  supraclavicular 
glands,  extending  to  the  lower  border  of  the  thyreoid  cartilage, 
were  enlarged  to  the  size  of  a  goose  egg  on  either  side. 

On  January  16,  1893,  when  first  seen  by  me,  he  complained 
of  great  weakness  and  loss  of  appetite.  Temperature,  100°; 
pulse,  98;  respiration,  26.  No  dyspncea.  The  tracheal  canal 
was  well  formed.  No  voice,  but  some  words  could  be  under- 
stood. The  patient  was  sent  to  St.  Mark's  Hospital  for  thor- 
ough observation.    Inunctions  were  daily  made. 

A  lary  ngoscopical  examination  revealed  an  irregular  musH, 
broadly  infiltrating  and  filling  the  laryngeal  cavity.  I  may  add 
that  a  foetid  odor  was  present.  The  whole  extent  of  the  dis- 
ease, of  course,  could  not  be  recognized. 

On  January  23d  the  patient  became  chilly  and  vomiting 
set  in  at  the  same  time.  Temperature,  104'4°  ;  pulse,  100;  res- 
piration, 30.    Treatment  was  expectant  for  two  days. 

As  there  was  no  change  for  the  better,  extirpation  of  the 
larynx  was  performed.  After  having  introduced  Trendelen- 
burg's tampon  cannula  a  longitudinal  cut  was  made  in  the  me- 
dian line  reaching  from  the  hyoid  bone  to  the  third  tracheal 
I'ing.  A  cross  incision  alongside  the  hyoid  bone  was  added. 
After  having  dissected  the  soft  tissues,  they,  with  the  perios- 
teum, were  pushed  aside  and  by  the  blunt  use  of  Cooper's  scis- 
sors the  whole  cartilage  was  laid  bare. 

The  cricothyreoid,  and  later  on  the  superior  laryngeal,  artery 
could  be  ligated  before  being  cut  through.  With  a  blunt  hook 
the  cartilage  could  then  be  pulled  forward,  and  in  connection 
with  it  the  epiglottis  was  removed  after  having  dissected  the 
attachments  to  the  njsophagus. 

After  insertion  of  two  ligatures  into  the  third  tracheal  ring, 
the  trachea  was  severed. 

When  the  operatioH  was  completed  the  large  cavity  was  left 
open  and  packed  with  iodoform  gauze;  an  oesophageal  tube  was 
inserted  and  left  in  situ  for  three  days.  The  microscopical 
examination  elicited  evidence  of  carcinoma. 

The  patient's  condition  was  excellent  after  the  operation. 
For  the  next  six  days  the  average  temperature  was  normal,  the 
pulse  90,  and  the  respiration  21. 

In  the  place  of  the  tampon  cannula,  an  ordinary  one  was  in- 
serted the  following  day. 

Profuse  salivation  was  the  only  complaint  of  the  pa- 
tient. 

The  gauze  was  renewed  twice  daily. 

On  February  4th  the  gauze  was  found  saturated  with  arte- 
rial blood,  wherefore  it  was  pulled  out  carefully.  After  the 
last  piece  was  extracted  the  bleeding  increased.  With  my  index 
■finger  I  was  able  to  compress  it  till  the  head  was  brought  into 
a  dependent  position.  Now  I  could  see  the  bleeding  from  a 
small  branch  of  the  cricothyreoid,  from  which  the  ligature  had 
slipped  off. 

It  was  easily  caught,  and  the  cavity  again  packed  with  iodo- 
form gauze.  The  oesophageal  sound  had  been  removed  already 
two  days  ago,  and  was  only  introduced  three  times  a  day  for 
purposes  of  nutrition. 

On  February  10th,  after  having  been  in  an  excellent  condi- 
tion (he,  for  instance,  was  able  to  walk  around  in  the  wards 
of  the  hospital),  he  suddenly  became  chilly  and  pneumonia  de- 
veloped. Death  the  following  day.  Autopsy  showed  double 
broncho-pneumonia.  The  considerable  enlargement  of  the 
bronchial  glands  made  it  probable  to  me  that,  if  the  operation 
had  been  performed  earlier,  the  chances  of  success  would  have 
been  considerable. 


Case  VI.  Carcinoma  of  the  S\q>raclavicular  Gland. — Mrs. 
Adelaide  S.  (case  presented  to  the  New  York  County  Medical 
Society's  stated  meeting  of  November,  1892),  aged  fifty-three 
years,  sterile,  a  native  of  Germany.  Mother  had  died  from  a 
tumor  in  the  abdomen. 

Patient  has  always  been  well  until  January,  1888;  she  then 
first  noticed  a  small  lump  in  the  right  mammary  gland,  near  the 
nipple. 

She  had  first  treated  the  lump  by  external  application  till  she 
was  advised  by  her  house  ])hysician  to  undergo  an  operation  for 
carcinoma. 

On  May  20th  I  amputated  the  whole  breast,  extirpating  at 
the  same  time  several  glands  of  the  axilla,  which,  by  the  way, 
could  not  be  distinguished  through  the  skin  before  the  opera- 
tion. 

Union  took  place  by  first  intention,  and  the  patient  gained 
considerable  in  weight. 

In  April,  1890,  when  two  nodules,  of  filbert  size,  were  dis- 
covered in  the  scar,  I  made  a  second  extirpation,  followed  by 
perfect  recovery. 

In  February,  1892,  six  nodules,  from  pea  to  marble  size, 
which  lately  had  made  their  appearance,  were  extirpated. 

Four  months  later  the  supraclavicular  glands  commenced  to 
swell.  Injections  of  iodoform  ether  and  the  internal  use  of 
Eoncegno  water  seemed  to  stop  their  growing. 

On  October  29th,  after  three  months  of  absence,  she  showed 
up  again  with  a  nodule  of  marble  size  in  the  middle  of  the 
scar  of  the  mamma. 

The  patient's  general  condition  was  not  as  good  as  usual. 

Immediate  extirpation  was  done,  and,  although  a  great  quan- 
tity of  skin  was  removed  this  time  again,  the  edges  could  be 
brought  together,  and,  in  spite  of  considerable  tension,  union 
took  place  by  first  intention. 

No  glands  in  the  axilla  were  found  this  time. 

I  was  astonished  to  find  the  supraclavicular  glands  decrease 
in  size  after  this  fourth  removal. 

Until  now — that  is,  five  years  after  the  first  removal — the 
patient  has  been  in  a  fair  condition. 

The  hardened  supraclavicular  glands  are  still  enlarged,  but 
cause  no  trouble. 

Case  VII.  Carcinoma  (Esophagi. — Philipp  N.,  aged  fifty- 
nine  years,  German,  family  history  good.  For  the  last  year 
he  had  noticed  a  burning  sensation  while  swallowing  warm 
meals;  in  the  last  four  months  deglutition  was  interfered  with 
also. 

On  January  4th,  when  seen  first,  he  appeared  sick.  Tem- 
perature and  pulse  were  normal.  Nine  inches  from  the  front 
teeth  a  stricture  was  detected,  which  only  allowed  a  very  thin 
sound  to  pass. 

Repeated  sounding  improved  his  condition  temporarily,  but 
later  on  deglutition  became  very  tedious.  Patient  left  our  de- 
partment.   No  further  report  could  be  furnished. 

Case  VIII.  QSsophagectomy .■ — Martha  R.,  aged  sixty-one 
years,  widow,  born  in  Germany.  Mother  died  from  carcinoma 
uteri.  Among  four  of  her  children,  one  liad  died  early,  the 
other  three  are  well.  The  patient  had  been  feeling  well  until 
six  months  ago,  wiien  she  noticed  difficulty  in  deglutition.  Two 
months  ago  a  swelling  on  the  left  side  of  the  larynx  had  ap- 
peared at  the  same  time.  She  was  only  able  to  swallow  li()uid 
food. 

A  very  thin  sound  passed  a  stricture  six  inches  from  the 
teeth. 

On  February  7th  longitudinal  incision  on  the  [losterior  mar- 
gin of  the  right  sterno-cleido-mastoid  was  made,  to  which  later 
on  a  cross  incision  toward  the  middle  of  the  larynx  was  added. 

The  nervus  vagus  and  carotis  and  ju{;ulariti,  together  with 


520 


BECK:   .SURGICAL  DISEASES  OF  THE  NECK. 


[N.  Y.  Mko.  Jock.. 


the  ramus  deseendens  of  the  nervus  hypoglossu?,  could  be  pulled 
back  with  blunt  hooks.  A  lead  sound,  previously  introduced 
through  the  mouth,  could  not  be  felt,  wherefore  tlie  oesophagus 
was  iflcised  between  two  forceps. 

A  tumor  of  hen's-egg  size  could  easily  be  felt.  After  first 
having  bluntly  loosened  the  lower  part  of  the  growth,  it,  to- 
gether with  the  (esophagus  in  its  whole  circumference,  was  re- 
sected with  Cooj)er's  scissors.  Then  it  was  easy  to  remove  the 
npper  border. 

The  interspace  between  the  two  esophageal  fragments 
amounted  to  an  inch  and  a  half.  Sewing  was  abstained  from. 
A  soft  catheter  was  left  in  situ  for  the  purpose  of  nutrition. 
Packing  witii  iodoform  gauze.  The  following  day  the  patient 
was  very  weak.    Temperature,  101°;  pulse,  120. 

One  day  later  fa^tid  odor  and  profuse  sero-purulent  di.seharge 
from  the  wound  was  noticed. 

On  the  fourth  day  the  patient  died  with  the  symptoms  of  a 
pleuritis  on  the  I'ight  side.    No  autopsy  was  allowed. 

Three  cases  of  .tijjihilitic  tinnors  were  turned  over  to  the 
department  of  venereal  diseases. 

Case  I.  Flhroma. — William  O.,  aged  forty-one  years,  (h-iver, 
for  the  Inst  nine  years  is  suffering  from  seventeen  tumors  of 
peanut  to  goose- egg  size. 

The  growths  iiad  not  been  growing  dui'ing  the  last  four  years, 
and  were  situated  at  the  subauricular  and  supraclavicular  re- 
gion of  both  sides. 

As  disfiguration  was  the  only  symptom  complained  of,  the 
patient,  who  had  expected  to  be  cured  by  the  use  of  an  oint- 
ment, declined  an  operation. 

Case  II.  Jacob  W.,  aged  forty-one  years,  peddler,  born  in 
Germany.  For  the  last  three  years  he  noticed  a  hard  lumji  in 
the  subauricular  region,  which  now  had  readied  the  size  of  a 
goose  egg.  K.Ktirpation  on  May  6,  1892.  Union  by  first  inten- 
tion,   lias  recently  been  reported  well. 

Lipoma, — Three  cases,  all  males,  twenty-one,  thirty,  and 
fifty-three  years  of  age.  Two  were  situated  in  the  subclavicu- 
lar region,  one  occupied  the  region  above  the  transverse  pro- 
cesses of  the  tifth  and  fourth  cervical  vertebrte.  Extirpation 
was  followed  by  first  intention. 

The  one  lipoma,  concerning  a  man  fifty-three  years  of  age, 
was  considered  to  be  a  fibroma  before  extirpation  on  account  of 
its  hardness,  which  was  caused  by  several  thick  bands  of  fibrous 
tissue,  extending  through  the  fat-flaps. 

Struma. —  Six  cases  (two  colloid — struma  gelatinosa — and 
four  fibrous),  two  males,  four  females,  fourteen,  seventeen, 
thirty,  forty,  forty-two,  and  fifty-one  years  of  age. 

Four  were  born  in  Germany,  two  in  Switzerland. 

None  of  the  strumas  exceeded  the  size  of  a  goose  egg. 

No  pressure  symptoms  except  in  the  case  of  a  Swiss  gentle- 
man, fitty-one  years  of  age,  who  sometimes  had  asthmaric  par- 
oxysms. All  the  cases  were  cured  by  from  seven  to  twenty- 
four  injections  of  iodoform  ether.  At  the  same  time  iodide  of 
potassium  was  given. 

All  cases  of  struma  observed  by  me  in  this  country  during  a 
period  of  eleven  years  could  not  in  the  least  compare  with  those 
commonly  occurring  in  many  parts  of  South  Germany,  Switzer- 
land, and  the  Tyrol,  this  probably  being  due  to  the  excellent 
drinking  water  of  this  country  if  we  assume  the  non-parasitic 
nature  of  struma. 

AnffeAoma. — Three  cases  of  children  (one  male,  two  females), 
one  being  one  month,  another  three  inontlis,  the  third  one  eight- 
een months  old,  when  they  underwent  treatment.  One,  being 
of  the  size  of  a  quarter,  was  situated  at  the  right  upper  trigonum, 
the  two  others  right  above  the  manubrium  sterni;  one  of  those 
cases  was  of  the  size  of  a  fifty-cent  piece,  the  other  one  larger 
than  a  silver  dollar. 


While  the  two  angeiomas  named  first  were  easily  removed  by 
the  use  of  I'aquelin's  cautery,  the  latter,  belonging  to  agirl  eight- 
een months  of  age,  on  account  of  its  contents,  was  first  treated 
by  puncture  with  the  galvanic  needle.  As  this  slow  process  ex- 
hausted the  patience,  I  removed  the  entire  growth  with  Paque- 
lin's  cautery  at  one  time.  A  very  large  scar  was  forming  which 
was  treated  by  massage,  so  tl)at  now  no  interference  with  the 
mobility  of  the  muscles  of  the  neck  can  be  observed. 

Atheroma  (superficially  located). — Two  cases,  both  being 
single  and  not  sliowing  adhesions,  successfully  extirpated  by  niy 
method  described  above. 

lli/drocele  Colli. — One  patient,  Martin  L.,  fourteen  months  of 
age,  has  had  a  soft  lutnpof  jK-anut  size  on  the  middle  of  the  an- 
terior margin  of  the  sterno-cleido-inastoid  ever  since  birth.  The 
family  physician  diagnosticated  a  cold  abscess  and  advised  incis- 
ion on  account  of  tlie  presence  of  fluctuation,  although  the  child 
was  looking  a  picture  of  health.  Operation,  which  never  in  a 
doubtful  cpse  should  be  omitted,  revealed  a  serous  fluid. 

iodoform  ether,  injected  four  times,  effected  a  cure. 

ileningopele  Spinalis. — One  patient,  Anna  K.,  two  days  old. 
was  born  with  a  tumor  of  iien's-egg  size  in  the  middle  of  the 
posterior  neck.  Healthy  appearance.  No  paralytic  symptoms ; 
slight  fluctuation.  Aspiration  yielded  clear  serous  fluid.  As  the 
tumor  was  movable,  a  chasm  in  the  corpus  of  the  fourth  cervical 
vertebra  could  be  felt.  Incision  of  the  tumor  on  March  10. 
1893,  revealed  a  sac  filled  with  cerebro  spinal  fluid  and  consist- 
ing of  dura  mater  which  was  removed. 

The  edges  could  be  united  with  three  catgut  sutures  (thin- 
nest size).  Union  by  first  intention  followed.  Up  to  date  the 
child,  with  the  exception  of  frequent  vomiting,  has  remained 
well.  As  the  communication  with  the  s|)inal  canal  was  very 
small,  a  thorough  and  final  obliteration  may  be  expected. 

Congenital  Fistula. — One  patient,  Rebecca  R.,  twenty-one 
years  of  age,  born  in  Austria,  since  birth  has  suffered  from  a 
small  opening  on  the  anterior  margin  of  the  sterno-cleido-mas- 
toid,  about  one  inch  above  the  upper  border  of  the  sternum.  A 
thin  probe  introduced  into  the  fistula  touched  the  cornu  majus 
of  the  thyreoid  bone.  A  gelatinous  fluid  was  discharged  from 
the  canal  once  in  a  while.  Repeatedly  it  had  closed  spontane- 
ously. After  a  thin  galvanic  needle  was  introduced  seven  times 
perfect  occlusion  was  obtained. 

As  only  six  months  have  elapsed  since,  I  am  uncertain  yet 
in  reference  to  the  final  result. 

Torticollis. — Three  cases.  Slight  scoliosis  present  in  all  cases, 
which  were  one  of  seven,  one  of  eighteen  months,  and  one  thir- 
teen years  of  age  ;  two  males,  one  female.  All  the  cases  were 
operated  by  a  free  incision,  this  allowing  a  thorough  separation 
of  the  thick  fibers  of  the  sterno-cleido-mastoid.  Union  by  first 
intention.  After-treatment  by  jury  mast  was  always  followed 
by  perfect  recovery. 

Caries  and  Necrosis  of  Cervical  Vertehroe.  Case  I. — Carrie 
N.,  four  years  of  age,  born  in  New  York  city.  Family  history 
good.  Kyphotic  for  one  year  (history  of  a  fall) ;  showed  an  ab- 
scess on  the  posterior  margin  of  the  right  sterno-cleido-mastoid 
in  its  middle.  An  incision  made  by  the  family  physician  brought 
forth  two  tablespoon fuls  of  thick  pus  of  offensive  odor.  Pa- 
tient's condition  did  not  improve  after  this  interference. 

On  May  29,  1892,  she  was  seen  first  by  me,  and  I  could  make 
a  carefully  manipulated  probe  touch  bare  bone. 

A  trap-door  flap  incision  was  made  on  the  posterior  margin 
of  the  sterno-cleido-mastoid.  By  ])roceeding  blunily  the  prever- 
tebral space  was  reached,  wherefrom  about  a  tablespoonful  of 
cheesy  pus  was  emptied.  The  third  and  fourth  transverse  pro- 
cesses, besides  the  portion  of  the  arcus,  were  found  loose  and  in 
a  necrotic  state,  wherefore  they  were  extracted.  The  cavity 
was  packed  with  iodoform  gauze  and  plaster-of-Paris  dressing 


May  13,  1893.] 


BECK:  SURGK'AL  DISEASES  OF  THE  NECK. 


521 


iipl)lie(i,  wliicli  embraced  chest  and  Iiead.  A  fenestra  corre- 
sj)onding  with  tlie  opening  was  left.  Considerable  itnprovetneiit 
followed  for  three  months,  when  the  |)atient  fell  a  victim  of  tlie 
grippe. 

Case  II. — Jacob  R.,  two  years  of  age;  family  history  good. 
Six  months  ago,  after  a  short  period  of  illness,  in  the  left  sub- 
maxillary region  a  tumor  was  forming,  which  was  incised  by 
the  family  jjliysician.  A  considerable  amount  of  pus  was  dis- 
charged, but  the  wound  did  not  heal  in  spite  of  "  a  drainage- 
tube  and  the  most  careful  antiseptic  precautions." 

On  December  8,  1802,  when  first  seen  by  me,  a  probe 
touched  denuded  bone.  A  longitudinal  incision  was  made  on 
the  posterior  border  of  the  sterno-cleido-mastoid,  and  the  rest 
of  tlie  operation  done  as  above.  The  transverse  process  of  the 
epistropheus,  whicli  was  found  diseased,  was  chiseled  away  en- 
tirely. 

By  open  treatment,  recovery  followed  eleven  weeks  later. 

Immobilization  was  secured  by  the  use  of  my  modification 
of  a  Kramer's  wire  splint,*  which  extended  from  the  eighth 
dorsal  vertebra  up  to  the  forehead. 

Case  III. — Rosalia  B.,  twenty-four  years  of  age,  born  in 
Russia,  housewife.  Mother  of  two  healthy  children.  Family 
history  good.  Eight  months  ago,  in  the  middle  of  the  right 
neck,  she  noticed  a  painful  swelling  which,  after  four  weeks" 
standing,  had  been  incised  by  the  family  physician.  The  after- 
treatment  consisted  in  various  kinds  of  poultices.  Puticnt  lost 
twenty-seven  pounds.  The  slightest  motion  of  the  spinal  col- 
umn caused  severe  pain. 

On  January  18,  1892,  when  first  seen,  a  fistula  was  noticed 
behind  the  cornu  majus  of  the  hyoid  bone.  A  carefully  ma- 
nipulated probe  at  last  touched  denuded  bone. 

A  T-shaped  incision  (longitudinally  on  the  posterior  margin 
of  the  sterno-cleido-mastoid)  was  made.  The  rest  of  the  opera- 
tion was  done  as  mentioned  above.  A  necrotic  bone  fragment 
of  the  size  of  a  filbert,  slightly  attached  to  the  arcus  of  the  fifth 
cervical  vertebra,  could  easily  be  removed.  Open  treatment. 
Perfect  union  after  three  months.  (Four  weeks  ago  the  pa- 
tient was  confined  with  a  healthy  child.) 

Retropharynfjeal  Ahsi'ens  (three  cases). — In  tliis  connection 
I  may  state  that  as  early  as  May  18,  1886,  Dr.  Max  Bracker 
and  myself  made  use  of  external  incision  in  a  child,  eighteen 
months  of  age,  suffering  from  retropharyngeal  abscess,  as  we 
regarded  it  impossible  to  use  antiseptic  treatment  after  having 
made  an  internal  incision.  Later  on  I  made  it  a  habit  to  add  a 
counter-incision  on  the  other  side  of  the  neck,  introducing  my 
finger  into  the  mouth  and  incising  on  its  tip  at  tlie  posterior 
margin  of  the  opposite  sterno  cleido-mastoid. 

I  then  introdu<^ed  a  drainage-tube,  surrounded  by  fifty-per- 
cent, iodoform  gauze,  right  through  for  the  next  few  days,  thus 
surely  avoiding  retention  of  pus. 

Case  I. — Charles  H.,  four  years  of  age,  born  in  New  York 
city  ;  family  history  good.  On  May  10,  1892,  I  was  called  by  a 
prominent  physician  to  perform  tracheotomy  for  croup.  The 
little  patient  had  been  suffering  from  chronic  catarrh  of  the 
nose,  and  since  the  last  seven  weeks  he  could  nut  breathe 
through  the  nasal  passages  at  all.  Since  five  days  the  symp- 
toms of  dyspntjca  and  hoarseness  had  gradually  commenced. 
When  I  came,  the  little  patient  was  found  to  have  dyspnoea; 
at  the  same  time  slight  snoring  indicated  that  nasal  breathing 
was  interfered  with. 

There  was  only  a  very  slight  swelling  on  both  sides  of  the 
neck,  which  was  not  painful  by  pressure;  a  few  glands  of  the 
average  size  of  a  pea  present.  The  pharynx  showed  a  nearly 
normal  condition ;  palpation  of  the  same  could  detect  no  tJuc- 


*  See  New  York  MM'u  'nihche  Mon  tlxxchrift,  January,  189:1 


tuation.  But  the  swelling  led  me  to  suspect  a  deep-seated  ab- 
scess being  the  cause  of  pressure  upon  the  larynx.  I  therefore 
insisted  upon  making  an  external  incision  before  tracheotomy 
could  come  into  (juestion. 

And,  actually,  on  making  an  incision  on  the  posterior  edge 
of  the  sterno-cleido-mastoid,  as  in  cesophagotomy,  I  detected 
about  one  tablespoonful  of  creamy  pus  on  a  level  with  the  fifth 
vertebra.  A  slight  but  sufficient  relief  was  afforded  immedi- 
ately, and  uninterrupted  recovery  (lasting  six  weeks)  followed. 

Case  II. — Bella  N.,  two  years  of  age,  born  in  New  York 
city;  family  history  good.  Nasal  catarrh  since  many  months ; 
for  the  last  two  days  snoring  and  difficulty  in  respiration  and 
deglutition. 

On  March  1,  1892,  first  seen  by  me.  The  child  appeared 
cyanotic;  expression  of  face  very  anxious.  Mouth  wide  open. 
Respiration,  snoring  and  snuffling.  The  whole  neck  ajipeared 
to  be  stitT.  In  the  right  submaxillary  region  a  tumor  of  goose- 
egg  size.  Inspection  of  the  pharynx  shows  a  small  tumor 
which  pushed  the  posterior  pharyngeal  wall  forward.  Touch 
by  the  index  finger  revealed  fluctuation.  Immediate  incision 
and  contra-incision  under  chloroform  brought  instant  relief. 

Perfect  recovery  was  obtained  four  weeks  afterward. 

Case  III. — Moritz  P.,  eleven  months  of  age,  born  in  New 
York  city;  family  history  good.  Nasal  catarrh  since  the  time 
of  his  birth.  For  the  last  six  days  perfect  obstruction  of  the 
nose  and  the  peculiar  sound  produced  by  breathing  through  the 
mouth  only.  Since  two  days,  difficulty  in  deglutition  and  im- 
possibility of  nursing. 

On  July  27th,  when  first  under  observation,  the  very  ana;- 
mic  child  was  restless  and  had  liis  mouth  wide  open.  Snoring 
could  be  heard  before  the  sick  room  was  entered. 

In  the  left  submaxillary  region  a  hard  tumor  of  Jien's-egg 
size  could  be  noticed.  The  pharyngeal  space  was  nearly  filled 
up  by  a  tumor  of  the  same  size.  Fluctuation  well  marked  on 
the  pharyngeal  walls.  Immediate  incisions  on  both  sides  under 
anaesthesia  brought  relief  at  once.  Recovery  perfect  after  four 
weeks. 

Angina  Litdovici. — Fred  A.,  forty  years  of  age;  born  in 
Germany;  family  history  good.  Has  never  been  siik  until  two 
days  ago  he  suddenly  became  chilly,  and  shortly  after  noticed  a 
sharp  pain  in  his  pharynx.  The  family  physician  diagnosticated 
tonsillitis.  The  next  day  his  symptoms  became  aggravated  ;  u 
hard,  submental  swelling  appeared. 

On  December  20,  1892,  when  first  seen,  he  gave  the  appear- 
ance of  a  septic  patient.  Temperature,  102°;  pulse,  12.5.  la 
the  submental  region  and  in  the  right  submaxillary  region  a 
swelling  of  goose-egg  size  could  be  noticed. 

Slight  dyspnoia  and  very  marked  dysphagia  were  present. 
The  posterior  wall  of  the  pharynx  protruded  forward.  A  longi- 
tudinal incision  on  the  posterior  margin  of  the  sterno-cleido- 
mastoid,  to  which  a  cross-incision  alongside  the  inferior  margin 
of  the  lower  jaw  was  added,  discharged  a  teaspoonful  of  sero- 
purulent  fluid  and  some  necrotic  tissue.  Uninterrupted  recov- 
ery followed  (juickly. 

Spondi/lifin  (nine  cases — six  in  males,  three  in  females). — 
Two  were  born  in  (xermany,  three  in  Austria,  one  in  Rus>ia,  and 
three  in  New  York  city  ;  four  were  under  three,  three  between 
three  and  thirteen,  and  two  above  this  age.  In  four  cases  the 
family  history  was  good,  five  had  repeatedly  suffered  from 
bronchitis,  pneumonia,  and  enteritic  attacks.  All  of  them  were 
treated  with  the  jury  mast  locally,  while  internally  the  same 
principles  as  described  for  tuberculosis  were  employed.  Four 
patients  are  well;  five  have  considerably  improved  and  are  still 
under  treatment. 

Partial  Dix/orafion  (diastasis  of  tlie  vertebne),  two  cases. 

Case  I. — (Jeorge  N.,  brewer,  aged  forty-three,  born  in  (Jer- 


522 


BARUCH:   NON-MEDICINAL  REMEDIES  IN  ANEMIA. 


[N.  Y.  Med.  Joub., 


many,  a  liealthy  man,  one  week  ago  fell  from  a  beer  truck  and 
at  the  same  time  a  lieavy  beer  barrel  struck  bis  neck.  He  was 
unconscious  for  two  hours;  then  his  only  complaint  was  a  stifif- 
ness  in  his  neck  and  both  shoulders  and  a  sharp  pain  alongside 
the  cervical  column.  Both  arms  could  only  be  lifted  to  a  lim- 
ited degree.  The  sensibility  was  interfered  with  nowhere. 
Ditticulty  in  deglutition  and  pronunciation.  No  mobility  of  the 
spinal  column.  On  June  23,  1892,  I  found  that  the  spinous 
process  of  the  fourth  cervical  vertebra  showed  considerable  pro- 
jection ;  the  one  of  the  third  was  sunk  in.  The  index  finger,  in- 
troduced into  the  pharynx,  felt  the  third  vertebra  protruded, 
while  the  fourth  one  appeared  to  be  pushed  back.  The  recum- 
bent position  and  permanent  extension  for  at  least  ten  weeks 
in  Glisson's  cradle  was  advised,  but  the  patient  did  not  show  up 
again. 

Diantush  of  Fifth  Cervical  Vertehra  (New  York  Med.  Mo- 
natsschrift.  May,  1892).— John  T.,  aged  twenty-six,  of  tall  stat- 
ure, born  in  New  York  city.  Specific  history  :  Seven  weeks  ago 
wliile  carrying  stones  he  fell  off  a  step-ladder  and  was  uncon- 
scious for  several  minutes.  A  marked  disfiguration  on  his  neck 
was  noticed  by  his  comrades  at  once.  The  neck  was  entirely 
stiff  and  very  painful,  just  as  well  as  the  upper  dorsal  region. 
No  paralytic  symptoms  were  present. 

On  February  8,  1892,  when  first  seen  by  me,  he  looked  like 
a  kyphotic  patient.  Only  with  the  use  of  an  immobilizing  collar 
was  he  able  to  sit  or  stand  up.  No  mobility.  No  interference 
with  sensibility.  Slight  disturbance  of  deglutition.  Voice  weak 
and  hoarse.  A  protuberance  very  sensitive  to  the  touch,  of  nearly 
the  size  of  a  man's  fist,  extended  from  the  second  dorsal  up  to 
the  third  cervical  vertebra.  It  was  impossible  at  this  period  to 
discover  the  particular  vertebrsB  participating  in  the  swelling.  On 
inspection  of  the  pharynx,  a  curvature  of  the  spinal  column  could 
be  noticed.  On  palpation,  it  was  found  that  the  sixth  cervical 
vertebra  was  protruding,  while  the  fifth  was  lying  far  back.  A 
laryngoscopical  examination  by  Dr.  Freudenthal  was  almost 
impossible,  as  the  projection  nearly  overlapped  the  epiglottis. 

After  a  treatment  with  Glis«on's  cradle  for  three  months, 
combined  with  inunction  of  blue  ointment,  recovery  was  ob- 
tained so  that  the  protuberance  in  the  pharynx  has  entirely 
disappeared.  On  the  outside  still,  one  year  after  the  ac- 
cident, an  elevation  of  peanut  size  could  be  noticed.  There 
was  no  more  trouble,  however.  It  is  questionable  to  what  ex- 
tent the  luetic  condition  had  added  to  the  original  swelling, 
the  vitality  of  the  tissues  having  perhaps  thus  been  impaired. 

In  reference  to  enlarged  tonsils  (nine  cases)  it  may  be  stated 
that  extirpation  was  always  performed  with  the  blunt-pointed 
knife,  as  by  pulling  the  tonsil  forward  with  Muzeux's  forceps 
much  more  could  be  exsected  from  the  hypertrophied  organ. 

Disfiguring  and  Deforming  Scar,  caused  hy  a  Burn. — Jacob 
W.,  aged  three,  born  in  New  Y'ork,  on  April  30,  1892,  bad 
been  burned  over  the  whole  right  side  of  his  neck,  the  burns 
being  of  the  third  degree.  Healing  was  completed  three 
months  later,  but  the  cicatricial  tissue  had  become  so  hardened 
that  contraction  took  place,  causing  the  chin  to  approach  the 
sternum.  Glisson's  cradle  applied  for  six  months  had  improved 
the  position  of  the  head  so  much  that  by  the  use  of  an  immo- 
bilizing collar  the  neck  could  be  kept  up  straight. 

Foreign  Bodies  in  the  (Fsoi^liagus.  Oase  I.- -Deborah  L., 
aged  eighteen  months,  born  in  Russia  (see  New  Y^ork  Med. 
Monatsschrifl,  April,  1892),  while  playing  had  swallowed  a 
quarttT-  of  a  dollar  piece.  Physicians  had  at  once  tried  to  pro- 
duce  emesis  and  afterward  to  extract  it,  but  without  any  effect. 
The  little  patient,  however,  was  able  to  swallow  liquid  food, 
but  lately  she  vomited  rei)oatedly.  When  I  heard  the  i)arents' 
report,  four  weeks  iiftor  the  accident  had  happened,  it  seemed 
to  me  hardly  credible.    I  could  not  understand  how  a  piece  of 


such  a  size  could  i)ass  the  (esophagus  of  a  child  of  lier  age,  nor 
that  the  condition  could  continue  without  developing  more 
alarming  symptoms.  Therefore  I  had  the  impression  that  the 
patient,  who  was  not  looking  bad  at  all,  was  more  the  victim 
of  forcible  medical  and  surgical  interference  than  of  anything 
else.  More  as  a  matter  of  duty,  therefore,  than  in  the  expecta- 
tion to  find  the  foreign  body,  I  introduced  my  coin-catcher. 
After  first  having  touched  the  walls  of  the  pharynx  without 
noticing  anything  abnormal,  I  passed  the  isthmus.  There  I 
met  with  a  resistance.  Instinctively  I  turned  the  sound,  made 
a  slight  traction,  and  indeed  felt  it  yielding.  After  this,  resist- 
ance was  experienced  again  and  further  traction  was  impossible. 
So  1  introduced  my  index  finger  far  into  the  pharynx,  where, 
to  my  great  surprise  and  joy,  I  could  feel  the  coin  and  extracted 
it.  Perfect  recovery  followed.  The  appearance  of  the  coin 
had  somewhat  changed.  On  some  portions,  probably  where  it 
was  lying  free,  it  looked  polished ;  on  some  other  portions, 
where  it  bad  been  impacted  in  the  mucous  membrane,  a  crust 
of  dried  up  secretions  covered  its  surface. 

Case  II. — Willy  N.,  aged  eleven  months,  born  in  New  York 
city  (see  Medical  Record,  January  21,  1893,  p.  89).  Two  days 
ago,  while  playing,  he  had  swallowed  a  so-called  campaign 
button,  being  of  the  size  of  a  ])enny.  Various  means  were 
resorted  to  to  fish  it  up  or  to  i)ush  it  down  by  several  col- 
leagues, but  they  did  not  avail.  On  December  17, 1892,  when  I 
first  saw  the  child,  I  performed  a'sophagotomy.  The  button 
was  found  on  a  level  with  the  upper  border  of  the  first  rib, 
where,  on  account  of  its  sharj)  edges,  it  had  perforated  the 
oesophagus  toward  the  tiachea,  on  which  it  had  exerted  press- 
ure. The  incision  had  been  made  alongside  the  left  anterior 
margin  of  the  sterno-cleido-mastoid.  The  wound  was  only  par- 
tially closed  and  the  remainder  left  open  and  packed  with 
iodoform  gauze.  As  the  operation  could  be  done  quickly  and 
without  considerable  injury  or  loss  of  blood,  I  had  hopes  for 
the  patient;  but  he  died  the  next  dcyfrom  broncho-pneumonia. 

This  case  illustrates  the  great  danger  of  delaying 
cesophagotomy  after  extraction  or  pushing  down  bad  been 
tried  in  vain. 

In  conclusion,  I  like  to  state  that  I  am  very  much  in- 
debted to  Dr.  F.  Haendel,  Dr.  A.  H.  Stiebeling,  and  Dr. 
A.  Haymann  for  taking  the  records  of  the  cases  reported 
above. 

37  East  Thirty-first  Strkkt. 


NON-MEDICINAL  REMEDIES  IN  ANEMIA.* 

By  SIMON  BARUCH,  M.  D. 

Upon  the  recognition  of  the  aetiology  of  anaemia  de- 
pends its  successful  treatment.  So  long  as  anaemia  shall 
remain  associated  with  iron  treatment  in  the  minds  of 
physicians,  so  long  will  its  management  remain  unsatisfac- 
tory. Pure  empiricism  is  to  be  deprecated  at  all  times. 
While  tlierapeusis  may  never  become  strictly  scientific,  ow- 
ing to  the  varying  condition  of  the  premises  involved  in 
each  therapeutic  problem,  we  may  at  least  aim  at  some 
rational  basis  for  our  treatment  of  disease.  The  reputation 
of  iron  in  anaemia  rests  upon  an  entirely  empirical  basis. 
Modern  physiology  teaches  that  the  action  of  this  remedy, 
undoubted  as  is  its  value,  can  not  be  explained  upon  rational 

*  Read  before  the  Section  in  General  Medicine  of  the  New  York 
Academy  of  Medicine,  April  18,  1893. 


May  13,  1893.] 


BARUCH:  NON-MEDIGINA 


L  REMEDIES  IN  ANAEMIA. 


523 


principles.  Indeed,  the  idea  long  held  that  iron  improves 
the  blood  by  furnishing  to  it  the  lacking  mineral  constitu- 
ent is  liappily  losing  ground.  It  has  been  calculated  that 
the  entire  (juantity  of  iron  in  the  human  body  amounts  to 
about  fifteen  to  forty-five  grains,  and  that  the  greatest  loss 
of  iron  discovered  in  an  anasmic  patient  is  about  three  to 
four  grains.  A  quarter  of  a  pound  of  good  beef  is  capable 
of  furnishing  this  quantity.  Iron  is  an  important  and  neces- 
sary constituent  of  the  blood,  one  which  is  constantly  lost 
in  various  secretions,  chietly  in  the  bile,  and  which  is  elimi- 
nated in  the  fiieces  aiid  urine  ;  but  it  is  regularly  furnished 
by  the  food,  especially  the  albuminoids. 

Primary  anaemia  appears  to  be  generally  regarded  as  the 
manifestation  of  a  defective  balance  between  the  intake  and 
outgo  of  iron  in  the  blood.  We  say  that  a  patient  is 
anaemic  when  his  tissues  lack  the  ruddy  color  indicative  of 
a  perfect  condition  of  the  blood.  It  is  an  elementary 
physiological  fact  that  this  color  is  due  to  the  presence  not 
only  of  a  sufficient  proportion  of  red  corpuscles,  but  to  the 
presence  in  the  latter  of  a  sufficient  proportion  of  lucmo- 
globin,  or  rather  of  ha-matin,  whose  most  important  con- 
stituent is  known  to  be  iron.  How  this  iron  is  supplied  to 
the  haemoglobin  is  still  too  obscure  to  afford  a  basis  for 
therapeutic  deduction. 

This  much,  however,  is  positively  known  :  that  the  func- 
tion of  iron  in  the  haemoglobin  is  respiratory  ;  in  other  words, 
iron  is  the  great  oxygen  carrier  of  the  blood,  and  therefore 
of  the  whole  body.  This  is  proved  by  the  fact  that,  when 
strong  sulphuric  acid  is  added  to  the  haematin,  it  takes  up 
the  iron  contained  in  it,  and,  while  the  color  still  remains, 
its  power  of  combining  loosely  with  oxygen  is  entirely  de- 
stroyed. 

It  must  be  considered  that  the  change  from  venous  to 
arterial  blood  is  due  not,  as  was  formerly  supposed,  to  ex- 
change from  a  ferrous  to  a  ferric  salt,  but  to  a  change  in 
the  haemoglobin  of  the  venous  blood  to  that  of  oxyhaimo- 
globin  of  arterial  blood.  While  tlie  hiemoglobin  of  venous 
blood  contains  some  oxygen,  the  haemoglobin  of  arterial 
blood  is  nearly  saturated  with  oxygen. 

It  follows,  therefore,  that,  since  iron  is  essentially  the 
oxygen- carrying  constituent  of  hiemoglobin,  even  a  seem- 
ingly trivial  lack  of  it  in  the  blood  must  seriously  embar- 
rass the  arterializing  process  which  lends  to  the  tissues  their 
ruddy  hue.  I  have  already  referred  to  the  improbability 
of  large  quantities  of  medicinal  iron  being  necessary  to 
supply  this  lack  in  the  hajmoglobin.  May  we  not  deduce 
a  more  rational  method  of  treating  anaemia  from  the  con- 
sideration of  the  brief  physiological  data  referred  to  ? 

I  have  mentioned  these  elementary  physiological  facts 
in  order  to  emphasize  the  necessity  of  greater  regard  to  the 
aetiological  factors  dominating  this  condition,  and  thence  to 
make  therapeutic  deductions. 

Unfavorable  environment  is  a  frequent  cause  contribut- 
ing to  the  development  of  aniemia.  Confinement  to  badly 
ventilated  schoolrooms,  deprivation  of  outdoor  exercise, 
digestive  troubles  due  to  these,  improper  and  insufficient 
food,  and  mental  anxiety  are  recognized  factors.  Of  what 
avail  would  the  administration  of  iron  be  in  such  cases  so 
long  as  these  aetiological  elements  are  active  ?    Of  what 


use  would  an  addition  of  iron  to  the  haemoglobin  be  if  its 
hunger  for  oxygen  can  not  be  appeased  by  iexposure  of  the 
patient  to  pure  air  ?  I  would  plead,  therefore,  first,  for  the 
provision  of  an  ample  supply  of  oxygen  to  anaemic  patients, 
not  ox^'gen  artificially  made  and  forced  into  the  lungs,  but 
oxygen  obtained  in  the  only  perfect  form — from  natural 
sources,  in  the  fields,  in  the  woods,  in  the  parks,  freed  from 
human  emanations,  which  contaminate  it  even  in  the  belter 
class  of  city  and  town  dwellings.  Those  who  have  done 
much  dispensary  practice  will  agree  that  among  the  pa- 
'tients  of  the  tenement  districts  iron  is  particularly  unsuc- 
cessful. The  latter  is  also  true  in  school  girls  and  boys 
who  are  subjected  to  continuous  lessons  and  are  thus  de- 
prived of  access  to  pure  air  and  muscular  exercise.  The 
lesson  taught  by  common  sense  would  be  to  remove  the  pa- 
tient from  his  unfortunate  surroundings  rather  than  to  ply 
him  with  medicinal  agents  and  improve  his  blood.  Severe 
ana'inics  among  the  poorer  classes  must  be  brought  to  the 
hospital,  where  at  least  the  air  is  pure,  and  other  important 
agencies  of  restoration  are  available.  It  is  surprising  how 
such  a  change  brings  back  the  color  to  the  pallid  cheek 
of  the  factory  girl  and  the  clerk.  Though  they  may  act 
be  ill  enough  to  have  life  threatened,  these  poor  creatures 
are  entitled  to  the  same  care  as  a  case  of  typhoid  or  pneu- 
monia. A  few  weeks'  residence  in  a  clean,  well- aired  hos- 
pital ward  will  do  more  to  restore  such  cases  to  health 
than  iron  or  arsenic  alone.  And  this  brings  me  to  another 
point  I  desire  to  dwell  upon — viz.,  the  inutility,  nay,  the 
impropriety,  of  advising  active  exercise  for  every  case  of 
anannia. 

Too  often  the  direction  is  given  to  the  ansemic  who  is  in 
good  financial  circumstances  :  Take  plenty  of  exercise,  good 
food,  and  these  iron  pills  three  times  a  day.  Many  cases, 
especially  those  which  suffer  from  dyspnoea  and  rapid  heart 
action,  would  be  more  improved  by  being  exposed  for 
hours  in  the  open  air,  quite  at  rest,  in  a  hammock  in  sum- 
mer, or  a  steamer  chair  wrapped  in  furs  or  blankets  in 
winter. 

Passive  exercise  by  massage  and  Swedish  movements 
once  or  twice  a  day  would  be  far  more  valuable  exercise 
than  walking  or  even  riding.  Putnam  Jacobi  has  by  care- 
ful observation  brought  out  the  value  of  massage  in  anae- 
mia, and  Weir  Mitchell  has  demonstrated  the  impor- 
tance of  rest  combined  with  massage  methodically  admin- 
istered. Their  success  after  failure  of  active  exercise  and 
medication  vouches  for  the  correctness  of  the  view  here 
inculcated. 

2.  Systematic  exercise  in  the  open  air  should  be  ad- 
vised. Special  stress  must  be  laid  upon  the  adjective 
"systematic."  Let  the  direction  for  exercise  be  as  precise 
as  for  the  pills ;  let  the  duration,  variety,  and  frequency  of 
repetition  be  distinctly  ordered.  Ranke  has  investigated 
the  effect  of  muscular  action  upon  the  total  blood  in  the 
body.  He  has  shown  that  its  first  effect  is  diminution  of 
the  blood  quantum,  which  becomes  more  marked  as  the 
intensity  of  the  muscular  action  increases  ;  but  when  the 
body  became  accustomed  to  active  exertion,  the  total  blood 
quantum  was  increased.  Thus  is  physiologically  demon- 
strated the  great  benefit  of  methodical  exercise,  and  espe- 


524 

cially  the  necessity  of  adapting  it  to  each  individual  case 
of  anaemia. 

3.  Diet. — Tlie  adaptation  of  a  proper  diet  to  ana-niia  is 
not  a  difticiilt  problem.  1  plead  only  for  more  piuictilious 
regard  to  flie  needs  of  each  case  than  is  usually  given.  The 
fancies  and  caprices  of  the  patient  should  be  less  regarded 
than  is  the  jjractice  now,  for  many  articles  of  food  that 
seem  repugnant  to  the  patient  may  be  gradually  adminis- 
tered if  a  good  nurse  is  instructed  to  persist  in  their  sys- 
tematic use.  Weir  Mitchell  has  in  this  respect  taught  us  a 
lesson  also.  Many  patients  who  were  absolutely  without 
appetite  and  to  whom  all  food  was  repugnant  liave  been 
systematically  fed  by  properly  selected  attendants  until  the 
quantity  consumed  by  them  was  enormous.  We  yield  too 
easily  to  the  predilections  of  the  patient  in  this  regard.  It 
inust  be  borne  in  mind  that  usually  all  appetite  is  lost  or 
impaired,  and  that  therefore  a  choice  of  acceptable  food  is 
impossible. 

Careful  attention  to  methodical  feeding  will  accomplish 
more  than  simple  direction  to  take  good  food,  etc.  The 
.same  precision  which  is  exercised  in  ordering  medicines 
will  in  the  case  of  diet  produce  more  positive  results  tlian 
are  usually  obtained. 

4.  A  valuable  auxiliary  to  the  methodical  application  of 
])ure  air,  exercise,  and  food  may  be  found  in  the  use  of 
water  upon  the  skin.  I  do  not  advocate  cold  baths  for 
ansemic  patients,  nor  indeed  for  any  patient,  except  one  suf- 
fering from  an  infectious  fever.  The  abstraction  of  heat 
should  be  always  avoided  in  anaemia.  It  is  my  custom  to 
produce  an  artificial  surface  lieat  before  ajDplying  cold 
water.  If  the  latter  is  done  just  after  rising  from  bed,  it 
will  in  many  cases  be  sufHcient.  AVhile  standing  in  a  tub 
of  water  at  100°,  the  temperature  of  the  room  being  not 
below  68°,  the  patient  receives  a  rapid  ablution  with  water 
at  70°  which  is  daily  reduced  two  or  three  degrees.  After 
this  he  is  rapidly  dried  and  induced  to  go  into  the  open 
air.  In  weaker  patients  the  dry  pack,  which  is  simply  a 
snug  wrapping  in  a  woolen  blanket  until  they  are  warm, 
followed  by  ablution  as  here  stated,  is  useful.  The  ab- 
straction of  heat  must  be  guarded  against  and  chilliness 
prevented. 

When  the  cutaneous  surface  has  thus  been  daily  disci- 
plined and  educated  to  bear  the  shock  from  gradual  im- 
pingement of  cold  water,  larger  quantities  may  be  used  : 
the  dripping  sheet,  so  highly  commended  by  Weir  Mitchell ; 
the  wet  pack,  followed  b}^  the  half  bath,  and  later  rain 
baths  and  jet  douches  judiciously  adapted  to  each  case» 
offer  the  most  valuable  means  for  restoring  the  blood  to 
its  normal  condition.  Actual  examination  with  Fleischl's 
Ijjemometer  has  convinced  me  of  this  therapeutic  fact. 

I  am  now  treating  a  young  lady  who  has  taken  six  hun- 
dred Blaud  pills  without  the  slightest  efEect.  She  has  re- 
ceived twelve  rain  baths  and  is  now  steadily  improving  in 
color,  strength,  and  ability  to  exercise  without  breathless- 
ness.  In  a  case  referred  to  me  last  summer  by  Dr.  T.  G. 
Thomas  the  ha;moglobin  percentage,  which  had  been  re- 
duced to  thirty-one  per  cent.,  was  raised  to  one  hundred 
j)er  cent,  under  systematic  douches  and  rain  baths  gradu- 
allv  reduced  in  temperature.    There  is  no  class  of  cases  in 


[N.  Y.  Med.  Jodk., 

which  a  judicious  hydrotherapy  offers  more  pronounced  re- 
sults than  in  ana;mia. 

The  rationale  of  its  action  is  probably  a  stimulation  of 
the  nerve  centers  presiding  over  nutrition,  a  deepening  of 
respiration,  and  invigoration  of  cardiac  action,  all  of  which 
may  be  observed  clinically  and  by  the  aid  of  instruments  of 
precision.  The  dilatation  of  the  cutaneous  vessels,  which 
results  after  a  thorough  general  douche,  probably  acts  by 
what  the  Germans  call    Hautatlmimuj^'' — skin  respiration. 

5.  De/pletion  is  a  method  of  treatment  which,  para- 
doxical as  it  may  seem,  has  demonstrated  its  value  clinic- 
ally. Scholz,  of  Bremen,  has  recently  written  a  monograph 
on  this  subject  whose  conclusions  have  been  extensively  re- 
produced in  the  medical  journals.  The  dry,  livid  condition 
of  the  skin  of  ana;mic  patients  is  aroused  to  renewed 
activity  by  exposure  to  hot-air  baths.  Excretion  is  thus 
rendered  more  energetic,  tissue  change  is  enhanced,  and  an 
increase  of  appetite  and  nutrition  is  tlius  induced. 

Repeated  small  bleedings  for  chlorosis  was  taught  by 
Boerhaave,  Hoffmann,  and  others,  and  has  in  recent  times 
been  advised  by  Dyes  and  Wilhelmi.  The  latter  reports 
thirty- one  cases  of  chlorosis  thus  treated.  Schubert  reports 
the  successful  application  of  bleeding  and  diaphoresis.  He 
bleeds  fifteen  to  twenty  drops  for  each  two  pounds  of  body 
weight.  After  the  bleeding  he  advises  rest  in  bed  for 
twenty-four  or  forty-eight  hours.  While  I  have  not  yet 
tried  venesection,  it  is  my  constant  practice  to  ordei'  for 
anaemic  patients  one  or  more  thorough  diaphoretic  (hot-air) 
baths  a  week,  followed  by  gradually  reduced  douclies,  for 
the  purpose  of  overcoming  the  spasmodic  contraction  of 
the  arterioles,  enhancing  tissue  change,  and  thus  improving 
assimilation  of  albuminoids. 

It  is  interesting  to  note  that  the  existence  of  arterial 
spasms  in  chlorosis  was  noted  as  long  ago  as  1731  by  Em- 
merich, who  lays  down  the  following  therapeutic  indica- 
tions : 

1.  To  remove  the  impure  blood  and  the  mixture  of  the 
juices. 

2.  To  improve  the  tone  of  the  stomach  and  intestines. 

3.  To  restore  those  natural  eliminations  which  are  sup- 
pressed. 

4.  To  remove  the  vascular  spasm. 

It  may  be  observed  that  this  shrewd  physician  had 
made  the  same  observations  with  regard  to  arterial  narrow- 
ing in  anaemia  and  chlorosis  which  in  recent  times  has 
been  demonstrated  scientifically  by  Virchow.  May  not 
diaphoresis  and  .surface  douching  owe  their  value  chiefly  to 
the  overcoming  of  the  arterial  spasm,  just  as  in  infectious 
fevers  the  same  spasm  is  overcome  by  cold  baths  and  fric- 
tions ?  Whatever  the  rationale  may  be,  in  my  hands  this 
treatment,  together  with  systematic  regulation  of  diet,  ex- 
ercise, and  exposure  to  good  air,  has  often  been  crowned 
with  success  after  failure  of  medicinal  agents.  Let  me  not 
be  understood,  however,  as  undervaluing  the  latter.  Iron 
especially,  which  was  used  long  before  its  being  a  constitu- 
ent of  the  blood  was  known,  and  has  had  the  enthusiastic 
approval  of  clinicians  like  Niemeyer  and  Trousseau,  is  use- 
ful. I  plead  only  against  its  indiscriminate  use  and  against 
the  idea  that  it  is  absorbed  into  the  blood. 


liARUCH:   NON-MEDICINAL  REMEDIES  IN  AN^JMIA. 


May  13,  1893.] 


McKEE:  LAPAROTOMY  FOR  MULTILOCULAR  OVARIAN  CYST. 


525 


The  chief  aim  of  tliis  paper,  however,  is  to  emphasize 
a  more  methodical  application  of  non-medicinal  remedies. 
If  there  is  any  point  upon  which  we  are  derelict  as  a  class, 
it  is  the  lack  of  precision  in  our  prescription  of  remedial 
measures,  especially  those  valuable  non-medicinal  agencies 
which,  as  Nothnagel  and  more  recently  Osier  have  shown, 
are  coming  to  the  front  as  chief  remedies.  While  there  is 
no  lack  of  insistence  upon  the  systematic  administration  of 
medicines,  while  the  regulation  teaspoonful  three  times 
daily,  or  powder  every  three  hours,  is  swallowed  with  the 
utmost  punctuality,  the  patient  suffering  from  anannia  or 
otlier  chronic  malady  is  allowed  to  drift  along  as  best  he 
may,  taking  his  exercise,  his  diet,  his  airing,  his  rest,  his 
bath,  as  pleases  his  sweet  will  or  suits  liis  personal  con- 
venience. 

I  plead  for  the  more  methodical  a[)plicatioii  of  these 
remedies  in  anaemia. 

■)!  Wkst  Seventieth  Street. 


THE  TECHNIQUE  OF  A  LAPAROTOMY  FOR 
MULTILOCULAR  OVARIAN  CYST 

COMPLICATED  WITH  PREGNANCY  AT  FIVE  MONTHS; 

recovery. 
By  frank  L.  MoKEE,  M.  D., 

PLYMOUTH,  PA. 

On  the  afternoon  of  August  25,  1892,  I  was  called  to  see 
Mrs.  W.  S.,  aged  twenty-eight  years,  of  sliglit  build,  weighing 
one  hundred  and  fourteen  pounds.  Mrs.  S.  thought  that  she 
was  pregnant,  aod  wished  me  to  verify  her  opinion.  After 
carefully  examining  her  by  bimanual  methods  I  located  a  hard 
mass  that  apparently  grew  from  the  left  ovary ;  it  was  about 
the  size  of  an  ordinary  man's  list.  With  a  uterine  sound  pass- 
ing into  the  womb  it  was  cjuite  easy  to  Tuove  the  mass  without 
moving  the  wouib.  Mrs.  hiul  continued  to  menstruate  regu- 
larly, all  positive  symptoms  of  pregnancy  were  absent,  the 
uterus  was  small  and  separate  from  the  tumor,  and  the  cervix 
was  softened.  I  then  assured  the  patient  that  she  was  all  right 
and  that  her  pregnancy  (?)  would  go  on  to  full  term,  fearing 
that  if  I  told  her  the  exact  state  of  affairs  she  would  go  the 
rounds  and  I  would  lose  the  opportunity  of  performing  a  brill- 
iant operation,  which  it  has  since  proved  to  be.  Mrs.  S.  pro- 
ceeded to  enlarge  with  great  regularity  and  with  fearful  speed 
until  the  I7th  of  January,  1893,  when  I  told  her  the  condition 
she  was  in  and  assured  her  that  unless  she  was  operated  on  very 
soon  she  could  not  live.  She,  being  a  philosopher,  demanded  the 
operation  be  done  forthwith  then  and  there.  1  immediately  pro- 
(!eeded  to  give  general  directions  for  her  toilet  preceding  the 
operation — to  wit,  to  bathe  night  and  morning,  to  take  a  ca- 
thartic at  bedtime,  to  restrict  herself  to  liijuid  diet  for  forty- 
eight  hours,  to  abstain  from  food  on  the  day  of  operation,  and 
to  em])ty  her  bowels  on  the  evening  previous  to  operation. 
These  conditions  were  carried  out  as  directed. 

On  the  afternoon  of  January  19,  1893,  the  patient  was  on 
the  table  in  the  dining-room  of  her  home.  Half  a  grain  of  sid- 
phate  of  inorpliine  and  one  fiftieth  of  a  grain  of  atrojiine  were 
injected  hyj)odormically  ;  the  patient  was  then  auicsthetized 
and  the  abdomen  thoroughly  scrubbed  with  soap  ;ind  water, 
then  washed  with  sterilized  water,  then  with  a  solution  of  bi- 
chloride of  mercury  (1  to  1,500),  and  again  washed  with 
sterilized  water.  An  incision  four  inches  long  was  made  in  the 
median  line,  commencing  just  below  the  umiulicus,  deepened  to 


the  ])eritonaMnn,  iind  the  same  nicked  and  opened  on  a  grooved 
director.  No  adhesions  being  found,  the  sac  was  punctured 
with  a  trocar  and  sixteen  pints  of  fluid  were  drawn  oil  in  the 
usual  manner,  the  assistant  elevating  the  .sac  with  a  strong 
volsella  forceps  while  counter-pressure  was  being  made  on  the 
abdominal  walls  The  tumor  was  now  drawn  out  of  the  ab- 
dominal incision  and  a  Staffordshire  knot  was  ap])lied  to  its 
base.  Strong  double-braided  silk  was  used  for  this  j)urpose. 
The  tumor  was  then  separated  at  the  base,  which  was  exceed- 
ingly broad  (it  being  at  least  seven  inches  in  breadth),  and 
dropped  into  the  abdominal  cavity.  The  pedicle,  besides  the 
one  large  cyst,  contained  two  smaller  and  harder  cysts  with 
semi-fluid  contents,  which  could  easily  be  felt  through  the  ab- 
dominal wall  before  the  operation.  In  examining  for  other 
cysts  a  tumor  was  found  on  the  left  side  of  the  womb,  with 
walls  as  thin  as  tissue  paper,  which  contained  a  semi-fluid  mass. 
The  uterus,  which  was  very  much  enlarged,  was  sounded  to 
ascertain  if  a  communication  existed  with  this  "  new  develop- 
ment '•  Nothing  of  the  kind  being  found,  it  was  decided  to 
puncture  the  cyst  (?),  which  was  done.  It  being  utterly  impos- 
sible to  get  any  fluid  through  the  tube  or  to  diminish  the  size 
of  the  tumor,  the  cannula  was  withdrawn,  and,  to  my  immense 
disgust,  there  popped  out  of  the  opening  made  by  the  cannula  the 
umbilical  cord  of  a  f(Btus. 

A  hurried  consultation  was  held,  and  we  decided  to  do  the 
proper  thing — to  enlarge  the  uterine  wound  and  enucleate  the 
foetus  and  placenta.  This  was  hurriedly  done,  after  which  the 
womb  was  stitched  with  the  continuous  catgut  suture ;  the  cer- 
vical canal  was  then  dilated  to  its  utmost  capacity  with  a  pair 
of  powerful  cervical  dilators.  The  object  in  so  dilating  was  to 
secure  natural  drainage,  which  we  got.  We  now  began  to  look 
around  to  ascertain  where  all  the  haemorrhage  was  coming 
from.  My  chief  assistant.  Dr.  H.  L.  Whitney,  found  it.  Our 
Staffordshire  knot  had  slipped.  We  then  proceeded  to  purse- 
string  suture  the  stump,  which  acted  effectually  and  has  never 
slipped.  After  being  perfectly  reassured  that  all  haemorrhage 
was  under  control,  tlie  abdominal  cavity  was  flushed  with  sev- 
eral wasli-pitcherfuls  of  sterilized  water,  the  clots  all  washed 
out,  and  the  abdominal  wound  closed  with  deep  and  superticial 
sutures.  No.  7  silk  being  used  for  this  purpose. 

A  liberal  amount  of  iodoform  was  dusted  over  the  line  of  sn- 
tures  and  ten-per-cent.  iodoform  gauze  applied  ;  then  bichloride 
gauze,  borated  cotton,  and  a  binder.  The  patient  was  put  into 
bed  just  an  hour  after  having  been  put  on  the  table.  Severe 
vomiting  was  the  next  unpleasant  feature  to  be  combated ; 
cracked  ice  was  used,  small  pieces  being  swallowed,  but  to  no 
avail.  1  next  tried  wine  of  pepsin,  one-drachm  doses,  'iced? 
every  fifteen  minutes.  This  preparation  acted  like  a  charm ; 
whether  it  was  the  wine  or  the  pepsin  I  am  not  prepared  to 
state. 

Nourishment  consisted  of  beef  juice,  taken  cold,  for  the  first 
eighteen  hours. 

Tympanites  developed  on  the  third  day,  and  was  relieved  by 
enemata  of  an  emulsion  of  turpentine  and  asafoetida.  The  case 
progressed  favorably  from  this  time.  The  highest  temiierature 
was  developed  on  the  sixth  day  after  the  operation  (100°  F.), 
due  to  retained  fseces,  the  temperature  remaining  normal  after 
the  bowel  was  emptied.  The  patient  was  able  to  sit  up  in  bed 
on  the  fourteenth  day,  and  is  now  (March  19th),  two  months 
from  the  operation,  going  about  doing  light  household  duties.  I 
neglected  to  mention  that  the  stitches  were  removed  from  tlie 
abdominal  wound  on  the  seventh  day  ;  the  cicatrix  was  perfect; 
no  stitch  abscesses. 

All  antiseptic  precautions  were  observed  in  regard  to  instru- 
ments, hands,  sponges,  etc. 

I  am  indebted  to  Dr.  II.  L.  Whitney,  Dr.  J.  1'.  Hichl,  Dr. 


526 


ROCKWELL:   A  NEW  INDUCTION  COIL. 


[N.  Y.  Mkd.  Jodh., 


L.  II.  Edwards,  and  Dr.  G.  W.  McKee  for  valuable  assistance  in 
manipulating  this  case.  The  tuiru)r  and  contents  weighed  just 
twenty-four  pounds. 

The  unique  feature  of  the  case  centers  on  the  compli- 
cation of  pregnancy.  Conception  must  have  taken  i)lace 
very  soon  after  my  first  examination  on  August  25,  1892; 
but  the  patient  contnued  to  menstruate  during  September 
and  October;  then  menstruation  ceased.  (Remember,  this 
foetus  was  seven  inches  long.)  I  again  examined  her  and 
sounded  the  uterus,  using  considerable  force  in  examining 
her.  Also  on  the  I7th  of  January  her  uterus  was  sounded 
(with  both  small-sized  and  large-sized  sounds),  at  which 
time  there  was  a  gush  of  fluid,  when  Dr.  Whitney  remarked 
that  "  we  must  have  punctured  the  tumor." 

The  extreme  thinness  of  the  left  uterine  wall  can  be  ex- 
plained by  stating  that  the  pressure  exerted  by  the  tumor 
on  the  left  half  of  the  uterus  cut  off  nutrition  and  blood 
supply  to  that  half  of  the  organ,  rendering  the  opposite  side 
hypertrophic,  which  was  very  misleading. 

I  think  I  should  have  been  justified  in  removing  the 
ftt'tus  had  not  the  uterine  wall  been  punctured.  The  uterus 
had  been  sounded  several  times  in  examinations ;  it  was  as 
thin  as  the  paper  you  arc  reading.  The  patient  would  have 
aborted  surely  ;  one  good  pain  would  have  ruptured  this 
thin-walled  uterus,  and  my  operation  would  have  gone  on 
record  as  another  failure  due  to  neglect  or  improper  tech- 
nique. 


A  NEW  INDUCTION  COIL 
FOR  CURRENTS  OF  QUANTITY  AND  TENSION.* 
By  A.  D.  ROCKWELL,  M.  D. 

The  importance  of  distinguishing  between  induced  cur- 
rents of  quantity  and  those  of  tension,  and  of  rightly  adapt- 
ing these  various  qualities  of  current  to  morbid  conditions, 
is  beginning  to  be  appreciated.  I  long  ago  called  attention 
to  the  very  remarkabk'  difference  in  the  effects  produced  by 
induced  currents  of  quantity  and  those  of  tension  when  ap- 
plied through  the  skin  and  the  mucous  membrane  of  the 
body — or,  in  other  words,  through  high  and  low  resistances. 
Currents  of  quantity  of  a  tension  so  low  as  to  be  almost  if 
not  quite  imperceptible  when  applied  through  the  external 
parts  of  the  body  powerfully  affect  both  sensory  and  motor 
nerves  when  applied  to  internal  surfaces,  and,  per  contra, 
tension  currents  hardly  appreciable  when  used  internally 
become  unbearable  when  used  externally.  In  fact,  the  ex- 
traordinary action  of  seemingly  weak  induced  currents  of 
quantity  when  applied  to  low  resisting  surfaces  will  hardly 
be  credited  without  actual  demonstration.  It  is  a  very 
easy  thing  to  demonstrate  this  fact  unwittingly  to  the  in- 
jury of  the  patient  and  to  the  operator's  mortification. 

An  intravaginal  or  intra-uterine  application  is  being 
made  with  the  cnirrent  of  tension.  The  patient  comjjlains 
of  an  uncomfortable  sensation  which  may  or  may  not  be 
due  to  the  action  of  the  current,  and  you  shift  the  slide  so 
as  to  exchange  the  current  of  great  for  one  of  lesser  tension, 
which,  according  to  all  the  experiences  of  external  applica- 

*  Rend  licforc  the  New  York  Nciir<il()<;ical  Society,  May  2,  1893. 


tion  through  the  high  resistance  of  the  skin,  is  infinitely 
weaker. 

Instantly  a  shock  is  occasioned,  associated  with  the  acut- 
est  pain  and  the  most  rigid  contractions,  that  astonishes  your- 
self and  terrifies  your  patient — a  jnishap  which  I  have  known 
to  excite  neuralgia  and  other  severe  nervous  symptoms  of  a 
distressing  and  more  or  less  permanent  character.  It  be- 
comes, therefore,  absolutely  essential,  in  utilizing  these 
currents  of  high  tension  and  large  quantity,  that  we  be  able 
to  increase  them  by  almost  imperceptible  gradations  fi'om 
zero  to  the  maximum  strength  required.  In  what  are 
termed  the  separate-coil  apparatus  (wound  for  high-tension 
currents)  this  is  readily  accomplished  by  a  stationary  pri- 
mary coil  over  which  are  glided  at  will  helices  composed 
of  wire  of  vai-ying  thickness  and  length.  The  continuous- 
coil  apparatus  as  oi'dinarily  constructed  comprised  in  a 
single  compact  helix  all  the  merits  of  the  separate-coil 
apparatus  with  its  various  and  cumbersome  helices,  with  the 
single  exception  of  an  inability  in  the  beginning  to  yield  a 
sufficiently  slight  current,  especially  when  the  so-called 
(juantity  currents  were  used  internally  by  the  bipolar 
method.  In  the  device  which  I  have  suggested  and  here 
present  this  difficulty  has  been  successfully  overcome  by 
having  a  permanently  fixed  helix.  A,  with  a  movable  pri- 
mary coil,  B.* 


The  total  length  of  the  coil  of  this  helix  is  7,552  feet, 
with  the  following  subdivisions  :  Six  hundred  and  ninety-six 
feet  of  No.  21  wire  tapped  at  116  and  580  feet ;  2,116  feet  of 
No.  32  wire  tapped  at  78-3  and  1,335  feet ;  4,740  feet  of  No. 
36  wire  tapped  at  1,740  and  3,000  feet.  The  heavy  coil  of 
No.  16  wire  has  been  discarded  and  the  No.  21  coil  so  ar- 
ranged as  to  yield  a  current  equal  to  the  No.  16.  The 
merit  of  this  arrangement  consists  of  one's  ability  to  use 
the  whole  7,000  feet  and  more  of  wire,  or  to  utilize  at  will 
each  section  of  the  coil  with  its  subdivisions  far  more 
readily  than  when  they  are  wound  on  separate  spools,  and 
at  the  same  time  to  increase  the  curient  strength  by  imper- 
ceptible gradations  from  zei'o  to  the  maximum. 

So  high  is  the  resistance  offered  by  the  great  length  of 
wire  in  such  a  helix  as  this  that  a  comparatively  large 
electro-motive  force  is  necessary  to  run  it.  Almost  any 
form  of  cell  can  be  used. 

If  any  one  of  the  sal  ammoniac  cells  is  used,  it  is  a 
good  idea,  and  one  that  I  adopt,  to  combine  them  in  mul- 
tiple arcs  of  two  each.  In  this  way  polarization  takes  place 
much  less  rapidly  than  when  they  are  connected  in  simple 
series,  and  six  cells  are  sufficient  for  any  strength  of  current 
desired. 

It  is  this  insusceptibility  of  low  resisting  tissues  to  cur- 

*  This  coil  was  made  for  me  by  the  Kidder  Manufacturing  Coiri 
pany. 


May  13,  1893.] 


SAWTFLLE:   EPITHELIOMA  OF  TEE  PENIS. 


52T 


rents  of  exceedingly  high  tension  that  renders  this  quality 
of  current  of  so  much  value  for  the  relief  of  pelvic  pains 
of  a  non-inflammatory  character,  while  the  extraordinary 
readiness  with  which  currents  of  large  quantity  and  low 
tension  affect  these  same  tissues  gives  to  them  a  special 
value  in  certain  nutritional  disturbances. 


EPITHELIOMA  OF  THE  PENIS. 

AMPUTATION. 

raPLANTATION  OF  URETHRA  THROUGH  THE  SCROTUM. 
By  henry  W.  SAWTELLE,  M.  D., 

SURGEON,  U.  S.  MARraE-HOSPITAI,  SERVICE. 

This  form  of  disease  is  occasionally  met  with  among  sea- 
faring men.  According  to  the  annual  reports  of  the  United 
States  Marine-Hospital  Service  for  the  five  years  ending 
June  30,  1891,  there  were  70,826  patients  treated  in  hospi- 
tals, of  whom  seventy-three  were  returned  as  having  epi- 
thelioma involving  different  regions  of  the  body.  In  seven 
instances  the  penis  was  the  seat  of  the  lesion.  This  case 
presented  the  usual  objective  symptoms  peculiar  to  the  af- 
fection. The  patient  first  noticed  a  small  ulcer  on  the  pre- 
puce, which  gradually  advanced,  and  the  glans  penis  soon 
became  involved  in  the  process  of  ulceration. 

The  subject  was  a  large,  robust-appearing  seaman,  aged  sixty 
years,  and  a  native  of  Maine.  He  was  admitted  to  the  Boston 
Marine  Hospital  December  8,  1891.  He  stated  that  the  disease 
appeared  about  a  year  before,  and  that  up  to  that  time  he  had  been 
a  vigorous  man.  Upon  inspection,  the  organ  presented  a  foul, 
fuDgating  sore  of  a  cauliflower  appearance.  The  characteristic 
odor  was  intensely  offensive;  penis  greatly  enlarged  and  nodu- 
lar; prepuce  tightly  stretched  over  the  mass  and  adiierent;  dis- 
charge ichorous  though  not  profuse.  Patient  stated  that  within 
a  short  time  there  had  been  occasional  slight  hiBmorrhagesfrom 
the  penis;  one  occurred  a  few  hours  after  admission.  There 


was  no  marked  glandular  enlargement ;  no  evidence  of  syphilis. 
Had  been  in  a  hospital  for  six  weeks  up  to  November,  1891. 
His  features  and  conversation  indicated  great  mental  anxiety. 
The  systemic  treatment  ordered  consisted  of  the  use  of  iron  and 
quinine.  On  December  4,  1891,  the  day  after  admi.ssion,  the 
penis  was  amputated  at  the  upper  third,  the  patient  being  under 
the  influence  of  ether.  Antiseptic  precautions  were  observed 
during  and  after  the  operation.  The  stump  did  not  heal,  and 
soon  the  upper  border  of  the  scrotum  became  involved.  The  case 
demanding  further  surgical  interference,  the  operation  originally 
done  and  described  by  Humphrey  in  such  cases  was  ])erfoniiyd 
on  January  18,  1892,  with  the  assistance  of  Passed  Assistant 
Surgeon  P.  0.  Kalloch,  the  patient  being  under  ether.  The 
neoplasm  of  the  scrotum  was  removed;  the  urethra  was  dis- 
sected out  and  about  two  centimetres  of  the  end  wiiicli  was 


infected  excised.  The  urethra,  which  was  now  about  ten  centi- 
metres in  length,  was  then  implanted  in  an  opening  made 
through  the  scrotum  and  stitched  to  the  skin  below.  The  re- 
mainder of  the  organ  was  then  amputated  ju.st  above  the  bifur- 
cation of  the  corpora  cavernosa.  The  parts  healed  by  granu- 
lation, and  the  patient  was  discharged  on  February  24,  1892, 
feeling  well  and  able  to  urinate  without  difficulty  in  the  sitting 
posture. 

The  accompanying  photograph,  showing  the  parts  after  re- 
covery from  the  operation,  was  taken  tiie  day  before  the  pa- 
tient left  the  hospital  for  his  home  in  Maine.  A  small  tube  was 
inserted  in  the  mouth  of  the  urethra,  which  shows  its  new  po- 
sition in  the  figure. 

A  few  days  ago  the  writer  was  informed  that  the  disease 
had  not  recurred  and  that  the  man  was  in  good  health. 

U.  S.  Mari.ne  Hospital,  Port  of  Boston,  Mass.,  March,  1893. 


FRACTURE  OF  THE  SKULL. 
By  D.  L.  PEEPLES,  M.  D., 

NAVASOTA,  TEXAS. 

P.  S.,  of  this  city,  aged  ten  years,  received  a  severe  fracture 
of  the  skull  by  the  kick  of  a  horse.  The  tip  of  the  horse's  foot 
came  in  contact  with  the  anterior  superior  parietal  bone,  frac- 
turing that  portion  over  which  the  animal's  foot  covered  com- 
pletely, and  wedging  it  securely  beneath  the  frontal  bone.  This 
blow  not  only  drove  this  piece  of  bone  in  the  position  of  com- 
pression of  the  brain,  but  caused  several  other  minor  fractures. 
On  reception  of  injury,  the  patient  fell  unconscious  to  the 
ground.  Shortly  afterward  he  was  carried  into  bis  home,  and 
soon  revived  with  some  general  paresis  and  inequality  of  the 
pupils;  no  vomiting,  and  but  little  pain  experienced.  On  ex- 
amination, I  saw  what  had  to  be  done,  and  made  preparations 
accordingly.  The  scalp  was  dissected  away  sufficiently  to  expose 
the  wound.  The  trephine  was  then  used  and  passed  through 
both  tables.  The  circular  piece  cut  by  the  instrument  was  re- 
moved, and  then  the  above  piece  was  elevated  and  drawn  out 
by  means  of  a  strong  bone  forceps ;  then  with  a  rongeur  the 
rough  fragments  were  pared  off;  the  dura  mater  was  then  thor- 
oughly asepticized,  a  drainage-tube  introduced,  and  the  wound 
closed.  Every  antiseptic^  precaution  was  taken  throughout  the 
entire  operation.  Immediately  after  arousing  the  patient  fifteen 
grains  of  mild  chloride  of  mercury  were  administered,  and  two 
more  similar  doses  were  given  every  two  hours.  Eight  hours 
later  an  ounce  of  castor  oil  and  ten  drops  of  turpentine  were 
administered.  Heavy  doses  of  quinine  were  given  frequently. 
Next  d.ay  he  was  put  on  large  doses  of  potassium  iodide  and 
small  doses  of  red  iodide  of  mercury.  Quinine  continued,  but 
not  administered  near  the  potassium  iodide. 

Occasionally  the  potassium  iodide  mixture  would  be  stopped, 
and  three  more  similar  doses  of  calomel  would  be  given.  After 
the  operation  all  .signs  of  paralysis  disappeared,  very  little 
fever  followed,  and  pain  only  once  or  twice  sufficient  to  cause 
the  administration  of  opium.  This  injury  was  received  June 
14,  1892,  and  on  the  30tli  of  June,  just  sixteen  days  after  the 
injury,  the  patient  was  out  shooting  marbles  and  contending  in 
loud  exclamations  for  each  game.  His  health  has  been,  and  is 
still,  splendid. 


The  Death  of  Dr.  Ely  McClellan,  of  the  Medical  Corps  of  the  Army. 

is  reported  to  have  taken  place  in  Cliicaf^d  on  Monday,  the  Stii  Inst. 
Lieutenant-Colonel  and  Deputy  Surgeon-General  MtK'lelliui  was  con- 
spicuous for  his  profes.sional  acliievenieuts  with  the  army  during  the 
late  civil  war,  and  made  many  important  contributions  to  the  literature 
of  military  surgery. 


528 


THK 

NEW  YORK  MEDICAL  JOURNAL, 

A   Weekly  Review  of  Medicine. 

Published  by  Edited  by 

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


NEW  YORK,  SATURDAY,  MAY  13,  1893. 

THE  TREATMENT  OF  SPRAINED  ANKLE. 

De.  V.  P.  GiBNEY,  of  the  New  York  Polyclinic,  offers,  in 
the  journal  of  that  institution  for  January,  some  suggestions 
concerning  the  treatment  of  sprained  ankle.  For  four  years  he 
has  relied  chiefly  on  the  use  of  an  adhesive-plaster  supporting 
dressing,  and  he  has  had  a  success  so  nearly  uniform  and  .satis- 
factory that  lie  has  no  inclination  to  exchange  the  method  for 
any  of  the  older  ones.  Dr.  (libney  owns  his  indebtedness  for 
the  new  method  to  a  little  book  by  Mr.  Edward  Oottcrell,  of 
the  University  College  Hospital,  London.  It  was  not  until  the 
end  of  1888  that  the  treatment  advocated  in  the  brochure  was 
fully  digested  and  put  into  use  by  Dr.  Gibney.  He  had  all 
through  his  previous  sui'gical  career  looked  upon  a  sprain  as  a 
kind  of  mystery  "not  always  so  bad  as  a  fracture,  but  some- 
limes  more  tedious,"  requiring  fomentations  for  a  little  while, 
then  a  fi.xed  dressing  of  plaster  of  Paris  or  silicate  of  sodium, 
crutches  perhaps,  and  rest  and  massage  afterward.  He  had 
never  been  attracted  toward  tliese  methods,  and  he  had  come 
to  expect  a  "  stiffish "  joint  in  nearly  every  case  that  came 
under  his  charge. 

His  first  case  to  be  tried  according  to  CotterelFs  plan  was 
that  of  a  lady  who -had  wrenched  her  right  ankle  severely. 
The  usual  external  features  of  a  sprain  were  present ;  no  dis- 
location or  fracture  could  be  made  out.  Dr.  Gibney  first  cut 
strips  of  rubber  adhesive  plaster  about  half  an  inch  in  width 
and  long  enough  to  completely  encircle  the  foot.  Then,  with 
the  foot  well  raised,  he  strapped  it,  the  ankle,  and  the  lower 
third  of  the  leg  with  these  strips,  very  much  as  if  he  had  had 
an  ulcer  to  treat.  The  first  strip  was  carried  over  the  outer 
side  of  the  foot  from  near  the  base  of  the  little  toe.  The  second 
strip  crossed  the  first,  the  third  lapped  over  the  first,  the  fourth 
overlapped  the  second,  and  so  on,  until  at  the  conclusion  he  had 
practically  constructed  a  .Scultetus's  bandage  of  adhesive  strips 
extending  far  enough  to  include  the  lower  third  of  the  limb. 
Over  this  he  placed  a  cheese-cloth  bandage  to  help  the  plaster 
.strips  to  adhere  to  one  another  and  to  make  the  dressing  more 
tidy.  The  patient  was  told  to  put  on  her  stocking  and  shoe 
and  to  walk  about  the  room.  The  walking  was  accomplished 
with  some  diffidence,  but  with  no  real  ditficulty.  She  was 
made  to  walk  the  next  day  and  went  out  shopping  without  any 
bad  results.  The  recovery  was  without  relapse,  and  the  use- 
fulness of  the  ankle-joint  was  unimpaired. 

This  plan  of  treatment  has  been  used  by  Dr.  Gibney  and 
his  assistants  in  their  hospital  service,  as  well  as  in  private 
practice.  Not  a  few  medical  friends  of  his  have  followed  his 
exani|)le  in  the  em[)loyment  of  what  he  terms  the  "modern 
treatment  of  sprained  ankles,"  and  Iheir  reports  are  uniformly 


[N.  Y.  Med.  Johk., 

in  praise  of  the  method ;  he  does  not  recall  that  any  of  them 
has  made  an  adverse  report.  This  plan  of  treatment  has  the 
advantage  of  entailing  the  minimum  amount  of  enforced  deten- 
tion from  the  ordinary  pursuits  of  life,  and  does  not  tend  to 
leave  a  stiffened  joint. 


THE  HYSTERICAL  BLUE  (KI)EMA  OF  CHARCOT. 

Abovt  three  years  ago  Charcot  first  called  attention  to  a 
rare  form  of  hysterical  asdema  with  blneness,  to  which  he  gave 
the  name  of  a>deine  hleu  den  hysteriques.  We  find  in  the 
BrooUi/n  Medical  Journal  for  April  an  account  by  Dr.  Shaw 
and  Dr.  Duryea  of  a  case  marked  by  rare  if  not  unique  condi- 
tions. Tiie  patient  was  a  young  and  highly  hysterical  woman. 
According  to  her  own  history  of  her  case,  she  had  received  a 
blow  on  her  left  breast  while  being  rescued  from  drowning, 
and  in  a  few  days  after  the  rescue  she  had  begun  to  have  con- 
vulsions. These  seizures  had  averaged  two  a  week  for  a  time, 
and  during  that  time  the  left  breast  had  increased  in  size  and 
become  so  painful  that  an  incision  had  been  made  into  it  in  the 
expectation  of  finding  pus.  but,  according  to  the  surgeon  of  the 
hospital  where  the  patient  had  been,  no  pus  had  been  found. 

When  the  patient  came  under  the  authors'  observation,  in 
April,  1892,  the  breast  was  enlarged,  somewhat  pendulous,  soft, 
(Edematous,  and  rather  cyanotic.  It  was  also  intensely  hyper- 
{Bsthetic.  There  was  blue  (edema  of  the  left  hand  and  fore- 
arm, with  coldness.  The  hypera^sthesia  extended  from  below 
the  breast  to  the  shoulder,  and  a  similar  area  existed  over 
tiie  left  scapular  region.  There  were  also  considerable  areas  of 
anaesthesia  on  the  left  side,  limited  to  the  anterior  aspect  of  the 
extremities.  She  had  nmneroiis  convulsive  attacks  and  other 
hysterical  manifestations. 

Dr.  A.  J.  C.  Skene  was  consulted  in  reference  to  the  state 
of  her  pelvic  organs,  and  he  reported  that  they  were  free  from 
disease. 

The  authors  state  that  oedema,  as  a  symptom  of  hysteria, 
comes  under  the  observation  of  the  profession  at  large  so  rarely 
as  to  be  almost  unknown,  althongh  it  has  been  mentioned  by  a 
number  of  authors  from  the  time  of  Sydenham  down  to  the 
present.  It  is  almost  always  associated  with  convulsive  mani- 
festations or  with  stigmata ;  it  comes  on  suddenly  and  without 
any  known  physical  cause;  the  affected  part  is  generally 
white,  and  does  not  pit  on  pressure.  The  blue  oedema  of  Char- 
cot is  accompanied  by  a  subnormal  temperature  of  the  part. 
So  far  as  the  writers  have  learned,  this  cyancjtic  form  has  hitii- 
erto  been  rei)orted  as  limited  to  the  extremities,  either  an  arm 
or  a  leg,  oftener  the  former,  and  it  has  been  unilateral.  The 
paper  is  illustrated  by  diagrams  that  assist  in  understanding  the 
situation  of  the  various  vaso-motor  disturbances  in  this  inter- 
esting and  possibly  unique  case. 


MINOR    PA RA  GRAPHS. 

A  LESSON  IN  ANTISEPSIS. 

The  scene  occurred  in  one  of  the  most  prominent  of  our 
New  York  hospitals,  the  time  of  action  was  within  the  last  five 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


May  13,  1893.] 


MINOR  PARAGRAPHS. 


52^ 


years,  and  the  dramatiK  personoB  were  a  patient  who  was  to 
liave  a  portion  of  liis  cerebral  cortex  removed,  one  of  the  best 
of  New  Yorl<  surg-eons,  a  prominent  ncurolou^ist,  assistants, 
visitors,  and  students.  Tlie  siirf^eon  had  deftly  and  carefully 
removed  the  bone  and  made  a  flap  in  the  meninges,  and  the 
neurologist  was  about  to  decide  the  location  of  the  cortical 
center.  Turning  on  the  current  of  bis  battery,  he  applied  the 
electrodes  to  his  tongue  to  determine  the  strength  of  the  cur- 
rent, and  was  about  to  transfer  tbe  electrodes  to  the  cortex 
when  the  surgeon,  who  had  watched  this  method  of  current- 
testing  with  evident  concern,  arrested  the  neurologist's  hand,' 
saying  at  tiie  same  time  that  the  electrodes  must  be  disinfected 
over  again  after  contact  with  his  mouth.  The  disinfection  of 
the  instrument  being  completed,  the  neurologist  confirmed  the 
location  of  the  center,  and  the  surgeon  prepared  to  complete  his 
work.  As  he  took  his  stool  to  resume  the  use  of  the  knife  he 
found  that  the  light  was  insufficient ;  rising,  he  caught  hold  of 
the  gas  fixture  placed  above  the  operating-table,  pulled  it  down 
over  the  field  of  work,  placed  his  stool  in  a  little  more  conven- 
ient position,  and,  forgetting  to  disinfect  his  hand.s,  proceeded 
with  the  operation.  The  mote  caused  by  the  neurologist's 
ijnucherie  had  been  removed,  hut  the  beam  of  the  surgeon's 
forgetfulness  resulted  in  the  death  of  the  patient  in  conse(]uence 
of  suppurative  meningitis. 


SOME  POINTv'^  IN  TERMINOLO(JY. 

Our  esteemed  contem|)orary,  the  Medical  Record,  criticises 
the  author  of  the  Academy  of  Medicine's  announcement  for  al- 
lowing an  author  to  use  the  -word  symphyHiotomy  instead  of 
symphyseotomy .  As  the  Record  correctly  remarks,  the  genitive 
of  (Ti\x.^v<TLi  is  av^(f)v(Tfws,  and  it  implies  from  that  fact  that  the 
epsilon  ought  to  be  represented  in  an  English  derivative  of  the 
word.  While  we  are  not  ready  to  say  that  symphyseotomy  is 
not  the  preferable  form  of  the  word,  we  can  not  admit  the 
cogency  of  the  Record's  argument,  for  the  epsilon  is  simply  a 
part  of  the  genitive  termination,  and  not  a  ])art  of  the  stem. 
Such  Greek  words  in  -ly  take  -iv  in  the  accusative,  for  example ; 
moreover,  (rvn(f)v(Tis  is  only  a  compound  of  <^vcns,  and  must  be 
as  free  as  that  word  in  the  formation  of  further  compounds ; 
and,  with  such  classical  compounds  of  (fyvais  before  us  as  (ftva-io- 
Xoyia  (and  none  that  we  can  find  in  -ea--),  we  are  unable  to  see 
that  symphysiotomy  is  inadmissible.  While  we  are  on  this  sub- 
ject, we  may  express  our  wonder  that  the  same  journal,  in  the 
same  issue,  heads  an  editorial  article  "  Tracheology — a  New  Spe- 
cialty." At  first  we  supposed  that  the  author  had  been  the  vic- 
tim of  a  printer's  error,  but  in  the  text  of  the  article  we  find  the 
word  "  tracheologists."  Does  not  our  contemporary  mean 
trachelology  and  t rachelologists~ir om  Tpaxrjkos,  the  neck  ? 


TRAINED  NURSES'  WAtJES. 

One  of  tiio  best-known  New  York  physicians  writes  to  us 
as  follows : 

"For  several  weeks  one  of  my  servants  has  been  very  ill, 
and  I  employed  to  care  for  her  a  trained  nurse.  Last  week  her 
(•ondition  was  such  as  to  require  two  nurses,  and  Mrs.  P.,  from 
the  bureau  of  a  Mrs.  T.  (there  is  a  '  power  behind  the  throne  ' 
whose  name  does  not  api)oar),  emjjloyed  a  woman  recommend- 
ed highly  by  the  manager.  At  the  end  of  a  week  I  was  asked 
to  pay  $30  as  the  'usual'  compensation,  and  an  extra  $5  (iu 
all  |35),  because  she  had  done  '  night  service.'  She  went  on 
duty  at  8  p.m.;  went  oft'  at  8  a.m.  Is  this  right?  True,  no 
specific  arrangement  was  made  as  to  compensation,  therefore 
no  contract  was  violated;  but  is  there  no  fixed  charge  for 
trained  nurses?    If  they  can  demand  $30,  why  not  $40,  etc.? 


"  On  Mrs.  P.'s  expressing  surprise  at  the  charge,  she  was  met 
by  the  statement  that  she  (the  nurse)  '  did  not  consider  herself 
an  ordinary  trained  nurse.'  The  case,  however,  was  one  of  no 
special  requirement  as  regarded  skill  in  nursing.  Several  mem- 
bers of  the  ])rofession  to  whom  I  have  spoken  of  it  regard  the 
charge  as  extortionate,  '  entirely  improper.'  One  nurse,  on  the 
other  hand,  told  me  she  could  not  see  why  physicians  should  fix 
nurses^  charges  any  more  than  nurses  should  fix  the  fees  of 
physicians.    Shade  of  ^E^culapius,  what  next?  " 


THE  NEW  SURGEON  GENERAL  OF  THE  NAVY. 

The  retirement,  for  age,  of  Surgeon-GeneralJ.  Mills  Browne 
on  the  11th  inst.  has  caused  the  promotion  of  Medical  Inspector 
J.  Rufus  Tryon  to  the  office  of  surgeon  general  of  the  navy. 
Dr.  Tryon  is  at  present  attached  to  the  flag  ship  "  Chicago  "  as 
fleet  surgeon.  He  is  a  native  of  New  York,  entered  the  medi- 
cal corps  of  the  navy  in  1863,  and  served  in  the  West  Gulf 
squadron  until  1865,  when  he  was  ordered  to  the  naval  hospital 
at  Boston.  He  served  with  the  Asiatic  squadron  from  1870  to 
1873,  and  from  the  latter  year  until  1876  he  was  on  special 
duty  at  Pensacola  in  connection  with  the  yellow-fever  epidemics 
at  that  point.  He  has  been  on  duty  at  New  York  and  Phila- 
delphia, and  with  the  Pacific  and  Eurojjean  squadrons.  Pro- 
fessionally and  personally  Dr.  Tryon  is  a  most  interesting  com- 
panion, and  his  administration  will  doubtless  redound  to  the 
credit  of  the  Bureau  of  Medicine  and  Surgery. 


THE  CONDITION  OF  THE  TEETH  AS  AN  INDEX  OF  THE 
GENERAL  STATE  OF  HEALTH. 

In  the  Lancet  for  April  8th  there  is  a  letter  from  J.  Leon 
Williams,  D.  D.  S.,  L.  I).  S.,  of  London,  in  which  the  belief  is 
stated  that  it  is  erroneous  to  look  upon  the  condition  of  the  teeth 
as  expressive  of  the  general  state  of  health.  Every  observant 
dentist,  the  writer  says,  is  familiar  with  the  fact  that  many  per- 
sons of  mature  years  have  excellent  teeth  although  they  have 
perhaps  never  had  perfect  health  and  have  comparatively  low 
powers  of  endurance,  while,  on  the  other  hand,  many  otherwise 
vigorous  and  healthy  persons  have  teeth  that  are  poor  in  struc- 
ture and  decay  rapidly.  Of  course,  he  adds,  early  loss  of  the 
teeth  may  lead  to  serious  impairment  of  the  healWi. 


GALLANOL  IN  THE  TREATMENT  OF  PSORIASIS  AND 
ECZEMA. 

At  the  recent  annual  meeting  of  the  French  Sdciety  of 
Dermatology  and  Syphilography,  according  to  the  report  in 
Progres  medical  for  April  22d,  Dr.  Cazeneuve  and  Dr.  E. 
PoUet,  of  Lyons,  made  known  the  results  that  they  had  ob- 
tained in  the  treatment  of  psoriasis  and  eczema  by  means  of 
gallanol.  This  body,  isolated  by  them  in  a  state  of  purity  from 
gallic  acid,  acts  powerfully  upon  the  skin  as  a  reducing  agent. 
In  psoriasis,  the  aftected  part  is  painted  with  a  ten-per-cent. 
solution,  and  the  layer  is  covered  with  trauinaticine.  After  a 
very  short  time  the  psoriasis  is  found  to  have  disappeared.  In 
chronic  eczema,  a  ten-per-cent.  or  twenty-five-per-cent.  oint- 
ment causes  the  itching  to  subside  and  brings  about  a  jirompt 
cure. 


A  NEW  MEDICAL  ENCYCLOP.KDLV. 

We  have  received  the  first  number  of  a  new  Bibliothek  der 
gesammten  medicinischen  Wissenschaften,  edited  by  Professor 
A.  Drasche,  of  Vienna,  with  the  collaboration  of  a  large  corps 
of  writers,  and  ])Til)lished  in  Vienna  and  Loipsic.  Tbe  number 
consists  of  forty-eight  i)ages,  and  it  is  announced  that  the  entire 


530 


MINOR  PA  RA  GRAPHS.— ITEMS. 


[N.  Y,  Med.  Jode., 


work  will  comprise  from  eight  to  ten  volumes  of  from  fifteen  to 
twenty  numbers  each.  The  first  number  gives  ns  the  impression 
that  the  work  will  prove  to  be  one  of  great  value. 


BREAD  IN  THE  DIABETIC'S  DIETARY. 

At  a  recent  meeting  of  the  Berlin  Balneological  Society  Dr. 
A.  Kallay,  of  Karlsbad,  read  an  instructive  paper  on  Diabetes 
Mellitus  which  has  been  published  in  the  Wiener  medizinische 
Wochemchrift.  Speaking  of  the  matter  of  diet,  the  autlior  ex- 
pressed doubt  as  to  the  value  of  tlie  various  substitutes  for 
wheat  bread,  such  as  bran  bread,  almond  bread,  and  aleurono 
bread,  and  gave  it  as  his  opinion  that  from  two  to  four  ounces 
of  ordinary  bread  daily  was  absolutely  harmless  to  a  diabetic. 


THE  GOVERNOR'S  VETO  OF  THE  EPILEPTIC-COLONY  BILL. 

It  is  to  be  regretted,  we  think,  that  the  Governor  of  the 
State  of  New  York  has  felt  constrained  to  withhold  his  ap- 
proval of  the  bill  to  establish  an  epileptic  colony  in  the  State. 
The  document  in  which  he  gives  his  decision  recounts  the  great 
outlay  that  the  State  has  already  made  in  establishing  charita- 
ble institutions  and  in  maintaining  them,  and  bases  his  hesita- 
tion to  sign  the  bill  mainly  on  considerations  of  economy. 


THE  BUCHANAN  MURDER  TRIAL. 

The  prisoner's  conviction  in  this  case  seems  to  show  that 
the  peculiar  style  of  cross-examination  introduced  by  one  of  the 
counsel  for  the  defense  does  not  seriously  befog  decent  jury- 
men, however  much  it  may  bore  and  weary  them.  We  are  un- 
able to  see  that  on  any  material  point  the  medical  testinrrjny 
against  the  accused  was  shaken. 


BENZONAPHTHOL  AS  AN  INTESTINAL  ANTISEPTIC. 

In  the  Union  medicale  for  April  16th  we  find  a  formula  for 
the  preparation  of  wafers  each  containing  three  grains  of  ben- 
zonaphthol  and  a  grain  and  a  half  each  of  poplar  charcoal  and 
magnesia.  Four  wafers  are  to  be  given  in  the  course  of  a  day, 
one  just  before  eating  and  one  about  an  hour  after  the  meal. 


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  May  9,  1893  : 


DISEASES. 

Week  ending  May  2. 

Week  ending  May  9. 

Cases. 

Deaths. 

Cases. 

Deaths. 

10 

10 

10 

8 

6 

5 

14 

3 

196 

18 

168 

23 

11 

1 

15 

14 

1.36 

10 

180 

1 

106 

31 

123 

34 

4 

2 

14 

1 

The  Association  of  the  Alumni  of  St.  Luke's  Hospital. — About  forty 
members  of  the  association  were  present  at  the  annual  dinner,  at  the 
Savoy,  last  Monday  evening.  Dr.  Robert  Abbe  was  toastmaster.  The 
toast  "St.  Luke's  Hospital"  was  responded  to  by  Mr.  Charles  Russell, 
of  the  board  of  managers ;  that  of  "The  E.xeeutive,"  by  the  Rev.  George 
S.  Baker,  D.  D.  ;  that  of  "  The  Medical  Board,"  by  Dr.  L.  Bolton  Bangs; 
that  of  "Our  Sister  Societies,"  l)y  Dr.  George  F.  Shrady,  of  the  New 
York  Hospital  Alumni,  and  Dr.  I).  Bryson  Delavan,  of  the  Charity  Hos- 
pital Alumni  ;  and  that  of  "  The  Ex-Interne,"  by  Dr.  W.  K.  Otis.  The 


oldest  ahuniius  present  was  Dr.  W.  H.  Carinalt,  of  New  Haven.  Al)out 
ten  years  afjo  the  Association  of  the  E.x-Interncs  of  St.  Luke's  Hospital 
had  a  brief  and  not  very  eventful  career,  and  the  attempt  this  spring  to 
reanimate  its  ashes  has  resulted  in  the  formation  of  the  present  society, 
which  differs  in  several  ways  from  its  predece.ssor.  All  ex-internes  of 
St.  Luke's  Hospital  of  New  York  city  are  eligible  to  membersliip.  It 
meets  on  the  second  Tuesdays  of  November,  January,  and  March  for 
the  (lisc\ission  of  scientific  subjects,  on  the  second  Tuesday  in  April  for 
business,  and  annually  at  diuner.  Its  officers  are  :  Dr.  A.  A.  Davis, 
president ;  Dr.  W.  H.  (Caswell,  vice-president ;  Dr.  L.  F.  Warner,  secre- 
»tary  ;  and  Dr.  V.  H.  Norrie,  treasurer. 

Bellevue  Hospital  Medical  College.— At  the  recent  annual  meeting 

of  the  fiiculty  the  foll(iwiii<r  changes  and  appointments  were  made: 
The  title  of  Dr.  H.  M.  Biggs's  chair  was  made  materia  medica  and 
therapeutics,  diseases  of  the  nervous  system,  and  clinical  medicine. 
The  title  of  Dr.  H.  D.  Noyes's  chair  was  made  ophthalmology,  instead  of 
o|)hthalmology  and  otology.  The  title  of  Dr.  Samuel  Alexander's  chair 
was  made  genito-urinary  surgery  and  syphilis.  The  title  of  Dr.  G.  H.  Dun- 
ham's chair  was  made  pathological  anatomy,  bacteriology,  and  hygiene. 
Dr.  Edward  B.  Dencli  was  appointed  professor  of  otology  for  the  regu- 
lar  session.  Dr.  .lohn  A.  Fordvce  was  apjwinted  professor  of  derma- 
tology and  syphilology  for  the  regular  session.  Dr.  David  H.  McAlpin, 
Jr.,  was  ap|)ointed  professor  of  histology  and  demonstrator  of  patho- 
logical anatomy  for  the  regidar  session.  Dr.  Austin  Flint,  Jr.,  was 
appointed  adjunct  professor  of  obstetrics  for  the  regular  session. 

The  Health  of  Dr.  Francis  P.  Kinnicutt. — Last  Saturday  Dr.  Kin- 
nicutt  was  suddenly  attacked  with  symptoms  that  suggested  perforation 
of  the  vermiform  appendix,  and  on  the  evening  of  that  day  he  was 
operated  upon.  We  learn  that  no  perforation  was  found,  but  that  the 
appendix  was  removed  and  found  to  l)e  affected  with  catarrhal  inflam- 
mation. On  Sunday  and  Monday  the  patient's  condition  was  such  as 
to  give  rise  to  grave  apprehension,  but  our  present  information  is  to  the 
effect  that  his  progress  since  that  time  has  been  thoroughly  satisfactory, 
and,  we  are  very  glad  to  be  able  to  say,  that  little  if  any  doubt  is  now 
felt  of  his  prompt  and  perfect  recovery. 

The  Medical  and  Surgical  Society  of  Baltimore. — The  7.57th  regu- 
lar meeting  was  held  on  Thursday  evening,  the  11th  inst.  Papers  had 
been  announced  as  follows :  The  Care  and  Treatment  of  the  Nipples 
and  Breasts  of  the  Pregnant  and  Puerperal  Woman,  by  Dr.  Wilmer 
Brinton ;  and  A  Case  of  Post-diphtheritic  Paralysis  of  both  External 
Recti  Muscles,  by  Dr.  Harry  Friedenwald. 

The  Medical  Society  of  the  County  of  Kings  has  received  legal  au- 
thority to  hold  real  estate  to  the  value  of  S;l0o,OO0,  and  to  fix  the  rate 
of  annual  dues  of  membership  at  $10.  The  growth  of  the  library  has 
been  such  as  to  demand  more  space,  and  the  value  of  the  collection 
seems  to  require  that  it  shall  Ije  housed  within  fireproof  walls. 

The  University  of  Vienna.— The  Lancet  states  that  Professor  Krafft- 
Ebing  has  been  promoted  from  the  second  to  the  first  chair  of  psychi- 
atry and  neurology,  and  that  Professor  Wernicke,  of  Breslau,  has  been 
appointed  to  succeed  him  in  the  second  chair. 

Grandin  and  Gunning's  Electricity  in  Gjmaecology. — It  is  an- 
nounced in  the  May  number  of  the  American  Journal  of  Obstetrics  that 
the  Treatise  on  Electricity  in  Gynaecology,  by  Dr.  Egbert  H.  Grandin 
and  Dr.  J.  H.  Gunning,  has  been  translated  into  Spanish  by  Dr.  Ramon 
Martin  Gil  and  published  in  Spain. 

The  Presbyterian  Hospital. — The  new  operating  pavilion  was 
opened  to  inspection  by  an  invited  company  on  Monday  afternoon,  the 
8th  inst. 

The  University  of  BuiFalo. — On  the  2d  inst.  commencement  exer- 
cises were  held  in  the  departments  of  medicine  (forty-nine  in  the  gradu- 
ating class),  of  phaiinacy,  and  of  dentistry.  Dr.  Paul  F.  Munde  de- 
livered an  address  on  the  sul)ject  of  Specialism  in  Medicine. 

Changes  of  Address.— Dr.  W.  H.  Bates,  to  No.  156  Montague  Street, 
Brooklyn  ;  Dr.  Louise  Fiske  Bryson,  to  No.  56  West  Forty-sixth  Street; 
Dr.  H.  N.  \'ineberg,  to  No.  127  Ea.st  Sixty-first  Street;  Dr.  J.  Van 
Doren  Young,  to  No.  108  West  Seventy-fifth  Street. 


May  13,  1893.) 


ITEMS.— LETTERS  TO  THE  EDITOR. 


531 


Columbia  College. — It  i.s  reported  tliat  the  trustees  have  deeide<i  to 
make  the  course  in  the  medical  school  (the  College  of  Physicians  and 
Surgeons)  one  of  four  years  instead  of  three. 

Typhus  Fever  in  Paris. — According  to  the  Union  tnedicalc  for  April 
11th,  typhus  was  then  ei)ideniic  in  Paris.  There  ^vere  cases  in  several 
of  the  hospitals,  notably  the  IIotel-Dieu  and  the  Charite. 

The  Death  of  Dr.  Rufus  W.  Mathewson,  of  Durham,  Connecticut, 

is  announced.  Dr.  Mathewson  had  for  many  years  been  a  well-known 
and  highly  respected  practitioner. 

Army  Intelligence. —  Official  List  of  Changes  iti  the  Stations  and 
Duties  of  Officers  serving  in  the  'Medical  Department,  United  States 
Army,  from  April  30  to  May  6,  1893: 

A  Board  of  medical  officers,  to  consist  of  Sternberg,  George  M.,  Lieu- 
tenant Colonel  and  Deputy  Surgeon  (Jeneral,  Wolverton,  William 
D.,  Lieutenant  Colonel  and  Deputy  Surgeon  (jreneial,  and  Gibson, 
Joseph  R.,  Major  and  Surgeon,  is  appointed  to  meet  at  West  Point, 
N.  Y.,  June  1,  1893,  or  as  soon  thereafter  as  practicable,  for  the 
physical  examination  of  the  cadets  of  the  graduating  class  of  the 
S.  Military  Academy,  and  such  other  cadets  of  the  academy  and 
candidates  for  admission  thereto  as  may  be  ordered  before  it. 

Janeway,  John  H.,  Major  and  Surgeon,  is,  by  direction  of  the  Acting 
Secretary  of  War,  granted  leave  of  absence  for  three  months  and 
fourteen  days. 

TuRRiLL,  Henry  S.,  Captain  and  Assistant  Surgeon,  is  ordered  to  report 
in  person  to  the  president  of  the  Examining  Board  at  Omaha,  Ne- 
braska, for  examination,  with  a  view  to  determine  his  fitness  for  pio- 
motion,  as  contemplated  by  the  act  of  Congress  approved  October 
1,  1890. 

Alexander,  Charles  T.,  Colonel  and  Assistant  Surgeon  General,  is 
detailed  as  a  member  of  the  Army  Medical  Board,  vice  Alden, 
Charles  H.,  Colonel  and  Assistant  Surgeon  General,  hereby  relieved. 

Naval  Intelligence. — Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  weelc  ending  May  6,  1893  : 
Field,  James  G.,  Assistant  Surgeon.    Ordered  to  examination  prelimi- 
nary to  promotion. 

Society  Meetings  for  the  Coming  Week : 

Monday,  May  15tli :  New  York  County  Medical  Association  ;  New 
York  Academy  of  Medicine  (Section  in  Ophthalmology  and  Otology) ; 
Hartford,  Conn.,  Medical  Society;  Chicago  Medical  Society. 

Tuesday,  May  16th :  American  Gynsecological  Society  (first  day — Phila- 
delphia) ;  Illinois  State  Medical  Society  (first  day — Chicago) ;  New 
York  Academy  of  Medicine  (Section  in  Theory  and  Practice  of  Medi- 
cine) ;  New  York  Obstetrical  Society  (private) ;  Medical  Societies  of 
the  Counties  of  Kings  and  St.  Lawrence  (annual),  N.  Y. ;  Ogdens. 
burgh  Medical  Association ;  Hampshire,  Mass.,  District  Medical  So- 
ciety (annual — Springfield) ;  Baltimore  Academy  of  Medicine. 

Wednesday,  3fay  17th  :  American  (iyna^cological  Society  (second  day) ; 
Illinois  State  Medical  Society  (second  day) ;  New  York  Academy 
of  Medicine  (Section  in  Public  Health  and  Hygiene) ;  Harlem  Medi- 
cal Association  of  the  City  of  New  York ;  Northwestern  Medical 
and  Surgical  Society  of  New  York  (private) ;  Medico-legal  Society ; 
New  Jersey  Academy  of  Medicine  (Newark). 

Thursday,  May  18lh :  American  Gyniccological  Society  (third  day) ; 
Illinois  State  Medical  Society  (third  day) ;  New  York  Academy  of 
Medicine ;  Brooklyn  Surgical  Society ;  New  Bedford,  Mass.,  Society 
for  Medical  Improvement  (private). 

Friday,  May  19th :  New  York  Academy  of  Medicine  (Section  in  Ortho- 
picdic  Surgery) ;  Baltimore  Clinical  Society ;  Chicago  Gynaecological 
Society. 

Saturday,  May  SOth  :  ('linical  Society  of  the  New  York  Post-gradu- 
ate Medical  School  and  Hospital. 

Answers  to  Correspondents : 

No.  JfOJf. — Appointments  to  the  position  of  acting  assistant  surgeon 
in  the  Marine-Hospital  Service  are  subject  to  the  discretion  of  the  Sec- 
retary of  the  Treasury  for  the  time  being.  We  believe  that  the  faith- 
ful and  efficient  discharge  of  the  duties  outweighs  political  considera- 
tions in  settling  the  question  of  a  man's  retention  or  dismissal. 


,   f  ttttrs  to  \\t 

PRENATAL  MEASLES. 

*  Chicago,  April  3,  1893. 
To  the  Editor  of  the  New  Yorl'  Medical  Journal: 

Sir  :  In  the  Journal  of  April  1st  I  noted  a  report  of  prenatal 
measles  in  which  the  foetus  showed  "  spots  "  of  eruption.  In 
1882  I  was  called  to  a  woman  in  confinement.  On  arriving  at 
the  house  I  found  the  child  just  born.  It  was  an  eight-months 
child.  The  mother  was  then  in  the  .stage  of  full  eruption  of  an 
active  attack  of  measles.  The  child's  body  was  covered  with  as 
severe  a  rash  of  measles  as  I  ever  witnessed.  Every  inch  of  its 
little  body  was  as  red  as  a  beet,  and  the  eruption  was  as  distinct 
as  it  was  on  the  mother.  The  labor  was  premature  and  the 
measles  eruption  no  doubt  induced  endometritis  and  consequent 
expulsion  of  the  child.  So  in  this  case  prenatal  measles,  con- 
tracted from  the  mother,  was  a  plain  fact.  So  far  as  I  was  in- 
formed, both  mother  and  child  recovered  without  any  untoward 
events.  '  F.  Byron  Robinson,  M.  D. 


WOUNDS  AVITHOUT  INJURY  TO  OVERLYING  CLOTHING. 

Cuba  Landing,  Tenn.,  April  10,  1893. 
To  the  Editor  of  the  New  York  Medical  Jourrtal: 

Sir:  1  see  mentioned  in  the  Journal  for  February  25th  a 
case  of  a  lacerated  wound  resembling  a  stab  wound  without  in- 
jury to  clothing,  together  with  the  case  of  Dr.  Wagner  of  March 
11th.  This  causes  me  to  report  the  case  of  J.  B.,  who  was 
sent  to  a  neighbor's  house  in  haste,  was  running  down  bill,  and 
fell  upon  his  right  side,  the  right  knee  striking  a  rock.  He 
severed  the  integument  for  about  an  inch  in  length  just  beneath 
the  patella,  but  he  did  not  even  know  there  was  anything  wrong 
until  he  had  reached  his  journey's  end.  However,  the  injury 
proved  to  give  considerable  trouble  before  the  wound  was 
healed.  Search  was  made  for  injury  to  the  clothing,  but  none 
could  be  found.  J.  N.  Smith,  M.  D. 

A  LONG-LIVED  FAMILY. 

Spokane,  Wash.,  April  18,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  The  following  family  history  will  be  of  interest  to  life- 
insurance  examiners.  Applicant,  aged  thirty,  is  the  eldest  of  a 
family  of  nine  children,  all  living  and  in  good  health.  Appli- 
cant's father  living,  aged  sixty-four,  in  good  health  ;  applicant's 
mother  living,  aged  fifty-four,  in  good  health  ;  applicant's 
father's  father  dead,  aged  eighty-eight,  cause  unknown  ;  appli- 
cant's father's  mother  dead,  aged  seventy-seven,  cause  unknown ; 
applicant's  mother's  father  living,  aged  ninety-four,  in  good 
health ;  applicant's  mother's  mother  living,  aged  ninety,  in  good 
health. 

Three  of  his  great-grandparents  are  living,  the  youngest  be- 
ing one  hundred  and  five,  and  all  in  fair  health. 

D.  C.  Newman,  M.  D. 

THE  NEW  YORK  STATE  EXAMINATION. 

New  York,  May  J,,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  Some  time  ago  the  Regents  of  the  University  of  the 
State  of  New  York  agreed  to  demand  from  every  student  of 
medicine  about  to  practice  in  this  State  some  evidences  of  his 
fitness  for  his  work,  and  tlierefore  established  a  State  exami- 
nation. 

The  ground  to  be  covered  by  the  student  in  this  exauiiaation 


532 


BOOK  NOTICES. 


I N.  Y.  Med.  Jodb., 


was  to  be  determined  by  the  State  rtiedical  soeietie.s,  all  tbree 
schools  being  represented. 

When  the  matter  was  brought  before  the  State  medical 
societies  of  the  three  schools  it  was  referred  to  a  committee, 
which  committee  drew  up  for  the  use  of  the  regents  a  medical 
syllabus,  the  purpose  of  which  is  specified  to  be  "  for  the  guid- 
ance of  candidates  as  to  the  topics  covered  by  the  examinations 
required  for  a  license  to  practice  medicine  and  surgery  in  New 
York  State."  This  medical  syllabus  was  published  in  Albany  in 
October,  1892.  It  is  stated  U|)on  the  cover  that  it  is  prei)ared 
under  the  direction  of  the  State  boards  of  medical  examiners  by 
Dr.  George  R.  Fowler  and  Dr.  Maurice  J.  Lewi,  representing 
the  Medical  Society  of  the  State  of  New  York;  Dr.  William  S. 
Searle  and  Dr.  John  McE.  Wetmore,  representing  the  lloma'o- 
pathic  Medical  Society  of  the  State  of  New  York;  and  Dr. 
Edwin  S.  Moore  and  Dr.  William  L.  Tuttle,  representing  the 
Eclectic  Medical  Society  of  the  State  of  New  York. 

In  reading  this  bulletin  I  find  tlie  following  statement  under 
the  head  Diseases  of  the  Nervous  System,  including  diseases  of 
the  brain,  spinal  cord,  and  functional  nervous  diseases : 

Diseases  of  the  brain  :  Cerebral  hypertemia  (active  or  pas- 
sive);  cerebral  anfemia ;  meningitis;  cerebral  thrombosis  and 
embolism;  cerebral  softening;  cerebral  apoplexy;  abscesses  of 
the  brain;  cerebral  tumors;  sclerosis  of  the  brain;  hyper- 
trophy of  the  brain. 

Diseases  of  the  sjjinal  cord  and  its  meninges:  Spinal  hyper- 
temia; spinal  meningitis;  acute  myelitis;  chronic  myelitis;  non- 
intiammatory  softening;  acute  bulbar  paralysis;  infantile  spinal 
paralysis;  acute  s[)inal  paralysis  of  adults;  chronic  anterior 
myelitis;  progressive  muscular  atro[)hy  ;  cerebro  spinal  sclero- 
sis; locomotor  ataxia ;  spasmodic  tabes  dorsalis;  amyotrophic 
lateral  sclerosis;  pseudo-hypertrophic  paralysis;  spinal  apo- 
plexy. 

Functional  diseases  of  the  nervous  system  :  Epilepsy  ;  hys- 
teria; hystero-epilei)sy  ;  catalepsy;  chorea  ;  sunstroke ;  tetanus; 
facial  paralysis;  paralysis  agitans ;  chronic  lead  poisoning; 
chronic  mercurialism  ;  vertigo;  neuralgia;  migraine;  eclampsia; 
seasickness. 

I  desire  to  call  attention  to  this  syllabus  and  to  make  cer- 
tain criticisms  upon  it.  The  titles  of  the  diseases  i.sed  through- 
out indicate  a  standpoint  of  about  thirty  years  ago.  At  the 
present  time  it  is  pretty  well  agreed  that  cerebral  hypera>mia 
and  anaemia  are  not  to  be  considered  as  diseases  any  more  than 
dropsy  or  dyspnoea.  They  are  conditions  secondary  to  other 
pathological  states.  Cerebral  apoplexy  is  also  a  condition  no 
longer  described  as  a  disease  in  itself,  but  considered  in  every 
modern  text-book  under  the  heading  of  thrombosis  and  embo- 
lism or  haemorrhage.  Cerebral  softening  is  also  to  be  consid- 
ered as  a  result  of  one  of  the  three  conditions  just  named  or 
else  as  the  result  of  meningo  encephalitis.  Hypertrophy  of  the 
brain  does  not  exist.  Sclerosis  of  the  brain  is  a  term  which  I 
I  do  not  understand,  there  being  no  general  sclerosis,  but  sev- 
eral forms  of  multiple  disseminated  sclerosis.  It  will  therefore 
be  noticed  that  six  out  of  ten  conditions  mentioned  undei-  dis- 
eases of  the  brain  would  not  be  recognized  as  diseases  by  the 
students  who  have  received  the  current  instruction  in  nervous 
diseases. 

The  same  criticism  applies  to  the  diseases  of  the  si)inal  cord. 
Just  what  the  examiners  intend  to  convey  by  the  terms  non- 
inflammatory softening,  acute  spinal  paralysis  of  adults,  spas- 
modic tabes  dorsalis,  I  do  not  know.  Pathologists  do  not  rec- 
ognize "  non-inflammatory  softening." 

Since  acute  myelitis,  chronic  anterior  myelitis,  and  spinal 
apoplexy  (by  which  latter  term  I  suppose  spinal  hasmorrhago  is 
indicated)  are  mentioned,  I  am  at  a  loss  to  know  what  condition 
is  intended  by  the  term  acute  spinal  paralysis  of  adults,  unless  i)os- 


sibly  Landry's  paralysis  is  indicated,  which  is  not  a  spinal  tlisease, 
but  one  of  the  peripheral  nerves.  As  to  "si)asmodic  tabes  dor- 
salis," I  su[)pose  the  group  of  symptoms  is  intended  which  is 
now  described  under  the  three  pathological  conditions  of  lateral 
sclerosis,  descending  degeneration,  and  combined  sclerosis. 
The  authors  of  the  syllabus  appear  to  bo  ignorant  of  the  fact 
that  this  term  was  abandoned  twenty-five  years  ago,  when  the 
pathology  of  the  symptoms  indicated  by  the  term  "  spasmodic  ' 
began  to  be  understood. 

Why  progressive  muscular  atrophy  and  [jseudo- hypertrophic 
paralysis,  now  known  to  be  purely  muscular  diseases  without 
spinal-cord  lesion,  should  be  classified  under  the  diseases  of  the 
spinal  cord  is  a  mystery. 

The  entii'e  absence  of  any  questions  regarding  localization  of 
cerebral  and  spinal  functions  is  another  indication  of  the  medi- 
eval standpoint  of  the  authors. 

Under  "functional  diseases  "  of  the  nervous  system  I  noticed 
facial  paralysis  and  sunsti'oke,  both  of  which  are  supposed  to 
have  a  well-known  pathological  basis.  Multiple  neuritis  seems 
to  be  beyond  the  neurological  horizon  of  the  authors,  while 
vertigo  and  eclampsia,  both  of  them  symptoms  and  not  diseases, 
have  attracted  their  attention. 

It  is  quite  evident  from  this  review  that  a  student  instructed 
in  the  modern  pathology  and  terminology  of  nervous  diseases, 
or  preparing  tor  his  examination  witii  the  aid  of  the  text-books 
of  Dana,  Cray,  or  Cowers,  or  even  with  the  general  works  of 
O.sler  or  Striimpell,  would  be  sadly  at  a  loss  to  know  what  was 
indicated  by  questions  based  upon  this  syllabus. 

This  criticism  is  intended  as  a  comment  upon  the  policy 
adopted  by  the  State  medical  societies  of  placing  this  subject  of 
examination  in  the  hands  of  members  who  are  not  professors  in 
any  college  or  engaged  in  teaching  medicine,  and  who  are  mani- 
festly about  twenty  years  behind  the  present  standpoint. 

I  have  referred  this  syllabus  to  several  gentlemen,  professors 
in  various  medicsil  colleges  of  this  city,  and  I  find  that  an  equal- 
ly scathing  criticism  can  bo  made  of  almost  every  section  of  this 
syllabus  with  tlie  excei)tion  of  that  on  anatomy. 

The  first  step  toward  any  reform  necessarily  comes  by  criti- 
cism of  existing  methods.  In  the  foregoing  I  have  no  personal 
animus,  as  I  am  not  acquainted  either  personally  or  by  reputa- 
tion with  any  of  the  members  of  the  State  l>oard  of  medical  ex- 
aminers. But  I  desire  that  the  students  whom  I  teach  should 
be  able  to  pass  a  fair  examination,  and  I  do  not  care  to  be 
obliged  to  even  mention  to  them  names  and  diseases  long  since 
discarded.  M.  Allen  Stake,  M.  D. 


^ooh  lloticcs. 


Handhook  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Throaty  Nose,  and  Nasopharynx.  By  Cael  Seiler,  M.  D. 
Fourth  Edition.  Philadelphia:  Lea  Brothers  &  Co.,  189.3. 
Pp.  xii-412. 

Though  the  three  preceding  editions  of  Dr.  Seller's  book 
have  made  it  familiar  to  the  greater  number  of  those  interested 
in  laryngohjgy,  and  though  the  favorable  impression  created  by 
it  renders  a  complete  review  of  the  fourth  edition  uncalled  for, 
yet  we  may  briefly  comment  upon  it.  Though  the  work  aims  at 
brevity  and  conciseness,  and  though  much — in  fact,  almost  all — 
that  is  theoretical  has  been  omitted,  yet  thereby  has  the  work 
gained  in  practical  value  and  interest.  Complete,  in  an  ex- 
haustive sense,  it  certainly  is  not;  and  yet  in  a  more  practical 
sense,  and  particularly  from  the  therapeutic  standpoint,  its  lack 


May  13,  1893.] 


BOOK  NOTICES.— REPORTS  ON 


THE  PROGRESS  OF  MEDICINE. 


533 


of  completeness  is  of  the  greatest  value,  since  it  casts  aside  the 
chaff  and  preserves  the  wheat,  presenting  it,  moreover,  in  well- 
arranged,  concise,  and,  what  is  still  more  nnusnal,  exceedini>ly 
readable  form. 

Certain  new  features  ap|)ear  in  this  edition,  and  of  these  hy 
far  the  best  is  the  chapter  on  intranasal  neoplasms,  which, 
though  brief,  is  yet  sufticient,  and  gains  ratlier  than  loses  by 
that  brevity.  Another  new  chapter  is  on  influenza  and  wiiat 
the  writer  calls  "  American  grippe."  The  wi-sdom  of  this  intro- 
duction we  must  question,  for  influenza  surely  is  not  a  disease 
of  the  upper  respiratory  passages  alone.  Moreover,  it  was  tiiis 
reason  which  led  the  author  to  omit  diphtheria  from  his  trea- 
tise, for  in  the  i)reface  to  the  first  edition  he  says:  "Several 
affections  which  are  classed  among  systemic  diseases  and 
merely  exhibit  severe  laryngeal  symptoms,  such  as  scarlet  fever, 
diphtheria,  etc.,  have  been  omitted,  since  they  do  not  strictly 
belong  to  maladies  of  the  throat."  The  handling  of  this  sub- 
ject, we  think,  might  better  be  left  to  the  general  practitioner, 
to  whom  it  more  properly  belongs,  and  indeed  the  matter  shovvs 
too  much  the  specialist  and  does  not  gain  thereby. 

The  size  of  the  volume  is  most  convenient,  and  the  book- 
making  excellent. 


Diseases  of  t/ie  Skin.  A  Manual  for  Students  and  Practitioners. 
By  Charles  C.  Ransom,  M.  D.,  Assistant  Dermatologist, 
Vanderbiit  Clinic,  New  York.  Series  edited  by  Been  B. 
Gallaudet,  M.  D.,  Demonstrator  of  Anatomy,  College  of 
Physicians  and  Surgeons,  New  York.  Philadelphia:  Lea 
Brothers  &  Co.,  1893.  Pp.  0-17  to  201.  [The  Students'  Quiz 
Se7-ies.] 

It  can  scarcely  be  intended  that  this  little  volume  should 
serve  as  a  substitute  for  the  text-books  on  dermatology,  and 
perhaps  it  might  have  been  better  to  omit  from  the  title-page 
the  statement  that  it  was  a  manual  for  practitioners.  As  a 
concisely  arranged  work  presenting  certain  salient  points  in 
dermatology  it  may  be  of  value  to  the  student  during  his  class 
work,  but  the  i)ractitioner  that  would  be  satisfied  with  the  in- 
formation it  contains,  judiciously  selected  as  it  maybe,  would 
be  content  rather  with  the  semblance  than  with  the  substance 
of  information.  We  should  not  condemn  the  work  because  it 
refers  to  but  four  varieties  of  acne,  to  but  three  of  alopecia, 
or  to  but  four  of  herpes,  but  from  this  necessary  restriction  of 
the  consideration  of  other  than  the  more  important  varieties  of 
a  disease  the  character  of  the  condensation  may  be  judged.  In 
fact,  the  author  is  to  be  congratulated  on  getting  as  much  mate- 
rial as  he  has  got  into  the  book.  The  index  would  have  been 
more  serviceable  if  moi'e  complete. 

BOOKS,  ETC.,  RECEIVED. 

The  Recrudescence  of  Leprosy  and  its  Causation.  A 
lar  Treatise.    By  William  Tebb.    With  an  Appendix.   London  : 
Swan,  Sonnenschein  &  Co.,  1898.    Pp.  20-21  to  412. 

Atlas  of  Electric  Cystoscopy.  By  Dr.  Emil  Bnrckhanlt, 
late  Assistant  Surgeon  to  the  Surgical  Clinic  of  the  University 
of  Bale,  and  E.  Hurry  Fen  wick,  F.  R.  C.  S.  Eng.,  Surgeon  to  the 
London  Hospital,  etc.  With  34-  (Colored  Plates,  embracing  83 
Figures.  London :  J.  &  A.  Churchill,  1893.  Pp.70.  [Price, 
21  shillings.] 

Remarkable  Se(]uence  of  Operation  for  Necrosis  at  Base  of 
Skull;  a  New  Method  of  Resecting  the  Third  Branch  of  tlie 
Fifth  Nerve.  By  (i.  Lenox  (Jurti.s,  M.  D.,  of  New  York.  [Re- 
printed from  Xhe  Journal  of  the  American  Medical  Assoeiatio/i.] 

Clinical  Cases  of  (Edema  of  the  Larynx  in  Children.  By  J. 
W.  Robertson,  M.  D.,  Litchfield,  Minn.  [Reprinted  from  the 
Northwestern  Lancet.] 


Two  Cases  of  a  Peculiar  Tyjie  of  Primary  Crural  Asymmetry. 
By  Henry  Ling  Taylor,  M.  D.,  New  York.  [Reprinted  from  the 
Unirersity  Medical  Magazine.] 

Remarks  on  the  Management  of  Suppuration  complicating 
Tuberculous  Disease  of  the  Bones  and  Joints.  By  Henry  Ling 
Taylor,  M.  D.,  New  York.  [Reprinted  from  the  Annals  of  Sur- 
gery.] 

Symphyseotomy,  with  the  Report  of  a  Successful  Case.  By 
Henry  J.  Garrigues,  M.  D.,  New  York.  [Reprinted  from  the 
American  Journal  of  the  Medical  Sciences.] 

Osteitis  Deformans  (Paget),  with  Report  of  Two  Cases.  By 
Henry  Ling  Taylor,  M.  D.,  New  York.  [Reprinted  from  the 
Medical  Record.] 

Surgical  Dressings,  Aseptic  and  Antiseptic.  By  Seward  W. 
Williams,  Ph.  C,  F.  C.  S.  [Reprinted  from  the  Pharmaceutical 
Record.] 

Character,  the  True  Test  of  the  Physician.  By  J.  W.  Long, 
M.  D.,  Randleman,  N.  C.  [Reprinted  from  the  Maryland  Medi- 
cal Journal.] 

Cholera.  By  E.  R.  Axtell,  M.  D.,  Denver,  Col.  [Reprinted 
from  the  Denver  Medical  Times.] 


gcports  on  tin  progress  of  P^etiinne. 


GYNiECOLOGY. 

By  ANDREW  F.  CURRIER,  M.  D. 

The  Relations  of  the  Mucous  Membrane  in  Atresia  and 
Deformity  of  the  Genitals,  also  the  Subject  of  Tubal  Men- 
struation (Landau  and  Rheinstein,  Ctrlhl.f.  Gyn.,  1893,  No. 
1). — The  following  cases  were  under  investigation  : 

1.  One  in  which  there  was  complete  absence  of  the  vagina, 
normal  uterus  without  hiematometra,  double  hajmatosalpinx. 

2.  One  in  which  there  was  a  transverse  speptum  of  the  vagina 
in  its  upper  segment,  hasmatometra,  double  haimatosalpinx. 

8.  One  in  which  there  were  multiple  fibroids  of  the  uterus 
In  a  nullipara  forty-three  years  old,  haematosalpinx  of  the  right 
side. 

4.  Double  uterus  with  atresia  of  the  right  half,  hseraatometra 
of  the  right  side,  hfematosalpinx. 

The  preparations  in  the  first  and  third  cases  were  obtained 
by  abdominal  section;  the  others  were  post-mortem  specimens 
and  were  very  carefully  examined.  In  three  of  the  cases  it  was 
found  that  the  tube  was  actually  concerned  in  menstruation,  and 
was  not  filled  with  blood  by  reflux  from  the  uterus.  The  con- 
clusions of  the  authors  with  reference  to  these  investigations  are 
that  in  deformities  of  the  genital  organs,  whether  atresia  or  double 
formations,  the  mucous  membrane  is  normally  disposed  in  all 
portions  of  the  genital  tract.  The  uterine  mucous  membrane  is 
eventually  destroyed,  pressure  atrophy  resulting  from  the  re- 
tained menstrual  secretion.  The  corporeal  mucous  membrane 
is  capable  of  witiistanding  degenerative  changes  for  a  long  time. 
The  tubal  mucous  membrane  possesses  at  first  a  great  absorptive 
capacity  which  is  at  length  exhausted  as  the  destructive  effects 
of  pressure  are  continued. 

Aside  from  the  intrinsic  imi)ortance  of  these  investigations 
by  Landau  and  Rheinstein,  their  suggestiveness  in  a  field  of  un- 
usual interest  is  very  great.  Medical  literature  is  at  present 
flooded  with  accounts  of  cases  of  so-called  tubal  gestation.  Na- 
ture certainly  does  make  mistakes  in  the  work  which  she  has  to 
perform  in  gestation,  but  if  the  proportion  of  mistakes  is  as  largo 
as  these  rei)orts  would  have  us  believe,  she  had  better  go  out  of 
the  business  and  let  us  have  an  era  in  which  there  would  be  a 


534 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Mkd.  Joub., 


little  more  regard  for  uniformity  in  a  matter  of  such  supreme 
importance.  There  are  many  cases  in  which  the  clinical  symp- 
toms suggest  ectopic  gestation,  cases  in  which  evidences  of  in- 
ternal haemorrhage  are  marked,  cases  of  prolonged  intermen- 
strual interval,  cases  with  well-marked  tubal  tumor.  These 
cases  demand  prompt  treatment  by  abdominal  section,  but  the 
evidence  of  gestation  is  not  complete  by  the  finding  of  blood 
clot  in  the  pelvis  or  even  in  tlie  distended  tube.  Iliematosal- 
pinx,  as  these  cases  show,  is  not  necessarily  associated  with  ges- 
tation ;  it  may  be  an  accompaniment  of  menstruation.  Yet  other 
cases  are  associated  with  a  history  of  falls  or  bruises,  and  there 
may  or  may  not  be  an  accompanying  hsematoma  of  the  ovary  or 
broad  ligament. 

Another  important  point  to  wliich  we  have  as  yet  seen  no 
reference  in  this  connection  is  the  very  unfortunate  position  in 
which  single  and  perfectly  virtuous  young  women  may  be  placed 
by  assuming  that  all  haamatomata  or  hismatoceles  of  the  pelvis 
are  prima  facie  evidence  of  impregnation.  History  repeats  it- 
self; it  is  the  same  possibility  which  was  faced  many  times  in 
the  early  history  of  ovariotomy,  when  many  young  women  weut 
to  their  graves  with  a  cloud  of  unjust  suspicion  or  open  con- 
demnation hanging  over  them.  It  would  be  a  good  plan  if  all 
gynsecologists  were  as  frank  with  their  doubtful  cases  as  a  mem- 
ber of  the  New  York  Obstetrical  Society,  who  recently  reported 
six  cases  in  which  the  tem[)tation  to  pronounce  them  cases  of 
ectopic  gestation  was  great,  but  honesty  and  the  microscope  for- 
bade it.  In  the  absence  of  a  foetus  or  very  decided  microscopic 
evidence  of  tubal  gestation,  let  us  pause  before  making  up  our 
series  of  cases  for  publication. 

The  Pathology  of  the  Uterine  Mucous  Membrane  (Uter, 
Ztsch.f.  Geh.  u.  Gyn.,  xxv,  2). — The  author's  investigations  were 
made  upon  material  obtained  by  curettage  in  cases  of  abortion, 
gonorrhoea,  chronic  endometritis,  uterine  myomata,  and  malig- 
nant degeneration. 

In  cases  of  abortion  the  presence  of  decidua  cells  is  usually 
considered  necessary  to  the  determination  of  a  diagnosis,  but 
the  author  points  out  that  they  may  be  absent  on  account  of 
rapid  changes  within  the  first  few  days  after  expulsion  of  the 
ovum,  or  the  specimen  examined  may  have  been  removed  from 
a  portion  of  the  uterus  in  which,  in  the  early  portion  of  preg- 
nancy, decidua  cells  are  not  found.  On  the  other  hand,  even 
if  decidua  cells  are  found,  they  do  not  absolutely  determine  the 
recent  existence  of  pregnancy,  since  they  have  also  been  found 
in  the  unimpregnated  uterus  with  endometritis,  dysmenorrhoea 
membranacea,  and  pseudo- menstruation  after  phosphorus  poi- 
soning. Five  cases  were  studied  in  which  the  history  was  that 
of  abortion  during  the  second  month  of  pregnancy.  The  dis- 
tinctive microscopical  appearance  cousisted  in  cubical  epithelial 
cells  or  also  the  so-called  decidua  cells  in  the  connective  tissue. 
These  were  found  in  three  of  the  five  cases.  Tlie  decidua  cells 
were  for  the  most  part  necrotic,  or  in  colloid  or  granular  de- 
generation, as  if  the  eera  of  abortion  had  been  converted  into 
ordinary  mucous  membrane  again.  Between  the  cubical  cells 
were  found  in  two  cases  small  round  cells,  considered  by 
Gottschalk  substitution  cells  for  epithelium.  In  the  inter- 
glandular  tissue  were  small  round,  nuclei  like  lymph  bodies — 
substitution  cells  for  connective  tissue. 

Gonorrhoeal  catarrh  of  the  endometrium  was  studied  in 
its  acute  and  chronic  forms.  The  (dianges  in  the  mucous  mem- 
brane were  mainly  those  of  endometritis;  the  superficial  epi- 
thelium was  absent;  the  glands  were  slightly  or  not  at  all 
changed.  Their  number  was  not  increased,  their  lumen  was 
small,  and  they  were  in  many  instances  filled  with  secretion 
and  detached  epithelium.  Their  epithelium  was  rapidly  re- 
!ie(ved,  and  many  of  the  nuclei  contained  nucleoli.  The  inter- 
glandular  tissue  was  composed  of  small  round  cells,  with  round- 


ish nuclei  in  abundance.  In  one  case  only  the  vaginal  mucous 
membrane  was  inflamed,  the  endometrium  being  almost  nor- 
mal. Sim])le  chronic  endometritis  showed  two  varieties  of 
changes  in  the  uterine  mucous  membrane.  In  the  first  the 
glands  were  changed  both  as  to  number  and  form,  their  epi- 
thelium showing  a  variety  of  changes,  the  interglandular  tissue 
always  showing  hyperplastic  processes.  The  cells  and  nuclei 
were  increased,  and  there  was  an  abundance  of  spindle  cells. 
This  constitutes  the  chronic  hyperplastic  endometritis  of  Ols- 
hausen,  or  endometritu  fungom.  In  the  second  form  the 
mucous  membrane  is  not  so  thick  as  in  the  first;  the  glandular 
apparatus  is  unchanged ;  the  interglandular  tissue  shows  an  in- 
crease in  the  number  of  nuclei.  With  this  fonn  the  haemor- 
rhage at  the  monthly  period  is  very  profuse,  while  with  the 
first  there  are  both  profuse  luomorrhage  and  dysmenorrhoea. 

In  a  case  in  which  repeated  abortions  occurred  during  the 
first  two  months  of  pregnancy  the  scrapings  showed  great 
hyperplasia  of  the  glands.  In  two  cases  in  which  involution 
after  labor  was  tardy  and  im]>erfect,  fresh  inflammation  of  the 
mucous  membrane  was  ai)parent,  though  the  labors  had  been 
normal.  In  two  cases  of  tumor  of  the  cervix  uteri  with  pro- 
fuse haemorrhage  at  the  period  of  the  menopause  the  scrapings 
showed  no  evidence  of  malignancy,  the  glands  being  very  little 
changed,  while  the  interglandular  tissue  was  the  seat  of  a 
small-celled  infiltration. 

In  a  case  of  carcinoma  of  the  ovaries  the  appearance  of  the 
uterine  mucous  membrane  was  simply  that  of  fungous  endome- 
tritis— abundant  glandular  proliferation,  with  increase  in  the 
nuclei  of  the  connective  tissue. 

A  considerable  number  of  cases  was  studied  in  which  there 
were  fibromyomata  in  the  uterine  wall.  In  these  cases  the 
mucous  membrane  was  thickened  over  most  of  its  area,  but  in 
some  portions  it  was  atrophic.  In  some  cases  the  surface  had 
the  appearance  of  granulation  tissue,  the  ojjenings  of  the 
glands  being  apparent  to  the  naked  eye.  The  microscope 
showed  hyperplasia  of  the  glands  and  proliferation  of  the  cells 
of  the  interglandular  tissue,  in  addition  to  normal  arrangement 
and  normal  appearance  of  the  cells.  In  cases  with  inflamma- 
tory phenomena  there  was  proliferation  of  the  glandular  epi- 
thelium with  small-cell  infiltration. 

It  was  believed  that  disease  of  the  mucous  membrane  pre- 
ceded the  development  of  the  fibromyomata,  and  was  to  a  cer- 
tain extent  responsible  for  such  development,  though  this  is 
contrary  to  conclusions  recently  reached  by  Ehrendorfer  as  the 
result  of  careful  investigations. 

A  case  of  diffuse  sarcoma  of  the  endometrium  which  was 
definitely  diagnosticated  showed  the  difficulty  of  diagnosis  from 
carcinoma  and  from  endometritis  following  abortion. 

Purulent  Parametritis  in  which  the  Pus  contained  Pro- 
teus Vulgaris  and  a  Streptococcus  which  had  Lost  its  Viru- 
lence and  its  Vitality. — The  subject  which  is  covered  by  the 
foregoing  title  of  a  paper  by  Dol6ris  and  Bourges  (Nouvelles 
archives  W obstetrique  et  de  rnjnecologie,  Nov.  25,  1892)  is  a  very 
important  one.  It  is  only  in  recent  times  (since  the  aid  of  bac- 
teriology has  been  invoked)  that  we  have  begun  to  understand 
the  real  pathology  of  the  disease.  The  history  of  the  case 
which  forms  the  basis  of  this  paper  is  a  familiar  one :  post-par- 
tum,  peritonitis,  recovery,  subsequent  intra-uterine  treatment 
(after  a  period  of  six  years),  infection,  parametritis.  The  acute 
symptoms  lasted  two  months,  and,  as  it  was  believed  that  the 
uterine  veins  and  lymphatics  were  ciiarged  with  the  poison, 
though  the  acute  symptoms  had  subsided,  it  was  decided  to  re- 
move the  uterus.  When  the  abdomen  was  opened,  however, 
this  was  found  impracticable.  Large  sacs  of  pus  were  found 
in  the  appendages  of  either  side.  That  on  the  left  was  so  firm- 
ly attached  that  it  was  left  intact;  that  on  the  right  was  rup- 


May  13,  1893.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


535 


tnrod  in  attempting  its  removal;  its  edges  were  stitched  to  tlie 
borders  of  the  abdominal  wound,  and  its  cavity  packed  with 
gauze.  The  patient  was  entirely  well  in  six  weeks,  the  tumor 
on  the  left  side  having  gradually  contracted  and  disappeared. 
The  pus  from  the  tumor  contained  specimens  of  Streptococcus 
pyogenes  and  Proteus  vulgaris,  the  latter  a  normal  resident  of 
the  intestine,  but  susceptible  of  doing  injury  when  present  in 
great  numbers.  Cultivation  of  these  two  microbes  and  experi- 
mentation upon  rabbits  showed  that  the  streptococcus  had  lost 
its  virulence.  The  question  arises  whether  this  was  due  to  the 
length  of  time  the  disease  had  lasted  (two  months),  or  to  the 
antagonism  between  the  two  varieties  of  microbes,  association 
causing  modification  of  their  properties,  as  shown  by  Garr{\ 
The  authors  made  a  series  of  experiments  which  disproved  the 
position  of  Garr6,  and  hence  they  were  obliged  to  accept  the 
other  horn  of  the  dilemma.  That  the  acute  symptoms  in  this 
case  should  have  been  absent  for  fifteen  days  prior  to  the  oper- 
ation, while  a  great  quantity  of  fcBtid  pus  remained  in  the  pel- 
vis, infiltrating  the  uterus  and  intestine;  furthermore,  that  a 
quantity  of  this  offensive  material  should  be  allowed  to  remain 
in  the  body  without  apparent  harm  to  the  individual,  is  an  illus- 
tration of  some  of  those  mysterious  conditions  of  which  no  one 
has  yet  given  a  satisfactory  explanation.  That  women  with 
disease  of  this  character  occasionally  get  well  without  an  oper- 
ation, the  pus  being  absorbed,  or  the  system  becoming  tolerant 
of  it  and  its  contents  in  some  way  or  other,  the  history  of  the 
many  cases  which  were  formerly  treated  as  cases  of  cellulitis 
would  seem  to  show.  We  also  know  that  some  of  them  get 
well  when  only  an  exploratoiy  operation  is  performed.  In  any 
event,  it  seems  very  probable  that  the  bacterial  life  which  is 
concerned  with  the  disease  is  modified  by  age,  by  exposure  to 
air,  and  by  other  conditions  of  which  we  as  yet  know  nothing, 
so  that  an  apparently  hopeless  case  results  in  recovery.  A 
practical  suggestion  for  cases  like  that  which  is  here  narrated 
would  be  that  an  attempt  to  do  too  much  by  operative  meas- 
ures will  frequently  i)roduce  a  fatal  issue;  an  exploratory  incis- 
ion will  frequently  prove  curative. 

The  Operative  Treatment  of  Retroflexio  TJteri  (Diihrssen, 
Internat.  klin.  Rundschau,  Dec.  4,  1892). — The  condition  of 
retroflexion  of  the  uterus  in  women  was  believed  to  be  one 
which  always  leads  to  more  or  less  serious  disease.  Its  treat- 
ment with  pessaries  is  not  an  ideal  one  and  brings  with  it  many 
disadvantages.  This  is  the  justification  for  the  operative  treat- 
ment of  the  condition,  and  an  operation  is  to  be  desired  which  is 
not  dangerous  to  life,  which  will  cure  the  retroflexion  without 
giving  rise  to  other  troubles,  and  which  will  not  interfere  with  the 
performance  of  the  functions  of  the  uterus.  Such  an  operation 
has  been  devised  by  the  author  and  practiced  in  a  hundred  and 
thirty  cases.  The  first  step  consists  in  releasing  adhesions  of 
the  uterus  and  ovaries,  if  any  exist,  by  Schultze's  method.  The 
vagina  and  external  genitals  are  then  disinfected  with  a  one- 
per-cent.  lysol  solution,  the  posterior  vaginal  wall  retracted 
with  a  Simon  speculum,  anterior  lip  of  the  portio  vaginalis 
seized  with  two  bullet  forceps,  the  uterus  drawn  down  and  its 
interior  curetted  and  irrigated,  the  lysol  solution  being  used. 
The  bladder  is  then  pushed  forward  and  upward  with  a  male 
catheter,  which  has  been  introduced  into  it,  while  the  assistant 
on  the  right  side  draws'down  the  portio  vaginalis  to  the  vulva. 
The  operator  then  makes  a  transverse  incision  one  centimetre 
long  in  the  anterior  vaginal  wall  just  in  front  of  the  portio, 
grasps  the  upper  border  of  the  wound  and  drags  it  forcibly  up- 
ward, lengthens  the  incision  by  one  centimetre  with  scissors 
and  also  deepens  it  into  the  fascia  until  an  opening  is  large 
enough  to  admit  the  index  finger,  by  which  the  attachment  of 
the  bladder  is  separated.  A  sound  is  then  introduced  into  the 
uterus  and  held  by  the  assistant  on  the  left,  who  depresses  the 


organ  until  the  fundus  can  be  felt  by  the  index  finger  of  the 
operator.  Then  four  provisional  ligatures  are  passed,  one 
above  the  other,  through  the  anterior  wall  of  the  uterus,  their 
ends  being  |held  by  the  assistant  on  the  right,  who  drags  the 
uterus  downward  and  forward  by  traction  upon  the  ligatures. 
Next  three  sagittal  sutures  are  passed  through  the  anterior  por- 
tion of  the  vaginal  wound,  but  beneath  the  mucous  membrane, 
each  one  passing  also  through  the  anterior  portion  of  the  fundus 
uteri.  These  sutures  having  been  tied,  the  mucous  membrane 
of  the  vaginal  wound  is  closed  over  them  with  a  running  cat- 
gut suture,  the  uterus  is  irrigated,  and  the  vagina  is  tamjjoned 
with  iodoform  gauze.  This  operation  is  performed  by  the  au- 
thor in  about  teu  minutes.  The  patient  should  remain  in  bed 
eight  days  after  the  operation,  and  should  abstain  from  severe 
work  for  a  somewhat  longer  period.  Of  the  bad  results  which 
may  possibly  follow  the  operation,  retention  of  urine  and 
metrorrhagia  are  mentioned.  In  one  case  the  three  sutures 
were  passed  off  through  the  urethra  several  months  after  the 
operation.  In  none  of  the  hundred  and  thirty  cases  was  there 
a  fatal  issue,  in  very  few  cases  was  there  any  septic  complica- 
tion, and  a  hundred  and  two  cases  resulted  in  cure.  In  two 
thirds  of  the  cases  which  were  cured  the  uterus  was  adherent  as 
well  as  retrofiexed  before  the  operation.  Metritis,  endometri- 
tis, and  fixation  of  the  ovaries  were  also  frequent  complica- 
tions, and  massage  and  intra-uterine  applications  were  required 
to  complete  the  treatment.  In  those  cases  in  which  the  cervix 
was  fixed  posteriorly  by  adhesions  in  the  vicinity  of  the  os  inter- 
num the  rectification  of  the  malposition  was  not  always  satis- 
factory. In  not  a  few  cases  the  cure  was  only  temporary,  the 
uterus  returning  after  a  few  weeks  or  months  to  its  vicious  po- 
sition. It  was  thought  that  this  might  frequently  be  avoided 
by  the  judicious  use  of  massage  after  the  operation.  [This  op- 
eration adds  one  more  to  the  list  of  methods  for  the  treatment 
of  retroflexion  of  the  uterus,  and  the  ideal  method  is  yet  to 
come.  We  agree  entirely  with  Diihrssen,  as  do  most  gynaecolo- 
gists now,  that  the  pessary  treatment  of  uterine  displacements 
is  unsatisfactory  and  seldom  curative ;  also  that  the  condition 
of  retroflexion  is  one  which  under  all  conditions  demands  atten- 
tion for  possible  if  not  for  existing  evils.  We  think  the  method 
of  Schultze — of  tearing  adhesions  without  knowing  what  else 
may  also  be  torn — is  a  bad  one  and  must  often  be  dangerous. 
Very  few  operators,  we  think,  could  perform  the  operation  that 
has  been  described  in  ten  minutes,  or  have  so  large  a  percentage 
of  recoveries  as  its  author.] 

The  Biology  of  Fibromyomata  of  the  Uterus  (Klein- 
wachter,  Ztsch./.  Oeb.  w.  Gyn.,  xxv,  2). — The  author  considers 
it  a  remarkable  fact  that,  notwithstanding  the  great  amount  of 
study  which  has  been  directed  to  the  subject  of  uterine  myoniata 
in  general,  almost  nothing  has  been  done  with  reference  to  the 
subject  of  their  developmental  relations.  Only  Gusaerow  and 
Schorler  have  paid  attention  to  this  subject,  and  their  work  has 
not  been  exhaustive.  According  to  Gusserow,  the  rate  of  growth 
is  very  slow,  the  pure  fibromata  growing  much  more  slowly  than 
the  myomata.  The  somewhat  rapid  enlargement  which  is  some- 
times seen  in  myomata,  especially  during  the  coexistence  of  preg- 
nancy, was  to  be  attributed  not  to  increase  and  growth  of  the 
constituent  elements,  but  to  changes  in  the  blood  supply,  to 
oedema,  and  to  inflammatory  changes.  Changes  in  size  in  my- 
omata are  often  quite  noticeable  before  and  after  menstruation. 
Temporary  diminution  in  size  is  sometimes  associated  with  ex- 
hausting disease.  Among  fourteen  cases  which  Gusserow  stud- 
ied he  observed  that  after  six  months  the  tumor  in  one  case  was 
as  large  as  a  fist;  another  was  as  large  as  a  fist  after  a  year's 
duration.  In  two  cases  which  had  continued  a  year  and  a  half 
the  diameter  of  one  tumor  was  fifty-five  itiillimotres,  and  of  the 
other  forty  millimetres.   In  one  which  had  lasted  two  years  tliv 


536 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Mbd.  Jodb  , 


size  was  that  of  a  child's  head,  and  there  was  no  enlargement 
the  next  two  years.  In  one  of  three  years'  duration  the  tumor 
extended  from  the  pelvis  to  the  navel.  One  tumor  of  six  years' 
growth  was  no  larger  than  tlie  fist,  and  another  of  equal  age  ex- 
tended three  fingers'  breadth  above  the  symphysis.  One  of  eight 
years'  growth  was  no  larger  than  a  fist,  and  another  of  nine  years 
and  a  half  was  as  large  as  a  man's  head.  Gnsserow  admits  that 
these  statistics  are  not  very  accurate  or  very  satisfactory. 

Schorler  made  a  study  of  eighteen  cases  of  uterine  myoinata 
and  concluded  that  the  first  appreciable  symptoms  might  appear 
within  three  montlis  from  the  origin  of  the  disease,  that  after 
one  year  the  tumor  might  still  be  very  small,  in  five  years  it 
might  be  as  large  as  a  fist,  and  in  thirteen  years  as  large  as  a 
man's  head.  In  two  cases  an  increase  of  twenty  centimetres  in 
the  body  measurement  was  observed  in  three  years,  in  one  case 
the  same  degree  of  enlai'gement  took  place  in  a  year  and  a 
half.  To  the  foregoing  data  Kleinwiichter  adds  the  statistics  of 
forty  oases  which  he  had  carefully  followed  in  his  own  practice. 
They  are  divided  into  two  classes,  in  one  of  which  the  growth 
was  rapid  and  in  the  other  slow.  The  general  supposition  that 
tumors  cease  to  grow  during  and  after  the  menopause  was  not 
demonstrated  in  the  majority  of  the  cases  which  were  seen  by  him 
during  that  period.  In  the  greater  number  of  cases  the  devel- 
opment continued.  In  some  of  the  cases  growth  was  slow  at 
first  and  then  became  rapid  and  considerable.  In  three  cases 
only  was  permanent  diminution  in  the  size  of  the  tumor  ob- 
served.   In  one  case  cancerous  degeneration  took  place. 

The  Extensive  Distribution  of  the  Nerves  in  the  Human 
Ovary  (Herff,  Clrlhl.  f.  Gyn.,  189.3,  No.  1).— A  series  of  in- 
vestigations upon  the  human  ovary,  with  special  reference  to 
the  ending  and  distribution  of  the  nerves,  has  been  made  by 
the  author.  Specimens  were  used  which  had  been  obtained  by 
operation  and  ( thers  from  cadavers  and  new-born  infants.  The 
conclusions  were  that  the  ovarian  nerves  were  principally  vaso- 
motor nerves.  Their  number  is  so  great  that  they  include  a 
considerable  portion  of  the  structure  of  the  organ.  They  form 
in  most  cases  a  thick  plexus,  but  not  an  anastomosing  arrange- 
ment. They  are  distributed  alike  to  capillaries  and  to  vessels 
with  muscular  fiber.  A  relatively  small  number  of  fibers  end 
in  the  muscle  cells  of  the  hilum,  or  between  the  cells  of  the 
germinal  epithelium.  There  are  also  nerves  in  the  follicular 
epithelium,  but  whether  they  extend  to  the  cumulus  proligerus 
was  not  determined.  The  presence  of  ganglion  cells  could  not 
be  satisfactorily  determined,  but  their  presence  at  least  in  the 
hilum  was  considered  very  probable. 

A  New  Method  of  extirpating  the  Uterus  (Hochenegg, 
Ctrlbl.  f.  Gyn.,  1892,  No.  48).— The  sacral  method  of  op- 
eration recommended  by  this  author  met  with  a  sympathetic 
reception  at  first,  but  since  then  has  been  more  or  less  dis- 
carded, and  there  is  danger  of  its  obsolescence  notwithstand- 
ing the  fact  that  the  results  of  the  operation  have  been  good. 
Of  thirty-three  reported  operations,  the  mortality  has  been  but 
nine  per  cent.  The  causes  of  the  unpopularity  of  the  operation 
are  the  difficulty  of  its  performance,  the  occasional  trouble- 
some hsemorrhage,  but  especially  the  distaste  which  gynascolo- 
gists  have  for  bone  operations.  Against  these  disadvantrges 
should  be  weighed  the  great  advantages  of  the  sacral  over  the 
vaginal  method,  consisting  especially  in  the  accessibility  which 
is  given  to  the  diseased  structures. 

The  incision  should  extend  from  a  centimetre  above  the 
sacro-iliac  junction  in  the  middle  line  as  far  as  the  anus,  then 
pass  around  the  anus  on  the  left  side,  ending  in  the  middle  line 
at  the  perinajum.  The  iipper  portion  of  the  incision  should  ex- 
tend down  to  the  bone,  the  lower  portion  extending  to  the  cir- 
cnmreotal  cellular  tissue,  while  at  the  perinseum  only  the  skin 
is  to  be  incised.    The  tissues  are  separated  from  the  ischium. 


the  rectum  is  loosened  along  the  left  side,  while  on  the  right 
and  anteriorly  its  attachments  are  not  disturbed.  This  brings  one 
around  the  rectum  to  the  posterior  vaginal  wall,  the  left  side  of 
which  is  isolated;  long  scissors  are  introduced  into  the  vagina, 
and  an  opening  in  it  is  made.  The  rectum  is  now  to  be  dissected 
in  the  ujiper  angle  of  the  wound  from  the  posterior  surface  of  the 
uterus,  the  space  of  Douglas  opened — and  this  rnay  be  done 
without  danger  to  the  intestines — the  entire  posterior  aspect  of 
the  genital  apparatus  being  then  brought  into  view.  One  can 
now  cut  away  the  organs  securely,  separate  the  bladder,  expose 
the  ureters,  tie  vessels,  separate  the  parametrium,  and,  if  neces- 
sary, remove  a  portion  of  the  vagina,  everything  being  under 
control  of  the  sight.  The  haemorrhage  by  this  method  is  very 
slight,  and  the  wound  large  enough  to  remove  not  only  the 
uterus,  but  the  ovaries  and  contiguous  tissues.  The  peritoneal 
opening  should  then  be  sewed  up  with  buried  sutures,  the  va- 
ginal wound  closed,  the  rectum  fixed  in  its  former  position  with 
buried  sutures,  and  the  external  wound  tamponed  with  gauze 
or  drained  and  sutured. 

After  the  operation  the  patient  should  be  kept  in  the  hori- 
zontal posture  with  the  pelvis  elevated  to  prevent  intestinal 
obstruction. 

This  method  is  recommended  for  all  cases  of  uterine  car- 
cinoma, and  it  will  enable  one  to  remove  diseased  glands  in  the 
space  between  the  uterus  and  rectum.  The  author  has  often 
found  these  glands  infected  when  others  are  not  yet  diseased. 
The  operation  is  analogous  to  that  for  cancer  of  the  breast,  in 
which  it  is  now  generally  regarded  as  proper  to  open  the  axiPa 
in  all  cases  and  remove  the  glands. 

Occlusions  of  the  Intestinal  Tract  and  Intra-abdominal 
Hernise  in  Connection  with  Pathological  Changes  in  the 
Female  Genital  Organs  (Stratz,  Ztach.f.Geb.u.  Gyn.,  xxv, 
•2). — Reports  of  incarceration  ot  the  intestine  occurring  after 
abdominal  operations,  especially  after  vaginal  extirpation  of  the 
uterus,  are  not  uncommon.  The  accidents  are  usually  explained 
as  resulting  from  severe  operations,  from  the  action  of  air  and 
disinfectant  solutions  upon  the  intestinal  serous  membrane,  or 
from  the  formation  of  adhesions  within  the  peritoneal  cavity. 
Such  causes  are  not  considered  in  the  author's  present  paper, 
but  only  those  in  which  occlusion  or  hernia  arises  from  physio- 
logical or  what  the  author  styles  natural  pathological  condi- 
tions. Ten  cases  are  narrated  from  various  sources,  including 
five  of  the  author's,  in  nine  of  which  the  obstruction  was  due 
to  peritoneal  adhesions,  and  in  one  to  the  long  pedicle  of  an 
ovarian  tumor  associated  with  pregnancy.  Two  of  the  cases 
were  fatal  from  peritonitis.  Seven  of  the  cases  were  due  to 
peritoneal  diseases  or  their  consequences,  and  the  others  to  tu- 
mors. In  many  cases  in  which  adhesions  are  present  the  con- 
tinuity of  the  intestinal  tract  is  not  interrupted,  but  we  have 
constipation  alternating  with  diarrhoea  without  decided  ileus. 
This  circumstance  is  explained  by  the  gradual  pouring  out  of 
exudate  and  the  adaptation  of  the  intestine  to  changed  condi- 
tions. As  the  exudate  is  absorbed  the  intestines  are  usually 
released  from  their  abnormal  conditions.  Occasionally  an  ad- 
hesion between  the  intestine  and  the  genital  organs  persists,  and 
an  opportunity  is  furnished  for  the  development  of  an  intra- 
abdominal hernia. 

The  most  important  symptom  in  making  the  diagnosis  ot 
intra-abdominal  hernia  is  ileus,  and  this  is  the  symptom  which 
usually  calls  for  operative  interference.  Subjectively  there  are 
feelings  of  discomfort  in  the  intestines,  vomiting,  and  constipa- 
tion ;  objectively  there  is  a  very  sensitive  tumor,  which  does 
not  proceed  from  the  genital  organs,  bnt  has  very  intimate  rela- 
tions with  them. 

Ascites  from  a  Gynaecological  Standpoint  (Gnsserow, 
Ctrlbl.  f.  Gyn.,  1803,  No.  1). —  Fn  all  cases  of  ascites  which 


May  13,  1893.] 


MISCELLAFY. 


537 


can  not  be  accounted  for  by  disease  of  tbe  circnlatory  system, 
liver,  or  kidneys,  Gusserow  recommends  incision  of  the  abdo- 
men, rather  than  puncture,  as  a  means  of  diagnosis.  The  for- 
mer is  not  more  dangerous  than  the  hvtter,  and  allows  one  to 
obtain  more  accurate  information  of  the  existing  condition,  as 
well  as  to  evacuate  the  contained  tiuid.  Cases  of  this  condition 
•ire  divided  into  four  groups: 

1.  Those  which  are  caused  by  tuberculous  peritonitis. 

2.  Those  which  are  due  to  papilloma  of  the  ovaries. 

;).  Those  which  arise  from  carcinoma  of  the  ovaries  or  peri- 
confeum. 

4.  Those  which  are  associated  with  benign  disease  of  the 
ireuital  organs. 

The  term  peritonitis  nodosa  is  preferred  to  tubercular  peri- 
tonitis, for  tlie  cases  which  are  thus  denominated  frequently 
lack  the  characteristics  of  tuberculosis — caseation,  giant  cells, 
and  tubercle  bacilli.  In  the  third  group  are  distinguished  cases 
in  which  all  the  diseased  tissue  is  removable,  those  in  which 
only  a  portion  is  removable,  and  those  in  which  nothing  is  re- 
movable. Even  in  the  latter  an  incision  is  often  followed  by 
improvement. 


l[t  i  s  c  c  1 1  a  n  » . 


Lymphadenia. — In  the  third  volume  of  the  Johu  Hopkins  Hospital 
Keportg  there  is  an  interesting  article  by  Dr.  Simon  Flexner,  on  Multiple 
Lympho-sarcomata,  in  which  he  reports  two  cases  aud  gives  the  follow- 
ing resume  of  our  present  knowledge  of  the  subject : 

"  Much  has  been  written  on  the  affection  known  as  lympho  sarcoma, 
and  the  literature  of  the  subject  is  to  be  sought  under  a  score  of  names 
which  have  been  proposed  for  it  at  ditferent  times  and  in  different 
places.  The  disease  was  first  described  by  Hodgkin  in  1832;  after- 
ward it  was  called  by  Wilks  Hodgkin's  disease,  anaemia  lymphatica ; 
by  Cohnheim,  pseudo-leukaemia ;  by  Trousseau,  adenie ;  by  Kanvier, 
lymphadenia;  by  Musick,  lymphatic  cachexia.  With  reference  to  the 
pathological  changes  which  it  induces  in  the  various  organs,  it  has 
been  called  vascular  sarcoma  of  the  lymphatic  glands,  Craigie ;  malignant 
lymphoma,  Billroth  ;  lympho-sarcoma,  Virchow  ;  maliguant  lympho-sar- 
ooma,  Langhans ;  lymphadenoma,  Wunderlich,  Ranvier ;  desmoid  car- 
cinoma, Schulz.  It  is  needless  to  say  that  much  confusion  is  neces- 
sarily introduced  into  the  study  of  the  disease  by  the  iibundance  of 
designations  which  it  possesses.  At  the  present  time,  however,  many 
i)f  them  have  fallen  into  disuse,  and  in  this  country  and  Germany  the 
affection  is  for  the  most  part  described  under  the  titles  lymphosarcoma, 
malignant  lymphoma,  and  pseudo-leukaemia,  to  which  in  England  is  to 
be  added  lymphadenoma. 

■'  Weisliaupt  has  just  discussed  the  applicability  of  some  of  these 
oames,  and  concludes  that  the  appellation  '  lympho-sarcoma '  should  be 
abolished  altogethei',  as  it  serves  only  to  bring  confusion  into  the  sub- 
ject, and  he  proposes  the  adoption  of  the  term  pseudo-leuk;cmia,  in 
preference  to  others  now  in  use.  This  view,  while  according  with  ours 
in  so  far  as  it  discards  the  idea  of  an  actual  tumor  process  characterizing 
the  disease,  assumes,  nevertheless,  an  actual  acquaintance  with  it  which 
it  is  needless  to  say  we  do  not  now  possess.  Until  such  a  time  as  the 
«tiology  of  this  affection  shall  become  known,  it  will  hardly  be  possible 
to  confine  its  description  to  any  one  of  its  names. 

''  We  have  already  referred  to  the  acuteuess  of  the  course  of  the 
disease  in  some  instances,  and  recently  Ebstein  has  described,  under 
the  title  'Das  chronische  Riickfallsfieber,  eine  neue  Infectiouskrank- 
heit,'  what  he  regards  as  a  previously  undescribed  acute  infectious  dis- 
ease. His  cases  have  been  reviewed  by  Pel  and  compared  with  .■similar 
oases  which  he  observed  aud  which  came  to  autopsy,  and  Pel  shows 
<K)nclusively  that  the  cases  of  Ebstein  are  to  be  regarded  as  acute  forms 
of  pseudo-leuksDmia.    Renvers  reports  another  case  associated  with 


recurrent  elevations  of  temperature,  in  which  the  glands  principally 
affected  were  the  mesenteric  and  retroperitoneal ;  metastases  were  pres- 
ent in  the  liver  and  spleen.  In  a  case  recorded  by  Dreschfeld  there 
was  a  large  mediastinal  tumor  with  infection  of  the  retroperitoneal  and 
mesenteric  glands,  liver,  and  kidneys,  in  which  the  disease  ran  its  course 
with  elevation  of  temperature;  but  the  blood  contained  an  excess  of 
white  cells. 

"  In  this  case  the  author  found  in  the  kidney  numerous  small,  thick 
bacilli.  No  cultm-es  were  made,  nor  is  it  stated  whether  there  were 
lesions  in  the  intestinal  nmcous  membrane  or  not.  Bacilli  were  culti- 
vated from  the  kidneys  in  our  case ;  they  were  identified  with  the 
colon  bacillus,  however,  and  their  presence  there  was  not  regarded  as 
of  any  significance,  for,  as  Professor  Welch  has  pointed  out,  the  colon 
bacilli  wander  regularly  when  there  is  a  lesion  of  the  intestinal  mucous 
membrane,  and  they  are  found  almost  uniformly  in  the  kidney  in  such 
cases. 

"Many  more  cases  arc  reported  in  which  irregular  elevations  of 
temperature  attended  the  disease  or  occurred  a  short  time  before  death. 
But  as  these  cases  led  to  no  misunderstanding,  nor  offer  anything  espe- 
cial on  their  own  account,  and  a  number  of  them  bear  more  directly  on 
another  part  of  the  paper,  they  will  be  passed  over  now. 

"  That  there  are  included  under  this  disease  affections  which  depend 
for  their  origin  on  totally  different  causes,  and  which  have  little  more 
in  common  than  the  enlargement  of  one  or  more  sets  of  glands,  is  quite 
sure.  And,  moreover,  it  would  appear  as  if  in  the  course  of  certain 
cases  of  lymphosarcoma  a  secondary  process  could  be  added  to  it,  this 
one  being  of  an  infectious  nature.  Such  would  seem  to  be  the  explana- 
tion of  those  cases  in  which  the  pyogenic  cocci  were  isolated  from  the 
diseased  glands. 

"  The  case  of  Weishaupt,  the  autopsy  having  been  made  by  Baum- 
garten,  shows  that  in  some  instances  tuberculosis  of  the  lymph  glands 
can  simulate  this  affection  so  closely  as  to  be  indistinguishable  from  it 
by  the  macroscopical  appearances  alone.  In  this  case  there  was  en- 
largement of  the  lymph  glands  of  the  neck,  with  implication  of  most  of 
the  glands  of  the  body.  There  were  nodules  in  the  kidney,  liver,  spleen, 
and  lungs.  The  macroscopical  appearances  of  the  glands,  and  the  nod- 
ules in  the  other  organs,  led  to  a  diagnosis  of  '  pseudo-leukaimia.'  The 
clinical  picture,  too,  was  in  accord  with  the  post-mortem  diagnosis. 
However,  the  microscopical  examination  of  the  affected  glands  exhibited 
areas  of  coagulation  necrosis,  and  in  them  tubercle  bacilli  were  found. 
The  minute  nodules  in  the  lungs,  liver,  and  kidneys  did  not  resemble 
tubercles  so  much  as  lymphomata  ;  yet  in  one  place  in  the  kidney  a  hy- 
aline change  was  found  in  a  nodule  similar  to  those  found  in  the  lym- 
phatic glands,  but  no  bacilli  could  be  detected.  Weishaupt  then  exam- 
ined the  lymphatic  glands  from  twelve  other  cases  of  pseudo-leukaemia, 
including  hard  and  soft  forms,  without  finding  tubercle  bacilli.  His 
conclusion  is  that  in  its  aetiology  pseudo-leukaemia  is  independent  of  tu- 
berculosis. 

"  Other  cases  in  which  tubercidous  affections  of  the  glands  are  said 
to  have  simulated  pseudo-leukaemia  are  reported  by  Watzoldt,  Brentano 
and  Tangl,  Delafield,  Cossy,  and  Crocq.  In  the  case  of  the  second- 
named  writers  there  were  old  and  healed  lesions  in  the  lungs,  tubercu- 
lous ulcers  in  the  intestine  aud  peritoneal  tuberculosis,  while  the  glands 
showed  no  caseation,  but  upon  inoculation  into  g\unea-pigs  gave  rise  to 
tuberculosis.  In  a  case  by  Clans  there  were  tidiercles  in  the  lungs  and 
tubercle  bacilli  in  the  sputa.  In  the  kidneys,  liver,  spleen,  and  lungs, 
even,  lymphomatous  nodules  were  present,  which  the  author  regards  as 
distinct  from  tubercles  and  readily  distinguishable  from  them.  Another 
case  in  which  both  affections  occurred  is  that  of  Liebmann,  but  neither 
of  these  can  be  said  to  be  conclusive. 

"  On  the  other  hand,  cases  of  pseudo-leuka;mia  have  been  described 
with  which  the  pus  organisms  have  been  associated.  Mafucci  found 
chain-cocci  in  a  case  of  malignant  lymphoma,  in  the  diseased  areas  only, 
and  succeeded  in  cultivating  them,  while  Roux  aud  Lannois  isolated  the 
Staphi/lot  orcus  pyogenes  aureus  from  another  case.  We  do  not  consider 
that  there  existed  any  relation  of  caiise  and  effect  in  either  of  these  in- 
stances. In  our  opinion,  they  merely  represent  an  infection  with  the 
pus  organisms  added  to  the  pre  existing  glandular  att'ection.  .\  case  is 
reported  by  Kelch  and  Vaillard  in  which  several  subcutaneous  tiunors 
existed  over  the  body  without  glandular  enlargement.    Although  the 


538 


MISVELLANY. 


[N.  Y.  Med.  Jock. 


authors  regarded  it  as  a  case  of  lyinpho-sarconia,  there  is  no  pood  reason 
to  suppose  it  was  one,  and  the  histological  description  of  the  tumors  cor- 
responds quite  as  well  with  libro-sarconia.  The  only  interesting  point  in 
this  ease  is  the  isolation  of  bacilli  from  the  blood  during  life  and  the 
cultivation  of  the  organisms.  In  addition  to  the  tumors  there  was  leu- 
cocytosis,  and  the  liver  and  spleen  were  enlarged.  A  case  reported  by 
Taylor  as  '  sloughing  lympho-sarcoma  of  the  back  and  other  lesions  of 
the  skin  and  internal  organs  '  was  probably  syphilitic  in  origin. 

"  There  are  certain  cases  of  lympho-sarcoma  of  (juite  undoubted  na- 
ture in  which  the  glandular  enlargement  diminished  under  treatment. 
Not  a  few  of  such  are  recorded.  The  improvement  has  followed  the 
use  of  arsenic,  given  internally,  and  applied  directly  to  the  diseased 
glands  by  parenchymatous  injection.  Examples  of  improvement  are  re- 
ported by  Israel,  Kiibner,  Striimpell,  Billroth,  Winiwater,  and  others. 
In  a  case  of  Arning's  in  which  there  were  tumors  in  the  skin,  mucous 
membranes,  and  muscles,  one  of  the  tumors  was  extirpated  and  its  char- 
acter determined  by  microscopical  examination  ;  improvement  occurred 
in  this  case  also.  Wunderlich  cites  two  cases  in  which  syphilis  could 
be  excluded,  which  improved  under  the  administration  of  iodide  of  po- 
tassium. 

"  The  occurrence  of  ulceration  and  other  forms  of  degeneration  in 
the  tissues  in  which  the  tumors  developed  and  in  the  tumors  themselves 
is  not  so  very  uncommon.  It  is  probable,  indeed,  that  the  tendency  to 
the  graver  forms  of  degenerative  changes  is  not  so  marked  in  this  as  in 
some  other  affections,  and  the  more  minute  and  less  evident  forms  have, 
perhaps,  not  received  the  attention  which  they  would  seem  to  deserve. 
Virchow  has  again  called  attention  to  the  persistence  of  lyrapho-sar- 
comata,  and  he  regards  them  as  belonging  essentially  to  those  tumors 
which  do  not  ulcerate  or  do  so  only  under  special  conditions.  He  says : 
'  What  is  especially  characteristic  of  them,  and  in  consequence  of  which 
they  have  few  parallels  among  tumors,  is  the  persistence  of  their  ele- 
ments, as  if  they  were  normal  elements  and  structvues  of  the  body. 
Lympho-sarcoma  does  not  become  caseous ;  does  not  suppurate,  does 
not  tend  to  ulcerate  ;  but  forms  nodules  of  a  lasting  nature.'  This  ut- 
terance was  made  in  the  course  of  a  discussion  on  tumors  of  the  medi- 
astinum. However,  there  are  a  number  of  undoubted  cases  of  ulcera- 
tion recorded,  although  the  proportion  is  not  large.  It  would  appear 
that  it  is  in  particular  situations  that  ulcerations  are  chiefly  found.  The 
most  usual  is  the  alimentary  canal,  and  in  particular  the  intestinal  tract ; 
next  to  this  in  the  skin. 

"  Coupland  reports  a  case  of  general  glandular  enlargement  in  a 
young  woman  of  twenty-five.  The  stomach  gave  evidences  of  post- 
mortem decomposition  at  the  fundus  ;  at  the  pylorus  the  mucous  mem- 
brane was  thickened,  opaque,  and  mammillated  ;  a  number  of  the  mam- 
millations  showed  central  pits  or  depressions.  These  he  regarded  as 
the  enlarged  and  ulcerated  solitary  follicles.  The  mucous  membrane  of 
the  duodenum  was  of  a  dead-white  color ;  it  was  infiltrated  uniformly 
with  an  opaque  white  material,  and  was  marked  here  and  there  with 
small  erosions  and  superficial  ulcerations.  The  ileum  showed  a  more 
pronounced  degree  of  the  same  process,  the  patches  of  Peyer  were  espe- 
cially affected,  and  the  generally  smooth  surface  of  the  mucous  mem- 
brane was  interrupted  by  a  ragged,  villous-looking  ulceration  that  had 
taken  place  along  the  margins  of  the  valvulae  conniventes  and  in  the 
site  of  a  Peyer's  patch. 

"  The  new  tissue  was  deposited  in  the  mucosa  and  submucosa.  The 
growth  of  it  between  the  crypts  of  Lieberkiihn  had  caused  them  to 
shrivel  and  atrophy.  The  muscular  coat  was  infiltrated,  and  the  amy- 
loid changes  were  prcs<  iit  in  tlie  intestines  and  mesenteric  glands. 

"  In  a  case  of  JanletVs  there  was  perforation  of  an  enlarged  and 
ulcerated  plaque  in  the  ileum.  In  most  of  the  ileum  the  patches  of 
Peyer  were  hypertrophied ;  a  few  only  had  ulcerated.  In  the  jejunum 
the  ulcers  affected  the  valvute  coimiventes  at  times  ;  several  ulcers  oc- 
curred in  the  duodeiuim,  one  just  below  the  pylorus.  The  intestines 
were  adherent  to  one  another,  and  over  the  ulcerated  areas  there  was  a 
thick  infiltration  of  the  peritoneal  and  other  coats,  the  enlarged  and 
ulcerated  ]ilaques  projecting  into  the  lumen  of  the  intestine  from  1  to  !5 
ctm.  The  mesenteric  glands  were  affected.  There  were  no  metastases 
in  other  organs. 

"  A  case  reported  by  Pitt  is  that  of  a  man  forty-eight  years  old.  In 
the  Ktomatih  were  large  masses  of  lymphoid  overgrowth,  situated  on  the 


mucous  wall,  forming  sessile  tumors.  At  the  cardiac  end,  two  inche.- 
from  the  diaphragm,  were  large  masses,  both  sessile  and  polypoid.  Tl.( 
growths  were  creamy  white,  soft  and  succulent,  and  the  largest  onci- 
were  breaking  down  at  their  bases.  Large  numbers  of  growths  wck- 
present  in  the  intestines,  beginning  in  the  duodenum  and  extending  Ui 
the  colon,  which  was  free ;  many  of  these  had  ulcerated  and  were  bile- 
stained.  The  mesenteric  glands,  lumbar  glands,  and  spleen  were  en- 
larged ;  the  peritona'um  healthy. 

"Another  is  that  of  Pick.  At  its  margin  between  the  jejunum  and 
ileum  was  a  mass  of  infiltration  15  ctm.  in  length;  this  growth  had 
thickened  the  mesentery  to  the  extent  of  3  ctm.  For  a  space  of  4  ctrn. 
square  the  njass  was  necrotic  and  ulcerated  ;  beyond  this  one  was  au- 
other  but  more  superficial  ulceration.  The  mesenteric  and  retroperito- 
neal glands  were  infiltrated.  There  wei-e  metastases  in  the  liver  and 
kidneys. 

"  In  the  case  of  Henoch  a  ring  of  tumor  mass  surrounded  the  intes- 
tine, and  in  the  mucous  membrane  corresponding  with  the  ring  was  a 
loss  of  su})Stance  about  the  size  of  a  dollar.  The  small  curvature  of 
the  stomach  was  infiltrated  with  the  tumor,  and  the  mesentery  through- 
out. Metastases  were  present  in  the  peritoneeum,  diaphragm,  kidneys, 
liver,  gastro-hepatic  glands,  retroperitoneal  glands,  and  mediastinal 
glands. 

"  Still  other  cases  are  reported  by  Moore,  Steiner,  Legg,  and  other  s  ; 
and  for  the  occurrence  of  similar  ulcerations  in  the  stomach  the  reports 
of  Herard,  Kutzner,  Wunderlich,  Hadden,  and  Kredel  are  to  be  re- 
ferred to.  In  the  description  of  the  affection  given  by  other  authors, 
moreover,  the  occurrence  of  ulceration  in  the  stomach  and  intestines  is 
freely  stated,  for  instance,  by  Birch-Hirschfeld,  Gowers,  Cornil  and 
Ranvier,  and  Ziegler. 

"  Other  forms  of  degeneration  in  lympho-sarcoma  are  hardly  men- 
tioned by  writers  on  the  subject,  and  the  pr  oduction  of  marked  changes 
in  the  surrounding  tissues  has  not  been  seen  to  any  extent,  if  we  ex- 
clude the  direct  effect  of  the  gi'owiug  tumor  masses  on  the  tissues  of 
the  part  in  which  they  are  found.  However,  the  case  of  Coupland, 
already  quoted,  might  be  regarded  as  an  instance  of  degeneration  in 
excess  of  the  purely  mechanical  effect,  and  in  those  reported  by  Ribbert 
there  was  atrophy  of  the  tissues  of  the  bronchi,  notwithstanding  a  mod- 
erate l3Tnpho-sarcomatous  development  within  them.  But  of  special  in- 
terest in  the  cases  of  Ribbert  is  the  occur-rence  of  actual  hepatization 
around  the  aggregated  lymphomatous  nodules  in  the  lung.  These  lym- 
phomata  could  be  distinguished  from  tubercles  Vjy  their  appearance, 
and  the  difference  was  confirmed  by  the  histological  and" bacteriological 
examinations.  The  character  of  the  exudate  about  the  nodules  was  un- 
like that  of  croupous  pneumonia  as  well  as  caseous  pneumonia,  and 
consisted  largely  of  epithelial  cells,  a  varying  number  of  lymphoid  cells 
and  fibrin.  No  micro  organisms  were  detected  in  the  tissues  nor  could 
any  he  cultivated.  Similar  lymphoid  nodules  were  present  in  other 
organs  and  parts. 

"  Schulz  reports  several  cases  in  which,  in  the  neighborhood  of  the 
new  growth  in  the  liver,  stomach,  intestines,  and  kidneys,  the  epithe- 
lium of  the  parts  was  swollen,  very  granular,  often  fatty  and  disinte- 
grated. .  .  . 

"  Murchison  reports  a  case  of  a  large  tumor  in  front  of  the  spine 
which  was  covered  by  the  intestines.  The  tumor  consisted  of  the  en- 
larged mesenteric  glands  together  with  an  enormous  thickening  of  the 
coats  of  the  duodenum  and  upper  parts  of  the  jejunum.  The  thicken- 
ing was  due  to  a  deposit  of  new  tissue  in  the  subserous  and  submucous 
tissues.  The  mucous  membrane  of  the  intestine  was  not  ulcerated,  nor 
were  the  follicles  enlarged.  Similar  deposits  occurred  in  the  perito- 
naeum, diaphragm,  fundus  of  urinary  bladder,  in  the  liver,  kidneys,  and 
heart  muscle.  The  new  growths  consisted  of  lymphoid  cells,  and  were 
distributed  along  the  course  of  the  portal  canals  in  the  liver,  and  occu- 
pied the  interstitial  tissues  of  the  kidneys  overlapping  the  tubules.  A 
second  case  of  Murchison's  had  general  glandular  enlargement  with 
metastases  in  the  spleen,  liver,  diaphragm,  lungs,  and  dura  matei-.  The 
kidneys  and  intestines  were  imatfected.  The  histological  examination 
of  this  case  by  Dr\  Sanderson  showed  that  the  new  growth  in  the  liver 
originated  in  the  por  tal  s))aces. 

"  In  a  case  pirblished  by  Suckling  there  were  multiple  growths  from 
the  dui'a  nuiter,  and  the  intestinal  glandular  apparatus  was  afl'ected. 


May  18,  1893.J 


MISCELLAXY. 


539 


Moreover,  there  were  eulargeineuts  of  tlie  inesenterie  glands  and  liver, 
and  the  left  kidney  contained  a  nodule.  Wiegandt  reports  a  case  with 
nodules  in  the  heart  muscle,  and  general  affection.  In  the  kidneys  the 
uodular  growths  were  not  so  sharply  circumscribed  as  they  appeared  to 
be  on  naked-eye  e.xamination. 

"  Cohnheim  has  described  an  interesting  case.  The  cervical,  sub- 
ma.xillary,  retroperitoneal,  and  inguinal  lymph  glands  were  enlarged. 
The  spleen  was  enlarged.  The  left  kidney  likewise,  and  the  whole  sur- 
face was  mottled  with  wide,  often  confluent,  blood-red  spots  and  Hues, 
the  ground  substance  being  white.  The  hjemorrhages  were  mostly 
superficial,  so  that  the  parenchyma  itself  exhibited  a  variegated  appear- 
ance, the  white  exceeding  the  red  patches.  The  right  kidney  was  simi- 
larly but  not  so  extensively  affected  as  the  left.  The  intestines  were 
normal.  The  liver  was  large,  the  acini  were  surrounded  with  remarka- 
ble regularity  by  a  translucent  ring  of  light  gray  color  half  a  centi- 
metre in  thickness.  These  were  made  up  of  collections  of  lymphoid  cells 
occupyiug  the  portal  spaces  and  sending  offshoots  into  the  acini  be- 
tween the  rows  of  liver  cells.  In  the  kidneys  the  greatest  accumulation 
of  cells  was  in  the  intertubular  tissues. 

"  In  the  case  of  Eberth  there  was  slight  enlargement  of  the  mesen- 
teric glands ;  the  mucous  membrane  of  the  stomach  contained  a  large 
number  of  superficial  medullary  nodules  of  the  size  of  a  pea ;  both 
kidneys  were  enlarged  and  presented  numerous  metastatic  nodules  the 
size  of  a  cherry.  The  actual  kidney  parenchyma  was  to  be  seen  in  a 
few  places  only.  No  macroscopic  change  in  the  liver  was  observed, 
but  on  microscopical  examination  there  were  considerable  collections 
of  lymphoid  cells  around  the  central  veins  and  in  the  interstitial  tissue. 

"  Several  cases  are  reported  by  Turner.  In  the  first  the  kidneys 
were  enormous  in  size,  owing  to  the  infiltration  with  lympho-sareoma- 
tous  tissue.  One  weighed  nineteen  ounces  and  the  other  nineteen  ounces 
and  a  half.  The  glands  under  the  jaw  and  the  axillary  glands  were 
enlarged.  There  were  purpuric  spots  over  the  body,  and  ecchymoses  in 
the  pleura  and  pericardium.  Another  case  in  which  the  kidneys  were 
much  enlarged  is  reported  by  him,  and  there  were  multiple  ecchymoses 
over  the  pericardium,  peritonasum,  dura  mater,  optic  discs,  and  pia  mater. 
The  microscopical  appearances  were  similar  to  those  in  other  cases,  the 
growth  in  the  liver  following  the  portal  spaces,  and  in  the  kidney  it  was 
intertubular,  with  a  tendency  to  surround  the  glomeruli.  Rosenstein 
has  published  a  case  in  which  the  superficial  glands  were  enlarged,  and 
metastases  had  occurred  in  the  spleen,  liver,  kidneys,  and  the  right 
adrenal  gland.  In  the  kidneys  there  were  atrophy  and  fatty  degenera- 
tion of  the  epithelium  of  the  tubules. 

"  Packard  reports  a  case  of  a  child  six  months  old  in  which  there 
were  numerous  subcutaneous  tumors,  and  in  which  the  thymus  was 
large  and  indurated  by  buckshot-sized  nodules  scattered  through  it. 
There  were  masses  of  tumor  surrounding  the  thoracic  aorta,  and  metas- 
tases in  the  lungs  and  liver ;  the  gastro-hepatic  glands  were  enlarged, 
but  the  mesenteries  were  not,  and  the  right  adrenal  gland  was  involved. 
Borlee  describes  a  colossal  tumor  of  the  lower  jaw  and  neck  in  a  man 
of  sixty-five.  The  axillary  and  inguinal  glands  were  affected,  and  those 
of  the  root  of  the  lungs  and  the  bronchi  also.  The  pancreas,  mesen- 
teric glands,  ciEcum,  and  vermiform  appendix  were  grown  together  into 
a  tumor  mass.  Both  kidneys  were  affected ;  in  the  knee  of  the  corpus 
callosum  was  a  tumor  of  the  size  of  a  hazelnut. 

"  From  this  brief  review  it  will  be  seen  that  few,  if  any,  structures 
of  the  body  are  free  from  the  invasion  of  this  affection.  Although 
the  place  of  origin  is  the  lymphatic  apparatus,  and  the  cervical  glands 
would  seem,  in  a  majority  of  cases,  to  be  the  earliest  affected,  Sehuiz 
believes  that  several  sets  are  simultaneously  involved.  However  this 
may  be,  as  Virchow  and  others  have  pointed  out,  the  process  sooner 
or  later  becomes  heteroplastic  and  all  structures  are  invaded  indiffer- 
ently. I 

"  A  certain  number  of  cases,  on  the  other  hand,  proceed  to  their 
termination  without  any  involvement  of  the  superficial  glands;  and  in 
still  others,  where  there  are  lymphatic  structures  closely  associated,  one 
will  be  affected  and  the  other  not.  In  our  cases,  for  example,  with 
great  involvements  of  the  lymphatic  apparatus  of  the  intestine,  the 
mesenteric  glands  escaped  altogether. 

"  The  production  of  metastases  in  other  organs,  in  the  kidneys, 
liver,  etc.,  is  clearly  due  todnfeetion'  by  means,  of  the  blood  current. 


The  distribution  of  the  affection  in  these  organs  is  uniformly  the  same 
and  follows  the  blood  supply.  In  our  first  ca.se,  again,  the  tendency  of 
the  disease  process  to  appear  about  the  blood-vessels  of  the  submucous 
coat  of  the  intestine,  rather  than  the  lymphatics,  may  account  for  the 
escape  of  the  mesenteric  glands  and  the  infection  of  the  liver  and 
kidneys. 

"  It  is  by  no  means  clear  why  the  kidneys  should  become  affected 
through  the  blood  and  the  lungs  escape.  This  is  seen  to  happen  in 
many  instances,  and  if  the  reported  cases  are  studied  there  is  seen  to 
be  a  preference  for  the  localization  of  the  process  in  certain  organs. 
Classing  the  spleen  with  the  lymphatic  glands — for  it  is  quite  as  often 
involved  as  any  set  of  glands — we  have  the  liver,  kidneys,  intestines, 
and  the  lungs  susceptible  in  the  order  of  their  mention.  Much  more 
rarely  are  other  organs  affected — the  central  nervous  system,  skin, 
heart,  ovaries,  testicles,  bone-marrow,  and  adrenals.  So  far  as  the  in- 
fection of  the  lungs  is  concerned,  it  is  possible  that  the  smaller  size  of 
the  nodules  which  develop  there  and  their  relative  inconspicuousness 
may  account  in  part  for  the  great  difference  observed. 

"  But,  on  the  other  hand,  it  is  evident  that  a  large  number  of  cases 
remain  in  which  the  process  can  not  be  followed  in  its  metastases  as 
cancer  can  be,  and  it  would  seem  to  follow  other  laws.  This  difficulty 
has  been  present  to  the  minds  of  other  writers,  and  Schulz  has  empha- 
sized the  fact  that  the  infection  in  lympho-sarcoma  is  not  to  be  viewed 
as  a  metastasis  in  the  usual  sense,  but  to  be  regarded  as  the  result  of  a 
virus  diffused  through  the  body,  following  an  affection  of  the  lymph 
glands. 

"  From  whatever  side  this  affection  is  viewed,  whether  from  its 
clinical  history  or  its  pathological  anatomy  (the  latter  being  taken  to  in- 
clude the  histological  structure,  the  alteration  in  the  tissues  produced 
by  its  presence,  its  mode  of  extension  from  one  place  to  another,  in  the 
first  instance  from  lymph  glands  to  lymph  glands,  and  then  from  the 
latter  to  other  organs),  we  are  met  with  the  necessity  of  regarding  it 
not  so  much  in  the  light  of  a  true  tumor  as  of  an  infectious  disease  due 
to  a  specific  micro-organism." 

A  Conference  of  State  Medical  Examining  and  Licensing  Boards. — 

The  third  annual  meeting  of  the  Conference  of  State  Medical  Ex- 
amining and  Licensing  Boards  will  be  held  in  Milwaukee  on  June  7th, 
under  the  presidency  of  Dr.  John  H.  Ranch,  of  Springfield,  111.  The 
following  subjects  will  be  discussed :  I.  The  Evolution  of  State  Medical 
Examining  and  Licensing  Boards  :  Their  present  and  prospective  influ- 
ence in  elevating  the  moral  and  intellectual  tone  of  the  profession.  II. 
Composition  of  Boards :  (a)  The  desirable  number  of  members.  (J) 
The  desirable  appointing  power.  (<•)  The  advantages  and  disadvantages 
of  separate  boards  representing  the  different  schools  of  practice.  III. 
Provisions  of  the  Various  State  Laws :  (a)  Should  the  possession  of  a 
diploma  from  a  recognized  medical  school  be  a  prerequisite  to  appear- 
ing before  a  board  for  examination?  (b)  What  reciprocal  relations 
should  exist  between  boards  ?  (c)  Should  teachers  in  medical  schools 
be  eligible  to  membership  on  State  examining  boards  ?  (d)  Defects  in 
existing  laws,  the  best  law  in  vogue,  the  ideal  law.  IV.  Methods  of 
conducting  Examinations  :  (a)  How  should  the  examination  be  pre- 
pared ?  (6)  The  scope  of  examinations.  (<•)  The  minimum  and  maxi- 
mum requirements. 

The  Colorado  State  Medical  Society. — The  twenty-third  annual 
meeting  will  be  held  in  Denver  on  the  20th,  21st,  and  22d  of  June, 
under  the  presidency  of  Dr.  W.  E.  Wilson,  of  Denver.  Papers  are  an- 
nounced as  follows :  Hysteria  in  Men,  by  Dr.  Howell  T.  Pershing,  of 
Denver ;  Diagnosis  in  Children,  by  Dr.  Hubert  Work,  of  Pueblo ; 
Treatment  vs.  Operation  in  Minor  Gyna3Cology,  by  Dr.  Mary  T.  Lowrie, 
of  Boulder;  The  Nature  of  Colorado  Mineral  Springs,  by  Dr.  Carl 
Ruedi,  of  Denver;  The  Park  System  of  Denver,  by  Dr.  Samuel  A. 
Fisk,  of  Denver;  The  Diagnosis  and  Treatment  of  Some  Connuon 
Forms  of  Nervous  Diseases,  by  Dr.  J.  T.  Eskridge,  of  Denver  ;  Cases  of 
Cerebral  Surgery,  by  Dr.  Clayton  Parkhill,  of  Denver;  Amputations, 
l)y  Dr.  G.  W.  Miel,  of  Denver;  Conservatism  in  Accidental  Surgery,  by 
Dr.  E.  J.  A.  Rogers,  of  Denver  ;  The  Early  Treatment  of  Clubfoot,  by 
Dr.  George  P.  Packard,  of  Denver;  The  Uric-acid  Diathesis,  by  Dr.  N. 
Wiest,  of  Denver ;  The  Causes  of  (Edema,  by  Dr.  Henry  Sewall,  of 
Deliver;  Intubation  of  the  Larynx,  by  Dr.  Austin  (t.  Case,  of  Denver; 


540 


MISCELLANY. 


[N.  Y.  Med.  JoiTk. 


The  Precordial  Area  in  Cliiidreu,  by  Dr.  H.  B.  Whitney,  of  Denver ; 
Heterophoria,  by  Dr.  Jolui  M.  Foster,  of  Denver  ;  Ulcers  of  the  Cornea 
(with  drawings),  by  Dr.  ^V.  C.  Bane,  of  Denver;  The  Treatment  of  Na- 
eal  Obstruction,  by  Dr.  H.  II.  Howland,  of  Denver ;  Essential  Details 
in  the  Conduct  of  Labor,  by  Dr.  Kate  Reynolds  Lobingier,  of  Denver ; 
Secondary  Post-partum  H;pmorrhage,  by  Dr.  J.  F.  Davidson, of  Denver; 
Vaso-motor  Disturbance  following  Spinal  Traumatism,  by  Dr.  E.  R. 
Axtell,  of  Denver;  The  Treatment  of  the  Complications  of  Typhoid 
Fever,  by  Dr.  J.  N.  Hall,  of  Denver ;  The  Indications  for  the  Use  of 
the  Uterine  Curette,  by  Dr.  W.  W.  Grant,  of  Denver.  Papers  have 
also  been  promised  by  the  following  members,  but  the  subjects  have 
not  yet  been  announced :  Dr.  John  M.  Keating,  of  Colorado  Springs ; 
Dr.  E.  C.  Rivers,  of  Denver ;  Dr.  P.  Thombs,  of  Pueblo ;  Dr.  Robert 
Levy,  of  Denver ;  Dr.  W.  C.  Davis,  of  Denver ;  Dr.  John  Chase,  of 
Denver ;  Dr.  Laura  L.  Liebhardt,  of  Denver ;  Dr.  A.  Stedman,  of  Den- 
ver; Dr.  J.  C.  Herrick,  of  Denver;  Dr.  Lewis  M.  Walker,  of  Denver; 
and  Dr.  W.  B.  Craig,  of  Denver.  The  president  will  deliver  the  ad- 
dress in  Therapeutics ;  Dr.  W.  J.  Rothwell,  the  address  in  Medicine ; 
Dr.  J.  W.  Collins,  the  address  in  Gynaecology ;  and  Dr.  Lewis  E.  Lemen, 
the  address  in  Surgery. 

The  Non-operative  Treatment  of  Strabismus. — After  alluding  to 
Dr.  Bernstein's  article,  published  in  the  Jmirnal  for  April  22d,  the 
Medical  News  says :  "  Instead  of  a  bandage  we  are  accustomed  to  use  a 
rubber  blinder  attached  to  the  spectacle-frame,  thus  permitting  the  eye 
to  be  open.  Another  method  we  have  found  most  serviceable  is  to 
mydriaticize  the  sound  eye  only  for  an  occasional  week  or  two.  This 
is  of  especial  use  when  children  are  too  young  to  wear  spectacles.  The 
relief  of  reflex  symptoms  by  glasses  alone  is  also  a  fact  of  great  in- 
terest, even  when  high  heterophoria  coexists.  A  patient  of  the  writer's 
is  now  wearing  simple  araetropic  correction  with  twenty  degrees  of 
eeophoria  uncorrected,  with  complete  relief  of  previous  severe  reflex 
symptoms,  and  with  constantly  strengthening  muscles.  We  are  very 
frequently  too  impertinent  with  our  surgery,  and  if  we  would  only  give 
the  natural  recuperative  powers  an  opportunity  and  the  means  of  self- 
cure,  we  should  bring  about  correction  by  normal  and  easy  methods. 
As  Dr.  Bernstein  courteously  says,  the  treatment  he  advocates  is  in  ac- 
cord with  the  method  of  treating  argamblyopia  proposed  in  the  Xews 
for  December  31,  1892." 

The  Society  of  Medical  Jurisprudence. — The  paper  announced  for 
the  meeting  of  Monday  evening,  the  8th  inst.,  was  on  Recent  Forensic 
Malpractice,  to  be  read  by  Dr.  E.  C.  Spitzka. 

The  late  Dr.  John  Halsey  Hunt,  of  Port  Jervis,  N.  Y. — The  fol- 
lowing resolutions  were  passed  at  a  recent  meeting  of  the  Society  of 
the  Alumni  of  Bellevue  Hospital : 

Whereas,  Our  associate.  Dr.  John  H.  Hunt,  has  been  removed  by 
an  untimely  death  from  the  activities  and  usefulness  of  his  profession, 
we,  his  colaborers  in  Bellevue  Hospital,  New  York  city,  desire  to  give 
expression  to  our  personal  regard  for  his  many  estimable  qualities  as  a 
man,  our  appreciation  of  him  as  a  friend,  and  our  sincere  regi-et  that 
in  his  decease  our  profession  has  lost  au  ardent,  conscientious,  and  ex- 
perienced practitioner.  Dr.  Hunt's  amiable  qualities  and  medical  acumen 
won  him  honored  consideration  while  a  fellow  worker  on  the  hos- 
pital staff ;  his  laborious  efforts  in  his  professional  life  have  secured 
for  him  reputation  and  regard. 

In  his  death  we  desire  to  reiterate  our  sense  of  personal  and  profes- 
sional loss,  and  to  his  family  and  fi-iends  give  fitting  testimonial  of  our 
sorrow  and  sympathy. 

(  L.  Bolton  Bangs,  i 
[Signed]  <  T.  H.  Bdrchard,    \  Committee. 

'  R.  A.  MnRRAV,  ' 

The  late  Dr.  William  Lomax,  of  Marion,  Indiana. — The  following 
is  condensed  from  a  sketch  kindly  furnislied  by  Dr.  A.  W.  Brayton,  of 
Indianapolis : 

Dr.  Loraax  attended  lectures  in  the  Ohio  Medical  College  in  1836 
and  in  the  Indiana  Medical  College  in  1847,  and  graduated  from  the 
University  of  the  City  of  New  York  in  1850.  He  practiced  at  Marion 
until  1861,  when  Governor  Morton  issued  to  him  the  first  surgeon's 
ooinmieeioa  grunted  by  the  State  of  Indiana.     He  was  made  sur- 


geon in  chief  of  division  and  medical  director  of  the  Fifteenth  Army 
Corps,  and  served  throughout  the  war.  His  wife,  nursing  the  wounded, 
fell  a  victim  to  disease  and  died  at  Sharpsburg,  Maryland,  in  December, 
1861.  Dr.  Lomax  was  the  leader  in  the  organization  of  the  State  Med- 
ical Society;  he  was  its  president  in  1856,  and  almost  solely  by  his  in- 
fluence was  it  constituted  in  ISTS  of  accredited  delegates  from  county 
societies  and  incorporated  under  State  law. 

Dr.  Lomax  had  a  large  library,  both  medical  and  secular,  and  wag  a 
friend  of  higher  education.  About  a  year  and  a  half  before  his  death 
he  bequeatlied  his  farm  near  Marion  and  other  property  to  the  amount  of 
over  fifty  thousand  dollars  to  the  Medical  College  of  Indiana.  Dr  Lomax 
was  an  enthusiast  in  his  jirofession ;  he  practiced  fifty-six  years  con- 
tinuously in  the  same  neighborhood,  was  a  member  of  the  order  of  Free 
Masons,  an  active  churchman,  and  a  philanthropist.  Through  his  aid 
and  influence  his  county  society  owns  its  own  meeting  place,  and  from 
its  commodious  hall  almost  the  entire  profession  in  the  county  of  Grant 
followed  his  remains  to  their  last  resting  place. 


To  Contributors  and  Correspondents. —  The  attention  of  all  wfu>  purpoM 
favoring  ux  with  voiniiiunhations  is  respectf idly  called  to  tllyC  follow- 
ing : 

Aiit/wr.s  of  articles  nitended  for  publication  under  the  /lead  of  '^original 
coiUributions  "  are  respectfully  informed  that,  in  accepting  such  arti- 
cles, we  ahoays  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  manuxcript  or  any  abstract  thereof  muxt  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  tiotifed 
of  t/ie  fact  at  the  time  the  article  is  sent  to  us  ;  (S)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  bt 
published  as  promptly  as  our  other  engagements  will  admit  of — int 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  aiit/ior  wishes  complied  with  mast  be  distiiuctlu 
staled  in  a  communication  accom[)anying  the  manmcript,  ami  no 
new  conditions  can  be  considered  after  tlie  manuscript  has  been  put 
into  the  type-setters^  hands.      We  are  often  constrained  to  declint 
articles  which,  although  they  may  be  creditable  to  tlieir  authors,  art 
not  suitable  for  publication  in  this  journal,  either  because  they  art 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profess\oy> 
at  large.     We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 
All  letters,  whether  intended  for  puldication  or  not,  must  contain  ifu 
writer's  name  and  address,  not  necessarily  for  publication.    No  ol- 
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  thu  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor- 
respondent informing  him,  under  what  number  tJie  answer  to  his  note 
is  to  be  looked  for.    All  communications  not  intended  _  for  publication 
under  the  author's  name  are  treated  as  strictly  confdential.     We  car, 
7iot  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi- 
vidual practitioners. 
Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  its  in- 
formed of  the  dates  of  their  societies''  regular  meetings.    Brief  notif- 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet- 
ings will  be  inserted  when  theij  are  received  in  time. 
NevKpapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem- 
bers o  f  the  Jirofession  who  send  us  informatioti  of  matters  of  interest 
to  our  readers  ivill  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  sub.stance  of  such  communications. 
All  communications  intended  for  the  editor  should  be  addressed  to  hin, 

in  care  of  the  publishers. 
All  communications  relating  to  the  business  of  the  journal  should  be  ad- 
dressed to  the  publishers. 
Contributors  who  wish  to  order  REPRINTS  of  their  articles  shoidd  do 
to  on  a  hiiink  prepared  for  that  purpose,  which  will  be  sent  to  theni 
by  tlie  publishers  on  recenpt  of  a  recptest  to  that  effect.  T7u  order 
tliould  be  sent  to  tlie  publishers,  and  not  to  the  editor. 


TPIE  NEW  YORK  MEDICAL  JOITRJSrAL,  May  20,  1893. 


Original  Communuiitions. 


PElilODICAL  SLEEP  SEIZURES  OF  AN 
EPILEPTIC  NATURE  * 
By  GEORGE  W.  JACOBY,  M.  D. 

Thkke  Cfiri  be  no  doubt  tbat  the  study  of  pliysiological 
sleep  is  surrounded  by  insuperable  difficulties,  and  that  no 
great  advance  in  our  knowledge  of  the  causes  and  laws 
wliich  govern  this  condition  has  been  made.  To  a  certain 
extent  this  failure  must  be  attributed  to  the  almost  exclu- 
sive employment  of  experimental  physiology  as  a  method 
of  study,  and  the  neglect  of  other  methods.  The  subject 
is  of  so  complex  a  nature  that  we  can  not  hope  to  attain 
any  results  from  one  method  alone,  and  it  would  seem  natu- 
ral that  we  should  give  more  attention  to  the  clinical  side 
of  the  question  than  has  hitherto  been  done.  Particularly 
does  it  seem  reasonable  that  the  study  of  pathological  dis- 
orders of  sleep  should  be  of  service  in  this  regard.  The 
production  of  artificial  sleep,  known  as  the  hypnotic  state, 
has  of  late  years  so  engrossed  the  attention  of  all  observers 
that  pathological  modifications  of  spontaneous  sleep  have 
been  almost  totally  disregarded.  The  appearance  of  Geli- 
neau's  publication  on  narcolepsy  in  1880  for  a  time  caused 
considerable  interest  to  be  taken  in  these  cases  of  abnormal 
sleep,  and  they  were  then  studied  and  classified. 

Under  the  designation  narcolepsy  are  classed  all  cases 
in  which,  from  whatsoever  cause,  an  imperative  and  irre- 
sistible somnolence  occurs  suddenly,  and  recurs  after  more 
or  less  short  intervals.  This  condition  may  occur  frotn  a 
variety  of  causes,  but  the  sleeping  states  known  as  hys 
terical  are  of  so  interesting  a  nature,  and  they  have  re- 
ceived so  much  attention,  that  all  other  causal  agencies 
have  been  overshadowed  by  them  ;  it  is  therefore  not  sur- 
prising that  the  majority  of  practitioners  are  prone  to  class 
all  cases  of  periodically  recurring  sleeping  attacks  as  hys- 
terical :  thus,  while  it  has  been  acknowledged  that  certain 
of  these  cases  of  sleep  seizures  may  be  epileptic  in  nature, 
this  characteristic  has  been  entirely  lost  sight  of.  These 
cases  of  epileptic  sleeping  attacks  are  undoubtedly  of  con- 
siderable interest  and  importance,  and  they  become  so  from 
the  diagnostic  difficulties  which  they  present,  as  well  as 
from  the  medico-legal  complications  which  they  may  lead 
to ;  there  can  be  no  doubt  that  they  occur  much  more  fre- 
quently than  the  scant  literature  of  the  subject  would  in- 
duce us  to  assume.  A  careful  study  of  all  published  cases 
of  sleeping  attacks,  of  whatsoever  nature,  certainly  leaves 
the  impression  that  a  number  of  these,  even  if  occurring  in 
hysterical  patients,  are  epileptic  in  nature.  It  is  my  inten- 
tion to  speak  of  such  cases  only  as  are  undoubtedly  epilep- 
tic, even  though  not  accompanied  by  convulsions,  and  for 
this  reason  I  can  not  enter  upon  the  cases  just  referred  to, 
which  for  tlie  most  part  are  described  as  cases  of  hystero- 
epilepsy.  Personally,  1  have  decided  objections  to  the  use 
of  this  compound  designation.    That,  epileptic  patients  not 

*  Read  before  the  Metropolitan  Medical  Society,  February  15,  IKiKf. 


only  may,  but  frequently  do,  have  hysterical  attacks  I  will- 
ingly admit ;  but  in  describing  these  attacks  we  should 
give  them  their  proper  designation — epileptic  or  hysterical, 
as  the  case  may  be — and  not  create  confusion  by  calling 
them  hystero-  epileptic. 

A  case  reported  by  Sahlmen,  which  Dana  includes  under 
those  of  epileptic  somnolence,  is  one  of  the  few  in  which 
the  author,  notwithstanding  the  marked  hysterical  symp- 
toms present  in  the  intervals  of  the  attacks,  pronounces  the 
convulsions  and  sleep  attacks  as  epileptic,  and  there  can  be 
no  doubt  but  that  he  is  correct  in  this  classification. 

Cases  of  recurrent  sleeping  attacks  unaccompanied  by 
convulsions,  but  probably  epileptic,  in  which  the  sleep  seiz- 
ure constituted  the  entire  palpable  attack,  have  been  de- 
scribed by  Westphal,  Fischer,  Mendel,  and  Putzel  (commu- 
nicated by  Dana),  and  very  recently  by  Berkan.  Possibly 
the  cases  of  Siemens  and  Foot  also  belong  to  this  category. 

The  application  of  the  term  epilepsy  has  of  late  years 
been  very  much  extended,  and  now  this  term  embraces  very 
much  more  than  the  train  of  symptoms  described  as  tonic- 
clonic  convulsions  with  loss  of  consciousness.  We  now 
distinguish  a  variety  of  epileptic  conditions,  making  use 
of  the  terms  haut  mal  and  petit  mal  as  designations  for  two 
gross  divisions.  In  this  latter  category  we  must  class  those 
cases  which,  while  they  have  little  or  nothing  in  common 
with  the  classical  epileptic  attack,  nevertheless  present 
symptoms  which  can  not  be  explained  in  any  other  way 
than  by  the  assumption  of  their  epileptic  nature.  These 
symptoms  are,  in  the  main,  short  disorders  and  interrup- 
tion of  psychic  action,  followed  in  all  instances  by  am- 
nesia. 

If  the  condition  known  as  haul  mal,  occurring  with  or 
without  psychic  disturbances,  is  of  itself  highly  interesting, 
that  variety  just  referred  to  must  attract  our  attention  in  a 
much  wider  way. 

One  of  the  most  interesting  chapters  in  the  study  of 
epilepsy  is  undoubtedly  that  of  sleep,  and  this  state  has 
been  fully  treated  of  by  Siemens.  It  is  well  known  that 
many  epileptics  sleep  after  every  convulsive  attack,  that  a 
smaller  number  do  not  sleep  after  their  attacks,  and  that 
there  are  patients  who  present  no  regularity  in  this  regard, 
but  who  sleep  after  some  attacks  but  do  not  sleep  after 
others.  What,  however,  is  not  so  well  known  is  that,  in 
some  patients,  attacks  of  sleep  constitute  the  chief  symp- 
tom, and,  as  stated,  it  is  with  cases  of  this  class  solely  that 
I  propose  to  deal  in  the  present  communication.  Such 
cases  as  Reynolds's  (that  of  a  young  lady  who  did  not  sleep 
when  she  had  severe  convulsions,  but  was  depressed  and 
comatose  all  day  when  slight  attacks  preceded),  Nothnagel's 
(that  of  a  lady  with  otherwise  short  and  light  sleep,  who 
very  shortly  before  her  epileptic  attacks  fell  into  a  very 
long  and  deep  sleep),  and  Schultz's  (that  of  an  epileptic 
sailor  in  whom  the  attacks  always  occurred  about  diimer 
time  and  were  announced  by  tiredness,  followed  by  a  sleep 
during  which  the  convulsion  occurred),  differ  from  the  cases 
which  I  wish  to  report,  and,  although  interesting,  can  not 
be  more  than  mentioned. 

Tiie  cases  of  periodical  recurrent  sleep  seizures  of  an 


542 


J  AC  0  BY:   PERIODICAL  EPILEPTIC  SLEEP  SEIZURES. 


[N.  Y.  Mkd.  Jodr., 


epileptic  nature  which  have  come  under  my  own  observa- 
tion are  the  following : 

Case  I. — A  man,  aged  twenty-niue  (seen  in  1887) ;  family  his- 
tory neuropathic;  mother  liad  "  nervous  spells  "  all  her  life ;  one 
brother  was  epileptic  and  died  suddenly.  Patient  himself  was 
perfectly  well  until  his  twelfth  year,  when,  in  consequence  of 
fright  produced  by  being  chased  by  a  dog,  he  fell  down  in  a  con- 
vulsive attack.  He  was  completely  unconscious,  bit  his  tongue 
and  frothed  at  the  month.  After  the  attack  he  slept  for  sev- 
eral hours.  This  was  the  only  purely  convulsive  attack  that  he 
or  his  family  admit  his  ever  having  had.  At  the  age  of  twenty- 
one  he  had  a  peculiar  attack  described  as  follows :  He  was 
walking  with  a  friend,  conversing  upon  ordinary  matters,  when 
he  suddenly  wheeled  around,  completing  a  full  circle,  and  then  be- 
gan to  run  at  full  spaed.  After  running  a  distance  of  about  five 
hundred  feet  he  fell,  and  when  his  friend  came  to  him  he  found 
hina  lying  upon  the  ground  apparently  fast  asleep.  The  asser- 
tions are  positive  that  no  convulsions  occurred.  He  slept  for 
about  fifteen  minutes,  attempts  at  arousing  him  proving  futile, 
and  awoke  as  from  a  normal  sleep,  with  total  amnesia  as  to 
what  had  occurred  from  the  time  he  started  to  run  ;  he,  how- 
ever, perfectly  remembered  the  subject  of  the  conversation 
which  he  was  engaged  in  prior  to  this  occurrence.  The  next  at- 
tack took  place  under  similar  circumstances  about  two  months 
later.  The  attacks  gradually  grew  more  and  more  frequent,  so 
that  of  late  years  they  have  occurred  almost  daily  and  sometimes 
he  has  had  several  in  one  day.  Whenever  these  attacks  have  been 
witnessed  from  their  commencement,  the  reports  all  agree  that 
the  first  intimation  of  the  attack  is  the  starting  oflf  on  a  run. 
He  never  runs  for  a  long  distance,  sometimes  only  a  few  yards; 
he  never  has  a  convulsion  of  any  kind;  and  when  he  ceases 
running  is  found  asleep,  generally  having  fallen,  sometimes 
leaning  against  some  support.  A  complete  attack  has  never 
been  witnessed  indoors,  but  he  has  been  found  asleep  in  all 
places  and  positions.  The  sleep,  as  far  as  known,  does  not  last 
more  than  fifteen  minutes,  generally  less.  Finally,  it  must  be 
nottd  that  the  patient  is  a  somnambulist,  performing  various 
automatic  actions  of  a  quiet  nature,  as  walking,  t.alking,  etc.  As 
a  child  he  was  subject  to  attacks  of  pavor  nocturnus.  I  never 
had  occasion  to  witness  one  of  his  attacks. 

It  is  hardly  probable  that  the  epileptic  nature  of  this 
case  can  be  doubted.  The  case  belongs  to  those  of  pro- 
cursive epilepsy,  being  made  up  of  the  automatic  action, 
which  here  seems  to  take  the  place  of  a  convulsion  and 
the  subsequent  sleep.  This  sleep  seems  to  me  to  be  simi- 
lar to  the  ordinary  sleep  of  epileptics  after  a  convulsive  at- 
tack. For  this  reason  the  case  liardly  belongs  to  the  cate- 
gory to  which  I  intended  confining  ray  remarks,  hut,  as  the 
patient  was  often  found  asleep  without  any  positive  knowl- 
edge of  preceding  occurrences,  we  are  justified  in  record- 
ing it  here.  He  is  totally  unconscious  from  the  time  he 
starts  to  run  until  he  awakens  from  his  sleep,  so  that  the 
possibility  remains  that  he  actually  falls  asleep  at  once  and 
that  the  running  is  an  automatic  (somnambulic)  action, 
forming  part  and  parcel  of  this  sleeping  state. 

Case  II.— (i.  F.  W.,  aged  thirty-five  (seen  in  1890);  family 
history  unimportant;  has  had  a  venereal  ulcer  without  any  sec- 
ondary symptoms;  professes  to  have  been  perfectly  well  other- 
wise. Ten  years  ago  he  began  to  increase  rapidly  in  weight,  so 
that  from  a  hundred  and  fifty  pounds  his  weight  within  a 
period  of  two  years  increased  to  two  hundred  and  sixty-seven. 
At  present  his  weight  is  two  hundred  and  fifty.    This  increase 


in  weight  did  not  trouble  him  ;  he  felt  ])erfcctly  well  and  was 
not  obliged  to  lose  a  single  day's  work  on  account  of  ill  health. 
His  occuijatioii  was  that  of  a  barber.    Four  years  ago,  while 
shaving  a  customer,  he  had  what  he  calls  an  "attack."  This 
attack  consisted  in  his  falling  asleep;  the  razor  with  which  he 
was  shaving  was  firmly  grasped  in  his  hand  and  he  was  bend- 
ing over  the  occupied  barber  chair;  when  he  awoke  everything 
was  in  the  same  position  except  the  customer,  whose  discretion 
had  probably  induced  a  precipitate  retreat.    Patient  felt  jier- 
fectly  well  and  bright  before  and  after  the  attack  ;  he  him- 
self says  the  entire  attack  came  like  a  rainstorm  from  a  clear 
sky.    The  following  day,  under  similar  circumstances,  lie  had 
another  attack,  and,  as  was  natural,  lost  his  situation.    The  at- 
tacks, which  from  the  first  recurred  daily,  increased  in  fre- 
quency so  that  he  would  have  a  number  in  one  day.  Mental 
and  bodily  quietude  favored  their  production,  so  that  sitting 
unoccupied  would  almost  certainly  superinduce  an  attack.  At 
present  these  attacks  occur  under  all  circumstances;   he  has 
fallen  asleep  while  smoking  a  pipe,  and  thereby  has  set  tire  to 
the  carpet;  he  has  often  fallen  asleep  while  washing  himself; 
and  a  few  days  ago,  while  seated  in  a  chair  near  a  hot 
stove,  he  had  an  attack  during  which  he  fell  upon  the  stove, 
burning  his  face  and  forehead  intensely.    He  has  also  been 
overtaken  by  this  sleep  while  standing  on  the  front  platform  of 
a  street  car,  and  has  then  fallen  oflf  into  the  street;  further- 
more, he  goes  to  sleep  while  walking  out  of  doors  and  continues 
walking  until  he  awakes,  having  encountered  some  obstruction 
or  having  fallen.    The  longest  intermission  between  the  attacks 
is  four  or  five  hours,  but  usually  not  more  than  an  interval  of 
an  hour  exists.    The  attacks,  which,  as  stated,  are  particularly 
frequent  when  patient  is  not  actively  engaged,  also  occur  in  the 
midst  of  hard  i)hysical  labor.    Unable  to  continue  at  his  trade, 
the  patient,  in  the  hope  that  hard  labor  might  prevent  the  re- 
currence of  the  attacks,  accepted  employment  as  a  longshore- 
man.   As  a  proof  of  his  physical  strength,  he  tells  me  that  he 
is  able,  unaided,  to  lift  and  load  upon  a  wagon  objects  weigh- 
ing three  hundred  pounds.    Even  work  of  this  kind  did  not 
infiuence  the  occurrence  of  the  seizures.     As  regards  the 
character  of  these  seizures,  the  patient,  whose  intelligence  is 
perfectly  normal,  can  give  but  little  information  ;  he  says  that 
his  eyes  grow  heavy  and,  notwithstanding  strenuous  efforts  to 
prevent  it,  they  close  and  he  sleeps;  he  has  no  further  premo- 
nition of  the  approaching  attack,  and  during  it  is  perfectly 
unconscious.    I  have  repeatedly  witnessed  these  attacks,  and 
can  add  that  his  face  becomes  intensely  congested  and  his  head 
falls  forward  upon  his  chest ;  his  pupils  during  the  sleep  are  con- 
tracted and  his  respiration  and  pulse  are  slower  than  usual. 
As  far  as  I  have  been  able  to  observe  them,  these  attacks  are  of 
two  kinds— light  and  severe  ones.    The  first  partake  more  of 
the  character  of  "absences,"  but  lasting  somewhat  longer,  and 
from  these  he  can  be  awakened  by  shaking  or  addressing  him 
roughly.    The  long  attacks  are  diS'erent.    In  the  beginning 
of  these  it  is  impossible  to  arouse  him  by  any  kind  of  irritation  ; 
even  with  a  faradaic  brush  I  have  failed ;  but  toward  the  end  of 
the  attack  pricking  with  a  pin  causes  him  to  make  warding-off 
movements  with  his  hands,  and  sometimes,  but  not  always, 
awakens  him.    The  attacks  which  I  have  witnessed,  when  not 
interfered  with,  have  all  terminated  as  normal  sleep  terminates 
in  normal  persons.    The  duration  of  his  attacks  varies  from  a 
few  minutes  to  three  cjuarters  of  an  hour.    They  also  occur 
when  he  is  in  bed,  and  his  relatives  at  such  times  distinguish 
these  attacks  from  normal  sleep  by  their  not  being  able  to 
awaken  him.  Otherwise  he  is  a  very  light  sleeper — in  fact,  very 
restless,  passing  the  greater  part  of  the  night  in  a  semi  wakeful 
condition.    Patient  has  been  a  somnambulist  since  childhood, 
his  automatic  actions  usually  being  of  a  quiet  nature ;  he  has, 


May  20,  1893.] 


JACOBY:  PERIODICAL  EPILEPTIC  SLEEP  SEIZURES. 


543 


however,  had  noisy  soniniunbiilistic  attacks  in  which  he  created 
disturbance  by  shouting  and  striking  about  himself  with  any 
object  within  his  reacli.  In  one  of  these  attacks  he  struck  his 
roommate  with  a  water  pitcher,  and  tlie  following  morning 
knew  nothing  of  what  he  had  done.  Convulsions  of  any  kind 
are  positively  denied  ;  nevertheless,  an  examination  of  his 
tongue  showed  scars,  and  he  says  tliat  it  is  often  sore  and  swollen. 
Treatment  of  various  kinds — with  bromides,  iodides,  and  reduc- 
tion of  weight — all  proved  unsuccessful  in  modifying  the  seizures 
in  any  way. 

Tliere  can,  in  the  light  of  our  present  knowledge,  hardly 
be  any  doubt  that  the  nature  of  tliis  case  is  epileptic,  but 
we  arc  not  warranted  in  classing  these  sleep  attacks  in  the 
same  category  as  the  sleep  of  epileptics  after  convulsions ; 
neither  is  it  admissible  to  class  them  among  the  somno- 
lent states  wliich  are  frequently  present  in  gross  brain  dis- 
ease, as  the  patient  in  the  intervals  between  the  attacks  was 
perfectly  bright  and  wakeful.  The  case  as  one  of  pure 
sleeping  attacks  is  very  interesting,  and,  as  will  be  readily 
acknowledged,  differs  entirely  from  those  frequent  cases  of 
epileptic  vertigo  with  momentary  loss  of  consciousness. 

Epilepsy  is  a  disease  of  the  brain  cortex,  and  is  caused 
by  a  temporary  affection  or  abolition  of  the  central  pro- 
cesses of  inhibition.  It  is  probable  that  the  clinical  pic- 
tures of  all  epileptic  phenomena  are  modified  by  the  topi- 
cal distribution  of  this  inhibitory  interference;  that  epilep- 
tic vertigo  is  due  to  a  disorder  in  the  cerebral  hemispheres 
and  tlie  typical  general  convulsion  is  dependent  upon  an 
extension  of  the  disorder  to  the  medulla  and  convulsive 
center  here  situated,  or  to  the  cortical  centers.  If  we  are 
right  in  these  assumptions,  it  follows  that  cases  of  epilep- 
tic psychic  equivalents  are  due  to  an  affection  of  the 
psychic  centers.  We  are  therefore  warranted  in  classing 
these  cases  of  epileptic  sleep  as  cases  of  psychic  epilepsy, 
and  in  attributing  their  causation  to  a  disorder  of  tliese 
psychic  centers. 

Siemens  believes  in  the  existence  of  a  sleep  center, 
probably  situated  in  the  medulla  not  far  from  the  convul- 
sive center,  with  which  it  is  supposed  to  possess  certain 
analogies.  Such  an  assumption  would  materially  aid  us  in 
understanding  the  mechanism  of  production  of  these  cases 
of  sleep  seizures  as  well  as  of  all  epileptic  sleeping  states, 
but,  unfortunately,  we  have  no  reason  to  take  the  existence 
of  such  a  center  for  granted. 

The  great  corpulence  of  our  patient  can  not  fail  to 
cause  remark,  and  the  first  question  which  forces  itself 
upon  us  is  whether  there  is  not  some  connection  between 
the  corpulence  and  these  attacks.  We  well  know  that  fat 
people,  particularly  when  they  are  seated,  easily  become 
drow.sy  ;  and  Dickens's  fat  boy  Joe,  whose  every  appearance 
is  greeted  by  the  remark,  "  Damn  that  boy,  he's  asleep 
again,"  is  familiar  to  us  all. 

That  there  is  some  connection  between  the  corpulence 
and  the  sleep  attacks  I  firmly  believe,  but  I  do  not  think 
that  these  attacks  are  due  to  the  corpulence,  but  consider 
it  more  likely  that  in  this  corpulence  we  must  recognize  a 
state  of  perverted  nutrition  due  to  the  pathological  con- 
dition in  the  psychic  centers.  A  case  of  marked  somno- 
lence extending  over  years,  with  psychic  and  physical 
characteristics  of  such  a  nature  as  to  raise  a  suspicion  of 


epilepsy,  described  by  Morrison,  weighed  two  hundred  and 
fifty-nine  pounds,  and  "  his  whole  physique  was  gross." 

Finally,  as  an  example  of  the  medico-legal  relations 
which  such  sleep  seizures  may  have,  I  will  briefly  report  the 
following  case : 

W.  B.  W.,  seen  in  prison  in  October,  1889,  for  the  purpose  of 
giving  an  opinion  in  regard  to  his  sanity.  The  prisoner,  whose 
wife  had  left  him  on  account  of  his  violent  temper  and  irregulari- 
ties of  lite,  purchased  a  butcher  knife,  and,  seeking  her  out  in  her 
own  dwelling,  attempted  to  murder  her,  and  nearly  succeeded 
in  so  doing.  He  was  arrested,  and  professes  to  have  total 
amnesia  for  all  occurrences  from  a  time  prior  to  the  purchase  of 
the  knife  until  he  found  himself  in  the  station  house — a  ])eriod 
of  over  two  hours. 

It  is  needless  here  to  enter  upon  the  details  of  the  case  or 
upon  the  reasons  which  led  me  to  consider  him  sane  and  a  ma- 
lingerer. Suffice  it  to  say  that  he  professed  to  have  had  three 
attacks  of  unconsciousness  during  his  life,  each  of  which  lasted 
for  several  hours.  In  one  of  these  attacks  he  says  he  traveled 
from  Buffalo  to  Niagara  Falls  without  knowing  that  be  had  done 
so.  He  gave  no  history  of  convulsions,  of  tongue  biting,  etc., 
but  my  notes  contain  the  following:  "Patient  says  that  he  falls 
asleep  easily  during  the  day;  tljat  he  falls  asleep  during  impor- 
tant conversations  and  under  circumstances  which  should  make 
him  wakeful ;  lie  furthermore  says  that  he  passes  restless  nights, 
and  he  has  been  a  somnambulist  since  childhood." 

To-day,  were  I  to  give  an  opinion  upon  the  same  case,  I 
think  that,  in  view  of  the  notes  last  cited,  I  should  be  more 
than  inclined  to  consider  the  subject  an  epileptic.  Whether 
such  a  decision  would  have  influenced  my  opinion  as  re- 
gards his  sanity  and  as  to  his  malingering  is,  however,  an 
entirely  different  question.  Westphal  enters  fully  upon 
the  forensic  import  of  these  sleeping  attacks  and  refers  to 
the  case  of  von  Zastrow  (detailed  in  Casper  and  Liman,  1876, 
vol.  i,  p.  509),  in  which  he  carefully  sought  for  a  history  of 
epileptic  attacks,  but  was  unable  to  find  any ;  Westphal, 
however,  remembers  that  von  Zastrow  said  that  he  frequently 
fell  asleep  during  the  day. 

This  much  is  certain:  that,  medico- legally,  a  history  of 
such  sleeping  attacks  merits  quite  as  much  attention  as 
does  a  history  of  absence,  or  even  of  marked  epileptic  con- 
vulsions. That  attacks  of  petit  mal  in  which  the  patient, 
while  in  the  midst  of  any  occupation,  suddenly  loses  con- 
sciousness, if  only  for  a  few  moments,  may  present  medico- 
legal relations  of  a  complicated  nature,  is  well  known ; 
that  psychic  equivalents,  psychic  disorders  which  take  the 
place  of  convulsions,  are  even  of  more  importance  is  seen 
from  the  fact  that  theft,  arson,  sexual  crimes,  and  murder 
have  all  been  committed  during  such  a  state,  and  have  be- 
come the  subject  of  medico-legal  inquiry.  All  that  I  wish 
here  is  to  empliasize  the  well-known  fact  that  in  all  dubi- 
ous cases,  of  whatsoever  nature,  in  which  amnesia  is  alleged, 
we  should  carefully  search  for  corroborative  data  of  an  epi- 
leptic character. 

One  more  question  I  desire  to  touch  upon  before  con- 
cluding, and  that  is  the  value  of  somnambulism  as  a  cor- 
roborative symptom  in  the  diagnosis  of  the  epileptic  nature 
of  any  trouble.  In  the  three  cases  which  I  have  here  re- 
,  ported  the  patients  were  all  subject  to  somnambulic  attacks. 
Of  Westphal's  case  it  is  said  that  the  woman  suffered  from 
nocturnal  insomnia,  and  could  sleep  only  a  small  portion  of 


5U 


OHMANN-DUMESNIL:   TATTOOING  AND  ITS  REMOVAL. 


[N.  Y.  Med.  Joub., 


the  night,  and  in  Fischer's  case  there  was  insomnia  when 
the  condition  first  came  on  ;  there  was  restlessness  at  night ; 
the  patient  had  bad  dreams,  during  wliich  she  saw  people, 
etc.  The  sister  relates  that  the  patient  often  sleeps  with 
open  eyes  ;  that  she  often  speaks  in  her  sleep  and  answers 
questions.  Of  these  nocturnal  occurrences  Fischer  says : 
"  Often  she  got  up  at  night  and  imagined  that  some  one 
was  in  front  of  her  door  who  wanted  to  kill  her;  but  she 
never  left  her  room.  She  says  that  she  sees  these  people 
in  her  dreams."  It  is  probable  that  both  these  patients 
were  somnambulists.  Of  Berkan's  cases,  two  of  the  three 
which  I  consider  typical  cases  of  sleep  seizures  also  pre- 
sented somnambulic  phenomena.  Of  the  nocturnal  condi- 
tion in  the  few  other  published  cases  nothing  is  said. 

While  it  is  true  that  somnambulism  (non  artificial)  may 
be  due  to  a  variety  of  causes,  we  know  that  foremost 
among  these,  beyond  a  doubt,  stands  epilepsy.  It  is  also 
well  known  that  epileptics  are  particularly  subject  to  vivid 
and  exciting  dreams.  So  it  happens  that  somnambulism 
is  frequently  the  first  symptom  which  may  attract  our  at- 
tention to  the  possible  epileptic  nature  of  an  affection,  and 
that  especially  in  patients  sulfering  from  recurring  sleep 
seizures  the  presence  of  somnambulism  is  of  diagnostic 
value. 

Diagnostically,  these  cases  will  have  to  be  distinguished 
from  cases  of  narcolepsy,  so  called,  and  from  cases  of  hys- 
terical sleep.  In  narcolepsy  there  is  always  consciousness 
of  what  is  going  on  during  the  attacks,  the  patient  is  never 
obtuse  when  awakened,  and  he  at  once  has  full  possession 
of  all  his  intellectual  faculties ;  sensibility  and  motility  are 
normal,  and  the  attack  can  be  cut  short  by  any  severe 
stimulus.  Hysterical  cases,  even  if  presenting  no  other 
stigmata  of  hysteria,  will  generally  show  a  complete  or  in- 
complete hemiansesthesia  or  a  retraction  of  the  visual  field ; 
the  attacks  occur  in  consequence  of  psychic  influence,  and 
are  prolonged,  lasting  several  hours  or  more. 

All  in  all,  I  would  formulate  the  diagnosis  as  follows  : 
Sleeping  attacks  occurring  alone  or  in  combination  with 
other  symptoms,  if  of  brief  duration  and  followed  by  am- 
nesia, are  probably  epileptic  in  character.  If  somnambu- 
lism, particularly  of  a  noisy  kind,  is  present,  this  probabil- 
ity becomes  a  certainty. 

Literature. 

1.  Berkan,  0.  Eigenthumliche  mit  Einschlafen  verbundene 
Anfiille.  Deutsche  Zeitschrift  fur  Nenenheilkunde,  Leipsic, 
1892. 

2.  Dana.  C.  L.  On  Morbid  Drowsiness  or  Somnolence. 
Journal  of  Nervous  and  Mental  Disease,  1884,  pp.  153-176. 

3.  Fischer,  F.  Epileptoide  Schlafzustande.  Archiv  fur  Psy- 
cJiiatrie,  vol.  viii,  p.  200. 

4.  Foot,  A.  Wynne.  Narcolepsy ;  Sudden  Periodical  Sleep 
Seizures.  Dublin  Journal  of  Medical  Sciences,  1886,  vol.  Ixxxii, 
p.  465. 

5.  Gelineau.  De  la  narcolepsie.  Gaz.  des  hdpitaiix,  1880, 
pp.  626,  635. 

6.  Mendel.  Ueber  Anfiille  von  Einscblafen.  Deutsche  med. 
Wochenschrift,  1880,  p.  260. 

7.  Morrison,  Alexander.  Somnolence  with  Cyanosi?. 
Practitioner,  1889,  p.  277. 

8.  Nothnagel.    Cited  by  Siemens. 


9.  Reynolds.    Cited  by  Siemens. 

10.  Sahlmen.    Berl.  Jclin.  Wochensehrift,  1881,  p.  95. 

11.  Rchultz.    Cited  by  Siemens. 

12.  Siemens,  F.  Zur  Lolire  voiii  epileptischen  Schlaf  und 
vom  Schlaf  iiberhaupt.  Archiv  fur  Psychiatrie,  1879,  vol.  ix, 
p.  72. 

13.  Westphal,  C.  Eigenthumliche  mit  Einsclilafen  verljun- 
dene  Anfiille.    Archiv  far  Psychiatric,  vol.  viii,  p.  200. 


TATTOOING  AND  ITS   SUCCESSFUL  REMOVAL. 
By  a.  H.  OHMANN-DUMESNIL,  A.M.,  M.  D., 

PROFESSOR  OF  DERMATOLOGY  AND  SYPHILOI.OOT 
IN  THE  ST.  I.OUIS  COLLEGE  OP  PHYSICIANS  AND  SURGEONS  ; 
CONSULTING  DERM  A  TOI.Oi  ,IST  TO  THE  ST.  LOUIS  CITY  AND  FEMALE  HOSPITALS  ; 
DERMATOLOGIST  TO  THE  ALEXIAN  BROTHEi  S'  HOSPITAL, 
PIUS  HOSPITAL,  POLYCLINIC  AND  EMERGENCY  HOSPITAL,  ETC. 

Tattooing  is  a  practice  which  seems  to  be  almost  uni- 
versally disseminated  on  the  globe.  Among  savage  tribes 
and  nations  it  is  a  species  of  totemism  indicative  of  the 
particular  tribe  to  which  the  individual  belongs,  or  it  is  a 
mark  of  rank,  according  as  the  figures  are  distributed  and 
the  manner  in  which  they  are  made.  The  process  consists 
essentially  in  introducing,  by  means  of  some  sharp  instru- 
ment, India  ink,  cinnabar,  or  indigo  into  the  skin,  thereby 
producing  an  indelible  mark  which  to  all  intents  and 
purposes  persists  during  the  lifetime  of  the  subject  of  the 
process.  While  there  can  be  no  doubt  as  to  the  dissemina- 
tion of  the  custom,  there  does  seem  to  be  some  question 
regarding  its  antiquity.  A  search  through  literature  shows 
it  to  be  very  ancient  indeed,  going  back  to  prehistoric 
times.  Traditions  are  extant  which  purport  to  allege  for  it 
a  divine  origin.  Be  this  as  it  may,  there  is  no  doubt  what- 
ever that  it  is  a  very  ancient  custom. 

A  classification  of  tattoo  marks  has  been  attempted,  and 
various  authors  have  given  varieties  and  divisions  thereof, 
which  may  be  all  included  in  the  following  general  divi- 
sions : 

I.  Ornamental. 

II.  Symbolic. 

III.  Amatory. 

IV.  Obscene. 

V.  Miscellaneous. 

In  the  first  class  we  encounter  the  largest  number  of 
cases.  We  find  included  in  the  examples  presented  all 
those  savages  devoid  of  rank  who  are  impelled  to  adorn 
their  bodies  with  some  designs  under  the  idea  that  it  lends 
beauty  or  grace  to  have  these  tattoo  marks.  There  exist 
also  a  certain  number  of  civilized  Caucasians  who  have  a 
certain  morbid  desire  to  have  a  decoration  of  some  sort  or 
other  tattooed  upon  the  skin,  looking  upon  the  matter  as  an 
ornament.  W^e  find  examples  of  this  in  the  form  of  rings, 
bracelets,  stars,  decorations,  etc.  In  the  latter  class  it  is 
usually  during  early  youth  or  adolescence  that  the  prac- 
tice is  most  generally  indulged  in,  mature  years  showing 
completely  the  foolishness  of  such  practices. 

The  second  class,  or  the  symbolical  form,  is  perhaps  the 
most  widely  disseminated  of  all.  As  indicated  above, 
among  savages  it  is  not  uncommon  as  a  badge  of  authority 
or  chieftainship.  The  principal  and  petty  chiefs  of  every 
tribe  have  each  one  his  peculiar  mode  of  marking  the  body  or 


May  20,  1893. J 


OBMANN-D  UMESNIL : 


TATTOOING  AND  ITS  REMOVAL. 


545 


face  or  botli,  and  can  he  easily  recognized  by  tliis  tattooing. 
It  is  to  the  savage  wliat  tlie  uniform  and  insignia  are  to  his 
civilized  brother.  In  addition  to  this,  it  is  adopted  by 
many  as  a  "  totem,"  and  is  one  of  the  most  common  forms 
of  "  totemism  "  which  we  have.  The  peculiarity  of  the  tat- 
tooing indicates  very  clearly  the  tribe  to  which  the  bearer 
of  the  marks  belongs,  and,  as  it  is  practically  permanent,  a 
renegade  can  be  very  easily  traced.  Among  civilized  nations 
we  find  that  symbolical  tattooing  is  most  common  among 
sailors.  kSoldiers  are  perhaps  next  in  frequency,  and  after 
them  we  find  the  various  trades  and  occupations  repre- 
sented. Among  sailors  nautical  emblems  are  naturally  in 
the  ascendant,  from  a  simple  anchor  to  a  full-rigged  man- 
of-war.  They  also  are  profuse  in  the  number  of  designs 
wliich  they  carry,  tliis  being  frequently  so  great  as  to  cover 
two  thirds  of  the  integument.  So  far  as  the  other  mem- 
bers of  this  class  are  concerned,  we  do  not  find  such  a  large 
number  of  subjects  represented,  although  almost  every  oc- 
cupation has  its  symbolic  attributes  tattooed. 

In  the  third  class  we  find  a  large  representation.  The 
most  common  amatory  emblems  are  without  doubt  hearts, 
wreaths,  initials,  and  true  lovers'  knots  combined  in  every 
manner  imaginable.  Sailors  are  very  prone  to  have  these, 
and  prostitutes  are  particularly  favorable  to  them.  The 
latter  class  is  not  always  satisfied  with  initials  merely,  but 
the  full  name  is  frequently  demanded.  Mottoes  of  an 
amatory  nature  are  aIso  favorites,  as  well  as  terms  of  en- 
dearment, with  or  without  accompanying  initials.  For  a 
time  it  was  quite  a  fad  for  respectable  young  ladies  to  have 
the  initials  of  their  fiances  tattooed  upon  the  instep  or  some 
other  equally  inconspicuous  place ;  but  the  disadvantages 
accompanying  this  custom  when  a  match  was  "  broken  off  " 
became  so  apparent  that  the  custom  was  discontinued. 

So  far  as  I  have  been  able  to  ascertain,  the  obscene  va- 
riety of  tattooing  seems  to  be  limited  to  two  classes — sol- 
diers and  criminals — the  practice  being  more  prevalent 
among  the  former.  All  the  most  indecent  and  obscene  pic- 
tures, mottoes,  sentiments,  and  designs  imaginable  are  repre- 
sented. Nothing  seems  too  lewd  or  debauched  for  these 
individuals  to  carry  upon  their  persons  in  the  indelible 
characters  conferred  by  tattooing.  Of  course  there  are  in- 
dividuals without  these  classes  who  also  carry  analogous 
markings,  but  they  are  so  few  in  number  as  to  make  but  a 
very  slight  proportion  of  the  whole. 

In  the  last  class  may  be  included  all  those  tattoo  marks* 
which  represent  nothing  in  particular  and  whose  origin  may 
he  traced  to  an  imitative  desire,  or  to  no  particular  reason. 
It  is  a  noteworthy  fact  that  many  individuals  possess  tat- 
tooings  who  are  unable  to  give  any  reason  for  their  exist- 
ence, alleging  as  a  cause  pure  "  cussedness."  The  designs 
in  these  cases  are  varied,  being  sometimes  two  or  three 
dots,  an  anchor,  a  letter  or  something  similar  (occasionally 
the  individual's  name  or  initials),  but,  as  a  general  rule, 
very  limited  in  extent. 

While  the  classification  given  above  is  general  in  char- 
acter, it  must  not  be  supposed  that  every  case  seen  will 
strictly  conform  to  a  type.  We  not  infre(juently  find  two 
types  commingled,  such  as  the  symbolical  and  amatory, 
ornamental  and  symbolical,  amatory  and  obscene,  etc.  As 


an  ethnological  study  that  of  tattooing  is  perhaps  as  inter- 
esting a  branch  as  any  other,  casting  as  it  does  much  light 
upon  habits,  customs,  and  individual  peculiarities. 

So  far  as  the  extent  covered  is  concerned,  we  find  that 
savages  are  more  prone  to  have  large  areas  tattooed  than 
the  civilized.  A  possible  exception  might  be  made  in 
regard  to  a  sort  of  professional  tattooed  subject  which 
is  now  fast  disappearing.  Captain  Costentenus,  a  Greek, 
was  exhibited  some  years  ago  as  the  most  extensively  tat- 
tooed human  being  living.  He  was  literally  tattooed  from 
head  to  foot,  his  eyelids  and  the  interior  of  his  ears  having 
been  subjected  to  the  process,  not  to  mention  his  genitals 
and  his  palms  and  soles.  This  led  to  a  demand  for  tattooed 
men  and  women  for  dime  museums,  and  a  number  were 
soon  forthcoming,  being  marked  (piite  extensively  for  the 
small  sum  of  fifty  dollars,  only  the  visible  portions  being 
subjected  to  tlie  operation.  The  Greek,  however,  remains 
to-day  the  most  remarkable  living  example  of  tattooing  ever 
seen,  there  being  not  a  quarter  inch  of  his  body  that  is  not 
the  seat  of  some  figure  or  part  of  it. 

The  methods  of  practicing  tattooing  vary  somewhat. 
Among  the  South  Sea  Islanders  the  tattooing  instrument 
consists  of  the  serrated  edge  of  a  sharp  shell  which  is 
dipped  in  the  staining  liquid  and  then  driven  into  the  skin 
with  a  sharp  blow.  Among  northern  tribes  fish-bones  are 
set  in  a  frame  and  used  in  the  same  manner.  Civilized 
man  employs  a  small  bunch  of  fine  needles,  varying  in  num- 
ber from  six  to  ten  or  twelve.  This  is  dipped  in  a  solution 
of  India  ink,  vermilion,  or  indigo,  and  sharply  driven  into 
the  integument  so  as  to  penetrate  into  the  corium  or  sub- 
cutaneous connective  tissue.  When  the  proper  pigments 
can  not  be  obtained,  charcoal  or  gunpowder  finely  pulverized 
is  employed  for  the  purpose.  The  ultimate  effect  of  India 
ink,  charcoal,  or  gunpowder  is  to  give  a  blue  stain,  whereas 
vermilion  or  cinnabar  remains  red. 

In  addition  to  these  deliberate  methods  of  tattooing  we 
also  have  accidental  means,  which  are  more  disfiguring  in 
their  effects.  Thus,  powder-burns  are  by  no  means  un- 
common, occurring  either  through  carelessness  or  purely 
accidentally.  Here  it  is  the  face  and  hands  which  are  most 
commonly  affected.  Injuries  infiicted  by  mineral  coal  also 
result  in  the  same  manner,  and  it  is  for  this  reason  that  we 
find  this  particular  variety  of  permanent  blue  stains  most 
often  in  coal  miners.  Millwrights  suffer  from  a  somewhat 
analogous  trouble  known  as  siderosis.  It  shows  itself  as 
brownish  stains  on  the  hands  and  forearms,  caused  by  par- 
ticles of  steel  thrown  off  their  chisel- hammers  as  they  trim 
millstones.  Drawers  of  gold  wire  also  have  staining  of  the 
hands  and  forearms,  caused  by  puncture  of  the  skin  and 
deposit  of  minute  particles  of  gold.  Every  metal  whose 
oxides  are  colored  is  capable  of  producing  its  peculiar 
stains  when  it  is  accidentally  introduced  into  the  integu- 
ment. 

A  question  which  naturally  arises  is  as  to  the  perma- 
nency of  these  stains.  All  tattoo  marks  are  regarded  as 
practically  indelible.  It  is  true  that  after  a  certain  num- 
ber of  years  they  become  more  or  less  dim,  but  their  pres- 
ence can  easily  be  verified.  More  especially  is  this  true 
when  they  have  been  produced  by  the  presence  of  carbon, 


546 


OEMANN-DUMESNIL :   TATTOOING  AND  ITS  REMOVAL. 


fN.  Y.  Med.  Jouk., 


in  the  form  of  India  ink  or  j^unpowder.  Vermilion,  intro- 
duced at  the  same  time  as  India  ink,  will  disappear,  while 
the  latter  still  remains  very  apparent.    Indigo  will  also 


Tattooing  on  a  woman's  arm. 


disappear  almost  completely  after  the  lapse  of  years.  I 
have  never  seen  a  clear  record  of  India-ink  tattooing  disap- 
pearing completely  except  in  the  report  of  the  case  of  the 
Tichborne  claimant,  in  which  some  medical  witnesses  testi- 
fied that  tattooing  could,  in  the  course  of  twenty  or  more 
years,  completely  disappear.  I  have  had  occasion  to  see 
tattooing  of  over  thirty  years'  standing,  and  it  was  still 
not  only  visible,  but  remarkably  clear  and  distinct. 

The  pathology  of  tattooed  skin  is  the  keynote  of  the 
permanency  of  the  condition  as  well  as  explanatory  of  the 
unsuccessful  methods  which  have  been  proposed  for  its 
eradication.  It  also  illustrates  very  clearly  the  rationale  of 
a  method,  which  I  propose  to  give,  which  is  successful,  and 
the  reasons  therefor.  When  a  section  of  tattooed  skin  is 
examined  with  the  microscope  a  condition  is  immediately 
apparent.  It  is  this :  Comparatively  large  masses  of  a  more 
or  less  black  color  are  perceived  in  proximity  to  each  other. 
They  vary  somewhat  in  size,  but  a  low  j^ower  will  show  them 
very  distinctly.  Beyond,  the  integument  again  appears  nor- 
mal. The  pigmentary  masses  of  the  normal  coloration  of 
the  skin  appear  not  only  light  in  color,  in  comparison,  but 
are  apparently  so  insignificant  as  to  elicit  comparatively  lit- 
tle attention.  The  large  masses  of  carbon — for  such  they 
are — due  to  the  tattooing,  are  located  below  the  epidermis, 
scantily  in  the  corium,  more  abundantly  in  the  subcutaneous 
connective  tissue,  and  almost  always  in  the  lymphatic  gan- 
glia as  well,  although  in  this  last  locality  they  do  not  make 
any  perceptible  showing  upon  the  surface  of  the  integument. 
It  is  this  deep  penetration  of  the  particles  of  carbon  and 


their  imprisomnent  in  the  interlacing  meshes  of  connective 
tissue  which  renders  their  presence  practically  permanent. 
The  change  of  color  from  black  to  blue  is  easily  explained. 
That  portion  of  the  carbon  which  is  inclosed  in  the  epider- 
mis appears  black,  but  it  is  thrown  off  in  a  short  time,  leav- 
ing behind  it  the  particles  situated  deeper  in  the  skin.  The 
transmission  of  light  through  the  epidermis  gives  them  a 
bluish  appearance,  as  it  does  to  all  black  substances  located 
in  that  portion  of  the  integument.  The  reason  that  cinna- 
bar (vermilion)  tattooing  does  not  last  so  long  as  that  of 
India  ink  is  that  it  is  not  so  diifusible  and  does  not  be- 
come enmeshed  in  the  lymphatics  so  rapidly,  if  at  all.  In 
addition  to  this,  cinnabar  undergoes  more  or  less  chemical 
change  and  finally  becomes  absorbed,  whereas  carbon,  the 
active  coloring  constituent  of  India  ink,  coal,  gunpowder, 
etc.,  is  unaltered  and  remains  in  situ.  This  is  but  a  brief 
summary  of  the  pathology,  but  it  is  sufficient  to  indicate 
the  character  of  the  condition  which  is  to  be  dealt  with  in 
the  treatment.  It  is  certainly  sufficiently  clear  to  satisfac- 
torily demonstrate  the  futility  of  any  attempts  at  treatment 
wherein  the  structures  of  the  epidermis  alone  are  involved 
and  the  absolute  necessity  of  dealing  with  the  corium  and 
subcutaneous  structures  to  a  limited  extent,  and  in  such  a 
manner  as  not  to  produce  scars  or  other  losses  of  tissue  so 
extensive  as  to  result  in  scars  or  other  permanent  deformi- 
ties. 

The  treatment  of  these  apparently  indelible  marks  is 
perhaps  not  the  least  interesting  of  the  subject.  As  a  rule, 
treatment  is  demanded  in  cases  of  more  or  less  long  stand- 
ing, and  various  methods  have  been  devised  which  are,  as 
a  rule,  unsatisfactory  in  their  results  or  leave  scars  which 
are  worse  looking  than  the  original  stains.    The  surgical 


Cross-sccluin  of  taltooi'd  skill. 


measures  employed  have  all  proved  failures.  The  actual 
cautery,  the  galvano-cautery,  the  knife,  the  sharp  spoon,  and 
electrolysis,  in  order  to  be  effective,  have  brought  about  such 
a  destruction  of  tissue  as  resulted  in  ugly  scars  of  greater 


May  20,  1893.] 


GHAT:  NEW  METHOD  OF  TAKING  EXPERT  TESTIMONY. 


547 


or  less  extent.  The  same  may  be  said  of  tlie  various  caus- 
tics, so  that  it  became  apparent  very  early  that  these  meth- 
ods would  have  to  be  abandoned.  A  method  was  then  sug- 
gested for  powder-burns,  immediately  after  their  occurrence, 
which  was  fairly  successful.  This  is  the  well-known  binio- 
dide- of- ammonium  and  hydrochloric-acid  process.  Unfor- 
tunately, it  is  but  partially  successful,  resulting  in  failure  in 
many  instances.  Following  tliis  came  Variot's  treatment, 
which  is  said  to  be  successful,  but  of  which  I  know  noth- 
ing from  actual  experience.  It  is  a  rather  complicated  pro- 
cess, and,  from  its  description,  it  must  be  very  painful  and 
entail  quite  an  amount  of  disfigurement  for  the  time  being, 
besides  subjecting  the  patient  to  the  possibility  of  acquiring 
scars.  The  method  which  I  propose  to  detail  is  one  which, 
it  is  alleged  by  Dr.  Dupuy,  originated  with  natives  of  the 
Indian  Archipelago.  However  that  may  be,  it  is  one  which 
is  certainly  good,  so  far  as  the  original  idea  is  concerned, 
but  which  I  have  only  found  a  success  by  using  a  particular 
preparation  to  cdrry  it  out. 

The  method  may  be  briefly  outlined  as  follows :  The  tat- 
tooed part  from  which  it  is  desirable  to  remove  the  mark- 
ings is,  first  of  all,  carefully  washed  with  soap  and  water. 
Then  a  bunch  of  needles  previously  prepared,  containing 
from  six  to  ten  very  fine  cambric  needles  tightly  wound  with 
silk  thread,  is  dipped  in  glycerole  of  papoid  (Johnson  and 
Johnson)  and  driven  with  a  sharp  blow  into  the  tattooed 
part.  This  is  repeated  over  the  entire  stain.  In  fact,  it  is 
a  tattooing  with  the  glycerole  of  papoid.  It  goes  without 
saying  that  this  tattooing  must  be  thorough  or  but  an  im- 
perfect result  will  be  obtained,  on  account  of  the  depth  at 
which  the  pigment  is  found.  I  have  found  it  necessary,  as 
a  general  rule,  to  go  over  certain  parts  a  second  time  in  order 
to  obtain  a  good  effect.  A  peculiarity  in  reference  to  this 
is  that  the  process  does  not  bring  about  the  swelling  or  in- 
flammatory reaction  observed  in  tattooing  with  India  ink  or 
other  pigments.  This  is  probably  due  to  the  fact  that,  in 
the  first  place,  the  glycerole  of  papoid  is  not  so  irritating  ; 
and,  in  the  second  place,  no  buccal  mucus  is  mixed  with  it, 
a  habit  which  is  not  only  filthy  but  dangerous,  inasmuch  as 
it  may  transmit  syphilis,  as  has  been  observed  in  many  in- 
stances. Not  only  this,  but  the  micro-organisms  of  the 
mouth  may  act  deleteriously  by  inducing  septic  conditions 
of  greater  or  less  virulence. 

The  rationale  of  the  method  is  one  which  appears  to  me 
to  be  about  as  follows  :  The  digestive  principle  of  the  papoid 
is  disseminated  about  the  deposit  of  pigment,  thus  liberating 
it.  A  portion  is  absorbed,  in  a  finely  divided  state,  by  the 
lymphatics ;  another  part  probably  finds  its  way  into  the 
upper  layers  of  the  epidermis  and  thence  to  the  surface.  In 
this  manner  we  obtain  a  disappearance  of  the  pigment.  The 
glycerole  of  papoid  is  the  only  agent  which  I  have  found  to 
act  satisfactorily  in  this  condition.  I  have  tried  solutions 
of  papoid  (Johnson  and  Johnson)  made  extemporaneously, 
and  they  did  not  procure  good  results,  although  tlie  pow- 
dered papoid  mitigated  with  some  alkaline  powder  has  acted 
very  satisfactorily  in  old  and  indolent  ulcers.  Papain  and 
papayotin  made  into  solution  have  also  proved  complete  fail- 
ures in  the  treatment  of  tattoo  marks  in  ray  hands,  so  that 
I  would  advise  all  who  intend  to  use  this  method  to  confine 


themselves  to  glycerole  of  papoid  as  made  by  Messrs.  John- 
son and  Jolinson,  of  New  York. 

For  those  who  may  be  interested  in  a  further  study  of 
tattooing,  the  following  partial  bibliography  is  appended. 

1.  Moyen  d'enlever  les  taclies  .  .  .  de  la  poudre  sur  la  peau. 
Jour,  de  mhl.  de  Paris,  1889,  p.  206. 

2.  Berclion,  E.    Ilistaire  med.  du  tatouage,  18G9. 

3.  Bergli,  E.  Ileber  Tatowierungen  der  Prostituierten. 
Monatsh.  f.  praM.  Dermat.,  March  1,  1891. 

4.  Blashko,  A.  Die  Siderosis  der  Miiller.  Monatsli.  f. 
pral-t.  Dermat.,  xi,  1890,  iSTo.  3. 

5.  Casper.  Ueber  Tatowierungen.  Viertelj.  f.  gericht.  u. 
offentl.  Med.,  i,  1852. 

6.  Chereau.    Le  tatouage.    Union  medicale,  vi,  1882. 

7.  Filomusi,  Guelfi  e  Rezzonico.  Sul  transporto  alle  glan- 
dole  linfatiche  della  materia  colorante  del  tatuaggi.  Giornal. 
internaz.  delle  scieme  viediclie,  1888,  No.  12. 

8.  Hansen,  S.  Om  Stigmata  hos  Forbrydere.  Hasp.  Tid., 
vii,  1889. 

9.  Hutin.  Recherches  sur  les  tatouages.  Bull,  de  VAcad. 
de  med.,  xviii,  1853. 

10.  Hutin.    Recherclies  sur  les  tatoitages,  Paris,  1853. 

11.  Joest,  W.    Tatowieren,  1887. 

12.  Joest,  W.  Korperbemalen  und  Tatowieren,  etc.  Zeit- 
schriftf.  Ethnolog.,  xx,  1888. 

13.  Lacassagne.    Les  tatouages^  1881. 

14.  Magitot,  E.  Recherches  ethnologiques  sur  le  tatouage. 
Union  medicale,  xxxii,  1881. 

15.  Pashko,  H.  Ueber  Tatowierung  und  deren  Anwendimg 
znr  Deckung  mangelnder  oder  fehlender  Hautpigmentation. 
Wiener  med.  WochenscJiri/t,  1892,  No.  4. 

16.  Rollet,  E.  Tatouage  .  .  .  d'origineprofessionelle.  Gaz. 
heidomad.  de  med.  et  de  cMr.,  Nov.  1,  1890. 

17.  Tardieu.  Etude  ra^dico-legale  sur  le  tatouage.  Ann. 
d^hyg.  puhUqve.  2  s.,  iii,  1885. 

18.  Variot,  G.  Les  tatouages.  Revue  scientijique,  May  12, 
1883. 

19.  Variot,  G.  Nouveau  proc6de  de  destruction  des  tatou- 
ages.   Comptes  rendus  de  la  Sac.  de  biolog.,  July,  1888. 

20.  Variot,  G.  Les  tatouages  et  les  peintures  de  la  peau. 
Revue  seientijique,  1889. 

21.  Variot,  G.,  et  M.  Raoult.  Recherches  sur  les  tatouages 
des  piqueurs  et  des  rhabilleurs  des  meules.  Gaz.  med.  de  Paris, 
1891,  No.  50. 


SUGGESTIONS  FOR  A 
NEW  METHOD  OF  TAKING  EXPERT  TESTIMONY.* 
By  LANDON  CARTER  GRAY,  M.  D., 

PROFESSOR  OP  NERVOUS  AND  MENTAL  DISEASE  IN  THE  NEW  YORK  POLYCLINIC. 

No  one  will  venture  to  deny  that  the  present  method  of 
taking  the  testimony  of  medical  experts  is  unsatisfactory, 
for  judges,  lawyers,  and  jurymen  regard  these  gentlemen 
with  distrust,  and  medical  men,  as  a  rule,  are  very  reluctant 
to  go  on  the  witness  stand.  To  us  physicians  the  reason  for 
all  this  is  perfectly  obvious.  The  machinery  of  the  law  is 
not  adequate  for  the  purpose  of  obtaining  for  judges  and 
juries  the  opinion  of  competent  medical  men.  One  of  the 
latter,  for  example,  who  is  to  give  liis  opinion  to  a  jury  upon 
a  great  question  of  medical  science  goes  upon  the  witness 

*  Read  before  the  New  York  Society  of  Medical  .hirispiudcnce, 
April  10,  1893. 


548 


GRA  Y:  NEW  METHOD  OF  TAKING  EXPERT  TESTIMONY.  [N.  Y.  Med.  Jouh., 


stand  in  a  radically  false  position  at  the  very  start,  since  he  is 
regarded  by  everybody  as  a  partisan,  this  opinion  often  being' 
held  most  strenuously  by  the  lawyers  who  have  retained  biin. 
His  successful  passage  through  the  cross-examination  to 
which  he  will  be  subjected  is  generally  dependent  much 
more,  I  am  sorry  to  say,  upon  his  quickness  of  wit  and 
repartee  than  upon  his  knowledge  of  medicine,  as  he  is 
seldom  a  match  for  the  trained  disputants  of  the  law,  facile 
with  experience  in  entrapping  the  unwary  or  the  confused 
into  real  or  seeming  inconsistencies  and  apparent  verbal 
contradictions.    Twenty-four  listening  ears  in  the  jury  box, 
sounding  portals  to  ignorant  and  untrained  brains,  drink  in 
eagerly  all  that  he  says,  and  the  jurymen  reach  their  con- 
clusions as  to  whether  he  is  trustworthy  or  not  much  more 
upon  the  data  furnished  by  his  personal  address,  his  cool- 
ness, and  his  adroitness,  than  through  any  exposition  that 
he  may  offer  them  of  the  facts  of  science.    Then  comes 
the  expert  upon  the  other  side  to  contradict  him,  for 
he  must  contradict  him  or  he  will  be  regarded  as  disloyal 
to  those  who  are  to  pay  him  his  fee.    It  constantly  hap- 
pens that  a  competent  physician  thus  has  his  conclusions 
rejected  by  an  incompetent  one.    Who  is  to  decide  be- 
tween them  ?    The  theory  of  the  law  is  that  the  lawyer  of 
the  competent  witness  should  make  the  competency  of  the 
latter  apparent,  and  that  he  should  make  equally  clear  the 
ignorance  or  the  false  conclusions  of  the  incompetent  wit- 
ness.   But  any  man  familiar  with  our  trials  knows  that  this 
is  very  rarely  done,  for  the  very  simple  reason  that  the  law- 
yer himself  seldom  has  a  sufficient  knowledge  of  medicine 
to  do  this  ;  so  that  between  the  theory  and  the  practice 
there  is  so  wide  a  divergence  that  in  very  few  trials  of  this 
kind  does  it  happen  that  an  entirely  incompetent  man  does 
not  obtain  as  much  credence  with  the  jury  as  an  entirely 
competent  one.    I  have  myself  been  present  at  many  trials 
in  which  some  acknowledged  master  of  the  art  and  science 
of  medicine  has  been  counterbalanced  in  the  minds  of  the 
jury  by  some  medical  man  who  would  not  have  been  fit  to 
act  as  his  third  or  fourth  assistant.    Lawyers  will  say  that 
this  difference  between  the  two  men  can  be  made  plain  to  the 
jury.    Theoretically  this  is  so,  but  in  practice  how  is  it  to 
be  done  ?  One  way  would  be  to  ask  the  opinion  of  the  com- 
petent man  about  the  incompetent  one,  but  if  this  is  at- 
tempted a  cry  of  professional  jealousy  is  raised  by  the  op- 
posing lawyer,  generally  with  deadly  effect.    Another  way 
is  to  call  in  other  medical  men  to  testify  as  to  the  compe- 
tency of  the  two  men,  but  such  testimony  is  difficult  to  ob- 
tain, because  physicians  are  very  reluctant  to  appear  in  such 
an  invidious  position,  and,  moreover,  the  testimony  of  six 
men  against  a  man  can  almost  always  be  offset  by  the  testi- 
mony of  six  other  men  for  him,  provided  the  attorney  of  the 
latter  is  energetic  enough.   A  third  way  is  to  show  the  incom- 
petency of  the  incompetent  man  by  a  rigid  cross-examina- 
tion ;  but  this  will  depend  upon  the  cross-examining  lawyer's 
knowledge  of  medicine,  which,  as  I  have  already  said,  is 
generally  an  unknown  factor,  and  frequently  none  at  all. 
Then,  too,  the  reporters  in  tlie  court  room,  on  the  alert  for 
what  is  piquant  and  sensatioruvl,  blazon  forth  to  the  j)ublic 
garbled  reports  of  what  the  coni])etent  man  has  said,  which 
arc  in  no  wise  offset  by  equally  faulty  sketches  of  what  the 


incompetent  man  has  said,  inasmuch  as  the  latter  has  no 
particular  reputation  to  lose  and  is  therefore  not  vulnerable 
in  this  regard.  The  result  of  this  system  of  obtaining  medi- 
cal testimony  is  that  the  competent  physician  goes  home 
feeling  that  he  has  not  been  properly  protected  or  reported, 
so  that  he  shuns  the  next  trial,  and  comes  to  believe  that  , 
such  leveling  processes  are  too  dangerous  to  his  reputation  to 
be  often  repeated.  The  lawyer  ought  to  be  able  to  appreciate 
these  feelings  very  well.  He  takes  precious  good  care  that 
no  question  of  legal  science  is  passed  upon  by  a  jury.  Ah, 
no  !  He  puts  his  questions  of  legal  science  in  the  first  place 
before  a  judge  trained  and  educated  in  legal  lore,  and  gen- 
erally with  an  experience  of  years  in  a  judicial  capacity. 
Then,  if  he  is  not  satisfied  with  this  judge's  decision,  he 
brings  the  matter  before  the  General  Term,  we  will  say, 
three  judges  silting  in  a  row,  generally  of  still  higher 
standing  at  the  bar  than  the  first  judge.  Still  again,  if 
he  feels  discontented,  he  goes  before  the  Court  of  Appeals, 
a  bench  of  judges  generally  of  yet  higher  training ;  and 
if  the  question  be  one  of  the  proper  kind  he  may  pass 
on  to  the  Supreme  Court  of  the  United  States.  Yet  we 
physicians  are  expected  to  be  content  with  the  haphazard 
conclusions  passed  upon  our  great  questions  of  medical  sci- 
ence by  a  body  of  twelve  men  taken  from  the  body  of  the 
people,  often  illiterate,  invariably  ignorant  even  of  the  ele- 
ments of  science,  and  still  more  crassly  ignorant  of  the 
great  principles  innate  to  the  higher  and  intricate  questions 
of  our  profession  that  are  taught  only  to  the  ablest  men 
after  a  decade  or  two  of  close  application  and  wide  experi- 
ence. The  history  of  our  courts  records  many  failures  of 
justice  in  determining  medical  questions  under  our  present 
system.  I  could  keep  you  here  many  hours  if  I  were  to  go 
into  the  details  of  all  that  have  occurred  in  the  last  twenty 
years.  Is  there  a  man  in  this  room  to-night  who  believes 
that  Guiteau  was  not  insane  ?  Yet  he  was  hanged  in  the 
sight  of  the  world  as  a  sane  man  ;  and  the  mockery  of  jus- 
tice was  made  apparent  beyond  cavil  by  the  autopsy,  which 
brought  to  view  his  distorted  brain  with  its  wasted  convo- 
lutioBis  and  its  diseased  membranes,  mute  testimonials  to 
the  accuracy  of  conclusion  of  the  few  courageous  scientists 
who  had  dared  to  stand  up  against  the  howling  mob  of 
medical  politicians  and  tell  the  truth.  Some  of  you  may 
remember  the  contest  in  the  northern  part  of  this  State, 
some  ten  or  twelve  years  ago,  over  the  will  of  the  wife  of  an 
ex-President  whose  lunacy  at  the  time  of  making  the  will  was 
so  conclusively  established  that  not  a  medical  witness  could 
be  found  to  take  the  stand  and  say  that  she  was  not  insane  ; 
and  yet  the  surrogate  admitted  the  will  to  probate,  and  a 
beautiful  city  on  the  border  of  one  of  our  western  lakes  is 
now  cultivating  art  and  aiding  religion  with  money  that 
rightfully  belonged  to  the  heirs  of  the  testatrix.  We  all 
know  that  a  year  ago  twelve  jurymen  and  a  judge  under- 
took to  decide  the  mental  condition  of  a  prominent  banker 
in  this  city,  the  world-wide  reputation  of  whose  father  had 
made  him  conspicuous,  and  that  after  two  weeks  of  the 
most  careful  elucidation  of  the  questions  at  issue  the  judge 
did  not  deem  the  jury  competent  to  decide,  confessed  his 
own  inability  to  do  so,  and  relegated  the  whole  question  to 
a  medical  superintendent  in  the  northern  part  of  the  State, 


May  20,  1893.] 


GRAY:  NEW  METHOD  OF  TAKING  EXPERT  TESTIMONY. 


549 


who,  although  entirely  able,  was  not  one  whit  more  so  than 
several  physicians  who  testified  at  the  trial,  while  his  selec- 
tion was  a  virtual  confession  of  utter  impotence  in  tlie  legal 
machinery  of  the  trial  court. 

How  these  defects  in  the  law  are  to  be  remedied  has 
been  to  me  occasion  for  much  thought,  as  well  as  many  con- 
ferences with  legal  friends  in  whose  judgment  I  have  con- 
fidence. At  the  outset  the  keynote  of  the  situation  seems  to 
me  to  be  contained  in  Julius  Cuesar's  remark,  who,  when  he 
was  asked  why  he  divorced  his  wife  Pompeia  when  he  had 
stated  liis  disbelief  that  she  was  any  party  to  the  plot  of  the 
profligate  Clodius  to  obtain  an  entrance  to  her  house  when 
she  was  alone  with  her  women  during  the  festival  of  the 
Good  (xoddess,  answered  haughtily  :  "  Cuesar's  wife  must 
be  above  suspicion  ! "  So  must  the  medical  expert  be.  He 
goes  into  the  court  now  as  a  partisan.  He  should  be  there 
as  a  judge.  There  are  two  methods,  in  my  opinion,  by  which 
this  object  can  be  effected  : 

First,  the  selection  of  medical  men  by  the  presiding 
judge  to  sit  on  the  bench  with  him  in  an  advisory  capacity 
in  trials  which  do  not  need  juries. 

Second,  a  conference  of  all  the  medical  men  in  cases 
tried  by  a  jury. 

In  England,  I  am  told,  it  is  the  custom  for  the  judge 
in  admiralty  cases  to  select  a  certain  number  of  retired  naval 
officers,  called  assessors,  who  sit  with  him  upon  the  bench 
and  advise  him  in  regard  to  nautical  matters.    I  see  no 
reason  why  such  a  custom  should  not  be  introduced  here  in 
trials  before  a  judge.    The  latter  can  always  ascertain  who 
the  competent  men  are  in  the  different  branches  of  medi- 
cine, either  by  consulting  two  or  three  physicians  of  charac- 
ter and  standing,  which  is  generally  well  known  in  the  lesser 
towns,  or,  in  a  large  city  like  New  York,  by  a  letter  addressed 
to  the  president  of  some  such  body  as  our  Medical  Society 
of  the  County  of  New  York  or  our  Academy  of  Medicine, 
which  elects  a  new  presiding  officer  every  year  or  every  few 
years,  and  which  is  therefore  reasonably  sure  to  be  free  from 
cliquism.    In  jury  trials  a  conference  of  the  medical  ex- 
perts has  been  the  custom  for  some  time  in  Leeds,  England, 
and  of  it  Sir  James  Fitzjames  Stephen,  Judge  of  the  High 
Court  of  Justice,  Queen's  Bench  Division,  writes  thus  in  his 
History  of  the  Criminal  Laio  of  England,  published  in  1883  : 
"  For  many  years  this  course  has  been  invariably  pursued 
by  all  the  most  eminent  physicians  and  surgeons  in  Leeds, 
and  the  result  is  that  in  trials  at  Leeds  (where  actions  for 
injuries  and  railway  accidents  and  the  like  are  very  com- 
mon) the  medical  witnesses  are  hardly  ever  cross-examined 
at  all,  and  it  is  by  no  means  uncommon  for  them  to  be  called 
on  one  side  only.    Such  a  practice,"  he  goes  on  to  say,  "  of 
course  implies  a  high  standard  of  honor  and  professional 
knowledge  on  the  part  of  the  witnesses  employed  to  give 
evidence ;  but  this  is  a  matter  for  medical  men.    If  they 
steadily  refuse  to  act  as  counsel,  and  insist  on  knowing  what 
is  to  be  said  on  both  sides  before  they  testify,  they  need  not 
fear  cross-examination."    These  pithy  words  sum  up  the 
whole  matter.    Such  a  conference  of  the  medical  witnesses 
was  suggested,  as  many  of  you  will  remember,  some  four 
years  ago  before  this  society  by  our  distinguished  fellow- 
member,  the  Hon.  Willard  Bartlett,  who  informs  me  that  a 


number  of  cases  have  been  tried  before  him  under  this  sys- 
tem witli  the  most  admirable  results.  The  medical  men  who 
go  into  such  a  conference  must  agree  upon  the  facts.  No 
one  of  them,  for  instance,  unless  he  is  exceptionally  pachy- 
dermatous and  unscrupulous,  would  deny  the  existence  of  a 
wasted  muscle  which  the  otliers  saw,  or  a  paralyzed  limb,  a 
lack  of  feeling  of  the  prick  of  a  pin,  a  tremor,  a  broken  ver- 
tebra, a  fractured  bone,  a  contracted  or  dilated  pupil,  or  any 
of  the  other  objective  evidences  of  disease  whose  recogni- 
tion constitutes  the  very  primer  of  a  physician's  education. 
Even  if  one  unscrupulous  physician  is  shameless  enough  to 
deny  that  he  has  seen  what  the  others  have,  his  testimony 
will  be  worthless,  because  it  would  be  contradicted  by  hon- 
est medical  men  testifying  upon  the  same  side  of  the  case. 
The  conferring  physicians  can  therefore  only  differ  in  the 
conclusions  which  they  may  draw  from  what  they  have  seen, 
and  this  would  simplify  the  trial  very  greatly,  because  it  is 
far  easier  to  judge  of  the  value  of  conclusions  when  the  facts 
are  admitted  than  it  is  to  do  so  wlien  the  facts  tliemselves 
are  in  doubt.  Suppose,  for  example,  that  six  physicians  in 
conference  admit  that  a  man  has  been  injured  in  a  railway 
accident  so  that  his  spinal  column  is  fractured  and  his  lower 
limbs  are  completely  paralyzed.  Suppose  that  three  of 
these  physicians  state  their  belief  that  the  man  will  never 
recover,  while  the  other  three  are  equally  positive  that  he 
will  get  perfectly  well.  All  that  the  lawyers  have  to  do  is 
to  bring  into  court  medical  books  treating  of  such  fractures 
and  their  consequences,  collect  the  statistics,  and  conclu- 
sively prove  that  one  or  the  other  side  must  be  mistaken. 
Some  one  may  object  that  even  the  medical  writers  upon 
this  subject  will  not  be  unanimous  in  their  conclusions. 
Admit  that  this  is  so,  even  then  it  is  perfectly  feasible  to 
compute  an  average  and  hence  arrive  at  what  the  law  calls 
a  reasonable  certainty. 

The  popular  belief  in  the  uncertainty  of  medical  science 
is  a  popular  error.  Medicine  to-daj'^  is,  in  many  of  its  de- 
partments, one  of  the  exact  sciences.  It  is  a  remarkable 
tribute  to  his  mental  breadth  that  a  man  who  has  been  so 
engrossed  as  Lord  Salisbury  has  been  in  the  varied  and 
pressing  demands  of  a  leader  of  a  great  party  in  a  vast  em- 
pire should  have  recognized  this  fact  as  he  has  in  a  recent 
address  at  Oxford.  I  do  not  believe  that  six  competent 
physicians  in  the  city  of  New  York  would  be  at  variance  in 
any  essential  particulars  in  their  recognition  of  the  condi- 
tion of  a  given  patient.  During  the  last  winter  it  has 
been  my  fortune  to  have  a  consultation  with  eight  neurolo- 
gists about  a  certain  patient  in  this  city,  and  my  diagnosis 
was  agreed  to  by  every  one ;  nor  was  there  any  essential 
difference  in  the  treatment  advocated.  For  fourteen  years 
a  brother  specialist  of  mine,  now  sitting  in  this  room  and 
known  to  you  all,  has  upon  many  different  occasions  been 
engaged  in  the  same  expert  trials  in  which  I  have  been  con- 
cerned, and  during  this  long  period  of  time  there  has  never 
been  a  disagreement  between  us,  as  to  either  diagnosis  or 
treatment,  except  in  one  case,  where  we  agreed  upon  thje 
facts  but  differed  in  our  conclusions — this,  too,  although  we 
have  fully  half  the  time  been  upon  opposite  sides.  The 
truth  of  the  matter  is  that  medicine  has,  to  a  very  large  de- 
gree, emerged  from  its  empirical  period  and  passed  into 


550 


GRAY:  NEW  METHOD  OF  TAKING  EXPERT  TESTIMONY. 


[N.  Y.  Med.  Joob. 


one  of  approximate  certainty.  The  attitudinizing,  pomp- 
ous physician  of  the  past — solemn,  white-cravated,  eking 
out  his  dignity  with  a  gold  cane,  and  looking  unutterably 
wise — has  given  place  to  the  scientist ;  just  as  the  rollick- 
ing, swaggering  sailor  of  the  olden  time,  gay  of  mien  and 
jolly  of  air,  profuse  with  his  oaths  and  equally  prodigal  of 
his  money,  has  made  way  for  the  educated  engineer,  thor- 
oughly trained  in  the  mechanism  of  the  intricate  machinery 
of  our  modern  ironclad  and  torpedo  boat.  That  the  popu- 
lar error  remains  rooted  is  due  to  the  lack  of  appreciation 
by  the  laity,  and  even  by  judges  and  lawyers,  that  medi- 
cine is  now  so  vast  a  science  that  a  man  who  may  be  an 
authority  in  one  department  of  it  may  be  an  utter  novice 
in  another.  There  are  now  published  each  year  in  the 
civilized  world  over  two  thousand  medical  journals  and  hos- 
pital reports.  Almost  every  large  capital  in  the  world  has 
two  or  three  weekly  journals.  Every  large  city  has  several 
that  are  issued  each  month,  besides  which  there  are  a  vast 
number  published  every  quarter.  There  is  now  being  pub- 
lished in  Paris  an  Annual  of  the  Universal  Medical  Sciences, 
an  American  enterprise,  which  for  five  years  past  has  been 
published  in  Philadelphia,  filling  each  year  five  octavo  vol- 
umes, and  containing  only  an  abstract  of  the  noteworthy 
publications  during  the  year.  Each  department  of  medical 
and  surgical  science  is  edited  by  some  distinguished  man, 
to  whom  the  editors  send  clippings  of  the  articles  perti- 
nent to  his  branch.  During  the  last  year  this  Annual 
quoted  from  two  thousand  one  hundred  and  sixty -six  dif- 
ferent medical  publications.  There  are  ten  great  depart- 
ments of  modern  medicine :  General  medicine,  embracing 
what  is  known  as  general  practice,  such  as  abdominal  and 
thoracic  diseases,  the  general  fevers,  and  the  so-called  zy- 
motic diseases ;  general  surgery ;  eye  and  ear  diseases ; 
laryngology,  or  diseases  of  the  nasal  and  throat  passages ; 
neurology,  or  diseases  of  the  mind  and  nervous  system ; 
dermatology,  or  diseases  of  the  skin ;  genito-urinary  sur- 
gery, with  which  is  generally  included  venereal  diseases  ; 
diseases  of  women ;  orthopasdic  surgery,  or  diseases  of  the 
joints ;  sanitation  and  hygiene  ;  and  in  the  larger  cities 
there  are  also  specialists  restricting  themselves  to  the  dis- 
eases of  childhood.  Although  each  one  of  these  specialists 
must  undergo  a  general  training  of  years  in  the  medical 
schools  and  hospitals  in  the  anatomy  and  physiology  of  the 
human  body,  the  varieties  and  properties  of  drugs,  and  the 
general  way  in  which  disease  affects  the  body,  and  al- 
though in  the  less  populated  districts  there  is  not  sufficient 
population  to  warrant  the  growth  of  the  physician  beyond 
the  stage  of  the  general  practitioner,  yet  in  our  great  cities 
these  ten  great  specialties  are  almost  as  distinct  from  one 
another  as  the  dentist  is  from  the  physician,  or  the  lawyer 
from  the  physician,  or  the  shoemaker  from  the  tailor,  or 
the  carpenter  from  the  plumber.  In  none  of  these  special- 
ties does  any  man  to-day  obtain  a  great  reputation  until  he 
has  been  from  ten  to  twenty  years  in  actual  practice,  and 
the  most  capable  of  minds  can  seldom  master  the  technique 
of  any  one  of  them  under  a  decade.  So  thoroughly  is  this 
fact  recognized  by  the  profession  at  large  that  no  specialist 
in  one  line  would  venture  for  a  moment  to  pit  his  opinion 
against  that  of  a  specialist  in  another.    Each  specialty  has 


its  own  society  in  the  city  of  New  York,  often  in  lesser 
cities,  and  also  a  national  society.  There  is  in  this  country 
a  congress  of  physicians  and  surgeons  which  meets  every 
three  years  in  Washington,  composed  of  fourteen  different 
special  societies.  Considering  all  these  facts,  it  is  evident 
that  such  a  system  as  I  have  advocated  to-night  can  never 
work  adequately  unless  the  medical  advisers  to  a  court  are 
selected  with  careful  regard  to  their  fitness  for  dealing  with 
the  matter  at  issue.  The  selection  by  a  judge  of  his  family 
physician  to  pass  upon  a  question  of  women's  disease,  ortho- 
paedic surgery,  neurology,  etc.,  would  not  be  a  proper  selec- 
tion ;  for  however  able  the  family  physician  might  have 
shown  himself  in  dealing  with  the  sicknesses  of  a  family, 
and  however  great  his  natural  ability  might  be,  he  would 
probably  himself  be  the  first  to  ask  for  a  consultation  with 
a  specialist  in  any  dangerous  case  outside  of  his  line  of 
general  practice. 

It  is  intimated  to  me  by  some  of  my  legal  friends  that 
the  system  of  medical  assessors  and  conferences  which  I 
have  proposed  will  be  open  to  the  objection  that  it  is  op- 
posed to  the  principles  of  our  law.  To  this  I  make  answer 
that,  if  this  be  the  case,  the  principles  of  our  law  are  radi- 
cally faulty.  We  are  confronted  with  a  condition  of  things 
which  has  grown  out  of  our  modern  civilization,  and  which 
was  not  contemplated  by  our  earlier  law-makers.  Are  we 
to  so  blindly  venerate  the  memory  of  our  bygone  jurists 
as  to  credit  them  with  omniscience,  and  stand  hopelessly 
shackled  in  the  face  of  miscarriages  of  justice  ?  Lord  Coke 
said  that  the  common  law  was  the  perfection  of  reason.  In 
his  recent  interesting  article  upon  the  Chicago  anarchists 
Judge  Gary  modernizes  this  into :  "  The  common  law  is 
common  sense."  Certainly  it  seems  to  me,  although  I  am 
no  lawyer,  that  a  law  that  ceases  to  be  the  embodiment  of 
common  sense  has  outlived  its  usefulness  and  ought  to  be 
superseded.  No  principles  should  stand  in  the  way  of 
necessary  remedial  measures. 

I  therefore  ask  the  sober  consideration  of  this  society 
of  my  two  suggestions — namely,  first,  the  selection  of  medi- 
cal men  by  the  presiding  judge  to  sit  on  the  bench  with 
him  in  an  advisory  capacity  in  trials  which  do  not  need 
juries ;  second,  a  conference  of  all  the  medical  men  in  cases 
tried  by  a  jury. 

If  the  society  will  coincide  with  me  in  the  advisability 
of  these  two  remedial  measures,  I  will  ask  for  the  appoint- 
ment by  the  presiding  officer  of  a  proper  committee  to  de- 
liberate upon  the  matter  and  secure  necessary  legal  enact- 
ments. 


The  Deutsche  Poliklinik. — The  faculty  held  its  tenth  annual  dinner 
at  Ariou  Hall,  Fifty-ninth  Street  and  Park  Avenue,  on  Wednesday 
evening,  the  l'7th  inst. 

The  Alumni  Association  of  the  Presbyterian  Hospital  held  its  sec- 
oud  annual  reunion  on  Thursday,  the  11th  inst.  Officers  for  the  ensu- 
ing year  were  elected  as  follows :  President,  Dr.  W.  K.  Simpson ;  vice- 
president,  Dr.  D.  B.  Dclavan ;  secretary  and  treasurer,  Dr.  David  Bo- 
vaird. 

The  Stockholm  Academy  of  Sciences,  says  the  Fortschritte  der  Medi- 
cin,  has  admitted  Dr.  Rol)ert  Koch,  of  Berlin,  to  foreign  fellowship. 

The  German  Congress  of  Surgeons.— Professor  von  Esmarch,  of 
Kiel,  has  been  elected  president. 


May  20,  1893.] 


ELSNER:  NEWER  METHODS  OF  STOMACH  EXAMINATION: 


551 


ON  THE  PRACTICAL  VALUE  OF 
THE  NEWER   METHODS   OF  EXAMINATION  IN 
THE  DISEASES  OF  THE  STOMACH, 

WITH  A   CONSIDERATION  OP  THE 
INDICATIONS  GIVEN  FOR  DIET  AND  TREATMENT  BY  SUCH  EXAMINATIONS. 

Being  part  of  a  Discussion  07i  the  Newer  Methods  of 
Diagnosis  and  2'reatment  of  Stomach  and  Intestinal  Diseases. 

By  henry  L.  ELSNER,  M.  D., 

PROrBSSOK  OP  CLINICAL  MBDICINE,  SYRACUSE  MEDICAL  COLLEGE  ; 

PHYSICIAN  TO  ST.  JOSEPH'S  HOSPITAL  ; 
CON8CXTINQ  PHYSICIAN  TO  ST.  ANN'S  HOSPITAL.  SYRACUSE,  N.  Y. 

(Concluded  from  page  494-) 

Atrophy  of  the  Gastric  Follicles. — The  pathological  con- 
dition which  can  be  diagnosticated  with  the  greatest  amount 
of  certainty  by  our  newer  methods  of  examination  is  atrophy 
of  the  gastric  follicles,  or,  as  Ewald  calls  it,  anadenia. 

This  may  be  either  an  independent  lesion  or  an  accom- 
paniment of  cancer,  or  it  may  complicate  the  later  stages 
of  chronic  gastritis. 

Einhorn  (82)  has  spoken  of  a  similar  condition  as 
"  achylia  gastrica "  in  a  very  able  article,  preferring  this 
term — meaning  lack  of  gastric  juice — to  any  other. 

Fenwick  (83)  was  the  first  to  call  the  attention  of  the 
profession  to  this  condition  in  1877,  while  Ewald  (84), 
Kinnicut  (85),  and  Boas  (86)  have  added  important  data, 
which,  in  conjunction  with  those  of  Nothnagel  (87),  Osier 
(88),  and  Eisenlohr  (89),  show  the  clinical  picture  of  the 
disease  to  correspond  very  closely  with  that  of  pernicious 
anaemia. 

It  is  still  an  unsettled  question  whether  the  progressive 
anaemia  always  precedes  the  atrophy  of  the  gastric  follicles, 
or  whether  the  latter  is  in  a  large  measure  due  to  the  same 
underlying  vice  which  gives  rise  to  the  former  condition. 
It  is  certain,  however  (and  Eisenlohr  (90)  has  recently 
written  an  article  which  gives  abundant  clinical  data),  that 
several  forms  of  anaemia  and  various  system  diseases  of  the 
cord  are  intimatelj^  associated  with  the  anadenia  of  Ewald. 

This  fact  was  first  insisted  upon  by  Lichtheim  (91), 
who  never  found  the  cord  normal  in  cases  of  atrophy  of 
the  gastric  follicles  with  pernicious  anaemia. 

In  these  cases  the  stomach  is  usually  empty  while  fast- 
ing ;  the  expressed  contents,  after  a  trial  meal,  contain 
neither  mucus,  HCl,  pepsin,  nor  rennet.  In  all  of  these 
cases,  where  there  is  atrophy  and  attending  absence  of  pep- 
sin, Jaworski's  method  of  administering  a  diluted  HCl 
solution  (200  to  300  c.  c),  and  siphoning  it  from  the  stom- 
ach in  half  an  hour  after  its  administration,  during  which 
time  it  should  have  stimulated  the  secretion  of  pepsin,  and 
then  testing  the  fluid  as  to  its  digestive  power,  will  demon- 
strate the  complete  inactivity  of  the  same.  This  test  gives 
positive  evidence  of  changed  or  unproductive  peptic  glands. 
This  is  a  very  valuable  point  in  the  differentiation  between 
atrophy  and  carcinoma.  In  the  latter  there  is  usually,  with 
similar  treatment,  a  small  quantity  of  pepsin  present.  These 
cases  require  for  their  more  thorough  study  a  microscopic 
examination  of  the  blood,  when  poikilocytosis  as  well  as 
microcytes  with  characteristic  granular  and  large  cells,  as 
described  by  Ehrlich  (92),  will  be  demonstrated. 

With  an  active  motor  function  in  the  early  stages  of 


these  cases,  and  an  active  digestion  in  the  duodenum  and 
intestines,  these  patients  remain  in  a  fairly  well  nourished 
condition.  In  most  cases,  however,  which  have  come  to 
my  notice,  the  process  of  atrophy  extends  to  the  intestinal 
glands  and  duodenum,  when  the  disease  runs  a  rapid 
course. 

While  the  diagnosis  of  atrophy  of  the  gastric  follicles 
in  the  majority  of  cases  can  be  made  after  a  number  of 
weeks  of  careful  watching  and  chemical  examination, 
Ewald  (93),  in  his  recent  publication,  mentions  the  diffi- 
culty experienced  in  distinguishing  this  condition  from 
carcinoma  and  some  of  the  more  severe  gastric  neuroses. 
The  form  of  carcinoma  which  is  most  readily  confounded 
with  simple  atrophy  is  the  infiltrating  variety.  Here 
physical  signs  avail  little,  for  aside  from  the  compensatory 
hypertrophy  of  the  muscularis  there  may  be  no  constric- 
tion at  the  pylorus,  and  consequently  no  gastrectasia.  In 
these  cases  the  microscopical  examination  of  the  expressed 
fluid  will  aiford  data  for  distinction  ;  the  carcinomatous 
stomach  contents  will,  as  a  rule,  contain  altered  blood  pig- 
ment, though  haematemesis  be  absent,  while  with  atrophy 
its  presence  is  unknown. 

All  of  the  chemical  characteristics  mentioned  in  con- 
junction with  the  study  of  atrophy  may  be  present  in  cases 
of  grave  neuroses,  or  nervous  anachlorhydria  ;  indeed,  these 
cases  may  assume  such  a  serious  aspect  as  to  simulate  infil- 
trating carcinoma.  Ewald,  in  the  article  above  quoted, 
after  mentioning  some  of  the  differential  points  already  re- 
hearsed, says  that  "  for  the  differentiation  of  anadenia  from 
severe  neuroses  there  are  as  yet  no  characteristic  symp- 
toms." 

The  neuroses  simulating  achylia  are  usually  associated 
with  general  disturbances  of  the  system,  so  that  it  is  pos- 
sible to  recognize  evidences  of  hysteria,  neurasthenia,  or 
spinal  irritation,  and  thus  establish  the  neuro-psychic  ele- 
ment. 

As  able  a  diagnostician  as  Ewald  reports  the  case  of  a 
woman  in  whom  he  had  all  of  the  symptoms  which  seemed 
to  justify  the  diagnosis  of  nervous  anacidity,  and  which  he 
made  after  long-continued  watching.  The  woman  under 
treatment  improved,  and  returned  from  Berlin  to  her  home 
in  Russia,  where,  after  a  few  weeks,  a  tumor  of  the  liver 
was  palpable  and  another  in  the  epigastric  region.  The 
early  symptoms  were  undoubtedly  connected  with  develop- 
ment of  the  case. 

Gastritis. — The  large  quantity  of  mucus  removed  by 
the  tube  in  the  average  cases  of  gastritis  must  serve,  in  con- 
junction with  the  chemical  examination  of  the  stomach  con- 
tents, to  make  the  diagnosis  of  that  disease  comparatively 
easy.  In  the  milder  cases  of  gastritis  free  hydrochloric 
acid  is  present  in  reduced  quantity  at  the  height  of  the 
digestive  process. 

With  a  progression  of  the  disease  there  is  usually  en- 
tire absence  of  free  HCl,  traces  of  peptone,  rennet  absent, 
propeptone  present.  With  the  waning  of  free  IICI,  pepsin 
is  absent  in  like  proportion.  In  many  of  the  more  severe 
cases  peptonization  may  still  progress,  until  in  the  later 
stages,  if  the  disease  is  unrelieved,  complete  atrophy,  with 
its  characteristic  anomalies,  finish  the  picture  of  the  disease. 


552 


ELSNER:  NEWER  METHODS  OF  STOMACH  EXAMINATION.         [N.  Y.  Med.  Joub., 


In  these  cases  the  reaction  of  the  stomach  contents  is 
strongly  acid,  a  condition  produced  by  the  presence  of  the 
organic  acids  (lactic,  acetic,  butyric,  and  fatty  acids),  main- 
ly due  to  the  fermentation  of  the  carbohydrates. 

Usually  the  motor  function  is  found  disturbed  ;  there  is 
an  atony  corresponding  with  that  so  often  found  in  the 
bladder  muscle  (Rosenheim  (94)),  which  may  be  functional 
or  due  to  interstitial  overgrowth,  or  degeneration  of  the 
muscular  coat.  As  the  disease  advances,  tlie  absorptive 
function  gradually  gives  way  with  the  destruction  of  the 
epithelial  elements. 

Hijperacidity. — The  disease  with  which  hyperacidity  is 
most  frequently  associated  is  ulcer  of  the  stomach.  There 
is  a  condition  of  superacidity  and  hypersecretion,  to  which 
we  will  also  refer  later  in  this  article,  which  may  exist  with- 
out ulceration  of  the  gastric  mucous  membrane. 

Riegel  (95)  was  the  first  to  call  our  attention  to  the  fact 
that  with  ulcer  of  the  stomach  there  is,  as  a  rule,  a  con- 
spicuously high  percentage  of  HCl,  and  Van  den  Velden 
(96)  has  demonstrated  beyond  controversy  that  in  many 
cases  of  ulcer  of  the  stomach  the  chyme  contains  an  ab- 
normally great  amount  of  the  acid.  In  considering  the 
diagnosis  of  simple  typical  ulcer  of  the  stomach  before  an 
assemblage  of  educated  physicians,  I  feel  that  I  will  be  sus- 
tained in  making  the  assertion  that  in  the  majority  of  these 
cases  there  are  sufficient  data  to  make  clear  the  diagnosis 
without  recourse  to  the  chemical  examination  of  the  stom- 
ach contents  which  we  are  to-day  considering.  The  age  of 
the  patient,  the  characteiistic  anaemia,  the  microscopical 
appearance  of  the  blood,  the  menstrual  anomalies,  ofttimes 
the  hsematemesis,  the  character  of  the  pain,  with  the  time 
of  its  occurrence — all  these  give  sufficient  data  in  the  ordi- 
nary case  to  make  the' diagnosis  clear. 

On  the  other  hand,  there  are  cases  in  which  the  usual 
symptoms  fail  to  clear  the  field  for  an  easy  and  positive 
diagnosis.  The  case  may  be  atypical,  or  there  may  be  a 
combination  of  circumstances  with  symptoms  which  make 
differentiation  difficult,  and  we  are  consequently  forced  to 
resort  to  our  tests  for  a  solution  of  the  question. 

It  is  safe  to  teach  that  in  all  cases  of  ulcer  of  the  stom- 
ach the  stomach  tube  should  not  be  used  without  great 
caution,  and  only  in  cases  where  its  use  is  made  imperative 
for  the  purpose  of  diagnosing  the  existing  condition  when 
other  means  fail. 

Ewald,  in  his  work,  asks  the  question  whether  it  is 
justifiable  or  necessary  in  a  case  of  gastric  ulcer  to  intro- 
duce the  stomach  tube.  In  answering,  he  says:  "You 
know  that  until  recently  this  question  was  answered  in  the 
negative.  The  introduction  of  the  soft,  flexible  tube  has  re- 
duced the  dangers  very  materially,  but  they  are  by  no 
means  overcome ;  and  when  we  consider  how  easily  vomit- 
ing and  retching  are  provoked,  the  tube  will  not  be  intro- 
duced without  a  thorough  appreciation  of  the  facts  enu- 
merated, and  the  adoption  of  means  to  prevent  accidents 
which  may  lead  to  serious  results."  In  no  case  of  stomach 
disease,  no  matter  what  lesion  we  suspect,  would  it  be  wise 
to  resort  to  the  use  of  the  tube  for  purposes  of  diagnosis 
during  the  persistence  of  hsematemesis  ;  or  the  presence  of 
symptoms  which  arc  suggestive  of  acute  localized  perito- 


nitis or  acute  gastritis.  In  these  cases  the  stomach  remains 
a  noli  me  tangere  (Rosenheim  (97)).  It  may  be  concluded 
that  in  cases  of  ulcer  in  which  there  is  no  gastrectasia  the 
motor  function  is  usually  good,  as  is  also  the  absorptive ; 
that  the  secretory  function  in  the  great  majority  of  cases 
(as  shown  by  Van  den  Velden  (98),  Riegel  (99),  and  Ja- 
worski  (100))  is  associated  with  hyperacidity. 

As  a  rule,  and  this  has  many  exceptions,  according  to 
my  experience,  HCl  is  present  in  quantity  to  exceed  0-3 
per  cent,  after  a  simple  test  breakfast,  and  with  a  full  Rie- 
gel-Leube  meal  it  may  reach  as  high  as  0'6  per  cent.  In 
one  third  of  the  cases  of  ulcer  the  acidity  is  found  normal 
(Rosenheim  (101)),  while  in  other  cases  the  quantity  of 
HCl  may  be  markedly  reduced.  In  the  latter,  cancerous 
degeneration  of  the  base  of  an  ulcer  may  be  strongly  sus- 
pected, when  an  ultimate  anacidity  may  be  expected  before 
death,  or  there  may  be  with  reduced  HCl  beginning  in- 
volvement of  the  glandular  elements  of  the  mucous  mem- 
brane (Rosenheim  (102)). 

Riegel  (103)  reports  three  hundred  and  eighty-two 
analyses  of  the  stomach  contents  in  forty-two  cases  of  ulcer 
of  the  stomach,  in  which  he  found  the  percentage  of  free 
HCl — at  the  height  of  digestion  abnormally  high — values 
of  0-4  to  0'5  per  cent. 

Gerhardt  (104)  reported  twenty-four  cases  of  gastric 
ulcer  with  presence  of  HCl,  as  shown  by  the  color  test  in 
seventeen,  while  in  seven  there  was  no  response. 

Rosenheim  (105),  in  eight  cases,  was  able  to  demon- 
strate hyperacidity  in  two  only ;  in  four,  HCl  was  within 
normal  limits ;  in  two  there  was  subacidity. 

Kinnicut  (106)  reports  four  cases,  in  all  of  which  HCl 
was  found,  with  thirty-one  examinations  after  test  meals, 
values  of  O'lY  per  cent,  to  0-23  per  cent. 

My  own  experience  in  six  cases  of  ulcer  of  the  stomach, 
with  repeated  examinations  during  the  past  three  years  (forty 
tests),  leads  me  to  conclude  that  in  the  majority  of  cases 
free  HCl  is  present ;  that  in  two  thirds  of  all  cases  there  is 
an  excess  of  HCl,  and  in  one  third  there  are  normal  and 
subnormal  percentages. 

^Yith  these  facts  and  the  statistics  before  us,  we  must 
conclude  that  in  cases  of  ulcer  the  gastric  juice  always  con- 
tains HCl,  and  usually  an  excess  of  it  (Ewald  (107)). 

The  chemical  analyses  in  a  case  of  stomach  disease  in 
which  there  are  symptoms  of  both  ulcer  and  cancer  be- 
comes of  the  greatest  value  to  the  physician  and  surgeon 
alike.  The  constant  presence  of  free  HCl,  in  a  case  where 
such  differentiation  becomes  necessary,  may  be  regarded  as 
strong  evidence  in  favor  of  ulcer  of  the  stomach  and  ab- 
sence of  cancerous  infiltration.  The  greatest  difficulty  in 
practice  is  ofttimes  experienced  in  distinguishing  between 
gastric  ulcer,  gallstone  colic,  and  duodenal  ulcer.  A  case 
which  has  been  under  treatment  during  the  past  winter 
demonstrated  that  fact  very  forcibly.  Without  giving  de- 
tails of  the  case,  it  may  be  said  that  the  patient  was  a  man, 
aged  eighty-one  years,  who  had  renal  colic  during  the  active 
years  of  his  life,  and  for  seven  years  has  had  more  or  less 
severe  pain  in  the  epigastrium,  usually  more  severe  during 
the  afternoon  about  four  o'clock.  No  one  tender  spot  could 
be  found ;  the  entire  epigastrium  seemed  hypersensitive  to 


May  20,  1893.] 


ELSNER:  NEWER  METHODS 


OF  STOMACH  EXAMINATION. 


553 


pressure.  lie  had  consulted  prominent  physicians  in  the 
East  and  AVest,  with  ahnost  as  many  different  diagnoses  as 
physicians  consulted,  but  without  relief.  For  five  weeks 
before  he  consulted  me  he  resorted  to  morphine  without 
benefit.  At  the  first  visit  nothing  could  be  elicited  from 
the  history  which  aided  in  making  the  diagnosis,  but  in 
examining  the  vomited  matter,  six  hours  after  a  meal  of 
milk  only,  we  found  more  free  HCl  than  is  normally  pres- 
ent at  the  height  of  digestion  after  an  ordinary  trial  meal 
(0"4  per  cent.).  The  fluid  contained  both  pepsin  and  ren- 
net. After  a  trial  meal  of  milk  and  egg  albumin,  it  was 
found  that  there  was  marked  hyperacidity  (0"6  per  cent.). 
This  gave  us  abundant  evidence,  in  conjunction  with  the 
examination  of  the  vomited  matter,  to  diagnosticate  both 
hyperacidity  and  supersecretion.  Close  questioning  revealed 
the  fact  that  the  patient,  seven  years  before,  had  a  well- 
marked  intestinal  hemorrhage,  which  fact  he  forgot  to  give. 
The  diagnosis  was  clear — duodenal  ulcer  with  supersecre- 
tion. It  would  not  have  been  made  without  chemical  exami- 
nation. Morphine,  after  a  short  struggle,  was  discontinued. 
Lavage  with  alkalies,  resorcin,  arsenious  acid,  and  a  suit- 
able diet,  rigorously  followed,  were  substituted  for  his 
previous  treatment.  The  aged  patient  is  well,  at  least 
without  a  symptom,  in  the  full  possession  of  his  faculties, 
relieved  from  the  slavery  which  would  soon  have  made  him 
more  wretched  than  the  disease  from  which  he  was  suffering'. 

Bucquoy  (108)  lays  great  stress  in  the  diagnosis  of 
duodenal  ulcer  on  the  following  points  : 

1.  "Sudden  intestinal  hiemorrhages  in  apparently 
healthy  people,  which  tend  to  recur  and  produce  a  profound 
anaemia  (haemorrhage  of  the  stomach  may  precede  or  ac- 
company the  melsena)." 

2.  "  Pain  in  the  right  hypochondriac  region  coming  on 
late,  two  or  three  hours  after  eating." 

3.  "  Gastric  crisis  of  extreme  violence,  the  hfemorrhage 
being  more  apt  to  occur  about  the  time  of  these  attacks." 

4.  Osier  (109)  says:  "The  point  upon  which  the  great- 
est stress  has  been  laid  in  the  diagnosis  of  duodenal  ulcer  is 
the  occurrence  of  melaina  without  haematemesis."  To  which 
I  would  add  the  great  importance  and  value  in  doubtful 
cases  of  chemical  examination  to  determine  the  degree  of 
acidity  and  the  amount  of  secretion. 

Gastric  Netiroses. — After  a  very  thorough  clinical  con- 
sideration of  the  more  frequent  neuroses  which  were  for- 
merly included  in  the  chapter  of  "  nervous  dyspepsia  " — a 
term  which  Leube  (110)  still  insists  upon  using — I  am  fully 
satisfied  that,  with  but  few  exceptions,  and  to  these  I  will 
refer  later,  the  newer  methods  of  chemical  examination  have 
added  little  to  make  the  diagnosis  easier,  or  in  any  way  ex- 
plain the  many  vagaries  of  these  disorders,  whose  symptoms 
are  as  variable  as  the  colors  of  the  chameleon. 

Leube  holds  that  the  diagnosis,  or  rather  the  suspicion 
that  the  disease  is  of  nervous  origin,  is  made  a  certainty  by 
the  examination  of  the  stomach  with  the  tube.  He  lays 
down  the  rule  that,  seven  hours  after  the  trial  meal,  the 
stomach  is  invariably  empty.  To  this  many  take  excep- 
tion, and  it  appears  to  me  with  reason ;  while  Leube  grants 
that  there  are  rare  exceptions,  he  says  "  these  ought  not  to 
upset  the  rule." 


Supersecretion  and  Hyperacidity. — It  is  certain  that 
these  conditions  exist  oftener  than  has  been  suspected  in  the 
past.  These  conditions  are  usually  associated.  When  we 
speak  of  supersecretion  we  include  that  pathological  con- 
dition in  which  the  excessive  secretion  gives  a  functionally 
active  juice  not  only  during  the  digestive  period,  but  long 
after  the  stomach  has  been  emptied  of  its  food.  In  other 
words,  it  is  not  so  much  an  increase  during  digestion  as  it 
is  a  continuous  secretion,  entirely  independent  of  the  di- 
gestive act. 

Reichman  (111)  was  the  first  to  call  our  attention  to  this 
condition.  Since  his  publication,  Riegel  (112)  and  Van  den 
Velden  (113)  have  added  valuable  reports  of  cases  to  our 
literature  on  the  subject. 

The  examination  of  the  vomited  matter  in  these  cases 
is  of  the  utmost  importance,  for  it  not  only  reveals  the 
presence  of  the  hypersecretion  when  the  stomach  should 
be  empty,  but  the  hyperacidity  as  well.  This  must  be  the 
"  exception  "  to  which  Riegel  (114)  refers  when  speaking  of 
the  value  of  the  examination  of  the  vomited  matter  in  dis- 
eases of  the  stomach. 

The  symptoms  in  these  cases  are  well  marked.  If  long 
continued,  we  ultimately  have  motor  insufficiency,  in  some 
cases  almost  complete  atony  of  the  muscular  coat. 

Gastralgia,  recurring  at  intervals  after  great  mental  emo- 
tion or  other  excitement,  is  a  prominent  symptom. 

Kinnicut  (115)  says :  "  I  have  fixed  as  high  a  limit  as 
fifty  cubic  centimetres  of  gastric  juice  as  a  basis  for  a  diag- 
nosis of  hypersecretion." 

In  a  case  which  recently  came  to  my  notice  I  found, 
after  washing  out  the  stomach  the  previous  night,  on  the 
following  morning  before  food  had  been  taken  two  hundred 
cubic  centimetres  of  an  acid  fluid,  with  0*15  per  cent.  HCl, 
pepsin,  and  rennet,  as  shown  with  the  milk  test.  In  this 
case  there  were  repeated  gastralgic  attacks,  requiring  hypo- 
dermics of  morphine,  which  have  entirely  ceased  since  the 
recognition  of  the  disease  and  its  proper  treatment. 

Sahli  (116)  found  this  condition  present  in  the  gastric 
crisis  of  tabes ;  it  has  also  been  observed  in  cases  of  melan- 
cholia, hysteria,  neurasthenia,  and  many  other  neuroses. 

The  diagnosis  is  made,  as  above  mentioned,  by  express- 
ing the  secretion  after  having  washed  out  the  stomach  six 
or  seven  hours  before,  the  patient  fasting  during  the  inter- 
val. It  will  be  found  that  the  fluid  digests  albumin  readi- 
ly, is  without  organic  acids  and  peptone,  has  free  IICl,  is, 
as  Kinnicut  says,  "hyperacid  gastric  juice." 

It  has  been  held  by  Talma  (117)  and  also  Suyling  (118) 
that  there  is  a  neurosis  which  shows  itself  in  a  hyperaesthe- 
sia  of  the  gastric  mucous  membrane,  more  particularly  to 
IlCl.  Lowenthal  (119)  has  failed  to  show,  by  the  adminis- 
tration of  IICl  in  large  doses  to  perfectly  healthy  subjects, 
that  there  is  such  hyperaesthesia,  and  his  experiments  with 
subjects  who  have  diseased  stomachs,  some  of  them  ulcers, 
with  IICl  administration  have  been  negative.  The  same 
he  found  to  be  true  also  with  the  organic  acids,  mainly  lactic 
acid,  with  healthy  subjects  and  those  suffering  from  organic 
diseases. 

It  may  be  taken  for  granted  that,  in  cases  where  there 
is  pain  after  eating,  which  ceases  when  the  gastric  juice  is 


554 


ELSNER:  NEWER  METHODS  OF  STOMACH  EXAMINATION.         [N.  Y.  Med.  Jodk., 


neutralized  by  alkalies,  or  diluted  with  water,  or  removed,  a 
gastric  ulcer  may  be  strongly  suspected,  and  not  a  neurosis 
or  liyperaestliesia  to  HCl. 

If  gastric  ulcer  can  be  eliminated  with  certainty,  we  must 
suspect  in  these  cases  with  supposed  hyperesthesia  to  HCl 
that  the  gastralgia  is  due  to  haimorrhagic  erosions. 

The  more  the  simple  neuroses  are  studied,  the  more 
firmly  and  indelibly  are  impressed  the  facts  that  their  recog- 
nition must  depend  largely  on  the  presence  of  a  well  de- 
fined neurotic  habit,  evidences  of  a  combine  of  symptoms 
which,  for  want  of  a  better  and  more  scientific  term,  we 
must  call  neurasthenia — in  many  cases  a  faulty  metabolism 
— and,  excepting  the  supersecretion  and  hyperacidity  with- 
out changes  in  the  mucous  membrane  of  the  stomach  and, 
as  Klemperer  has  pointed  out,  reduced  motor  force,  we  can 
not  rely  for  definite  information  upon  the  examination  of 
the  stomach  contents. 

From  what  has  been  said  of  the  practical  results  of  the 
examination  of  the  stomach  contents,  you  are  able,  without 
further  infliction  from  me,  to  draw  your  own  conclusions. 
Certain  it  is  that  by  these  newer  methods  we  are  made  to 
understand  just  what  the  stomach  is  doing — a  knowledge 
which  is  necessary  in  every  doubtful  case.  No  case  of 
chronic  disease  of  the  stomach,  in  which  the  diagnosis  can 
not  positively  be  made,  should  fail  to  be  examined,  that 
the  physician  may  thoroughly  acquaint  himself  with  the 
workings  of  that  organ,  not  only  for  his  own  enlighten- 
ment, but  for  the  greater  satisfaction  and  benefit  of  his 
patients. 

While  the  statement  of  Hirschfeld  (120)— that  "the 
chemical  method  of  investigating  the  stomach  has  been  to 
diseases  of  that  organ  what  the  ophthalmoscope  is  to  the 
diseases  of  the  eye  " — may  be  somewhat  exaggerated,  the 
tempered  conclusions  of  Ewald  (121)  may  be  readily  accept- 
ed. He  says :  "  I  consider  the  diagnostic  importance  of 
the  expression  method  to  be  so  great  and  the  safety  to  be 
absolute,  a  very  few  cases  excepted,  that  I  would  reproach 
myself  had  I  neglected  to  resort  to  it  in  any  doubtful  case." 

INDICATIONS   FOR  TREATMENT   AND   DIET  MEDICAL  AND 

SURGICAL. 

Medical. — It  naturally  occurs  to  us,  in  considering  the 
question  of  the  practical  value  of  the  chemical  examinations 
in  diseases  of  the  stomach,  to  inquire  into  the  indications 
which  have  been  offered  for  diet  and  treatment  as  an  out- 
come of  such  study. 

It  may  be  said,  and  I  think  with  a  considerable  degree 
of  certainty,  that  the  dietetics  and  therapeutics  of  gastro- 
intestinal diseases  have  been  placed  on  a  more  solid  and 
scientific  basis  by  these  newer  methods. 

It  is  not  within  my  province  to  dilate  upon  these  sub- 
jects, but  I  wish  to  add  a  few  observations  which  seemed 
to  me  indicated  after  considering  the  work  which  we  have 
been  doing  in  this  domain. 

First,  it  needs  no  comment  to  prove  that  an  exact  diag- 
nosis has  therapeutic  advantages ;  second,  we  have  learned 
from  our  recent  studies  that  the  most  important  treatment 
of  stomach  diseases  must  always  remain  dietetic,  and  must 
depend  for  its  successful  administration  upon  the  chemical 


constitution  of  the  digestive  fluid,  whether  anacid,  hyper- 
acid, or  normal. 

Without  such  knowledge  we  are  groping  in  the  dark, 
unscientifically  and  unsuccessfully.  What  the  dietetic  rules 
are  each  case  will  indicate  for  itself,  if  the  stomach  contents 
are  macroscopically,  microscopically,  and  chemically  ex- 
amined. 

The  satisfaction  which  a  physician  feels  in  outlining  a 
diet  which  he  knows  will  positively  find  a  suitable  reception 
and  ultimate  assimilation  must  be  suflacient  recompense  for 
the  extra  time  which  he  has  taken  to  study  his  case.  It 
would  be  as  nonsensical  to  give  a  patient  with  hyperacidity 
a  diet  composed  of  starchy  food  as  it  would  be  unwise  and 
fatal  to  give  a  meat  diet  to  one  without  a  digestive  fluid 
containing  the  necessary  HCl  for  its  digestion. 

Another  much-abused  method  of  treatment  has  been  the 
lavage  of  the  stomach.  How  often  have  we  heard  of  its 
use  when  absolutely  no  indications  demanded  it !  Useful 
and  beneficial  only  when  indicated,  the  tube  must  be  used 
only  with  caution  and  judgment.  (See  Rosenheim's  (122) 
exhaustive  article,  Ueber  die  Magendousche,  Therap.  Monats- 
hefte,  August,  1892.) 

Ever  since  the  discovery  of  the  fact  that  pepsin  and  hy- 
drochloric acid  are  the  important  constituents  of  the  gastric 
juice,  physicians  have  been  giving  these  drugs,  in  many 
cases  without  reference  to  the  pathological  condition  of  the 
stomach  or  the  chemical  constitution  of  the  secretion  which 
they  were  expected  to  modify  or  supplement. 

To-day,  when  it  is  comparatively  easy  to  inform  one's  self 
of  the  condition  of  stomach  digestion,  drugs,  more  particu- 
larly pepsin  and  HCl,  are  administered  empirically  to  the 
detriment  of  the  patient,  and  in  many  cases  their  long- con- 
tinued use  has  given  rise  to  a  glandular  inactivity  or  true 
atrophy  of  disuse  which  can  never  be  remedied. 

If  we  take  into  consideration  the  results  which  have 
been  recently  obtained  from  repeated  experiments  with 
alkalies  and  acids  in  healthy  stomachs,  we  can  readily 
epitomize  the  indications  for  their  administration  and  ex- 
plain the  statement  which  is  made  by  Leube  (123)  when 
speaking  of  the  effect  of  Carlsbad  water.  He  says  :  "  Car- 
bonate of  soda  not  only  overcomes  the  superfluous  acidity 
of  the  stomach,  but,  what  is  more  important,  it  has  the 
power  of  stimulating  the  mucous  membrane  to  renewed 
energy  and  a  further  secretion  of  gastric  juice. 

The  truth  of  that  statement  is  demonstrated  by  Jaworski 
(124),  and  also  by  Geigel  and  Abend  (125),  who  found, 
after  repeated  experiments  on  healthy  and  diseased  stom- 
achs, that  moderate  doses  of  the  sodium  salt  (one  to  two 
grammes)  neutralize  a  part  of  the  gastric  juice ;  but  the 
alkaline  reaction  which  first  follows  their  administration  is 
soon  followed  by  an  acid  secretion  in  excess  of  that  preced- 
ing the  administration  of  the  alkali  (Mesnil  (126)). 

Small  doses  (0*5  gramme)  are  more  likely  to  neutralize 
a  normal  acid  secretion,  while  with  hyperacidity  we  must 
use  the  larger  doses  of  the  sodium  salt  in  conjunction  with 
our  mechanical  treatment,  for  we  have  not  only  the  original 
hyperacidity  to  overcome,  but  must  administer  suflicient 
to  neutralize  the  excess  of  the  free  acid  secreted  as  a  result 
of  the  stimulation  by  the  alkali.    From  the  foregoing  it  is 


May  20,  1893.] 


ELSNER:  NEWER  METHODS 


OF  STOMACH  EXAMINATION. 


555 


clear  that  the  alkaline  treatment  of  stomach  diseases  must 
be  limited  to  such  cases  as  have  an  excess  of  HCl,  or  a  de- 
ficiency of  the  acid  with  glandular  structures  intact,  or  a 
sufficient  remnant  to  respond  to  stimulus.  (Subacidity, 
chlorosis,  and  nervous  dyspepsia  with  subacidity — Ritter 
and  Hirsch  (127),  Manassein  (128),  Cahn  and  Mering 
(129).) 

On  the  other  hand,  HCl  increases  the  pepsin  but  not 
the  IICl  (Mesnil  (130)).  Excess  of  IICl  is  very  likely  to 
reduce  the  secretion  of  the  gastric  juice  and  the  percentage 
of  HCl  (Jaworski  (131)).  HCl  does  not  increase  the  secre- 
tion in  proportion  to  the  size  of  the  dose  administered. 
HCl  and  pepsin  are  therefore  of  the  greatest  value  in  those 
cases  where  the  mucous  membrane  and  glands  are  diseased, 
as  we  find  in  catarrhal  inflammation,  glandular  atrophy,  and 
amyloid  degeneration  (here  in  small  doses  only  to  protect 
the  remnant  of  glands  still  functionally  active).  Also  in 
carcinomatous  disease,  nodular  and  infiltrating. 

If  HCl  could  be  administered  in  sufficiently  large  doses 
without  corroding  the  mucous  membrane  of  the  stomach, 
it  would  at  once  relieve  the  severest  case  of  hyperacidity 
by  checking  the  secretion  of  the  gastric  juice. 

To  improve  or  influence  the  absorptive  function  of  the 
stomach,  we  possess  no  agent,  unless  it  be  electricity. 

The  motor  function  will  be  considered  by  another  more 
worthy  and  competent  to  enlighten  you  with  the  result  of 
his  ripe  experience. 

Surgical. — It  has  occurred  to  me,  in  considering  this 
question,  to  consider  the  value  of  the  newer  examinations  as 
related  to  surgery.  The  literature  on  this  subject  has  un- 
til recently  been  very  meager,  and,  as  the  study  of  my 
cases  was  intended  for  diagnosis  and  medical  treatment 
only,  I  felt  justified  for  the  preparation  of  this  paper  in 
consulting  many  of  the  leading  surgeons  of  this  country, 
England,  Germany,  and  Austria  for  an  unbiased  opinion  on 
this  important  question.  To  them  I  sent  circular  letters 
asking  for  a  response  to  the  following  questions,  and  such 
other  information  as  they  might  offer  relating  to  the  clini- 
cal data  and  to  the  literature  of  the  subject.  (Forty  such 
letters  were  written,  to  which  I  have  received  thirty-eight 
replies.  At  this  time  and  place  I  thank  those  earnest 
workers  who  so  kindly  and  fully  answered  and  aided  me  in 
my  work.) 

I.  Have  you  in  any  case  been  led  by  a  chemical  exami- 
nation of  the  stomach  contents  to  operate  for  disease  of 
that  organ  ? 

II.  Do  you  believe  that  such  analysis  will  aid  in  the 
early  recognition  of  malignant  diseases  and  thus  lead  to 
early  radical  operations  for  their  removal  ? 

III.  Have  you  formed  any  opinion  of  the  practical 
value  of  the  chemical  analysis  of  the  stomach  contents  in 
the  recognition  of  stomach  disease  ? 

As  a  rule,  the  answers  were  not  separately  given.  The 
majority  have  held,  in  answer  to  the  first  question  mainly, 
that  while  chemical  analyses  give  evidence  of  great  impor- 
tance, they  can  be  considered  as  confirmatory  only,  and  can 
not  be  relied  upon  alone  in  deciding  the  question  of  opera- 
tive interference. 

Those  consulted  who  had  no  personal  experience,  or  in- 


sufficient to  warrant  conclusions,  were  Sir  Joseph  Lister,  Sir 
William  MacCormac,  McBurney,  Davies-CoUey,  and  Van- 
der  Veer. 

Billroth  writes :  "  It  is  true  that  free  HCl  is  more  often 
absent  from  the  gastric  juice  in  gastric  cancer  than  in  ulcer  ; 
but  this  phenomenon  is  not  sufficiently  constant  and  may  be 
physiological.  It  is  not  sufficiently  definite  to  be  of  prac- 
tical value." 

Among  those  who  would  not  rely  on  chemical  analysis 
for  surgical  indications  we  find  besides  Billroth,  Thomas 
Bryant,  Jessett,  of  London  ;  Klemperer,  Willy  Meyer,  Leo, 
Marcey,  Leube,  Goodhart,  W.  H.  H.  Jacobson  (London), 
Boas,  Mayo  Robson,  Lange,  of  New  York,  Weir,  and  Hal- 
sted. 

Most  of  these  grant  the  fact  that  the  results  can  only  be 
considered  confirmatory,  a  link  in  the  chain  of  evidence 
which  at  times  is  of  great  importance  as  an  adjunct.  Senn, 
who  might  be  included  in  the  foregoing,  writes :  "  I  would 
never  rely  on  chemical  examination  in  deciding  upon  the 
propriety  of  operative  interference.  I  regard  chemical 
tests  of  value  in  making  an  early  differential  diagnosis  be- 
tween ulcer  and  carcinoma."  Senn  recognizes  the  great 
value  of  these  methods  without  relying  upon  them  exclu- 
sively. The  answers  of  Keen  and  Bull  to  the  questions 
asked  correspond  very  closely  to  those  of  Senn.  Weir, 
after  his  large  experience,  says:  "I  have  received  help, 
but  never  relied  upon  chemical  gastric  evidences  alone  in 
considering  the  question  of  surgical  interference  in  carci- 
noma of  the  stomach." 

Pilcher  reports  a  case  in  his  answer  which  shows  a  fail- 
ure of  the  tests.  In  his  case  there  was  pyloric  stenosis, 
with  all  chemical  tests  indicating  non-malignant  disease ; 
he  did  a  gastro-enterostomy,  finding  a  typical  scirrhus. 

Czerny,  of  Heidelberg,  besides  his  answer,  in  which  he 
grants  a  confirmatory  value  to  the  chemical  tests,  sends  his 
monograph,  taken  from  the  Beitrdge  zur  klinischen  Chirur- 
gie,  in  which  he  reports  twenty  resections  of  the  pylorus 
for  cancer  and  thirteen  exploratory  laparotomies,  in  most 
of  which  the  tests  were  considered  and  were  of  value  in  the 
process  of  differentiation. 

In  Case  IX  he  found  IICl  absent  at  one  time  after  a 
test  meal,  and  present  at  another  in  the  vomited  matter, 
with  tumor  and  constriction  at  the  pylorus.  The  growth 
was  due  to  a  simple  ulcer  with  enormous  hypertrophy  and 
consequent  stenosis.  Czerny  afterward  upbraided  himself 
for  paying  so  little  attention  to  the  results  of  his  chemical 
tests. 

Unless  I  mistake  the  meaning  of  the  answers  received 
from  Roswell  Park,  Einhorn,  Stockton,  Ewald,  and  even 
Riegel  and  Kinnicut  (the  latter  has  written  a  valuable  paper 
on  this  subject  in  conjunction  with  Bull),  they  do  not  wish 
to  rely  in  doubtful  cases  on  the  chemical  tests  alone.  I 
judge  still  furtlier  that  Riegel,  Kinnicut,  Ewald,  Stockton, 
and  Einhorn  are  positive  in  their  belief  that  in  the  majority 
of  doubtful  cases,  where  repeated  examinations  arc  made 
and  free  IICl  is  absent,  that  the  diagnosis  of  cancer  is  jus- 
tified, and  they  probably  agree  with  Boas  that  with  such 
anacidity  and  the  presence  of  two  classical  symptoms,  such 
as  emaciation,  cedema,  or  tumor,  the  chances  are  decidedly 


556 


EISNER:  NEWER  METHODS  OF  STOMACH  EXAMINATION.  [N,  Y.  Med.  Jope., 


in  favor  of  cancer,  and  the  surgeon  has  ample  indications 
for  an  exploratory  laparotomy. 

This  exploratory  operation  (from  an  extended  study  of 
the  literature  of  this  subject  with  which  it  is  useless  to  bur- 
den you),  we  are  positive,  is  as  a  rule  without  danger,  and 
can  ultimately  lead  onlj'  to  the  saving  of  many  lives  which 
are  now  sacrificed  for  want  of  a  consideration  of  all  the  di- 
agnostic means  which  ought  to  be  used  for  the  conscientious 
study  of  these  cases. 

It  may  be  held  that  while  the  surgeon  is  not  justified  in 
making  a  diagnosis  from  the  chemical  examination  alone, 
he  ought  not  to  operate  without  a  thorough  understanding 
of  the  working  ability  of  the  stomach  which  claims  his  at- 
tention. 

So  far  as  the  simple  diagnosis  of  pyloric  stricture  is  con- 
cerned, no  method  can  equal  in  value  the  revelation  made 
by  the  stomach  tube. 

It  is  not  within  the  province  of  this  paper  to  dilate  upon 
the  results  or  advantages  of  the  different  operations  for  the 
removal  of  gastric  cancer.  This  can  be  studied  from  the 
statistics  of  Rydigier,  Czerny,  and  McArdle.  Suffice  it  to 
say  that  in  sixty-two  pylorus  resections  twenty-seven  (or 
43'5  per  cent.)  were  cured  (Rosenheim  (132)). 

In  fifty-one  per  cent,  of  all  cases  of  gastric  cancers 
(Ewald  (133))  the  growth  is  situated  at  the  pylorus;  the 
medical  treatment  of  this  condition  gives  an  absolutely  hope- 
less prognosis ;  the  surgical  offers  some  hope,  as  seen  from 
the  above  statistics  and  also  from  a  further  study  of  all  the 
cases  reported  in  Virchow  and  Hirsch's  Jahresherichte  dur- 
ing the  past  six  years.  The  consensus  of  opinion  of  all  con- 
sulted tends  to  strengthen  the  conclusion  that  pyloric  can- 
cer is  a  purely  surgical  affection  ;  its  diagnosis,  if  it  can  be 
made  early,  must  be  sufficient  indication  for  surgical  treat 
ment. 

The  modern  surgeon  has  learned  two  valuable  points 
from  a  consideration  of  this  subject : 

1.  Without  the  possibility  of  emptying  the  stomach  into 
the  duodenum  it  is  impossible  to  live. 

2.  The  obsti'uction  at  the  pylorus  removed,  chemical 
analyses  have  proved  beyond  doubt  the  ability  of  the  stom 
ach  after  a  few  months  to  regain  its  motor  activity  when  the 
duodenum  carries  on  the  further  digestion. 

With  methods  which  would  lead  to  the  earlier  recogni- 
tion of  these  cases,  why  are  we  not  justified  in  hoping  for 
results  which  will  approximate  those  which  follow  the  early 
removal  of  cancers  from  other  organs  of  the  body  ? 

Appreciate  if  you  will  the  positive  fact  that  no  operator 
has,  after  the  removal  of  the  pylorus  or  any  part  of  the  stom 
ach  for  cancerous  disease,  had  a  functionally  active  stomach 
left,  but  that  after  removal  of  the  pylorus  the  motor  func 
tion  of  the  stomach,  as  shown  in  Mikulicz's  Klinik  (134) 
also  by  Rosenheim  (135),  is  sufficiently  improved  in  three 
months  to  empty  the  stomach  of  its  contents  in  five  hours 
and  a  half,  that  the  duodenum  and  small  intestines  assume 
the  stomach's  work,  and  you  have  sufficient  data  to  justify 
you  in  concluding  that  in  no  field  of  medicine  is  concerted 
action  of  the  physician  and  the  surgeon  inore  necessary  for 
the  benefit  of  mankind. 

While  at  present  we  are  forced  to  repeat  that  our  tests 


are  strongly  confirmatory,  we  are  certainly  working  in  the 
right  direction.  With  a  larger  experience  and  more  exact 
methods  of  examination  which  must  be  evolved  from  the 
present,  we  entertain  for  the  future  a  well-founded  hope  of 
diagnosticating  malignant  diseases  of  the  stomach  before 
adhesions  are  formed,  before  the  tumor  becomes  of  a  size 
which  makes  it  easily  palpable  with  its  surroundings  infil- 
trated. 

When  the  skilled  physician  reaches  such  a  stage  of  pro- 
ficiency in  the  art  of  diagnosis,  the  surgeon  as  his  helpmate 
will  no  longer  be  charged  with  making  autopsies  in  vivo, 
many  lives  will  be  prolonged,  possibly  saved,  and  medicine 
will  have  become  more  nearly  an  exact  science. 

Bibliography. 

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31.  Klemperer.  Die  diagnost.  Verwertlibarkeit  des  Lab- 
ferm.   Ibid.,  p.  240. 


^\I;iy  20,  1893.] 


ELSNER:  NEWER  METHODS 


OF  STOMACH  EXAMINATION. 


557 


32.  Rosenthal.  Ueber  das  Labferment  u.  s.  w.  bei  Phthi- 
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48.  Leo.    Deutsche  ined.  Woch.,  1889. 

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51.  Kussmaul.    Loc.  cit..  No.  181. 

52.  Boas.    Loc.  cit.,  p.  101. 

53.  Bird.  Contributions  to  the  Chemical  Pathology  of  some 
Forms  of  Morbid  Digestion. 

54.  Martius.    Loe.  cit.,  p.  16  fF. 

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56.  Jaworski  and  Ghiczinski.  Zeitschrift  f.  klin.  Medicin, 
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57.  Ewald.    Berliner  klin.  Woch.,  1886,  No.  23. 

58.  Cahn  and  v.  Mering.  Deutsche  Arch iv  fiir  klin.  Medicin, 
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59.  Riegel.    Zeitschrift fUr  klin.  Medicin,  1887,  xii,  p.  426. 

60.  Riegel.    Loc.  cit..  Heft  2  u.  3,  S.  167,  1880. 

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02.  Kinnicut.    Medical  Record,  May  24,  1890. 
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04.  Krause.    Prager  med.  Woch.,  1887,  No.  12. 

05.  Levy.    Berliner  hlin.  Woch.,  1887,  No.  24. 

66.  Edinger.    Berliner  klin.  Woch.,  1886,  p.  71,  No.  9. 

67.  Boas.    Deutsche  medicinische  Wochenschrift,  1883,  No. 

24. 

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70.  Grundzach.  Berliner  Minische  Wochenschrift,  1887,  No. 
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71.  Ewald.    Loc.  cit.,  pp.  194,  195. 

72.  Henry.    International  Clinics,  vol.  ii,  second  series,  p. 

55. 

73.  Ewald.    Loc.  cit.,  p.  340. 

74.  Haberlin.  Deutsche  Archiv  fUr  Minische  Medicin,  Band 
xliv,  p.  491. 

75.  Rosenheim.  Kranhheiten  der  Speiserdhreu.  des  Magens, 
p.  182. 


76.  Rosenheim.  Zeitschrift  fur  klinische  Medicin,  Bd.xvii, 
p.  135. 

77.  Pulawski.  Berliner  klinische  Wochenschrift,  No.  42, 
1892. 

78.  Riegel.  Beitrage  zur  Diagnostik  u.  s.  w.  der  Magen- 
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u.  8. 

79.  Ewald.    Loc.  cit.,  p.  141.    (Manges's  translation.) 

80.  Haberlin.  Deutsche  Archiv  fiir  Minische  Medicin,  Band 
xliv. 

81.  Rosenheim.    Krankheiten  des  Magens,  p.  212. 

82.  Einhorn.  On  Achylia  Gastrica.  Medical  Record,  June 
11,  1892,  p.  650. 

83.  Fenwick.  Atrophy  of  the  Stomach.  London  Lancet, 
July,  1877. 

84.  Ewald.  Berliner  Minische  Wochenschrift,  No.  32,  1892, 
p.  886. 

85.  Kinnicut.  American  Journal  of  the  Medical  Sciences, 
October,  1887. 

80.  Boas.   MUnch.  medicinische  Wochenschrift,         'So.  4:2. 

87.  Nothnagel.  Deutsche  Archiv  f  iir  klinische  Medicin,  Bd. 
xxiv,  Heft  4  u.  5. 

88.  Osier.  American  Journal  of  the  Medical  Sciences,  April, 
1880. 

89.  Eisenlohr.  Primare  Atrophic,  etc.  Deutsche  medici- 
nische Wochenschrift,  No.  49,  1892. 

90.  Eisenlohr.  Ibid. 

91.  Lichtheim.  Heidelberger  Naturforscher  Versammlung, 
1889. 

92.  Ehrlich.  (Rosenheim  quotes  him.)  Krankheiten  der 
Speiserohre  u.  des  Magens,  p.  121. 

93.  Ewald.    Berliner  klin.  FocA.,  June  27,  1892. 

94.  Rosenheim.    Loc.  cit.,  p.  118. 

95.  Riegel.    Loc.  cit.,  p.  434. 

96.  Van  den  Velden,  Ewald.  Loc.  cit.  (translation),  p. 
228. 

97.  Rosenheim.    Loc.  cit..,  p.  176. 

98.  Van  den  Velden.  Volkmann's  Sammlung  klin.  Vor- 
trage, No.  280. 

99.  Riegel.  Beitrage  zur  Diagnose  u.  Therapie,  etc.  Zeit- 
schrift fur  klin.  Medicin,  Band  xi. 

100.  Jaworski,  Ewald.    Loc.  cit.,  p.  229  (German  ed.,  ii). 

101.  Rosenheim.    Loc.  cit.,  p.  176. 

102.  Rosenheim.    Loc.  cit.,  p.  177. 

103.  Riegel.    Zeitschrift  fiir  klin.  Medicin,  Bd.  xii,  p.  434. 

104.  Gerhardt.    Deutsche  med.  Woch.,  1888,  No.  18. 

105.  Rosenheim.    Idem,  No.  22. 

106.  Kinnicut.  Modern  Methods  of  Examination  in  Diseases 
of  the  Stomach.    Medical  Record,  May  24,  1890. 

107.  Ewald.    Loc.  cit.  (Appleton  &  Co.),  p.  230. 

108.  Rucquoy.    Archives  generales,  April,  May,  June,  1887. 

109.  Osier.  On  the  Diagnosis  of  Duodenal  Ulcer.  N.  Y. 
Med.  Jour.,  Nov.  24,  1888. 

110.  Leube.  Specielle  Diagnose  der  inneren  Krankheiten, 
p.  250,  etc. 

111.  Reichman.    .SerKner  ^Kto.  TFbcA.,  1886,  Nos.  32  and  33. 

112.  Riegel.    Zeitschrift  fiir  klin.  Medicin,  Band  xi. 

113.  Van  den  Velden.  Volkmann's  Sammlung  klin.  Vor- 
trage, No.  280. 

114.  Riegel.  Volkmann's  Sammlung  klin.  Vortrage,  No. 
289,  p.  2669. 

115.  Kinnicut.    Loc.  cit.  (reprint),  p.  21. 

116.  Sahli.    Correspondembl.  f'iir  schweizer  A  ertzte,  1885. 

117.  Talma.    Zeitschrift  fiir  klin.  Medicin,  Bd.  viii,  1884. 

118.  Suyling.    Berliner  Min.  Woch.,  1889,  p.  869. 

119.  Ldwenthal.    Berliner  klin.  TFocA.,  No.  47,  1892. 


658 


GRIFFIN:  HYSTERICAL  APHONIA. 


[N.  Y.  Med.  Jouh., 


120.  Hirschfeld.  International  Clinics,  Philadelphia,  vol. 
iii,  October,  1891,  p.  2. 

121.  Ewald.    Loc.  cit.  (translation),  p.  12. 

122.  Rosenheim.  TJeber  die  Magendousche,  etc.  Therapeu- 
tische  Monatshefte,  August,  1892. 

123.  Leube.    V.  Ziemssen's  Handlmeh  der  Therapie,  etc. 

124.  Jaworski.    Wiener  med.  Woch.,  1886. 

125.  Geigel  u.  Abend.    Virchow's  Archiv,  1892,  p.  130. 

126.  Mesnil.    iMitsche  med.  Woch.,  No.  49,  1892. 

127.  Ritter  u.  Ilirscb.    Zeitschrift  fur  Min.  Medicin,  1888. 

128.  Manassein.    Hoppe-Seyler's  Physiol.  Chemie,  p.  241. 

129.  Cahn  and  Mering.  Jahreshericht  fur  Thierchemie, 
1886. 

130.  Mesnil.    Deutsche  med.  Woch.,  No.  49,  1892. 

131.  Jaworski.    Deutsche  med.  Woch.,  1887. 

132.  Rosenheim.    Loe.  cit.,  p.  228. 

133.  Ewald.    Loc.  cit.,  p.  171. 

134.  Mikulicz  Klinik.    Deutsche  med.  Woch.,  No.  49,  1892. 

135.  Rosenbeim.    Deutsche  med.  Woch.,  No.  49,  1892. 


HYSTERICAL  APHONIA 

WITH  A  PERFECT  SINGING  VOICE. 
By  E.  HARRISON  GRIFFIN,  M.  D., 

LECTURER  ON  DISEASES  OP  THE  THROAT  AND  NOSE 

AT  BELLKVUE  HOSPITAL  MEDICAL  COLLEGE  ; 
ATTENDING  SURGEON  FOR  THE  THROAT  AND  NOSE, 
OUTDOOR  DEPARTMENT  OE  BELLEVUE  HOSPITAL,  NEW  YORK. 

An  interesting  case  of  hysterical  aphonia  with  an  un- 
usual history  came  under  my  care  in  November,  1892  : 

The  patient,  a  girl,  aged  eighteen,  of  German  parentage, 
came  complaining  of  loss  of  voice.  She  was  able  to  converse  in 
a  low  wliisper,  but  was  not  able  to  raise  her  voice  so  that  it 
could  be  heard  any  distance. 

The  aphonia  had  lasted  for  a  little  over  eleven  months.  It 
had  come  on  suddenly  after  she  had  had  a  nap  in  the  afternoon. 
Before  her  sleep  her  voice  had  been  perfectly  normal,  but  upon 
awakening  she  was  much  surprised  to  find  her  voice  completely 
lost.  Her  occupation  when  she  applied  for  treatment  was  sew- 
ing on  coats,  but  she  was  very  anxious  to  regain  her  voice  so 
that  she  could  take  a  position  in  some  family  and  do  general 
housework. 

The  treatment  previous  to  her  visit  to  the  clinic  had  con- 
sisted ill  electricity  to  her  throat  and  the  inhalation  of  steam. 
Some  internal  medicines  bad  also  been  prescribed.  These  had 
failed  to  benefit  her. 

This  information  was  given  in  a  low,  hoarse  whisper ;  she  was 
unable  to  elevate  her  speaking  voice  above  this  key.  She  sur- 
prised me  at  this  visit  by  telling  me  that  she  could  sing. 

I  had  her  run  over  the  scale  and  found  the  high,  middle,  and 
low  register  perfect  and  not  a  sign  of  hoarseness  when  she  vo- 
calized. 

She  sang  a  few  lines  of  a  song  with  which  she  was  familiar, 
and  during  the  singing  the  words  were  pronounced  freely, 
clearly,  and  loudly.  The  volume  of  her  voice  would  fill  a  large 
room. 

I  tried  her  on  do,  re,  mi,  etc.,  in  a  singing  voice,  and  then 
the  syllables  were  rendered  free  from  any  hoarseness  and  were 
given  without  any  effort  or  difficulty.  When  she  attempted  to 
speak  these  sounds  her  voice  again  sank  to  a  low  whisper.  Her 
speaking  voice  had  remained  constantly  bad  without  any  im. 
provement  for  over  eleven  months. 

An  examination  of  the  larynx  showed  the  cords  to  be  per- 
fectly normal  as  to  color  and  that  they  approximated  closely,  an 
unusual  condition  in  this  form  of  aphonia. 


When  she  sounded  A  short  and  sharp  in  a  speaking  voice 
the  false  cords  seemed  to  crowd  over  the  true  cords,  but  when 
she  sounded  .4  in  a  singing  voice  the  larynx  presented  a  norma 
appearance. 

I  prescribed  a  mixture  of  iron  and  strychnine  and  applied  a 
current  of  electricity  to  her  neck.  After  a  week's  trial  her  voice 
was  as  imperfect  as  before.  There  was  not  the  slightest  im- 
provement. 

One  day  when  I  was  noting  some  facts  in  regard  to  her  his- 
tory her  voice  was  so  indistinct  that  I  told  her  to  strike  a  note 
and  sing  her  replies  to  me.  The  minute  her  voice  took  a  mu. 
sical  key  the  answers  to  my  questions  were  given  clear  and 
loud. 

I  made  her  now  repeat  some  sentences  after  me,  telling  her 
that  I  should  alter  the  tone  of  my  voice,  but  she  was  to  follow 
in  exactly  the  same  key  that  my  voice  assumed.  I  first  im- 
pressed upon  her  that  1  should  sing  the  sentences.  After  I  had 
run  over  several  sentences,  arranging  the  words  to  the  scale  in 
music,  I  changed  my  voice  to  a  speaking  voice  and  told  her  to 
follow  me  in  the  same  tone. 

She  repeated  about  five  sentences  one  after  another  in  a 
speaking  voice  free  and  clear. 

Tiie  minute  she  heard  the  word  speah  her  voice  again  as- 
sumed the  buskiness  and  she  told  me,  "I  can't  speak."  Once, 
again  I  repeated  the  foregoing  treatment  and  before  she  left  she 
was  able  to  speak  loudly  and  plainly. 

During  the  first  week  the  aphonia  would  return.  A  quick, 
sharp  word  or  starting  her  in  a  singing  tone  and  then  assuming 
a  speaking  one  would  bring  back  her  normal  voice. 

At  the  date  of  the  report  (April  18, 1893)  her  voice  has  been 
constantly  good  and  her  aphonia  has  not  returned.  Tliis  pa- 
tient menstruated  regularly  and  gave  no  history  of  any  uterine 
trouble. 

I  have  found  that  this  form  of  aphonia,  although  more 
common  in  women,  does  exist  in  men.  Some  years  ago  a 
young  man  applied  to  me  for  a  loss  of  voice  that  had  existed 
for  some  months.  I  found  his  larynx  normal  with  the  ex- 
ception of  an  imperfect  approximation  of  the  cords.  The 
patient  was  a  nervous,  hysterical  individual.  He  was 
drinking  eight  cups  of  coffee  a  day  and  was  troubled  with 
"  bad  dreams." 

A  stopping  of  the  coffee,  a  little  bromide,  and  a  great 
deal  of  moral  suasion  completed  a  cure. 

These  cases  are  interesting  as  at  times  they  are  liable  to 
be  mistaken  for  some  serious  affection  of  the  larynx.  The 
length  of  time  the  hoarseness  has  existed  may  suggest  a 
tumor  or  a  paralysis,  but  an  examination  of  the  larynx  ren- 
ders the  diagnosis  simple  and  easy. 

112  West  Forty-fifth  Stref.t. 


The  New  York  State  Medical  Association. — The  ninth  annual 
meeting  of  the  Fifth  District  Branch  will  be  held  in  Wurzler's  Build- 
ing, No.  315  Washington  Street,  Brooklyn,  on  Tuesday,  the  23d  inst., 
at  1 1  A.  M.,  under  the  presidency  of  Dr.  S.  B.  W.  McLeod,  of  New  York. 
In  the  afternoon  papers  are  to  be  read  as  follows :  The  Prevention  of 
Blindness  from  Ophthalmia  Neonatorum,  by  Dr.  L.  A.  W.  AUeni.in ; 
Chronic  Nasal  Catarrh,  and  what  the  General  Practitioner  can  do  for 
it,  by  Dr.  Edward  J.  Bermingham ;  The  Treatment  of  Certain  Forms 
of  Fracture,  by  Dr.  Charles  Phelps  ;  The  Management  of  Hip  Disease, 
by  Dr.  A.  B.  .ludson. 

The  University  of  Heidelberg. — Privat-docent  and  prosector  Fried- 
rich  Maurer,  says  the  Fortschrilte  der  Medicin,  has  been  made  extraor- 
dinary professor  of  anatomy. 


May  20,  1893.J 


LEADim  ARTICLES.— MINOR  PARAGRAPHS. 


659 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

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

NEW  YORK,  SATURDAY,  MAY  20,  1893. 


THE  EARLY  DIAGNOSIS  OF  SMALL-POX. 

Nowadays  we  are  all — that  is,  those  of  us  who  are  not  in 
the  service  of  a  board  of  health  or  on  quarantine  duty — "out 
of  practice "  as  regards  small-pox.  Now  that  persistent  vac- 
cination has  almost  suppressed  the  disease,  it  so  rarely  comes 
under  the  physician's  observation  that  when  it  does  turn  up  it 
takes  hira  off  his  guard,  so  that,  as  Dr.  Thomas  D.  Savill  puts 
it,  in  an  article  published  in  the  Lancet  for  April  29th,  he  is 
very  apt  to  accept  the  patient's  diagnosis  of  "  heat  bumps."  In 
that  article  Dr.  Savill  gives  some  excellent  hints  calculated  to 
enable  the  practitioner  to  escape  such  a  pitfall.  In  the  lirst 
place,  one  should  never  take  it  for  granted  that  small-pox  is  out 
of  the  question  because  the  disease  is  not  "  about " ;  a  casual 
source  of  infection  may  come  to  light  at  any  time  and  in  any 
place,  only  after  it  has  served  as  the  starting-point  for  what 
may  prove  to  be  a  devastating  epidemic. 

The  initial  fever  is  sudden  in  its  advent,  and  on  the  first  day 
of  the  illness  the  temperature  runs  up  to  102°  F.  or  more. 
This  brusque  advent  of  pyrexia,  the  author  says,  is  met  with  in 
only  tvvo  other  acute  specific  diseases  that  are  common  in  such  a 
climate  as  that  of  England — namely,  scarlet  fever  and  erysipelas. 
Of  the  symptoms  that  accompany  the  initial  fever,  severe  pain 
in  the  back  and  nausea  or  vomiting  are  prominent.  Both  are 
usually  more  pronounced  than  in  either  scarlet  fever  or  ery- 
sipelas, and  the  failure  of  the  cutaneous  lesions  characteristic 
of  one  or  the  other  of  those  diseases  to  appear  within  from 
thirty  to  forty  hours  will  exclude  them.  The  rash  that  in  ex- 
ceptional cases  precedes  the  true  eruption  of  small-pox  may, 
however,  be  scarlatiniform,  but  in  only  about  one  fifth  of  the 
cases  investigated  by  the  author  has  it  appeared  earlier  than  on 
the  third  day.  As  to  the  true  exanthem,  it  is  chiefly  to  be  dis- 
tinguished from  that  of  measles.  In  both  measles  and  small- 
pox the  eruption  appears  on  the  fourth  day,  and  in  both  it  is 
papular,  but  in  measles  the  papular  character  is  less  pronounced 
and  rapidly  grows  fainter,  while  in  small-pox  the  "  shotty  "  feel 
goes  on  increasing  up  to  the  time  of  vesiculation ;  at  the  end  of 
twelve  hours  the  efflorescences  of  measles  begin  to  fade,  more- 
over, but  the  small-pox  papules  get  harder  and  harder.  This 
"  shotty  "  feel  is  so  characteristic  that  by  passing  the  hand  over 
the  forehead  and  cheeks  one  might  almost  diagnosticate  mea- 
sles in  the  dark.  In  spite  of  all  this,  doubtful  cases  will  now 
and  then  occur,  and  in  all  such  cases  the  patient  should  be 
secluded. 

CREOLIN  IN  THE  TREATMENT  OF  DISEASED  MUCOUS 
AND  SEROUS  SURFACES. 

De.  G.  a.  Fackler,  in  the  Ohio  Medical  Journal  for  April, 
proposes  that  a  freer  use  of  creolin  be  made  in  diseases  of  the 


urinary  bladder  and  other  parts  of  the  body  that  are  out  of 
sight.  The  employment  of  this  remedy  in  dysentery  and  colitis 
was  early  brought  into  notice,  also  its  use  as  a  disinfecting 
wash  for  the  rectum,  the  vagina,  and  the  buccal  cavity.  Dr. 
Fackler  goes  somewhat  further  and  uses  creolin  solutions  for 
washing  out  abscess  cavities,  irrigating  the  lower  bowel,  the 
pleural  cavity,  and  the  genito-urinary  tract.  He  maintains 
that  weak  and  non- toxic  solutions  of  creolin  may  be  employed 
in  those  passages  and  cavities  without  that  danger  from  absorp- 
tion that  attends  the  use  of  potent  solutions  of  corrosive  sub- 
limate and  carbolic  acid. 

The  urinary  bladder,  according  to  the  writer's  experience, 
has  been  especially  intolerant  of  the  agents  just  referred  to, 
and  boric  acid  has  been  widely  used  as  the  least  dangerous  of 
the  cleansing  agents  suitable  to  affections  of  the  cystic  lining 
membrane. 

During  the  past  year  Dr.  Fackler  has  used  a  one-half  to  one- 
per  cent,  solution  of  creolin  in  cases  in  which  irrigation  of  the 
bladder  was  required.  His  results  have  been  far  more  satisfac- 
tory than  had  been  obtained  in  the  use  of  boric  acid.  He  has 
been  especially  well  satisfied  with  the  results  in  a  case  of  gonor- 
rhoeal  cystitis,  for  he  is  able  to  record  tliat  the  use  of  three  creolin 
injections  put  an  end  to  the  urethral  and  vesical  symptoms  at 
the  same  time.  He  quotes  the  reports  of  Zielewicz  as  his  au- 
thority for  teaching  that  a  creolin  injection  is  superior  to  many 
others  (of  antiseptics)  for  the  relief  of  cystitis  caused  by  hyper- 
trophied  prostate. 

In  regard  to  the  treatment  of  the  pleural  cavity  in  cases  of 
empyema.  Dr.  Fackler  suggests  that  a  cleansing  creolin  injec- 
tion ofi"ers  to  the  surgeon  a  good  means  of  antiseptic  treatment 
after  opening  the  cavity.  Surgeons,  as  a  rule,  he  says,  have 
been  hampered  in  carrying  out  the  disinfection  steps  of  these 
operations  by  the  dread  of  retention  of  such  agents  as  carbolic 
acid  and  mercury  bichloride.  By  the  use  of  a  weak  solution  of 
creolin,  he  believes,  a  very  safe  and  eflFective  disinfection  may 
be  had  and  the  patient's  prospect  of  recovery  be  greatly 
improved. 

MINOR  PARAGRAPHS. 

TOILET  SOAPS  ANALYZED. 

The  Pharmacological  Record  for  May  is  devoted  to  an  ana- 
lytical study  of  the  toilet  soaps  to  be  found  in  the  London 
market.  Its  conclusions  are  pertinent  the  whole  world  round 
— namely,  first,  there  are  too  many  soaps  oflTered  that  contain 
free  alkali,  either  caustic  or  carbonated,  in  quantities  injurious 
to  the  skin;  secondly,  there  are  other  soaps  made  from  cheap 
and  inferior  grades  of  fat,  having  a  more  or  less  rancid  charac- 
ter, and,  further,  exhibiting  great  variation  in  the  proi)ortion  of 
water  present — interesting  to  the  consumer  as  an  economic 
factor — and  having  as  their  superfatting  components  glycerin 
fats,  petroleum,  and  terpenes;  thirdly,  there  are  low  grades  of 
soap  in  which  not  only  is  resin  substituted  for  refined  fat,  but 
there  are  added  inorganic  substances,  such  as  chalk,  alumina, 
and  finely  powdered  silica,  and  organic  substances,  such  as 
Btarch,  dextrin,  and  "  size."  In  one  case  a  highly  colored  soap 
was  found  to  contain  a  "vermilion"  obtained  from  a  mercuric 
salt,  and  aniline  coloring  matters  were  sometimes  found. 
While  their  injurious  nature  may  not  be  said  to  be  demon- 


560 


MINOR  PARA  GRAPES. 


[N.  Y.  Med.  Jona., 


strated,  they  are  reported  as  unnecessary  and  undesirable. 
High  coloration  in  soaps  is  generally  compatible  with  other 
materials  of  an  inferior  sort.  A  soap  that  is  superfatted  with 
lanolin  is  specially  commended  as  "agreeable  and  beneficial  in 
its  use,  and  obtainable  at  the  same  rate  as  the  inferior  grades." 
It  is  not  sufficient  that  an  article  i)urports  to  be  a  "lanolin 
soap,"  for  that  will  probably  be  professed  to  be  made  by  a  host 
of  manufacturers  as  soon  as  this  investigation  is  noised  abroad; 
but  there  should  be  a  confirmation  by  chemical  tests  or  by  a 
knowledge  of  the  reliability  of  the  manufacturer.  The  manner 
of  making  the  chemical  tests  is  given  in  the  Record.  The 
writers  in  that  journal  assert  that  legislative  steps  should  be 
taken  to  protect  the  public  against  the  use  of  injurious  chemi- 
cals by  tlie  soapinakers. 


A  BALTIMORE  GIRL'S  IMPRESSIOX  OF  MEDICAL  WOMEX. 

The  Sun  lately  published  an  account  of  the  rather  heartless 
treatment  accorded  by  passers-by  to  a  lady  doctor  of  Brooklyn 
who  had  slipped  on  the  street  and  received  a  disabling  injury  of 
her  knee.  Taking  the  affair  as  a  text,  a  Baltimore  girl  has  since 
written  to  the  editor  of  the  Sun  as  follows :  "  Sir — I  know  why 
the  woman  doctor  you  told  about  on  Sunday  had  such  a  bad 
time.  She  is  a  woman  doctor — that  explains  it.  I  never  saw 
one  yet  who  wasn't  peculiar  looking,  and  didn't  get  herself  up 
more  as  a  doctor  than  a  woman.  They  wear  a  sort  of  dress- 
reform  costume,  short  skirts,  no  corsets,  a  mannish  hat.  Some- 
how or  other  they  do  not  look  one  bit  attractive  or  womanly. 
I  am  a  good-hearted  young  woman,  stop  and  give  a  beggar  five 
or  ten  cents,  help  old  people  across  streets,  and  all  of  that;  and 
yet  I  would  really  have  to  make  an  effort  to  do  any  Good- Sa- 
maritan act  to  a  woman  doctor.  Why,  my  brother-in-law,  who 
is  a  doctor,  told  me  he  had  never  yet  heard  one  of  them  talk 
about  measles.  It  is  always  some  horrible  unmentionable  dis- 
ease they  must  harp  on.  You  see,  all  that  tells  on  a  woman's 
appearance,  even  when  she  isn't  unfortunate  enough  to  fall 
down  and  break  her  knee.  Under  those  circumstances,  dear 
me!  she  must  look  a  pretty  sorry  sort  of  object.  I  have  always 
longed  to  be  rich  for  two  reasons:  One  is  that  I  might  have 
horses  so  that  they  need  not  wear  check  reins,  and  the  other  is 
that  some  one  would  come  to  me  for  a  subscription  for  a  wom- 
an's medical  college,  so  I  could  refuse."  This,  we  are  obliged 
to  say,  is  not  a  fair  picture  of  the  medical  women  of  New  York, 
many  of  whom  are  as  feminine  and  attractive  in  looks  and  de- 
meanor as  one  could  wish  ;  and,  if  it  correctly  portrays  the  lady 
practitioners  of  Baltimore,  they  must  be  immigrants,  for  the 
young  women  of  that  city  are  noted  for  their  loveliness. 


REFORM  IN  THE  CORONER'S  SYSTEM  OF  NEW  YORK  CITY. 

The  Academy  of  Medicine  having  submitted  its  amended 
bill  to  its  tnembers  for  careful  consideration,  it  seems  justifiable, 
says  an  esteemed  correspondent,  to  come  forward  with  any  ob- 
jections that  might  be  made  against  the  measure.  The  weak 
and  objectionable  point  of  the  bill  seems  to  him  to  be  that  it 
divides  the  resjjonsibility  in  cases  of  sudden  or  otherwise  suspi- 
cious death  among  three  different  and  independent  bodies,  the 
board  of  health,  the  coroner,  and  the  district  attorney,  one  more 
than  at  present.  The  distance  of  each  of  their  ofiices  from  those 
of  the  others  would  alone,  he  says,  necessarily  involve  consider- 
able delay  in  the  transaction  of  business.  What  the  board  of 
health  has  to  do  with  the  matter  it  is  difficult  for  him  to  under- 
stand. It  clearly  belongs  to  the  department  of  justice — that  is, 
to  the  district  attorney — to  see  that  any  criminal  action  is  de- 
tected and  punished.    Would  it  not  be  much  simpler  and  more 


practical,  our  correspondent  asks,  to  attach  the  bureau  of  in- 
quest which  the  bill  would  create  to  the  district  attorney's 
office? 


ACUTE  ULCERATIVE  ENDOCARDITIS  DUE  TO  THE 
BACILLUS  DIPHTHERLE. 

In  the  Johns  JlopJcins  Hospital  Bulletin  for  April  Dr.  W.  T. 
Howard,  Jr.,  reports  the  case  of  a  Russian  Pole,  aged  forty-four 
years,  who  was  sick,  with  anomalous  symptoms,  for  twenty- 
four  days.  At  tlic  necropsy  the  heart  presented  the  lesions  of 
ulcerative  endocarditis,  and  a  microscopical  and  bacteriological 
examination  of  a  thrombotic  mass  on  the  mitral  valve  sliowed 
the  presence  of  a  bacillus  with  all  the  morphological  characters 
of  the  Bacillus  diplitherice.  The  bacillus  was  studied  by  Dr. 
Welch,  by  Dr.  Abbott,  of  Philadelphia,  and  by  the  author,  and 
none  of  them  was  able  to  distinguish  any  difference  between  it 
and  the  Klebs-Loffler  bacillus.  The  organism  was  also  found  in 
the  lungs,  liver,  spleen,  and  kidneys.  This  seems  to  be  the  first 
recorded  observation  of  ulcerative  endocarditis  caused  by  this 
organism. 


MEDICAL  COLLEGE  LIBRARIES. 

The  proceedings  of  the  first  joint  meeting  of  eight  scientific 
societies  of  New  York,  under  the  title  of  the  Scientific  Alliance 
of  New  York,  have  just  been  published.  The  contents  embrace 
a  number  of  addresses  delivered  on  the  occasion.  In  one  of 
them  we  find  it  stated  that,  with  tiie  excei)tion  of  the  Woman's 
Medical  College  of  the  New  York  Infirmary,  the  medical  colleges 
of  the  city  bad  all  reported  that  they  had  no  libraries.  What, 
then,  has  become  of  the  library  that  for  so  many  years  slumbered 
under  the  seats  in  the  old  amphitheatre  of  the  College  of  Physi- 
cians and  Surgeons  before  its  migration  from  Twenty-third 
l^treet?  As  regards  Brooklyn,  the  Hoagland  Laboratory  has, 
according  to  the  pamphlet,  a  collection  of  fair  size  and  rich  in 
foreign  serials  on  bacteriology,  pathology,  histology,  physiology, 
and  experimental  therapeutics. 


ANTISEPTIC  IRRIGATION  OF  THE  PARTURIENT  CANAL. 

At  a  recent  meeting  of  the  Philadelphia  County  Medical 
Society  a  paper  was  read  advocating  antiseptic  irrigations  be- 
fore and  after  labor.  In  the  discussion  Dr.  Charles  P.  Noble 
said  that  it  was  a  well-known  fact  that  the  skin  could  not  be 
disinfected  with  certainty,  no  matter  what  efforts  were  made. 
As  to  the  vaginal  mucous  membrane,  it  was  covered  with  mucus, 
and  water  would  slip  over  it  as  over  a  duck's  back.  In  the 
absence  of  experimental  proof  that  the  vaginal  secretions  were 
made  sterile  by  the  use  of  the  douche  he  should  doubt  that  such 
a  result  was  accomplished.  There  was  no  doubt,  however,  that 
if  there  was  a  collection  of  foul  discharge  in  the  vagina  the 
douche  would  wash  it  out,  and  in  so  far  its  use  was  excellent. 


THE  IODINE  TREATMENT  OF  GOtTRE. 

Dr.  E.  Nazaries  {Bulletin  de  la  Societe  de  pharmacie  de 
Bordeaux,  February,  1893;  American  Journal  of  Pharmacy^ 
May,  1893)  remarks  that,  while  iodine  has  long  been  used  in  the 
treatment  of  goitre,  he  has  met  with  unqualified  success  by  a 
particular  method  of  its  use.  He  dissolves  from  seventy-five 
to  ninety  grains  of  potassium  iodide  and  from  twenty  to  thirty 
drops  of  tincture  of  iodine  in  about  five  ounces  of  distilled 
water.  A  spoonful  [whether  teaspoouful  or  tablespoonful,  not 
stated]  of  this  solution  is  diluted  with  a  pint  of  water,  and  this 
amount  taken  daily,  during  and  after  meals.  The  author  insists 
on  the  continued  internal  use  of  the  drug. 


May  20,  1893.] 


MINOR  PARAGRAPHS.— ITEMS. 


561 


DE-EMBTINIZED  IPECAC  IN  DYSENTERY. 

In  the  Indian  Medical  Gazette  for  April  Surgeon-Lieu- 
tenant-Colonel Gronibie,  of  the  European  General  Hospital,  Cal- 
cutta, records  his  experience  in  the  treatment  of  dysentery  with 
ipecac,  especially  in  its  de-emetinized  form,  the  ipecacuanha 
sine  emetina  made  by  Merck,  of  Darmstadt.  This  preparation 
had  caused  vomiting  in  a  considerable  number  of  cases,  but  the 
vomiting  was  not  so  distressing  as  that  occasioned  by  ordinary 
ipecac,  and  was  not  a  bar  to  its  administration.  He  thinks, 
however,  that  neither  form  of  ipecac  has  any  special  advantage 
over  bismuth  and  Dover's  powder  in  the  treatment  of  dysentery, 
but  of  its  two  forms  he  prefers  the  de-emetinized. 


SALOL  IN  THE  TREATMENT  OF  DIABETES. 

NicoLAiER  (T/iera^.  Monatsh.,  March,  1893;  Rev.  gen.  de 
cliniqiie  et  de  therapentique,  April  26,  1893)  recommends  thirty- 
grain  doses  of  salol,  three  times  a  day,  as  a  palliative  in  diabetes 
mellitus  when  it  is  impracticable  to  enforce  an  antidiabetic  diet. 
In  the  course  of  a  week,  in  favorable  cases,  the  amount  of  urine 
passed  becomes  normal,  also  the  proportion  of  urea,  and  the 
sugar  and  acetone  disappear  completely.  In  severe  cases  the 
action  of  the  drug  is  less  decided,  but  is  still  perceptible.  The 
symptoms  recur  when  its  use  is  discontinued.  Sometimes  it 
causes  pain  in  the  stomach,  tinnitus  aui-ium,  and  vertigo,  and  in 
one  instance  the  author  observed  slight  albuminuria. 


PROFESSOR  KOCH'S  ALLEGED  DIVORCE. 

A  PRESS  dispatch  from  Berlin  gives  the  information  that 
Professor  Koch's  wife  has  obtained  a  divorce  from  him,  with 
an  allowance  of  alimony  to  the  amount  of  one  fourth  of  his  in- 
come. The  dispatch  further  announces  that  Professor  Koch  is 
about  to  marry  a  young  actress.  The  various  statements  above 
set  forth  may  be  true,  and  in  the  case  of  a  man  so  widely 
known  to  the  general  public  the  mere  announcement  of  the 
divorce  is  legitimate  matter  for  the  newspapers,  but  we  doubt 
the  propriety  of  the  statement  about  Koch's  intentions  as  to  an- 
other marriage. 


THE  LATE  DR.  JAMES  R.  LEAMING. 

We  are  glad  to  see  that  Dr.  J.  Leonard  Coming's  memorial 
address  on  the  occasion  of  Dr.  Leaming's  death,  delivered  be- 
fore the  New  York  Academy  of  Medicine  last  February,  has 
been  published  in  pamphlet  form.  The  title-page  is  faced  by 
an  excellent  portrait  of  Dr.  Leaming.  The  address  itself  is  full 
of  fine  feeling  expressed  in  very  graceful  terms. 


QUARANTINE  IN  THE  EAST. 

The  French,  according  to  the  Union  medicale,  feel,  in  view 
of  the  fact  that  representatives  of  Turkey,  Asia  Minor,  and 
Persia  were  not  participants  in  the  late  sanitary  conference  in 
Dresden,  that  a  special  conference  should  be  convened  in  Paris 
for  the  purpose  of  regulating  quarantine  measures  in  the  Orient. 


ITEMS,  ETC. 

A  Cancer  Hospital  for  Vienna. — The  FortKchritte  der  Mcdicin  states 
that  Baron  Albert  Rothschild  has  given  the  sum  of  500,000  Gulden  to 
found  a  cancer  hospital  in  Vienna. 

Changes  of  Address.— Dr.  Alfred  K.  Hills,  to  No.  669  Fifth  Avenue; 
Dr.  J.  A.  Jenkins,  to  No.  271  Jefferson  Avenue,  Brooklyn;  Dr.  S.  S. 
Jones,  to  No.  20  East  Sixty-third  Street ;  Dr.  Charles  E.  Nammack,  to 
No.  29  East  Twenty-fourth  Street. 


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  May  16,  1893  : 


DISEASES. 

Week  ending  May  9. 

Week  ending  May  16. 

Cases. 

Deaths. 

Cases. 

Deaths. 

10 

8 

21 

3 

14 

3 

9 

6 

168 

23 

206 

18 

15 

14 

23 

17 

180 

1 

187 

5 

123 

34 

122 

29 

14 

1 

8 

5 

The  Death  of  Dr.  Eundrat,  of  Vienna,  court  councillor  and  profes- 
sor of  pathological  auatoray,  is  reported  in  the  Fortscliritte  der  JSleAlcin 
to  have  occurred  on  the  26th  of  April,  as  the  result  of  apoplexy. 

The  Death  of  Professor  Hartmann,  of  Berlin. — The  Wiener  HiniscJia 
Wbchenschri/t  for  April  27th  announces  the  death  of  Dr.  Hartmann, 
professor  of  anatomy  and  first  prosector  of  the  Anatomical  Institute. 

The  Death  of  Dr.  Wegscheider,  of  Berlin,  is  announced  in  the  Fo7-t- 
sckritte  der  Medicin  for  May  1st.    He  was  in  his  seventy-fourth  year. 

Naval  iRtoMig^nCB.— Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  May  13,  1893 : 
Browne,  J.  Mills,  Surgeon  General.    Detached  from  duty  as  Chief  of 

the  Bureau  of  Medicine  and  Surgery,  May  10th,  and  placed  on  the 

retired  list. 

Tryon,  J.  RuFus,  Medical  Inspector.    Detached  from  the  U.  S.  Steamer 

Chicago,  and  appointed  Surgeon  General  of  the  Navy  and  Chief  of 

the  Bureau  of  Medicine  and  Surgery. 
HoEHLiNG,  A.  A.,  Medical  Inspector,  Bright,  G.  A.,  Surgeon,  and 

RoTHGANGER,  George,  Assistant  Surgeon.    Ordered  to  examination 

preliminary  to  promotion. 
Martin,  William,  Surgeon.    Ordered  to  duty  under  the  Surpervising 

Surgeon  General  of  the  Marine-Hospital  Service. 

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  iveeks  ending  May  6,  1893 : 

Bailhache,  p.  H.,  Surgeon.  To  report  to  Superintendent  of  Immigra- 
tion for  temporary  duty.    April  24,  1893. 

PuRviANCE,  George,  Surgeon.  Detailed  as  chairman  of  Board  of  Ex- 
aminers.   May  6,  1893. 

Gassaway,  J.  M.,  Surgeon.  Granted  leave  of  absence  for  two  days. 
April  19,  1893.  Detailed  as  member  of  Board  of  Examiners.  May 
6,  1893. 

Stoner,  G.  W.,  Surgeon.  Detailed  to  represent  service  at  International 
Congress  of  Charities,  etc.,  Chicago,  111.    May  3,  1893. 

Irwin,  Fairfax,  Surgeon.  To  proceed  to  Naples,  Italy,  for  temporary 
duty.    April  17,  1893. 

Carter,  H.  R.,  Surgeon.  Detailed  as  recorder  of  Board  of  Examiners. 
May  6,  1893. 

Wheeler,  W.  A.,  Surgeon.  To  proceed  to  Europe  as  inspector.  April 
17,  1893. 

Banks,  C.  E.,  Passed  Assistant  Surgeon.    To  proceed  to  Giosse  Isle 

Quarantine  Station,  Canada,  for  duty. 
Carrington,  p.  M.,  Passed  Assistant  Surgeon.   To  proceed  to  Hamburg, 

Germany,  for  duty.    April  17,  1893.    To  proceed  to  Marseilles, 

France,  for  temporary  duty.    April  28,  1893. 
Geddings,  H.  D.,  Passed  Assistant  Surgeon.    To  inspect  Fisherman's 

Island,  Virginia.    May  6,  1893. 
Stimson,  W.  G.,  Assistant  Surgeon.    To  proceed  to  Quebec,  Canada, 

for  duty.    April  29,  1893. 
Stewart,  W.  J.  S.,  Assistant  Surgeon.    To  report  at  Washington, 

D.  C,  for  duty.    April  22,  1893. 
Branham,  J.  W.,  Assistant  Surgeon.   To  proceed  to  New  York  for  duty. 

April  21,  1893. 

Sprague,  E.  K.,  Assistant  Surgeon.  To  pioceed  to  Charleston,  S.  C, 
for  duty.    April  21,  1893. 


562 


ITEMS.— OBITUARIES.— LETTERS  TO  THE  EDITOR. 


[N.  Y.  Med.  Jotje., 


Prochazka,  Emu,,  Assistant  Surgeon.  To  proceed  to  Ellis  Island, 
New  Tork,  for  duty.    April  21,  1893. 

Appointments. 

Branheim,  John  W.,  of  Virginia.  Commissioned  as  Assistant  Surgeon. 
April  19,  1893. 

Sprague,  Ezra  K.,  of  New  York.  Commissioned  as  Assistant  Surgeon. 
April  19,  1893. 

Prochazka,  Emil,  of  Wisconsin.  Commissioned  as  Assistant  Surgeon. 
April  19,  1893. 

Promotions. 

Perry,  J.  C,  Assistant  Surgeon.    Commissioned  as  Passed  Assistant 

Surgeon.    April  19,  1893. 
Smith,  A.  C,  Assistant  Surgeon.    Commissioned  as  Passed  Assistant 

Surgeon.    April  19,  1893. 

Society  Meetings  for  the  Coming  Week : 

Monday,  May  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,  May  23d:  American  Laryngological  Association  (New  York — 
first  day) ;  New  York  State  Medical  Association,  Fifth  District 
Branch  (Brooklyn) ;  New  York  Academy  of  Medicine  (Section  in 
Laryngology  and  Rhinology) ;  New  York  Dermatological  Society ; 
New  York  Otologieal  Society  (private) ;  Buffalo  Obstetrical  Society. 

Wednesday,  May  ZJftK :  American  Laryngological  Association  (second 
day) ;  American  PiBdiatric  Society  (West  Point — first  day) ;  New 
York  Surgical  Society  ;  New  York  Pathological  Society  ;  Metropoli- 
tan Medical  Society  (private);  American  Microscopical  Society  of  the 
City  of  New  York  ;  Medical  Society  of  the  County  of  Albany,  N.  Y. ; 
Philadelphia  County  Medical  Society. 

Thursday,  May  25th :  American  Laryngolo^cal  Association  (third  day) ; 
American  Picdiatric  Society  (second  day) ;  New  York  Academy  of 
Medicine  (Section  in  Obstetrics  and  Gynaecology) ;  New  York  Ortho- 
paidic  Society  ;  Brooklyn  Pathological  Society  ;  Roxbury,  Mass.,  So- 
ciety for  Medical  Improvement  (private). 

Friday,  May  26th:  American  Paediatric  Society  (third  day);  Yorkville 
Medical  Association  (private) ;  New  York  Society  of  German  Physi- 
cians ;  New  York  Clinical  Society  (private) ;  Philadelphia  Clinical 
Society  ;  Philadelphia  Larvngological  Society. 

Saturday,  May  27th :  New  York  Medical  and  Surgical  Society  (pri- 
vate). 

Answers  to  Correspondents : 

No.  405.— We  have  no  positive  information  concerning  the  Cincin- 
nati institution,  but  you  can  learn  of  its  standing  in  the  publications  of 
the  Illinois  State  Board  of  Health.  The  other  Institution  mentioned  is 
bogus. 

iVo.  4O6. — The  book  is  published  in  Vienna  and  Leipsic,  by  Max 
Merlin.    It  may  be  ordered  through  any  American  importer  of  books. 


Qhiimxxm. 


CHARLES  CARROLL  LEE,  M.  D.,  LL.  D. 

Dk.  Lee  died  on  Wednesday,  the  10th  inst.,  after  a  brief 
illness,  at  the  age  of  fifty-four,  therefore  in  the  height  of  his 
career.  He  was  a  native  of  Philadelphia,  had  spent  the  early 
part  of  his  life  in  Maryland,  obtained  his  medical  degree  from 
the  University  of  Pennsylvania  in  1859,  served  on  the  medical 
staii'of  the  army  during  the  late  civil  war,  and  had  lived  and 
practiced  in  New  York  eince  1868.  lie  was  associated  in  prac- 
tice with  the  late  Professor  George  T.  Elliot  up  to  the  time  of 
Dr.  Elliot's  death.  At  the  time  of  Dr.  Lee's  death  he  was  pro- 
fessor of  gynajcology  in  the  Now  York  Post-graduate  Medical 
School;  consulting  surgeon  to  the  Charity  liospilal,  the  Wom- 


an's Hospital,  and  St.  Elizabeth's  Hospital ;  physician  to  the 
New  York  Foundling  Asylum ;  and  a  member  of  the  Ameri- 
can Gynaecological  Society,  of  the  New  York  Academy  of 
Medicine,  of  the  Medical  Society  of  the  County  of  New  York 
(of  which  he  was  president),  of  the  New  York  Physicians'  Mu- 
tual Aid  Association,  of  the  New  York  Obstetrical  Society, 
and  of  the  New  York  Pathological  Society. 

Dr.  Lee  was  a  man  of  excellent  professional  attainments, 
eminent  as  a  practitioner,  clear  and  forcible  in  the  exposition 
of  his  views  in  medicine,  upright  as  a  citizen,  and  amiable  in 
his  personal  relations.  His  death  is  a  great  loss  to  the  medical 
profession  and  to  the  community. 


W^tttxB  to  t^t  €Vxtot. 


THE  CONTROL  OF  SEX  IN  GENERATION. 

Springfield,  Mass.,  May  9,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir  :  The  letter  of  Mr.  Samuel  H.  Terry  in  your  issue  of 
April  22d,  commenting  on  my  paper  which  was  published  in  your 
issue  of  July  2,  1892,  seems  to  call  for  some  reply.  Mr.  Terry 
makes  some  very  careless  and  erroneous  statements,  charging 
me  with  both  sins  of  omission  and  commission  of  which  I  am 
not  guilty.  I  shall  endeavor  to  notice  his  complaints  in  their 
order  as  briefly  as  possible,  but,  from  the  fact  that  he  has  made 
a  reply  containing  as  many  words  as  my  original  article,  my  re- 
ply must  be  more  lengthy  than  I  could  have  wished.  The  first 
complaint  is  that  I  call  his  book  "  Terry's  little  book."  When 
editors  are  sued  for  libel  they  usually  plead,  first,  want  of  mal- 
ice, and  secondly,  truthfulness  of  statement.  I  may  enter  the 
same  plea,  for  nothing  was  furtlier  from  my  intention  than  to 
disparage  either  the  author  or  the  book.  I  would  remind  him 
in  this  connection  that  little  books  are  frequently  ])regnant  with 
information  and,  indeed,  brilliant  in  style  and  fairly  glistening 
with  ideas,  both  original  and  valuable  ;  whereas  large  ones  are 
often  masses  of  padding  with  scarcely  a  single  witty  saying  or 
original  observation.  Regarding  the  size,  the  saying  was  the 
literal  truth,  for  the  copy  in  my  possession  is  less  than  octavo  in 
size,  containing  145  pages  of  very  large  type,  well  leaded,  and 
sells  for  one  dollar.  Surely,  as  books  go,  this  makes  a  very  small 
one  indeed;  nothing  like  Quain's  Dictionary  or  any  of  the  stand- 
ard works  on  the  practice  of  medicine.  With  regard  to  the 
charge  that  I  use  the  title  of  his  book  for  that  of  my  article,  I 
may  say  in  the  first  place,  and  in  extenuation  of  my  offense,  if 
it  may  properly  be  called  one,  that  after  writing  the  paper  it  was 
put  away  in  my  desk  without  any  title,  and  when  it  was  taken 
to  be  published,  several  titles  were  tried.  The  one  adopted  was 
found  to  be  the  best  for  indexing,  conveying,  as  it  did,  the  best 
idea  of  the  subject  matter  of  the  paper.  In  the  mean  time,  Mr. 
Terry's  book  had  not  been  handled  for  some  months,  and  its  ex- 
act title  forgotten,  so  that  I  did  not  know  I  was  using  exactly 
the  same  title.  It  may  be  said  that  I  ought  to  have  assured  my- 
self as  to  the  title  of  his  book.  Well,  I  did  not  feel  any  neces- 
sity for  so  doing;  I  felt  that  I  had  made  ample  acknowledgment 
for  any  use  that  I  might  make  of  it.  There  are  two  ways  of 
making  such  acknowledgments :  one  is  by  footnotes  indicating 
just  what  matter  is  taken,  and  another  and  more  conspicuous 
way  is  to  make  it  in  the  body  of  the  book  or  paper,  and  this 
seems  to  be  the  more  desirable  where  one  quotes  frequently 
and  extensively.  Had  Mr.  Terry  read  my  paper  as  carefully  as 
he  says  I  ouglit  to  have  read  his  book,  he  would  have  been 
saved  from  making  a  false  charge  against  me.    After  review- 


May  20,  1893.] 


LETTERS  TO  THE  EDITOR. 


563 


inf?  the  opinions  of  ancient  and  modern  times,  I  say  :  "  The  sub- 
ject has  recently  received  a  new  impetus  from  the  experiments 
and  orifj;inal  ideas  of  Mr.  D.  D.  Fi(jnett  and  Mr.  Thomas  B.  Armi- 
tage,  and  the  little  book  of  Samuel  Hough  Terry  and  the  trans- 
lation from  the  French  of  Dr.  H.  M.  Gourrier's  valuable  little 
book."  To  these  hooks,  especially  to  Gourrier's,  am  I  in- 
debted for  much  valuable  information  used  in  the  prepa- 
ration of  this  paper.  This  explains  why  I  gave  Mr.  Terry 
no  credit  in  "  footnotes,"  though  such  footnotes  abound  re- 
garding other  books.  The  other  books  were  not  so  exten- 
sively quoted  from,  and  were  not  given  credit  in  the  body  of 
the  paper.  Verily,  Brother  Terry,  rather  first  take  the  beam 
out  of  thine  own  eye,  etc.  I  think  I  have  now  effectively  dis 
posed  of  the  title  business,  failure  to  give  credit,  and  unfair- 
ness. I  am  next  accused  of  ignoring  the  details  of  his  book— 
"  While  he  aspires  to  erect  a  structure  of  his  own  on  its  foun- 
dations." Then  he  claims  not  only  this  change,  but  the  domi- 
nant idea  as  Ms  theory.''^  Here  we  have  two  complaints,  but  it 
is  convenient  to  treat  them  together.  With  regard  to  my  ignor- 
ing the  details  of  his  book,  I  would  say  the  statement  is  absurd 
on  its  face,  for  in  another  place  I  am  accused  of  mdk'mg  extensive 
quotations  from  it.  In  fact,  "the  numerous  passages  he  quotes 
from  my  book  show  this."  Again  he  says :  "  As  the  same  ideas, 
often  in  the  same  words,  are  found  throughout  niy  book." 
These  statements  alone  are  sufBcient  to  prove  that  I  did  not 
ignore  the  details  of  his  book.  Why,  my  friend,  I  have  quoted 
from  your  book  matter  enough  to  make  about  one  fourth  of 
my  paper,  and  more  than  from  any  other  one  source.  And 
now,  forsooth,  1  ignored  the  details!  Why,  the  paper  is  made 
up  largely  of  these  very  details.  So  far  as  claiming  the  dominant 
idea  as  my  idea,  I  nowhere  malce  any  such  claim.  Have  I  not 
said,  referring  to  ray  hypothesis  :  "  It  consists  in  adopting  Ter- 
ry's in  its  entirety,  minus  the  term  'highest  degree  of  sexual 
excitement'"?  How  then  can  I  claim  the  dominant  idea  when 
I  have  adopted  yours  in  its  entirety  ?  Verily,  you  are  setting 
up  a  man  of  straw  for  the  purpose  of  knocking  him  down. 
My  first  purpose  was  to  call  his  attention  to  what  I  conceived  to 
be  an  error  of  definition,  and  end  there,  but  the  more  I  reflected, 
the  more  I  studied  individual  cases,  the  more  I  was  satisfied  that 
the  excitement  theory  did  not  fill  the  reciuirements  of  the  case. 
And, /aZsMs  in  uno,Jalsus  in  omniht/s.  I  could  not  for  this  rea- 
son subscribe  to  it,  and,  since  this  was  the  essential  point  of  the 
theory,  its  rejection  and  the  substitution  of  a  new  definition 
made  the  hypothesis  really  a  new  one.  My  object  in  so  calling 
it  in  the  paper  was  not  for  any  notoriety  1  might  obtain,  but  as 
a  logical  consequence.  The  author  next  gives  us  an  exposition 
of  the  meaning  of  the  words  "  excitement  "  and  "erethism," 
and  kindly  informs  us  that  the  error  which  led  to  his  [my]  ob- 
jection to  my  term,  lies  in  his  misconception  of  the  meaning  of 
the  word  "  excitement."  When  all  your  readers  attended  the 
grammar  school,  I  dare  say,  they  knew  that  excitement  was  a 
noun  and  was  the  name  of  the  cause  or  motive  that  excited, 
the  essence  of  the  verb  excited,  and  that  excitability  was  the 
ability  to  be  excited,  etc.  But,  begging  his  pardon,  I  still 
insist  that,  so  far  as  I  am  concerned,  there  is  no  misconcep- 
tion, and  that,  after  reading  this,  his  latest  definition,  I  am 
still  of  the  opinion  that  it  is  a  corner-stone  fatal  to  his  ichole 
edifice,  and  I  think  the  great  majority  of  your  readers  will 
agree  with  me.  I  see  no  analogy  between  excitement  and 
vigor,  only  that  a  vigorous  person  may  be  able  to  sustain 
a  condition  of  excitement  longer,  though  the  grade  of  ex- 
citement need  not  necessarily  be  of  a  higher  order  or  even 
as  high.  He  says  in  this  connection :  "  Dr.  Keefe  admits 
that  in  my  book  the  element  of  sexual  vigor  is  eml)raced 
in  sexual  excitement."  True,  but  not  as  part  of  your  definition ; 
not  as  a  necessary  part  of  your  theory,  but  as  a  logical  deduc- 


tion from  your  reasoning.  If  you  intended  them  as  synony- 
mous, why  so  much  fault-finding  ?  Why  not  embrace  vigor  as 
part  of  your  definition  and  thank  Dr.  Keefe  for  having  called 
your  attention  to  an  important  oversight.  After  discoursing 
on  erethism,  Mr.  T.  says:  "One  might  with  equal  propriety 
maintain  that  materials  most  inflammable — that  is,  most  readily 
set  on  fire — produce  the  greatest  heat."  Is  not  this  the  fact, 
Mr.  T.  ?  Do  they  not  in  a  given  time  produce  the  greatest 
number  of  heat  units?  For  example,  a  pound  of  coal  will  pro- 
duce perhaps  a  heat  of  greater  intensity  than  a  like  quantity  of 
kerosene,  but  not  in  the  same  time,  and  if  the  fire  of  the  kero- 
sene be  applied  to  heat  anything,  it  will  heat  it  to  as  great  in- 
tensity as  the  coal.  1  instance  these  for  comparison,  not  insist- 
ing on  the  actual  correctness  of  the  quantities.  This  same 
reasoning  applies  to  other  things  of  the  same  class.  Mr.  Terry 
again  sa\s:  "The  highest  degree  of  sexual  vigor,  which  Dr. 
Keefe  prefers,  is  rather  the  capacity  to  ordinarily  take  on  the 
highest  degree  of  excitement."  If  such  is  the  case,  there  is  no 
controversy  between  us,  but  here  he  makes  a  serious  error.  As 
I  before  stated,  there  is  no  necessary  relation  between  them, 
only  that  the  vigorous  may  be  aide  to  maintain  the  condition 
for  a  greater  length  of  time.  He  continues:  "In  introducing 
what  he  calls  his  theory  of  the  reason  why  a  parent  impresses 
his  progeny  with  the  sex  opposite  to  his  own,  he  remarks,  Mr. 
Terry  has  offered  no  adequate  explanation  of  this ;  he  only  gives 
experiments  apparently  proving  the  fact,  but  not  the  reason 
for  it."  Here  follow  references  to  parts  of  his  book  where  we 
are  supposed  to  find  the  information  desired.  I  have  re  read 
these  parts,  and  particularly  chapter  xi,  and  am  able  to  reiterate 
the  statement  with  emphasis.  The  object  of  the  friction  of  the 
parts  is  not,  as  Mr.  T.  thinks,  to  generate  electricity;  but  to 
increase  the  active  circulation — arterial  blood — to  furnish  a 
pabulum  to  the  glands,  to  enable  them  to  secrete  a  lubricating 
fluid  on  the  one  hand,  and  to  perfect  and  eject  the  spermatic 
fluid  on  the  other.  The  friction  acts  here  just  as  it  will  in  a 
wasting  and  paralyzed  muscle.  It  increases  the  nutrition.  Our 
treatment  of  impotence  is  based  on  this  very  fact.  We  try  to 
get  rid  of  the  passive  and  increase  the  active  circulation. 
Again  he  says:  "Dr.  Keefe's  hypothesis  for  this  presents  no 
physiological  law  that  will  apply  to  the  lower  orders."  Being 
substantially  the  same  as  Mr.  Terry's,  I  fail  to  know  why  the 
physiological  law  that  applies  to  the  one  will  not  apply  with 
equal  force  to  the  other.  After  complimenting  the  writer  for 
his  perceptive  qualities,  Mr.  Terry  continues:  "But  his  capacity 
for  drawing  logical  conclusions  is  less  acute,  as  shown  by  his 
remarks  on  Dr.  Cook's  theory."  He  is  more  acute  than  you 
would  have  him,  my  friend,  for  he  is  not  too  obtuse  to  notice 
that  you  have  transposed  his  figures.  Instead  of  proving  the 
falsity  of  Cook's  theory,  as  you  say  they  do,  they  really,  as  given 
by  you,  do  exactly  the  reverse,  and  prove  the  correctness  of  it. 
I  have  often  heard  it  said  that  figures  could  bo  made  to  prove  any- 
thing, but  it  remained  for  Mr.  Terry  to  demonstrate  its  literal 
truth.  He  is  puzzled  to  know  how  the  writer  satisfied  himself 
that  all  those  children  born  between  12  m.  and  12  p.  m.  were  be- 
gotten between  midnight  and  morning.  I  reply,  firstly,  that 
12  M.  to  12  p.  M.  is  not  between  midnight  and  morning.  Sec- 
ondly, that  it  requires  not  such  a  great  "  stretch  of  occult  in- 
telligence "  as  he  seems  to  think.  I  satisfied  myself  in  the  fol- 
lowing manner :  I  concede  at  the  outset  that  insemination  and 
conception  are  not  synchronous  as  to  time ;  still,  in  a  large 
number  of  cases,  the  majority  would  strike  an  average  in  which 
the  time  would  be  pretty  constant ;  otherwise,  how  could  we 
predict  with  any  degree  of  confidence  the  date  of  an  expected 
delivery?  From  the  days  of  Aristotle  it  has  been  the  custom 
to  count  ten  lunar  months  of  twenty-eight  days  each  as  the 
period  of  uterogestation.   It  is  a  notorious  fact  that,  nine  times 


564 


LETTERS  TO  THE  EDITOR.—PROCEEDINOS  OF  SOCIETIES. 


[N.  y.  Med.  Jouk., 


out  of  ten,  coitus  occurs  in  the  hours  of  darkness  and  that,  al- 
most in  an  equal  ratio,  delivery  takes  place  in  the  same  hours. 
This  fact  alone  would  be  a  strong  presumption  in  favor  of  de- 
livery being  synchronous  as  to  time  of  day  with  coitus.  Act- 
ing on  this  assumption  is  how  I  satisfied  myself  that  tiie  infants 
referred  to  were  begotten  in  tlie  night.  Of  course  there  are 
many  elements  of  uncertainty  in  this,  and  the  conclusion  is  not 
beyond  cavil,  but  the  same  may  be  said  with  regard  to  many 
points  of  the  general  subject. 

In  reference  to  the  statements  that  many  ideas,  often  in  the 
same  words,  are  found  in  his  book,  I  have  only  to  say  that  my 
paper,  be  it  remembered,  purported  to  be  a  review  of  the  sub- 
ject with  observations  on  311  cases  in  the  human  family.  It 
can  not  be  gainsaid  that,  in  reviewing  a  somewhat  limited 
literature,  it  would  be  strange  if  some  of  the  same  ideas,  and 
often  in  the  same  language,  were  not  contained  in  the  paper  as 
in  Mr.  T.'s  book,  especially  after  it  had  been  acknowledged  that 
it  was  one  of  the  books  on  which  the  paper  was  based.  Again, 
I  am  asked  to  account  for  exceptiorjal  cases,  as  why  the  chil- 
dren of  plural  births  were  not  all  of  the  same  sex?  I  have  not 
time,  nor  is  a  letter  the  proper  place,  to  go  into  that  subject, 
and  I  fear  I  have  wearied  your  patience  already ;  but  I  may 
say  that  I  gave  many  reasons  in  my  paper,  and  Mr.  Terry  gave 
many  reasons  in  his  book.  All  he  has  accomplished  1  have 
aimed  to  give  liim  credit  for,  and  I  thank  him  for  producing  so 
interesting  a  "little  book."  It  is  well  written,  very  readable, 
and  wholly  good.  In  conclusion,  all  I  ask  of  him  is  to  read  the 
productions  of  others  with  more  care  and  a  little  charity  before 
he  launches  into  criticism.  D.  E.  Keefe,  M.  D. 


THE  NEW  YORK  STATE  EXAMINING  BOARD. 

New  York,  May  13,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal  : 

Sir:  In  Dr.  Starr's  letter,  which  appeared  in  t\\Q  Journal  of 
this  date,  criticising  the  Syllabus  on  Diseases  of  the  Nervous 
System  of  the  State  board  of  medical  examiners,  there  is  an 
error  of  statement  as  to  the  origin  of  this  board  that  I  beg  you 
will  allow  me  to  correct.  It  is  not  correct  to  say  that  "  the 
Regents  of  the  University  of  the  State  of  New  York  agreed  to 
demand  from  every  student  of  medicine  about  to  practice  in  this 
State  some  evidences  of  his  fitness  for  his  work,  and  therefore 
established  a  State  examination."  It  was  not  tlie  regents  at  all, 
but  the  Legislature  that  established  a  board  of  State  examiners. 
The  regents  are  simply  carrying  out  a  law  the  details  of  whose 
execution  were  intrusted  to  them.  I  am  not  competent  to  dis- 
cuss Dr.  Starr's  criticisms  upon  the  medical  syllabus  adopted 
by  the  examiners,  but,  whether  it  be  a  scientific  one  or  not,  I 
do  not  think  it  follows,  as  Dr.  Starr  intimates,  that  a  man  must 
be  a  teacher  of  neurology  in  order  to  draw  up  a  proper  form  of 
examination  in  this  department.  The  State  medical  societies 
are  limited  to  some  extent  by  the  law  as  to  the  examiners 
whose  names  they  may  send  to  the  regents,  but  they  did  send, 
when  the  board  was  first  created,  the  name  of  one  of  the 
autliors  to  whom  Dr.  Starr  alludes,  among  those  of  other  teach- 
ers. A  strong  influence  was  brought  to  bear  upon  the  regents, 
and,  as  I  think,  unfortunately,  which  induced  them  to  reject  all 
names  of  teachers.  I  agree  thus  far  with  Dr.  Starr,  that  teach- 
ers ought  not  to  be  debarred  from  becoming  examiners.  Yet  I 
believe  it  easy  to  secure  examiners  competent  to  frame  jjroper 
questions,  even  if  they  are  not  teachers,  although,  of  course,  it 
will  be  more  difliicult.  Yet  the  present  board  is  generally  con- 
ceded to  be  an  entirely  competent  one.  He  mu.st  be  himself, 
to  some  extent,  unknown  who  does  not  know,  at  least  by  repu- 
tation, as  Dr.  Starr  says  he  does  not,  such  men  as  William  0. 
Wey,  William  S.  Ely,  and  George  K.  Fowler,  who,  with  four 


other  thorouglily  educated  physicians,  well  known  througliout 
our  State  at  least,  constitute  the  board  of  examiners  in  afiilia- 
tion  with  the  Medical  Society  of  the  State  of  New  York. 

D.  B.  St.  John  Roosa,  M.  D. 


IProccctrings  of  Sodctus, 

NEW  YORK  NEUROLOGICAL  SOCIETY. 

Meeting  of  May  2,  1803. 

The  President,  Dr.  M.  Allen  Stark,  in  the  Chair. 

Ataxic  Paraplegia.— Dr.  L.  Stieglitz  presented  a  man, 
aged  forty  years,  who  had  been  under  observation  for  a  year 
past.  He  had  first  complained  of  weakness  and  paresthesia  in 
the  lower  limbs.  The  knee-jerks  were  greatly  increased;  there 
was  pronounced  ankle  clonus,  with  slight  ataxia,  slight  Rom- 
berg symptom,  and  some  paresis  on  the  right  side  of  the  face. 
His  condition  remained  about  the  same  for  a  few  months.  Last 
December  the  ataxia  of  the  lower  limbs  became  more  pro- 
nounced and  the  upper  limbs  were  also  affected ;  the  sensory 
disturbances  had  increased.  All  these  symptoms  had  steadily 
progressed.  There  was  now  also  slight  disturbance  of  the  func- 
tions of  the  bladder.  The  thermal  sense  had  been  lost.  The 
speaker  presented  the  case  as  one  of  sclerosis  of  the  lateral  and 
posterior  tracts  (ataxic  paraplegia)  with  involvement  of  the 
right  facial  nerve. 

A  New  Induction  Coil  for  Currents  of  Quantity  and 

Tension  was  shown  by  Dr.  A.  D.  Rockwell.    (See  page  .520.) 

Some  Considerations  concerning  Genito-urinary  Neu- 
rology.— Dr.  Thomas  H.  Burchaed  read  a  paper  on  this  sub- 
ject. He  stated  that  the  intimate  connection,  anatomical  and 
physiological,  that  existed  between  the  general  nervous  system 
on  the  one  hand  and  the  genito-urinary  system  on  the  other 
found  a  counterpart  in  the  reciprocal  manifestations  of  these 
systems  under  conditions  of  disease.  Diseases  of  the  brain, 
the  spinal  cord,  or  the  sympathetic  produced  corresponding 
disturbances  in  the  genito-urinary  system,  and,  conversely,  dis. 
eased  conditions  of  the  uterus,  ovaries,  bladder,  prostate,  and 
external  genitals  were  not  infrequently  the  cause  of  serious 
nervous  disease.  The  extent  to  which  the  brain  was  susceptible 
to  genital  irritation  was,  of  course,  largely  a  matter  of  conjec- 
ture. That  inordinate  sexual  indulgence,  particularly  during 
the  period  of  adolescence,  might  seriously  weaken  the  system  by 
sapping  its  vitality,  would  doubtless  be  admitted.  Even  here, 
however,  and  especially  among  the  insane,  the  sexual  mani- 
festations were  essentially  symptomatic,  and  must  not  be  re- 
garded as  causative.  The  important  point  was  that  long-con- 
tinued irritation  of  the  genito- urinary  system,  and  quite  inde- 
pendent of  sexual  indulgence,  was  capable  by  itself  of  produc- 
ing insidious  and  profound  nervous  disease. 

Short  liistories  of  three  cases  were  then  read  as  illustrating 
the  proposition  that  it  was  possible  for  irritation  of  the  genito- 
urinary system  in  either  sex  to  produce  the  highest  forms  of 
reflex  nervous  and  cerebral  irritation.  In  many  diseased  con. 
ditions  of  the  nervous  system  a  painstaking  and  thorough  in- 
vestigation would  carry  the  diligent  neurologist  into  an  ex- 
haustive examination  of  the  pelvic  viscera  and  the  genital 
apparatus. 

Dr.  Rockwell  said  it  was  always  interesting  to  consider  the 
question  as  to  whether  any  particular  form  of  neurosis  was 
peripheral  or  central  in  its  origin.  Many  of  these  cases,  no 
doubt,  are  out  of  the  domain  of  the  neurologist.    The  cases  of 


May  20,  1893.] 


BOOK  NOTICES. 


565 


central  origin,  however,  gave  symptoms  quite  different  from 
those  that  were  functional.  The  surgeon  naturally  looked  for 
some  source  of  peripheral  iri-itation,  and  he  might  ])ossibly  find 
it  in  lueniorrhoids,  iti  varicocele,  in  an  elongated  prepuce,  etc. 
Hut  if  these  morbid  conditions  were  not  the  cause  of  the  nerv- 
ous phenomena,  it  was  not  well  to  subject  the  patient  to  a  sur- 
gical operation,  because  the  nervous  conditions  were  often 
made  worse  thereby.  In  cases  of  central  origin  the  character 
of  the  symptoms  was  quite  distinct;  they  were  mental,  in  a 
great  measure;  the  patient's  sutferings  were  more  than  physical- 

Dr.  Joseph  Collins  fully  agreed  with  the  statements  made 
by  Dr.  Burchard  regarding  cases  of  reflex  neuroses.  The 
trouble  was  that  the  matter  had  got  into  bad  odor  on  account 
of  the  number  of  operations  that  had  been  performed  in  just 
such  cases  with  no  good  results.  A  case  exactly  smiilar  to  the 
first  one  recited  by  Dr.  Burchard  had  come  under  bis  observa- 
tion, and  the  removal  of  an  elongated  prepuce  and  a  varicocele 
had  permanently  relieved  the  patient  from  epileptoid  seizures. 
While  the  pertinency  of  such  cases  could  not  be  doubted,  one 
must  not  allow  himself  to  be  carried  away  by  them.  Where  one 
cure  had  been  reported  after  such  an  o))eration,  a  dozen  cases 
could  be  cited  where  no  beneficial  results  had  been  obtained. 

Dr.  E.  D.  FisiiER  said  he  did  not  think  that  genital  irrita- 
tion due  to  masturbation  alone  could  cause  mental  disease  un- 
less there  existed  a  previous  degenerative  type  of  brain. 
Masturbation  was  common  among  the  insane  in  all  forms  of  de- 
generation vs'here  dementia  was  present.  Everybody  thought 
that  genito-urinary  irritation  was  capable  of  producing  func- 
tional nervous  disturbances.  As  regarded  operations,  if  an 
organ  was  found  diseased  and  the  symptoms  pointed  to  that 
organ  as  the  cause  of  the  irritation,  we  must  remove  it;  but  to 
remove  a  healthy  ovary  for  epilepsy  or  hystero- epilepsy  was 
not  good  practice.  In  the  cases  cited  by  Dr.  Burchard  opera- 
tive procedures  had  certainly  been  clearly  indicated. 

Dr.  L.  0.  Gray  said  that  in  men  disorders  of  the  urethra 
were  prone  to  lead  to  a  prolonged  form  of  hypochondriasis 
which  it  was  difficult  to  relieve.  In  women  the  genital  organs 
played  a  larger  role.  About  seven  or  eight  cases  had  come  under 
his  observation,  in  women  who  had  l)een  operated  on  while  in- 
sane, and  who  had  either  made  relatively  good  recoveries  or 
been  improved.  All  these  had  belonged  to  the  same  type  ;  they 
were  of  the  class  of  hallucinatory  insanity.  In  three  or  four 
cases  of  melancholia  there  had  been  no  improvement  at  all. 

We  must  also  consider  the  converse  side  of  this  question.  It 
was  a  well-kuown  fact  that  operations  on  the  genital  or  urinary 
organs  had  produced  insanity.  Dr.  Thomas,  some  six  years  ago, 
had  reported  a  series  of  such  cases,  and  a  resume  of  the  litera- 
ture on  the  subject  had  been  given  by  Dr.  Mary  Putnam  Jacobi. 
There  was  a  singular  reluctance  on  the  part  of  many,  the  speaker 
said,  to  admit  that  the  brain  w-as  in  the  skull  and  could  do  busi- 
ness on  its  own  account;  every  specialist  wanted  to  transfer  it 
to  his  chosen  field. 

The  President  said  that  the  typical  cases  of  nervous  and 
mental  disease  were  never  reflex  in  their  origin.  Certain  cases 
were  of  reflex  origin,  hut  their  proportion  was  small.  Of  four 
hundred  and  seventy-two  cases  of  epilepsy  that  had  come  under 
his  observation,  only  eleven  had  been  of  reflex  origin.  One  of 
the  latter  cases  was  that  of  a  boy,  who  began  to  have  epileptoid 
convulsions  at  the  age  of  three  years,  and  had  sometimes  as  many 
as  sixty  attacks  (of  petit  mal)  in  a  day.  On  examination,  it  had 
been  found  that  the  boy  had  a  very  tender  penis,  the  prepuce  of 
whicli  could  not  be  retracted.  He  was  circumcised,  the  attacks 
ceased,  and  at  the  end  of  four  years  he  was  pronounced  cured. 
That  operation  had  been  performed  in  188.3.  Nine  months  ago 
the  boy  was  brought  to  the  clinic  by  his  mother,  who  stated 
that  the  epileptoid  convulsions  had  come  on  again  about  six 


months  before.  No  local  source  of  irritation  could  be  found, 
and  this  suggested  that  those  cases  which  we  considered  merely 
reflex  might  after  all  be  constitutional. 

In  neurasthenics  of  the  genito  urinary  type  the  seat  of  the 
irritation  was  often  situated  in  the  deep  urethra,  about  the  pros- 
tate, and  these  could  usually  be  promptly  cured  by  local  appli- 
cations of  silver  nitrate.  A  number  of  cases,  however,  had  come 
under  his  observation  which  had  failed  to  yield  to  this  treat- 
ment, and  in  four  of  them  one  or  more  small  ulcers  had  been 
found  on  the  anterior  wall  of  the  rectum,  adjacent  to  the  pros- 
tatic gland.  The  irritation  had  rapidly  disappeared  after  the 
ulcers  had  been  excised  or  treated  with  pure  niiric  acid.  This 
suggested  the  importance  of  making  a  careful  rectal  examina- 
tion in  these  cases. 

Dr.  Burchard  said  he  had  yet  to  see  any  disease  of  the 
genito-urinary  organs  that  of  itself  was  capable  of  giving  rise 
to  distinct  and  profound  nervous  disease  unless  the  patient  was 
predisposed  either  by  heredity  or  by  some  acquired  condition. 
In  the  three  cases  presented  by  him  the  patients  had  all  been 
more  or  less  broken  down  and  hysterical. 

The  Self-regulation  of  the  Beat  of  the  Heart.— Dr.  S.  J. 

Meltzer  read  a  paper  on  this  subject.    (See  pnge  513.) 

After  some  remarks  by  Dr.  B.  Sachs  and  Dr.  Collins,  the 
society  passed  a  vote  of  thanks  to  Dr.  Meltzer  for  his  paper. 

A  resolution  was  adopted  respectfully  requesting  Governor 
Flower  to  grant  his  approval  of  the  bill  passed  by  the  Legisla- 
ture providing  for  the  establishment  of  an  epileptic  colony  in 
Livingston  County. 


A  System  of  Genito-urinary  Diseases^  Syphilology,  and  Derma- 
tology.   By  Various  Authors.    Edited  by  Prince  A.  Mok- 
Eow,  A.  M.,  M.  D.,  Clinical  Professor  of  Genito-urinary  Dis- 
eases, formerly  Lecturer  on  Dermatology  in  the  LTniversiiy 
of  the  City  of  New  York,  etc.    W^ith  Illustrations.  In 
Three  A'olumes.    Vol.  I.    Genito-urinary  Diseases.  New 
York :  1).  Appleton  &  Co.,  1893.    Pp.  xxvii-lOU. 
The  tendency  of  modern  specialism  in  medicine  is  toward 
the  association  of  collateral  branches.    Especially  is  this  the 
case  in  the  smaller  cities,  where  there  is  not  sufficient  practice 
in  one  special  line  to  keep  an  active  practitioner  busy.    As  a 
consequence,  those  who  are  engaged  in  post-graduate  teaching 
come  constantly  in  contact  with  men  desiring  advice  on  points 
in  regard  to  which  two  or  three  particular  lines  of  practice  will 
combine  most  harmoniously.    Whatever  answer  may  be  given 
to  such  (questions  with  reference  to  the  other  branches  of  medi- 
cine, it  is  practically  settled,  in  this  country  at  least,  that  genito- 
urinary diseases,  syphilology,  and  dermatology  form  one  of  the 
most  practical  and  profitable  combinations.     Whoever  may 
have  originated  the  idea  of  a  systematic  treatise  upon  these 
combined  subjects,  to  Dr.  Morrow  will  be  given  the  credit  of 
having  brought  together  a  notable  list  of  contributors  and  of 
having  made  a  most  excellent  division  of  the  subjects.  The 
time  was  ripe  for  an  exhaustive  review  of  genito-urinary  dis- 
eases, and  in  the  volume  before  us  we  have  it  prepared  by  men 
selected  with  special  reference  to  their  experience  and  knowl- 
edge.   One  has  but  to  read  the  list  of  collaborators  to  feel  sat- 
isfied that  the  work  is  one  of  more  than  ordinary  merit.  The 
editor  has  carefully  reviewed  their  work  and  eliminated  as  far 
as  possible  any  overlapping  of  subjects,  and  yet  this  volume 
contains  over  a  thousand  pages.    Whatever  is  known  upon 


56G 


BOOK  NOTICES. 


[N.  Y.  Med.  Joub., 


genito-urinary  diseases,  with  few  exceptions,  seems  to  be  found 
witiiin  its  covers. 

It  would  be  a  pleasure  to  review  almost  every  article  in  the 
boot  did  space  permit,  and  no  invidious  distinction  is  intended 
when  we  call  attention  to  a  few  which  seem  to  us  to  mark  a 
particular  advance  in  tlie  literature  of  the  subject.  Amonj;  the 
first  of  these  is  the  article  on  endoscopy,  by  Dr.  Herman  Klotz. 
Heretofore  we  have  had  no  adequate  treatise  upon  this  subject 
in  the  English  language,  and  the  student  has  been  compelled  to 
depend  upon  Grilnfeld's  work,  either  in  German  or  in  transla- 
tions. Thanks  to  Dr.  Klotz,  we  now  have  in  our  mother  tonf,nie 
a  complete  and  concise  manual  upon  the  ocular  examination 
and  local  treatment  of  the  urethra,  and  any  one  interested  in 
the  subject  will  find  his  article  replete  with  facts  and  practical 
suggestions.  The  Diagnostic  Significance  of  Pathological  Modi- 
fications of  the  Urine,  by  Dr.  Eugene  Fuller,  is  a  most  timely 
and  excellent  contribution  from  an  accurate  observer.  Dr. 
Fuller,  in  his  association  with  Dr.  Keyes,  has  had  a  vigorous 
training  and  a  large  experience,  which  make  him  a  practical 
thinker,  and  this  characteristic  is  well  brought  out  in  the  pages 
before  us. 

The  article  on  Stone  in  the  Bladder,  Prostate,  Urethra,  and 
Ureters,  by  Dr.  A.  T.  Gabot,  is  one  of  the  most  complete  and  in- 
teresting in  the  book.  The  latest  and  most  practical  views  on 
this  subject  are  here  set  forth  in  a  concise  and  attractive  manner, 
while  new  and  ingenious  devices  are  suggested  with  an  almost 
unbecoming  modesty. 

Dr.  Morrow's  own  contribution,  on  The  Functional  Disor- 
ders of  the  Male  Sexual  Organs,  is  well  worthy  of  particular 
notice,  as  indeed  are  most  of  the  articles  in  the  volume. 

The  work  is  an  advance  upon  anything  heretofore  published 
upon  these  subjects,  and  no  practitioner  in  these  special  lines 
can  afford  to  be  without  it. 


A  Practical  Guide  for  Beginners  to  the  Dissection  of  the  Human 
Body.  By  Irving  S.  Haynes,  Ph.  B.,  M.  D.,  Demonstrator 
of  Anatomy  in  the  Medical  Department  of  the  University  of 
the  City  of  New  York.  New  York  :  E.  B.  Treat,  1893.  Pp. 
250.  [Price, 

This  little  work  is  intended  for  use  at  the  dissecting  table, 
directing  the  student  how  to  pursue  his  work  and  what  to  ob- 
serve during  dissection,  thus  supplementing  the  explanations  of 
the  anatomical  instructor.  It  is  based  on  the  author's  practical 
experience  in  the  latter  capacity,  and  will  undoubtedly  prove  a 
very  useful  work  to  the  student. 


Lehrhuch  der  physiologischen  Chemie  mit  Berilcksichtigung  der 
pathologischen  Verhaltnisse.    Fur  Studirende  und  Aerzte. 
Von  Richard  Neumeister,  Dr.  med.  et  phiL,  Privatdocent 
an  der  Universitiit  Jena.     Erster  Theil.    Die  Ernahrung. 
Jena  :  Gustav  Fischer,  1893.    Pp.  xii-337. 
The  advent  of  another  work  on  physiological  chemistry  so 
soon  after  the  appearance  of  those  by  Hammarsten  and  Halli- 
burton is  some  evidence  of  the  activity  prevailing  among  the 
workers  in  a  field  that  is  of  much  importance  to  the  advance  of 
medicine. 

This  is  the  first  part  of  the  projected  work  of  two  volumes, 
and  pertains  to  the  subject  of  nutrition.  As  was  to  be  expected 
from  the  character  of  the  author's  previous  work,  the  book  is 
an  excellent  presentation  of  the  subject.  It  is  not  a  mere  de- 
scription of  proximate  chemical  principles,  with  methods  of 
preparation  and  reactions,  but  is  a  systematic  story  of  the 
chemistry  of  the  nutritive  principles,  of  digestion,  and  of  nutri- 
tion. The  relations  of  the  facts  presented  to  pathology  are  suf- 
ficiently dwelt  upon,  and  frequent  reference  is  made  to  analo- 


gous phenomena  in  lower  forms  of  animals  and  in  vegetable 
organisms.  A  feature  of  great  value  to  the  advanced  student  is 
the  very  copious  references  to  authorities  given  in  the  form  of 
foot-notes. 

The  excellence  of  tlic  volume  leads  one  to  express  the  hope 
that  the  second  part,  relating  to  the  tissues  and  the  fluids  of 
the  body,  will  not  be  long  delayed. 


^pilepsie.  Par  Cn.  Ffint,  m6(lecin  de  Bicetre.  Encyclopedic 
scientificjue  des  aide-memoires,  publi^^e  sous  la  direction  de 
M.  L6aute,  membre  de  I'lnstitut.  Paris :  G.  Masson,  1892. 
Pp.  203. 

This  is  a  clear  and  masterly  exposition  of  a  disease  that  can 
nowhere  be  studied  to  better  advantage  than  at  the  hospitals 
where  our  author  has  officiated,  the  Salpetriere  and  the  Bicetre. 
The  air  of  these  refuges  is  fairly  impregnated  with  epilepsy,  the 
sufferers  from  which  are  either  domiciled  within  their  walls  or 
frequent  attendants  of  their  dispensaries.  Every  opportunity 
for  studying  this  neurosis  in  all  its  phases  is  therefore  oflFered 
to  the  medical  practitioner,  and  he  inevitably  becomes  well 
versed  in  the  epileptic's  possibilities  and  inevitabilities.  F^r6  is, 
as  is  well  known,  not  only  a  most  conscientious  student,  but  a 
man  of  long  experience,  as  could  indeed  be  deduced  from  the 
great  ease  with  which  he  marshals  his  facts.  The  present 
treatise  is  an  excellent  addition  to  his  already  long  list  of  works. 


Diseases  of  tlie  Nasal  Organs  and  Naso-pharynx.  By  Whit- 
field Ward,  A.  M.,  M.  D.,  Ten  Years  Surgeon  to  the  Metro- 
politan Throat  Hospital,  late  Clinical  Assistant  to  the  Lon- 
don Throat  Hospital,  Member  of  the  New  Y'ork  County 
Medical  Society,  etc.  New  Y'ork  and  London :  G.  P.  Put- 
nam's Sons,  1891.    Pp.  165. 

The  author's  aim  has  been  to  present  a  treatise  on  the  dis- 
eases of  the  nose  in  which  all  matter  of  a  simply  historical 
value  should  be  excluded,  while  all  due  attention  should  be 
given  to  the  description  of  the  diverse  treatments  and  opera- 
tions and  of  the  requisite  instruments.  For  the  better  compre- 
hension of  operations  and  instruments,  the  book  is  plentifully 
illustrated,  so  that  after  its  perusal  a  clear  picture  can  be  formed 
of  the  needs  and  requirements  of  both  patient  and  surgeon. 

BOOKS,  ETC.,  RECEIVED. 

Napheys's  Modern  Therapeutics,  Medical  and  Surgical,  in- 
cluding the  Diseases  of  Women  and  Children.  A  Compendium 
of  Recent  Formulaa  and  Therapeutical  Directions  from  the  Prac- 
tice of  Eminent  Contemporary  Physicians,  American  and  For- 
eign. Ninth  Edition,  revised  and  enlarged.  Volume  II.  Gen- 
eral Surgery,  Gynaecology,  and  Obstetrics.  By  Allen  J.  Smith, 
M.  D.,  Professor  of  Pathology,  University  of  Texas,  Galveston, 
etc.,  and  J.  Aubrey  Davis,  M.  D.,  Assistant  Demonstrator  of 
Obstetrics,  University  of  Pennsylvania,  etc.  Philadelphia:  P. 
Blakiston,  Son,  &  Co.,  1893.    Pp.  xix-17  to  1112.    [Price,  $6.] 

A  Handbook  of  Local  Therapeutics.  General  Surgery,  by 
Richard  II.  Ilarte,  M.  D.,  Demonstrator  of  Osteology  and  Syn- 
desmology.  University  of  Pennsylvania;  Diseases  of  the  Skin, 
by  Arthur  Van  Harlingen,  M.  D.,  Professor  of  Diseases  of  the 
Skin  in  the  Philadelphia  Polyclinic  and  College  for  Graduates 
in  Medicine ;  Diseases  of  the  Ear  and  Air  Passages,  by  Har- 
rison Allen,  M.  D.,  Consulting  Physician  to  the  Rush  Hospital 
for  Consumption ;  Diseases  of  the  Eye,  by  George  C.  Harlan, 
M.  D.,  Surgeon  to  Wills  Eye  Hospital  and  to  the  Eye  and  Ear 
Department  of  the  Pennsylvania  Hospital.  Edited  by  Harrison 
Allen,  M.D.  Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1893. 
Pp.  xxvii-17  to  505.    [Price,  $4.] 

Vertebrate  Embryology :  a  Text-book  for  Students  and  Prac- 


May  20,  1893.] 


BOOK  NO TICES.—MISGELLA N Y. 


567 


titloners.    By  A.  Milnes  Marshall,  M.  D.,  D.  Sc.,  M.  A.,  F.  R.  S., 

Professor  in  the  Victoria  University,  etc.  New  York:  G.  P. 
Putnam's  Sons.  London  :  Smith,  Elder,  &  Co.,  189:^.  Pp.  xxiii- 
640.    [Price  $G.] 

Malarial  Fever  in  a  New-born  Infant.  By  Floyd  M.  Cran- 
dall,  M.  D.,  New  York.  [Pei)rinted  from  the  I^ew  Yorl-  Poly- 
clinic] 

The  Ability  of  a  State  to  prevent  an  Epidemic  of  Cholera. 
By  Benjamin  Lee,  M.  D.,  Philadelphia.  [Reprinted  from  the 
Medical  News.] 

Responsibility  of  the  National  and  State  Governments  for 
the  Protection  of  the  Purity  of  the  Water  Supplies.  By  Benja- 
min Lee,  M.  D.,  Philadelphia.  [Reprinted  from  the  Journal  of 
the  American  Medical  Association.] 

On  the  Necessity  of  Amputation  of  the  Cervix  Uteri  in  a 
Certain  Class  of  Cases  of  Laceration.  By  -J.  W.  Hyde,  M.  D., 
Brooklyn.    [Reprinted  from  the  Brooklyn  Medical  Journal.] 

The  Structures  in  the  Mesosalpinx:  their  Normal  and  Patho- 
logical Anatomy.  By  J.  W.  Ballantyne,  M.  D.,  F.  R.  0.  P.  E., 
etc.,  and  J.  D.  Williams,  M.  D.,  etc.  Edinburgh :  Oliver  & 
Boyd,  1893.    Pp.  7  to  51. 

On  the  Relation  of  Eczema  to  Disturbances  of  the  Nervous 
System.  By  L.  Duncan  Bulkley,  A.  M.,  M.  D.,  New  York.  [Re- 
printed from  the  Medical  News.] 

The  Internal  Treatment  of  Lupus  Erythematosus  with  Phos- 
phorus. By  L.  Duncan  Bulkley,  A.  M.,  M.  D.,  New  York.  [Re- 
printed from  the  American  Journal  of  the  Medical  Sciences.] 

Clinical  Study  and  Analysis  of  One  Thousand  Cases  of 
Psoriasis.  By  L.  Duncan  Bulkley,  A.  M.,  M.  D.,  New  York. 
[Reprinted  from  the  Maryland  Medical  Journal.] 

Free  Incision  of  Ostitis  of  Hip,  and  Closure  without  Drain- 
age. By  H.  Augustus  Wilson,  M.  D.,  Philadelphia.  [Reprinted 
from  the  Transactions  of  the  Philadelphia  County  Medical  So- 
ciety.] 

Practical  Details  in  the  Preparation  of  Plaster-of-Paris 
Bandages.  By  H.  Augustus  Wilson,  M.  D.,  Philadelphia.  [Re- 
printed from  the  Philadelphia  Polyclinic] 

A  Clinical  Lecture  on  the  Prevention  of  Idiopathic  Rotary 
Lateral  Curvature  of  the  Spine.  By  H.  Augustus  Wilson, 
M.  D.,  Philadelphia.  [Reprinted  from  the  Annals  of  Gyne- 
cology and  Peed ia try.] 

The  Twentieth  Regular  Report  of  the  Medical  and  Surgical 
Staff  of  St.  Francis  Hospital,  Jersey  City,  N.  J.  For  the  Year 
1892. 

Annual  Address  before  the  State  Board  of  Health  of  Penn- 
sylvania.   By  Samuel  G.  Dixon,  M.  D. 

Thirty-second  Annual  Report  of  the  Cincinnati  Hospital  to 
the  Mayor  of  Cincinnati,  for  the  Fiscal  Year  ending  December 
31, 1892. 

Fifteenth  Annual  Report  of  the  State  Board  of  Health  of 
the  State  of  Connecticut,  for  the  Seven  Months  ending  June 
30,  1892,  with  the  Registration  Report  for  1891  relating  to 
Births,  Marriages,  Deaths,  and  Divorces. 

Transactions  of  the  American  Paediatric  Society,  Fourth 
Session.  Held  at  Boston,  Mass.,  May  2,  3,  and  4,  1892.  Edited 
by  William  Perry  Watson,  A.  M.,  M.  D.,  Recorder.   Volume  IV. 

The  Johns  Hopkins  Hosjjital  Reports.  Report  in  Pathology, 
III.    Volume  III.    Nos.  4,  5,  G. 

Thirty-fourth  Annual  Report,  Buffalo  General  Hospital. 
For  the  Year  1892. 

Die  Berufskrankheiten  der  Porcellanarbeiter.  Von  Dr. 
Theodor  Sommerfeld  (Berlin).  [Sonder- Abdruck  aus  der  Deut- 
schen  Vierteljahrsschrift  far  iiflentliche  Oesvndheitspjlege.] 

The  Creation  of  God.  By  Dr.  Jacol)  llartmann,  New  York. 
New  York:  The  Truth  Seeker  Company,  1893.  Pp.  viii-9  to 
432. 


On  Some  Fallacies  inherent  in  the  Parasitic  Theories  of  the 
.Etiology  of  Carcinoma.  By  James  P.  Warbasse,  M.  D.,  of 
Brooklyn.    [Reprinted  from  the  Annals  of  Surgery.] 

How  to  operate  for  Hsemorrhoids.  A  Clinical  Lecture  on 
Diseases  of  the  Rectum,  delivered  at  the  New  York  Post-gradu- 
ate Hospital.  By  Charles  B.  Kelsey,  M.  D.  [Reprinted  from 
the  Therapeutic  Gazette.] 

Report  of  a  Hundred  Cases  of  Ether  Anaesthesia  by  Clover's 
Inhaler.  By  G.  Gordon  Campbell,  B.  Sc.,  M.  D.  [Reprinted 
from  the  Montreal  Medical  Journal.] 

Certain  Problems  in  Abdominal  Surgery,  based  on  One 
Hundred  Celiotomies  done  at  the  Kensington  Hospital  for 
Women.  By  Charles  P.  Noble,  M.  D.,  Philadelphia.  [Reprint- 
ed from  the  Transactions  of  the  Philadelphia  County  Medical 
Society.] 

Symphysiotomy  versus  its  Substitutes;  with  the  Report  of  a 
Case  of  Symphysiotomy.  By  Charles  P.  Noble,  M.  D  ,  Phila- 
delphia.   [Reprinted  from  the  Medical  News.] 

Early  Diagnosis  and  Operation  in  Cancer  of  the  Uterus.  By 
Charles  P.  Noble,  M.  D.,  Philadelphia.  [Reprinted  from  the 
American  Gyncecological  Journal.] 

Case  of  True  Pelvic  Abscess.  By  Charles  P.  Noble,  M.  D., 
Philadelphia.  [Reprinted  from  the  Annals  of  Gynecology  and 
Pa'diatry.] 

Report  of  a  Successful  Elective  Caesarean  Section.  By 
Charles  P.  Noble,  M.  D.,  Philadelphia.  [Reprinted  from  the 
Annals  of  Gynmcology  and  Pediatry.] 

Vaginal  Hysterectomy  for  Cancer,  with  a  Report  of  Four 
Cases.  By  Charles  P.  Noble,  M.  D.,  Philadelphia.  [Reprinted 
from  the  Annals  of  Gynecology  and  Pediatry.] 

The  Cassarean  Section  and  its  Substitutes.  By  Charles  P. 
Noble,  M.  D.,  Philadelphia.  [Reprinted  from  the  American 
Journal  of  Ol/stetrics.] 

Metatarsalgia  (Morton's  Painful  Affection  of  the  Foot),  with 
an  Account  of  Six  Cases  cured  by  Operation.  By  Thomas  S. 
K.  Morton,  M.  D.,  Philadelphia.  [Reprinted  from  the  Transac- 
tions of  the  Philadelphia  Academy  of  Surgery.] 

Morphologic  esth^^tique.  Division  t6trapartite  du  squelette, 
th6orie  cardinale  de  I'organisme.  Par  Wallace  Wood,  M.  D., 
de  New  York. 


^  i  s  c  c  1 1  a  n  g . 


Metatarsalgia. — At  a  meeting  of  the  Philadelphia  Academy  of  Sur- 
gery held  oil  March  6th  Dr.  Thomas  S.  K.  Morton  read  a  paper  of 
which  the  following  is  the  substance  : 

The  affection  that  has  come  to  be  best  known  as  "  Morton's  painful 
atfeetion  of  the  foot,"  or  "  Morton's  toe,"  was  first  described  and  a 
method  of  certain  cure  presented  by  Dr.  Thomas  G.  Jlorton,  of  Phila- 
delphia, in  IS'TG,  under  the  title  of  A  Peculiar  Painful  Aft'eetion  of  the 
Fourtli  Metatarso-phalaiigeal  Articulation.*  In  subsequent  publications  f 
he  has  confirmed  his  views  relative  to  cause  and  treatment,  and  reported 
large  numbers  of  cases. 

The  disease  under  consideration  may  be  described  as  a  painful 
affection  of  the  plantar  digital  nerves,  directly  caused  by  pressure  upon 
or  pinching  of  them  by  certain  portions  of  the  metatarso-phalangeal 
articulations — especially  the  fourth. 

The  reason  for  the  fourth  toe  being  the  almost  invariable  seat  of 
origin  of  the  train  of  painful  and  neurotic  symptoms  to  be  described  is 
ascribed  to  anatomical  causes  by  Morton  in  the  following  language : 

*  American  Journal  of  the  Medical  Sciences!,  January,  18V6. 
f  Surgery  in  the  Pennsylvaiiia  Hospital,  1880,  p.  107.  Philadelphia 
Medical  Times,  October  2,  1886. 


568 


MISCELLANY. 


[N.  Y.  Med.  Jodr., 


"  The  occurrence  of  neuraln;i;i  may  be  uudeistood  l)y  a  reference  to 
the  anatomy  of  the  parts.  The  metatarso-phalangeal  joints  of  the  first) 
.'^econd,  and  tliird  toes  are  found  on  ahnost  a  direct  line  with  each  otlier, 
wliile  the  head  of  the  fourth  metatarsal  is  from  one  eighth  to  one 
fourth  of  an  inch  behind  the  head  of  the  third,  and  'the  head  of  the 
fifth  is  from  three  eighths  to  half  an  inch  behind  the  head  of  the 
fourth ;  the  joint  of  the  third,  therefore,  is  slightly  in  advance  of  the 
joint  of  the  fourth,  and  the  joint  of  the  fifth  is  considerably  behind  the 
joint  of  the  fourth. 

"  The  fifth  metatarsal  joint  is  so  much  posterior  to  the  fourth  that 
the  base  of  the  first  phalanx  of  the  little  toe  is  brought  on  a  line  with 
the  head  and  neck  of  the  fourth  metatarsal,  the  head  of  the  fifth  meta- 
tarsal being  opposed  to  the  neck  of  the  fourth. 

"  On  account  of  the  character  of  the  peculiar  tarsal  articulation, 
there  is  very  slight  lateral  motion  in  the  first  three  metatarsal  bones. 
The  fourth  has  greater  mobility,  the  fifth  still  more  than  the  fourth, 
and  in  this  respect  it  resembles  the  fifth  metacarpal.  Lateral  pressure 
brings  the  head  of  the  fifth  metatarsal  and  the  phalanx  of  the  little  toe 
into  direct  contact  with  the  licad  and  neck  of  tlic  fourth,  »H'fiifai:iiil,  and 
to  some  extent  the  extremity  of  tlie  fifth  metatarsal  rolls  above  and 
under  the  fourth  metatarsal. 

"  The  mechanism  of  the  affection  now  becomes  apparent  when  we 
consider  the  nerve  supply  of  the  parts.  The  branches  of  the  external 
plantar  nerve  are  fully  distributed  to  the  little  toe  and  to  the  outer  side 
of  the  fourth ;  there  are  also  numerous  branches  of  this  nerve  deeply 
lodged  in  between  these  toes,  and  they  are  liable  not  only  to  be  unduly 
compressed,  but  pinched  by  a  sudden  twist  of  the  anterior  part  of  the 
foot.  Any  foot  movement  which  may  suddenly  displace  the  toes,  when 
confined  in  a  shoe,  may  induce  an  attack  of  this  neuralgia.  In  some 
cases  no  abnormity  or  other  specific  cause  for  the  disease  has  been 
detected." 

This  explanation  undoubtedly  will  account  for  the  great  majority  of 
cases,  and  perhaps  all  could  be  ascribed  to  pinching  of  the  nerves  be- 
tween the  metacarpo-phalangeal  articulation.  Yet  there  have  been  re- 
ported a  few  cases  where  the  transverse  metatarsal  ligament  has  ap- 
peared to  be  lax  or  ruptured,  thus  permitting  the  metatarsal  heads  to 
descend  upon  the  nerves.  Auguste  Poullosson,  of  Lyons,  in  1889,* 
after  reporting  a  t3'pical  case,  says  that  "  the  cause  of  the  affection  is  evi- 
dently a  certain  laxity  of  the  tran verse  metatarsal  ligament,  w  hich  permits 
partial  infraction  of  the  arch  formed  by  the  heads  of  the  five  metatarsal 
bones,  one  of  the  middle  ones,  probably  the  third,  becoming  dislocated 
downward  and  compressing  the  nerves  running  along  each  side  of  it 
against  the  heads  of  the  neighboring  bones." 

L.  G.  Guthrie,f  in  writing  of  metatarsal  neuralgia,  states  his  belief 
that  "under  the  influence  of  [jrplonged  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." 

In  reference  to  the  supposed  dislocations  above  mentioned  Morton 
says : 

"  The  dislocation  referred  to  is  not  a  true  dislocation,  but  is  simply 
a  twist  of  the  toe,  and  a  violent  spasmodic  condition  of  the  muscles  of 
the  toe  incident  to  the  intense  pain,  siniidating  a  dislocation,  which,  when 
the  toe  is  compressed  laterally  and  in  its  rolling  between  the  third  and 
fifth  suddenly,  presses  upon  and  pinches  the  underlying  plantar-nerve 
branch." 

Edward  F.  Griin,|  himself  a  sufferer  from  the  affection,  believes 
that  the  pain  results  from  descent  of  the  tarsal  arch,  which  is  accom- 
])anied  by  lengthening  of  the  foot  and  spreading  to  the  outer  side,  so 
that  "  where  the  weight  comes  on  the  member  the  foot  spreads  in- 
ordinately ;  the  boot  is  not  constructed  to  allow  for  so  much  spreading, 
and  a  frightful  cramping  pain  is  the  result,  causing  the  patient  to  re- 
move the  boot  without  icgard  to  place  or  circumstances — often  the 
most  inconvenient. 


*  Linin:/,  March  2,  188'.»,  p.  346. 

f  On  a  Form  of  Painful  Toe.  Lance/,  1892,  vol.  i,  ]).  (128. 
t  Lancet,  April  i>,  1889,  p.  101. 


E.  II.  Bradford*  states  that  the  results  of  treatment  in  these  cases, 
as  well  as  tlie  symptoms  and  locali/.ation  of  the  point  of  severest  pain, 
make  him  agree  with  Morton  in  believing  the  affection  to  be  originated 
by  pinching  of  the  metatarsal  nerve,  rather  than  to  flattening  of  the 
tarsal  arch,  as  suggested  by  Poullosson.  In  none  of  his  thirteen  cases 
was  any  degree  of  flat  foot  present. 

In  a  large  number  of  cases  seen  by  me,  in  addition  to  those  herein 
reported,  it  has  not  been  possible  to  demonstrate  any  laxity  of  the 
metatarsal  ligaments,  and,  while  in  a  few  the  pain  was  referred  to  other 
of  the  metatarso  phalangeal  joints  than  the  fourth,  yet  upon  careful 
mani|)ulation  it  was  always  found  that  the  pain  was  reflected  from  the 
fourth  to  the  other  joints.  It  must  be  conceded,  of  course,  that  laxity 
or  rupture  of  the  transverse  ligament  would  predispose  to  injury  of  the 
nerves  at  the  fourth  joint  by  permitting  greater  motion  of  the  overlap- 
ping bony  points  in  that  situation.  However,  while  the  exact  aetiology 
of  the  affection  is  of  great  scientific  interest,  clinically  it  is  of  small  ac- 
count, as  excision  of  the  fourth  metatarso  phalangeal  articulation,  as 
originally  proposed  by  Morton,  or  amputation  of  the  fourth  toe,  includ- 
ing the  corresi)onding  metatarsal  head,  invariably  has  secured  an  al)so- 
lute  and  permanent  cure.  No  dissections  of  the  diseased  regions  have 
yet  been  pos.-^ible,  nor  have  the  nerves  been  in  any  case  excised  so  that 
microscopical  examination  could  be  made.  I  have  carefully  examined  a 
number  of  the  joints  that  have  been  removed  for  the  cure  of  the  affec- 
tion, and  in  no  instance  have  been  able  to  prove  any  anomaly  or  disease. 

Metatarsalgia  is,  in  its  lesser  degi  ees,  a  very  common  disease.  Al- 
most every  one  has  suffered  more  or  less  at  times  from  neuralgic  twinges 
radiating  from  the  joint  in  question.  These  mild  cases  occasionally  de- 
velop into  the  more  severe  forms.  In  them  occasional  attacks  of  pain 
are  often  followed  by  periods  of  complete  immunity. 

Morton  made  extended  jmiuirics  among  retail  shoe  dealers  and  found 
"  that  this  peculiar  condition  had  not  only  been  f  retjuently  recognized  by 
them,  but  that  it  is  also  considered  to  be  quite  common.  Almost  every 
intelligent  shoe  retailer  has  seen  a  number  of  persons  to  whom  this  dis- 
ease has  been  a  source  of  frequent  suffering,  and  who  believe  their 
malady  to  be  beyond  relief  by  medical  art ;  indeed,  it  would  seem  that 
in  some  of  the  most  severe  of  the  cases  it  has  been  found  impossible  to 
obtain  the  serious  consideration  of  their  condition  by  their  medical  at- 
tendants." 

So  recently  as  1891  Bradford  f  has  written: 

"  It  is  somewhat  singular  that  an  affection  that  is  not  infi'eqvient  in 
these  days  of  thorough  investigation  of  all  ailments  should  have  at- 
tracted but  little  attention,  either  in  the  researches  of  surgeons  or  of 
neurologists.  The  cases  are  so  usually  classed  among  the  ill-defined 
hysterical  or  nervous  affections,  and  not  thoroughly  investigated ;  or 
they  are  deemed  to  be  gouty,  as,  in  the  minds  of  many  practitioners, 
are  frequently  all  affections  of  the  toes." 

The  disease  has  not  been  observed  before  adolescence.  Women 
are  certainly  more  pi'edisposed  than  are  men,  and  its  occurrence  in  the 
former  sex  I  should  judge  to  be  almost  twice  as  frequent  as  in  the  lat- 
ter. One  foot  is  most  usually  involved,  especially  in  those  cases  appar- 
ently taking  origin  from  an  injury.  But  very  frequently  one  foot  is 
affected  to  an  almost  unbearable  degree,  while  its  fellow  is  but  slightly 
involved.  Neither  right  nor  left  foot  appears  to  be  most  liable  to  in- 
volvement unless  one  or  the  other  is  constantly  subjected  to  a  motion, 
as  in  running  certain  sewing  machines,  looms,  lathes,  etc.,  while  the 
other  is  not  employed.  In  this  case,  as  in  one  of  my  own,  the  pain  de- 
veloped in  the  foot  so  employed.  When  both  feet  become  simultane- 
ously affected  the  cause  will  often  be  found  in  ill-fitting  or  tight  shoes. 
Middle  life  is  the  period  at  which  the  disease  is  most  apt  to  develop  or 
to  become  severe.  The  aged  are  by  no  means  exempt,  although  in 
them  more  purely  gouty  or  neuralgic  forms  are  prone  to  occur,  and  per- 
sons at  any  age,  so  predisposed,  appear  to  be  much  more  liable  to  the 
affecti(m — idiopathic  or  traumatic— than  are  others. 

The  influence  of  heredity  is  very  marked.  I  know  of  several  fami- 
lies in  which  a  nvmiber  of  persons,  mainly  confined  to  the  female  sex, 
are  similarly  affected.    It  is  interesting  to  note  that  in  these  instances 

*  Metatarsal  Neuralgia,  or  Morton's  Affection  of  the  Foot.  Boston 
Med.  and  Burg.  Journal,  1891,  vol.  ii,  p.  .'52. 
•)•  Loc.  cit. 


May  20,  189;5.J 


MISCELLANY. 


569 


some  cases  have  aiiseu  from  twists  or  sprains  of  the  foot,  and  otliers 
apparently  idiopathically. 

The  exciting  or  immediate  cause  of  metatarsalgia  is  usually  excess- 
ive or  unusual  exercise  of  the  feet  while  confined  in  new,  tight,  or  ill- 
fitting  shoes,  as  in  walking  over  rough  surfaces  (mountain  climbing), 
dancing,  playing  lawn  tennis,  etc.,  or  in  changing  from  a  firm-soled 
shoe  to  one  that  permits  great  motion  of  the  metatarsal  arch.  When 
the  heads  of  the  metatarsal  l)ones  are  rigidly  held  in  contact  by  a  tight 
shoe  it  is  reasonable  to  believe  that  a  very  slight  twist  or  wrench  of  the 
foot  would  bring  great  pressure  to  bear  upon  the  sensitive  branches  of 
the  digital  nerves  distributed  upon  and  about  them,  and,  particularly  in 
those  predisposed  thereto,  bring  about  a  neuralgic  and  even  neuritic 
condition.  This  once  set  up,  and  the  nerves  having  become  sensitive, 
swollen,  or  inflamed,  ever  so  slight  repetitions  of  the  pressure  or  bruis- 
ing are  capable  of  originatmg  the  most  agonizing  suffering.  Later, 
continuous  or  fre(iuently  recurring  attacks  of  this  pain,  or  actual  ascent 
of  neuritis,  commence  reflex  contractions  and  other  neurotic  complica- 
tions, perhaps  of  the  gravest  type,  as  witness  in  Case  I  of  my  series, 
where  the  patient  had  become  bedridden  and  severely  neurasthenic. 

So  far  as  relates  to  symptomatology,  I  shall  depend  upon  quoting  a 
few  more  or  less  typical  cases  from  the  literature  of  the  subject  and 
upon  the  histories  of  my  own  operative  cases,  but  may  here  mention 
that  I  regard  the  imperative  necessity  of  removing  the  shoe,  regardless  of 
surroundings,  when  a  paroxysm  comes  on,  as  a  pathognomonic  symp- 
tom of  the  disease.  It  may  also  be  said  that  no  evidence  of  the  disease 
can  usiuilly  be  felt  or  seen,  except  that  the  parts  are  often  of  a  bluish 
tint  and  cold,  from  venous  stasis,  and  have  a  tendency  to  profuse  i)er- 
spiration. 

[The  author  then  related  the  histories  of  six  cases,  and  proceeded 
as  follows :] 

Morton  also  reports  the  following  from  another  medical  friend : 

"  For  several  years  previous  to  1864  I  had  been  subject  to  occa- 
sional dislocations  of  a  relaxed  joint  in  the  fourth  toe  of  my  right  foot. 
They  had  always  occurred  in  walking,  and  the  symptoms  were  perfectly 
distinct;  the  reduction,  which  was  usually  effected  without  diliicultv, 
by  simply  '  working '  the  toe,  was  equally  unmistakable. 

"  In  the  summer  of  that  year  I  was  climbing  a  mountain,  when  the 
joint  became  displaced ;  and,  as  it  would  speedily  have  slipped  out 
again  if  reduced,  I  allowed  it  to  remain  luxated  until  I  had  finished  the 
ascent  and  returned  to  the  base,  when  the  pain  was  so  great  as  to  make 
it  necessary  for  me  to  ride  home.  After  several  hours  of  suffering,  the 
joint  gradually  resumed  its  normal  state. 

"  Since  that  time  I  do  not  remember  that  the  luxation  has  ever 
taken  place  ;  but  I  have  had  many  attacks  of  neuralgic  pain  in  the  part, 
coming  on  generally  after  exercise,  but  sometimes  after  sitting  in  one 
position,  as  in  my  carriage.  Often  exercise  does  not  induce  it.  Heat, 
as  from  the  pavements  or  the  sand  in  summer,  is  a  much  more  frequent 
cause.  It  begins  gradually,  and  sometimes  wears  away  in  the  same 
manner,  but  sometimes  vanishes  suddenly,  as  if  by  magic,  without  the 
use  of  any  means  of  relief.  The  pressure  of  a  boot  always  aggravates 
it ;  but  it  has  attacked  me  while  in  bed  at  night.  Diversion  of  the  mind 
will  often  allay  it,  but  it  sometimes  comes  on  again  afterward  with  far 
greater  severity. 

"In  1869,  while  spending  most  of  the  summer  at  Atlantic  City,  I 
suffered  more  from  this  trouble  than  ever  before  or  since.  It  would 
then  often  come  on  at  night,  after  a  day  in  town ;  and  once  or  twice 
the  attacks  lasted  more  than  twenty-four  hours.  So  great  was  the  an- 
noyance from  it  that  I  proposed  amputation  of  the  toe  to  a  surgical 
friend,  but  he  advised  me  against  it.  Since  then  it  has  been  much  less 
troublesome,  though  I  have  sometimes  had  it  more  or  less  every  day 
for  a  week. 

"  Deep  pressure  over  the  metatarso-phalangeal  joint  is  painful,  but 
does  not  bring  on  an  attack  unless  long  continued.  Cold  has  given  me 
more  effectual  relief  than  any  other  remedy  1  have  tried." 

[The  histories  of  three  of  Dr.  Thomas  (}.  Morton's  cases  were  then 
quoted,  and  the  author  contiiuied  as  follows :] 

Charles  K.  Mills,*  in  a  lecture  upon  Pain  in  the  Feet,  relates  the  his- 


*  Journal  of  Nervous  and  Modal  Disease,  vol.  xv,  p.  4. 


toryof  a  typical  case  that  was  entirely  relieved  by  the  operation  of  Mor- 
ton. A  woman,  in  jumping  upon  rocks,  twisted  her  foot.  The  foot  ap- 
parently was  not  injured,  and  she  was  soon  about  as  usual.  During  the 
next  two  3-ears,  at  intervals  of  from  two  to  eight  weeks,  a  peculiar  pain 
in  the  foot  would  develop  that  would  last  two  or  three  days.  Two  years 
later  she  injured  the  foot  again  in  the  same  manner.  After  this  the 
pain  was  seldom  absent  more  than  a  few  days,  and  each  recurring  at- 
tack was  of  increased  violence.  Again,  two  years  later,  the  pain  be- 
came almost  constant.  The  pain  was  a  dull,  heavy,  sickening  ache, 
from  the  foot  to  the  hip,  and  with  a  sharp  pain  through  the  foot.  At 
times  the  ache  would  be  limited  to  the  foot,  but  the  sharp  pain  was 
there  constantly.  Arising  in  the  morning,  the  patient  could  not  put  her 
weight  upon  the  foot  until  she  had  taken  hold  of  it  suddenly  from  the 
top  and  pressed  it  hard  together,  and  held  it  in  both  hands  with  all  her 
strength  for  some  minutes.  After  exhausting  every  known  local  and 
general  remedy,  the  fourth  metatarso-phalangeal  articulation  was  ex- 
cised. The  patient  subsequently  slowly  became  free  of  every  vestige  of 
the  former  jjain,  and  was  entirely  restored  to  health. 

Poullosson  *  describes  an  instance  w  here  a  medical  man,  twenty-nine 
years  of  age,  had  suffered  from  this  affection  for  some  years.  It  gave 
no  trouble  when  the  foot  was  at  rest  and  without  a  shoe,  but  was  usually 
brought  on  by  wearing  boots  and  walking  a  good  deal.  It  was  much 
more  likely  to  occur  when  going  down  than  in  going  up  hill.  The  pain 
came  on  suddenly,  a  feeling  of  something  having  given  way  in  the  feet 
accompanying  the  onset,  together  with  a  kind  of  grating  sensation. 
After  this  the  patient  walked  lame,  for  all  pressure  of  the  anterior  por- 
tion of  the  sole  of  the  foot  to  the  ground  was  painful.  If  walking  was 
persisted  in,  the  pain  increased,  till  in  a  few  moments  it  attained  its  max- 
imum, rendering  all  further  attempts  at  locomotion  impossible. 

Edmund  Roughton  \  has  reported  the  following  case  : 

"  A  medical  man,  aged  thirty-three  years,  complained  that  for  eight- 
een months  he  had  suffered  from  attacks  of  burning  pain  in  the  fore 
part  of  the  sole  of  the  left  foot.  The  pain  occurred  several  times  a 
week,  and  was  usually  brought  on  by  prolonged  standing  or  by  walking 
any  considerable  distance,  and  w  as  so  severe  as  sometimes  to  cause  him 
to  remove  his  boot  and  grasp  the  sole  of  his  foot  with  his  hand.  On  ex- 
amining the  foot,  I  found  that  the  transverse  arch  formed  hy  the  heads 
of  the  metatarsal  bones  had  sunk,  so  that  a  distinct  convexity  replaced 
the  concavity  normally  found  in  this  situation. 

"  In  this  case  the  patient  had  increased  considerably  in  weight  dur- 
ing the  period  of  development  of  the  symptoms,  and  his  transverse 
metatarsal  ligament  had  presumably  been  unequal  to  the  increased 
strain." 

E.  H.  Bradford  :j:  has  reported  a  series  of  thirteen  cases,  none  of 
which,  however,  were  severe  enough  to  demand  operation.  In  these  the 
symptoms  were  not  in  a  single  instance  the  result  of  traumatism,  nor 
was  any  evidence  of  dislocation  or  other  local  change  observable.  These 
patients  were  all  in  enjoyment  of  excellent  health,  and  in  none  were 
there  evidences  of  gout  or  rheumatism. 

Treatment. — The  less  severe  forms  of  metatarsalgia  may  often  be 
prevented  from  running  into  the  more  serious  types  by  proper  shoe  con- 
struction or  by  wearing  a  narrow  flannel  bandage  about  the  ball  of  the 
foot.  Morton,  whose  suggestion  the  latter  is,  directs  that  the  bandage 
be  two  inches  wide  and  long  enough  to  wrap  neatly  and  firmly  about 
the  metatarsus  some  five  or  six  times.  The  end  is  pinned,  and  the 
stocking  drawn  over.  This  has  given  marked  relief  in  a  number  of 
cases. 

The  shoes  for  persons  suffering  from  this  disease  should  be  tirra- 
soled,  make  no  lateral  pressure  upon  the  metatarsus,  yet  have  the  in- 
step tight  enough  to  prevent  the  foot  slipping  forward.  The  great  ob- 
ject of  the  shoemaker  should  be  to  prevent  pressure,  either  lateral  or 
antero-posterior,  upon  the  metatai>al  arch,  and  also  to  prevent  any  roll- 
ing motion  of  the  outer  metatarsal  heads  up<m  their  fellows.  A  broad, 
rigid  sole  w^ould  appear  to  best  fulfill  this  last  indication.  Hradford 
l)roposes  the  use  of  digitated  stockings  in  these  cases,  with  a  view  of 


*  Loe.  cit. 

•f-  Lancet,  March  16,  1S8!),  p.  553. 
I  Loc.  cit. 


570 


MISCELLANY. 


[N.  Y.  Med.  Joue., 


kcepiiif;  tlie  toes  farther  apart.  As  the  foot  spreads  when  the  weight 
of  the  body  is  thrown  \\\w\i  the  member,  it  is  apparent  that  the  indi- 
vidual should  be  standing  when  the  measurements  for  shoes  are  made, 
as  has  been  advised  by  Griin. 

The  use  of  various  pads  in  the  shoe  and  about  the  toes,  also  such 
measures  as  the  hollowing  out  of  cavities  in  the  sole  opposite  one  or 
more  of  the  metatarsal  heads,  have  been  tried,  but  invariably  found  un- 
satisfactory. A  variety  of  the  affection  calling  for  so  much  attention 
to  secure  comfort  would  clearly  demand  the  certain  cure  to  Ix'  afforded 
by  operation. 

In  persons  where  rheumatic  or  gouty  diathesis  may  be  suspected 
appropriate  remedies  for  those  disorders  should  be  given  a  thorough 
trial  before  operative  measures  are  resorted  to.  But  when  the  condi- 
tion is  entirely  of  local  mechanical  origin  the  employment  of  general  or 
local  medicinal  agents  is  useless.  On  the  other  hand,  prolonged  rest  in 
l)ed  will  benefit  all  cases  more  or  less,  and  occasionally  secure  relief  for 
long  periods,  or  even  permanently  cure  the  milder  phases  of  the  dis- 
order. 

Operative  treatment  should  be  limited  to  excision  of  the  metatarso- 
phalangeal articulation  from  which  the  neuralgia  radiates,  or  perhaps 
to  am])Utation  of  the  corresponding  toe  above  the  joint,  as  have  been 
recommended  by  Morton  and  indorsed  by  other  writers.  These  pro- 
cedures are  among  the  safest  and  simplest  in  surgery.  Of  amputation 
of  the  toe,  together  with  its  metatarsal  head,  nothing  more  need  be  said 
than  that  by  this  measure  the  possibility  of  subsequent  trouble  arising 
from  a  tendency  of  the  toe  to  retract  and  ride  above  or  below  its  fellows 
is  e.xcluded.  However,  this  heretofore  occasionally  troublesome  seijuel 
can  be  avoided  by  dividing  the  extensor  and  flexor  tendons  while  ex- 
cising the  joint,  as  I  have  done  in  five  cases  with  most  satisfactory 
results. 

Operation. — Primary  union  should  l)e  aimed  at.  To  secure  this  the 
foot  must  be  scrupulously  cleansed.  The  nails  should  '  be  trimmed 
short.  Then  soap,  water,  and  nail-brush  should  be  liberally  applied. 
Following  this,  the  member  should  be  soaked  in  a  two-and-a-half-per- 
cent, carbolic-acid  solution,  and  finally  dressed  in  a  moist  carbolic  dress- 
ing of  the  same  strength  until  the  surgeon  is  about  to  operate.  Where 
the  foot  is  especially  foul  it  is  my  custom  to  finally  dip  it  into  a  satu- 
rated solution  of  permanganate  of  potash  until  colored  to  a  dark  ma- 
hogany hue,  and  then  transfer  it  to  a  saturated  solution  of  oxalic  acid 
■until  decolorized,  before  applying  the  temporary  dressing.  When  the 
surgeon  is  about  to  operate  the  temporary  dressing  is  removed  and  the 
parts  given  a  final  douche  with  l-to-1,000  sublimate  solution. 

A  vertical  incision  from  one  and  a  half  to  two  inches  long  is  made, 
beginnmg  over  the  proximal  interphalangeal  joint  and  extending  up- 
ward in  the  center  line  of  the  toe.*  The  extensor  tendon  now  comes 
into  view,  and  is  divided.  Another  stroke  of  the  knife  carries  the  in- 
cision through  its  entire  length  down  to  the  bone.  The  handle  of  the 
knife  or  other  moderately  Iiluut  implement  is  then  employed  to  separate 
the  tissues  from  the  upper  and  lateral  portions  of  the  joint.  Next  the 
blades  of  a  powerful  sharp-pointed,  narrow-bladed  cutting  pliers  are 
pushed  down  on  either  side  of  the  phalanx  immediately  below  its  base 
(hollow  of  the  blades  always  toward  the  articulation),  and  this  bone 
divided.  The  metatarsal  bone  is  then  similarly  divided  just  above  its 
head.  The  separated  joint  is  now  seized  by  bone  forceps  and  dissected 
away  from  any  remaining  attachments.  This  done,  the  flexor  tendons 
will  be  seen  lying  in  the  bottom  of  the  wound,  and  should  be  picked 
up  by  forceps  and  divided  with  scissors.  If  hemorrhage  is  severe  and 
not  controllable  by  moderate  compression  of  the  parts,  ligatures  should 
be  applied.  I  have  never  had  occasion  to  apply  a  ligature  in  this  op- 
eration, as  the  pressure  of  the  dressing  has  always  sufficed  to  control  any 
oozing  that  might  continue  after  the  sutures  had  been  applied.  The 
wounded  edges  are  next  to  be  approximated — no  drainage  being  re- 
quired if  asepsis  has  been  maintained — by  continuous  or  interrupted 
suture,  as  may  be  preferred.  A  gauze  and  cotton  dressing  is  finally 
applied  and  bound  firmly  on  with  a  wet  gauze  roller,  care  being  ob- 
served to  place  little  pads  of  the  gauze  in  such  positions  as  will  hold 
the  toe  in  its  proper  position  during  healing. 

*  This  joint  has  also  been  excised  through  an  incision  in  the  sole, 
but  the  method  is  objectionable  on  many  grounds. 


The  foot  should  be  kept  considerably  elevated  for  the  first  two  days, 
after  which  it  may  be  brought  to  the  level  of  the  bed.  I  prefer  ray 
cases  to  remain  in  bed  or  on  a  couch  until  the  fourth  or  fifth  day,  when 
they  may  be  permitted  to  sit  up  with  the  foot  resting  on  a  chair.  At 
the  end  of  a  week  the  sutuies  are  removed,  two  or  three  days  after 
which  the  patient  is  permitted  to  move  cautiously  around,  while  at  the 
termination  of  three  weeks  all  restraini  may  be  removed  and  a  finuly 
healed  wound  and  permanent  cure  confidently  expected.  No  siiecial 
form  of  shoe  or  i)articular  care  of  the  foot  is  afterward  requii-ed. 

In  case  sujypuration  should  arise  in  the  wound,  the  sutures  should 
be  at  once  removed,  the  wound  cavity  washed  out  with  full  strength 
peroxide-of-hydrogen  solution,  then  with  yiIoT)  corrosive-sublimate  solu- 
tion, and  gently  stuffed  with  iodoform  gauze,  all  of  which  should  be 
repeated  every  one  or  two  days  until  the  wound  closes  by  granulation. 

In  addition  to  the  references  given  in  the  text  the  following  may  be 
mentioned  to  complete  the  bibliography  of  the  subject : 

dross,  System  of  Surgery. 

Agnew's  Surgery. 

Erskine  Mason,  Am.  Joum.  of  the  Med.  Sri.,  October,  1877. 
Editorial,  N.  Y.  Med.  -Joum.,  Oct.  8,  189-2,  Morton's  Painful  Affec- 
tion of  the  Foot. 

Roswell  Park,  Med.  New.i,  1892,  vol.  ii,  p.  406,  Morton's  Affection 
of  the  Foot. 

Meade  V.  Kemper,  Virginia  Med.  Monthly,  vol.  viii,  p.  522,  Case 
of  Metatarsal  Neuralgia. 

In  the  discussion  Dr.  W.  W.  Keen  said  that  the  affection  had  not 
seemed  to  him  to  be  so  frequent.  He  had  seen  only  one  case — that  of 
a  lady  about  going  to  Brazil.  He  had  operated  five  yeais  before  on 
both  feet.  Since  then  she  had  been  able  to  walk  perfectly  well  and  to 
dance. 

Four  years  ago  the  speaker  had  had  an  attack  which  he  had  thought 
might  be  the  same.  This  attack  had  interested  him  in  connection  with 
the  diagnosis,  because  he  had  had  every  symptom  that  Dr.  Morton  had 
described.  The  attack  had  come  on  about  the  time  of  his  summer  holi- 
day, and  he  had  been  unable  to  walk  without  limping  from  the  excess- 
ive pain.  When  the  pain  came  on  he  was  compelled  to  go  to  his  room 
or  sit  down  where  he  happened  to  be  and  remove  the  shoe.  He  had  a 
pair  of  shoes  made  with  a  thicker  and  wider  sole  and  a  little  larger,  but 
without  relief.  When  he  came  home  he  was  tempted  to  have  the 
operation  done.  He,  however,  consulted  his  friend  Dr.  J.  C.  Wilson, 
who  suggested  a  gouty  origin  and  put  him  on  appropriate  treatment ; 
the  pain  disappeared,  and  he  had  been  perfectly  well  ever  since. 
He  mentioned  this  in  connection  with  the  diagnosis,  as  there  had  been 
the  pathognomonic  sign  of  having  to  sit  down  and  remove  the  shoe 
when  the  pain  came  on. 

Dr.  Thomas  G.  Morton  had  generally  found  the  disease  iu  one  foot, 
but  occasionally  in  both,  and  had  often  operated  on  both  feet  at  the 
same  sitting.  Now  and  then  he  had  amputated  the  toe  instead  of  resect- 
ing the  joint.  The  pain  in  many  cases  was  slight,  and  only  required  a 
proper  shoe  and  a  flannel  bandage  to  keep  the  toes  from  rolling ;  in 
others  nothing  except  an  operation  would  suffice.  In  regard  to  shoes, 
a  shoemaker  of  the  city  had  told  him  that  one  of  his  customers  had 
had  more  than  fifty  pairs,  hoping  in  each  new  pair  to  have  greater  re- 
lief. 

The  question  had  been  raised  as  to  whether  the  painful  nerve  might 
not  be  excised  instead  of  excising  the  joint  of  the  toe.  He  apprehended 
there  would  be  great  difficulty  in  finding  the  nerve,  and  unless  all  the 
soft  parts  surroimding  the  joint  were  removed,  some  branches  would 
remain ;  while  if  the  pain  was  due,  as  he  thought  it  was,  to  the  peculiar 
relation  of  the  fourth  joint  as  compared  with  the  third  and  the  fifth,  no 
treatment  except  joint  removal  would  answer. 

Professor  Virchow's  Welcome  Home. — The  British  Medieal  Jourmd 
for  April  2!)tli  pul)lishes  the  following  account  of  Professor  Rudolf  Vir- 
chow's welcome  at  the  first  meeting  of  the  Berlin  Medical  Society  (on 
April  19th)  after  his  return  from  his  visit  to  England  : 

"  On  his  entrance,  all  those  present  rose,  and  Dr.  Siegmund,  vice- 
president  of  the  society,  delivered  the  following  address  : 

"  Mucn-REVKiiKU  Pkksident  :  The  hmg  period  we  have  missed  you 
from  the  chair  has  been  for  you  one  of  the  richest  of  your  life.  A  great 


May  20,  1893.] 


MISCELLANY. 


571 


nation  lias  shown  you  its  ackno\vk'(l<;nicnt  and  reverence  to  an  extent 
and  with  an  enthusiasm  far  exceeding  all  homage  ever  rendered  to  a 
man  of  science.  Some  extolled  in  yow  the  teacher,  others  their  fellow- 
worker  in  the  most  diverse  scientific  fields.'  But  if  we  ask  what  was  it 
that  secured  you  your  exceptional  position  and  the  sympathy  of  all 
classes  of  society,  even  to  the  very  highest,  the  answer  nmst  be  that  it 
is  not  only  as  a  scientist  that  you  are  known  abroad  :  your  endeavor  to 
turn  every  advance  in  science  into  a  means  of  general  progress,  together 
with  the  manly  and  steadfast  manner  in  which  you  defended  what  you 
considered  to  be  right  and  useful,  have  gained  for  you  a  popularity  be- 
yond the  boundaries  of  our  empire.  No  nation  is  more  ready  to  ac- 
knowledge such  deeds  than  the  English,  which  as  regards  the  practical 
arrangement  of  life  serves  as  the  highest  model.  We  thank  the  Eng- 
lish nation  for  the  distinction  it  has  conferred  upon  you.  We  thank  you 
for  having  caused  the  part  taken  by  Germany  in  the  advance  of  science 
to  be  so  universally  acknowledged  ;  and  if  we  may  venture  to  add  a 
wish,  it  is  that  you  may  long  retain  the  {jualitics  in  which  you  excel  and 
the  strength  which  (loethe  called  the  '  endurance  of  the  North.' 

"  Professor  Virchow  replied  as  follows  :  Dear  Friend — Highly  Hon- 
ored Colleagues  :  I  must  confess  it  was  not  quite  necessary  that  you 
should,  by  this  unusual  reception,  continue  that  ovation  from  which  I 
have  oidy  just  freed  myself.  The  circumstances  which  made  my  recep- 
tion in  England  so  extraordinarily  warm  are  partly  to  be  traced  to  a  cer- 
tain indebtedness  on  my  side.  Many  years  since  some  of  the  learned 
bodies  in  England,  chiefly  both  the  older  universities,  expressed  to  me 
their  desire  to  bestow  on  me  some  special  honor,  and  invited  me  with 
that  view,  l)ut  I  withstood  these  requests  with  a  certain — I  might  say, 
perhaps,  not  quite  cointeous — firmness.  It  was  rather  difficult  for  me, 
but  I  may  say  that  this  kind  of  public  ceremony  is  not  quite  to  my  mind. 
This  time,  however,  I  could  not  refuse  it.  After  the  oldest  and  great- 
est of  the  scientific  bodies  of  England — the  Royal  Society — had  con- 
ferred this  gieat  honor  on  me,  and  conferred  it  in  absentia — a  very  un- 
usual thing — I  had  at  last  to  give  expression  to  that  feeling  of  gratitude 
which  indeed  stirred  me  deeply  ;  and  thus  I  went  at  last  also  to  Cam- 
bridge and  to  Oxford.  Anyhow,  you  now  see  me  before  you,  invested 
with  honors  of  a  rare  kind — as  Doctor  of  Civil  Laws  and  Doctor  of  Sci- 
ence, which  were  both  very  strange  titles  to  me.  In  one  respect,  how- 
ever, I  am  indeed  very  greatly  indebted  to  you  for  this  reception,  and 
that  is  that  you  have  told  me  through  your  chairman  that  you  wanted 
to  express  at  the  same  time  to  the  English  nation — we  may  almost  say 
so — at  least  to  the  English  learned  professions,  your  gratitude  for  the 
honor  rendered  to  one  of  your  compatriots.  I  have  indeed  looked  upon 
my  journey  to  England  as  a  kind  of  international  mission,  quite  as  much 
as  I  did  last  year  when  I  went  to  Russia.  I  have  always  been  of  the 
opinion  that  every  man  should  assist,  as  far  as  possible,  in  strengthen- 
ing the  cordial  relations  between  nations  by  means  of  his  own  personal 
influence  ;  that  I  have  succeeded  in  this  to  a  higher  degree  than  I  ever 
dared  to  hope  is  to  me  in  reality  the  greatest  gain  that  I  bring  home 
from  this  journey.  But  I  am  glad  to  see  that  you  also  acknowledge  this 
by  rendering  on  your  own  behalf  thanks  for  the  reception,  by  which, 
properly  speaking,  it  was  intended  to  honor  you  as  well,  for  in  bestow- 
ing honor  on  me  the  English,  in  reality,  wanted  to  bestow  it  on  Ger- 
many. This  was  intimated  to  me  on  several  occasions.  It  was  not  my 
own  person  alone,  it  was  German  science,  German  labor,  for  which  this 
acknowledgment  was  intended.  Gentlemen,  we  are  all  of  us  accus- 
tomed to  work  in  the  same  way,  and  perhaps  some  of  you  will  obtain  in 
future  something  similar.  Let  us  continue  to  work  assiduously.  So 
far  as  I  am  concerned,  I  am  glad  to  state  that  I  hope  my  strength  will 
still  last  long  enough  to  make  it  possible  that  you  should  still  now  and 
then  suffer  a  little  from  me." 

The  Association  of  American  Physicians. — The  eighth  annual  meet- 
ing will  be  held  in  the  Army  Medical  Museum  and  Library  Building  in 
Washington,  on  May  30th  and  31st  and  June  1st,  under  the  presidency 
of  Dr.  Alfred  L.  Loomis,  of  New  York,  besides  whose  address  the  pro- 
gramme gives  the  following : 

On  the  Course  and  Treatment  of  Certain  Uricmic  Symptoms,  by  Dr. 
Beverley  Robinson,  of  New  York  ;  The  Reaction  of  the  Urine  with 
Ether,  by  Dr.  A.  H.  Smith,  of  New  York ;  The  Detection  and  Signifi- 
cance of  Proteids  in  the  Urine,  by  Dr.  C.  W.  Purdy,  of  Chicago ;  The 


Piobable  Origin  and  Early  Symptoms  of  Certain  Chronic  Diseases  of 
the  Kidneys,  by  Dr.  C.  S.  Bond,  of  Richmond,  Ind. ;  A  Study  of  Addi- 
son's Disea.se  and  of  the  Adrenals,  by  Dr.  W.  (iilman  Thompson,  of 
New  York ;  Two  Cases  of  Cystin  Calculus,  by  Dr.  James  Tyson,  of 
Philadeljihia ;  On  a  Simple  Continued  Fever,  by  Dr.  G.  Baunigarten,  of 
St.  Louis ;  The  Treatment  of  Typhoid  Fever,  by  Dr.  S.  G.  Fisk,  of  Den- 
ver; Creasote  in  the  Treatment  of  Tuberculosis,  by  Dr.  J.  T.  Whit- 
taker,  of  Cincinnati ;  The  Intestinal  Origin  of  Chlorosis,  by  Dr.  F. 
Forchheimer,  of  Cincinnati;  Coffee  drinking  as  a  Frequent  Cause  of 
Disease,  by  Dr.  Norman  Bridge,  of  Los  Angeles ;  Experimental  Obser- 
vations concerning  the  Nature  of  Chorea,  by  Dr.  H.  C.  Wood,  of  Phila- 
delphia ;  Discussion  on  Myxedema  (referee.  Dr.  F.  P.  Kinnicutt,  of  New 
York ;  co-referees,  Dr.  James  J.  Putnam,  of  Boston,  and  Dr.  M.  Allen 
Starr,  of  New  York) ;  Report  of  a  Case  of  Myxoedema,  by  Dr.  W.  Gil- 
man  Thompson,  of  New  York  ;  Sporadic  Cretinism  in  the  United  States, 
by  Dr.  William  Osier,  of  Baltimore ;  Some  Problems  in  the  jEtiology 
and  Pathology  of  Texas  Cattle  Fever  and  their  Bearing  on  the  Com- 
parative Study  of  Protozoan  Diseases,  by  Dr.  Theobald  Smith,  of  Wash- 
ington ;  The  Prophylaxis  of  Cholera,  with  Special  Reference  to  Immu- 
nization, by  Dr.  E.  0.  Shakespeare,  of  Philadelphia ;  A  New  Pathogenic 
Bacillus,  by  Dr.  H.  C.  Ernst,  of  Jamaica  Plain,  Mass. ;  Experiments 
with  the  Bacillus  Diphtherias,  by  Dr.  A.  C.  Abbott,  of  Philadelphia ; 
Gonorrhooal  Myocarditis,  by  Dr.  W.  T.  Councilman,  of  Boston ;  The 
Parasitic  Nature  of  Cancer,  by  Dr.  Heneage  Gibbes,  of  Ann  Arbor, 
Mich. ;  Acute  Follicular  Tonsillitis,  by  Dr.  Starling  Ijoving,  of  Colum- 
bus ;  Sarcoma  of  the  Lung,  with  Specimen,  by  Dr.  D.  W.  Prentiss,  of 
Washington ;  The  Importance  of  Uterine  Displacements  in  the  Produc- 
tion of  Vonnting  during  the  Early  Stages  of  Pregnancy,  by  Dr.  G.  M. 
Garland,  of  Boston  ;  Uterine  Drainage  in  the  Several  Forms  of  Inflam- 
mation of  the  LTterus  and  its  Appendages,  by  Dr.  William  M.  Polk,  of 
New  York ;  Pulsating  Pleural  Effusions,  by  Dr.  James  C.  Wilson,  of 
Philadelphia;  Sul)phrenic  Abscess,  with  Special  Reference  to  Cases 
which  Simulate  Pneumothorax,  by  Dr.  A.  L.  Mason,  of  Boston ;  Sub- 
phrenic Abscess,  by  Dr.  S.  J.  Meltzer,  of  New  York ;  Two  Cases  of 
Diaphragmatic  Hernia,  by  Dr.  James  Tyson,  of  Philadelphia. 

The  American  Laryngological  Association  will  hold  its  fifteenth 
annual  congress  in  New  York  on  the  '22i\,  2od,  and  24th  inst.,  under 
the  presidency  of  Dr.  Morris  J.  Asch,  of  New  York.  The  sessions  will 
be  held  at  the  Academy  of  Medicine,  No.  17  West  Forty- third  Street. 
Besides  the  president's  address,  the  programme  gives  the  following 
titles : 

On  Spasmodic  Fixation  of  the  Vocal  Bands  in  or  beyond  the  Median 
Line,  by  Dr.  S.  Solis-Cohen,  of  Philadelphia;  A  Case  of  Complete 
Glottic  Spasm  in  an  Adult,  followed  by  Unconsciousness  and  Prolonged 
Drowsiness,  by  Dr.  W.  Peyre  Porcher,  of  Charleston ;  The  Withholding 
of  Statistics  in  Operations  for  the  Relief  of  Cancer  of  the  Throat,  by 
Dr.  D.  Bryson  Delavan,  of  New  York  ;  Arthritis  Deformans  of  the  Lar- 
3-nx,  by  Dr.  W.  E.  Casselberry,  of  Chicago ;  Recurrence  at  a  New  Site 
of  a  Larjnigeal  Growth  (Papilloma)  in  a  case  already  reported  under  the 
title  Evulsion  of  a  Laryngeal  Tumor  which  returned  Twenty-two  Years 
after  its  Removal  by  Laryngotomy,  by  Dr.  R.  P.  Lincoln,  of  New  York  ; 
Intubation  in  the  Adult,  by  Dr.  George  M.  Lefferts,  of  New  York ; 
Rhinitis  (Edematosa — Laryngitis  Hiemalis,  by  Dr.  J.  C.  Mulhall,  of  St. 
Louis ;  Two  Cases  of  Tuberculosis  of  the  Nose,  by  Dr.  John  W.  Farlow 
of  Boston ;  Remarks  on  the  Structure  of  (Edematous  Nasal  Polypi,  bv 
Dr.  Jonathan  Wright,  of  Brooklyn ;  The  Use  of  Ozone  in  Atrophic 
Catarrh,  by  Dr.  C.  C.  Rice,  of  New  York ;  The  Cautery  in  Uvulotomy, 
by  Dr.  T.  A.  DeBlois,  of  Boston ;  Salivary  Calculi,  with  Reports  of 
Cases,  by  Dr.  Clinton  Wagner,  of  New  York  ;  Buccal  Voice :  illus- 
trated by  the  Presentation  of  a  Patient  who  Phonates  without  a  Larynx 
and  without  the  Use  of  his  Lungs,  by  Dr.  J.  Solis-Cohen,  of  Philadel- 
phia ;  Remarks  on  Congenital  Defects  of  the  Face,  with  the  Exhibition 
of  a  Rare  Form  of  Cleft  Palate,  by  Dr.  Harrison  Allen,  of  Phdadeljihia  ; 
Aspergillus  Mycosis  of  the  Antrum  Maxillare,  by  Dr.  John  M.  Macken- 
zie, of  Baltimore ;  An  Improved  Method  of  draining  the  Antrum  of 
Ilighmore,  by  Dr.  George  W.  Major,  of  Montreal ;  On  souie  of  the 
Manifestations  of  Syphilis  of  the  Upper  Air-passages,  by  Dr.  J.  H. 
Bryan,  of  Washington  ;  A  Case  of  Sarcoma  of  the  Soft  Palate  illustrat- 
ing the  Degeneration  of  a  Benign  (Papilloma)  into  a  Malignant  Growth 


572 


MISCELLANY. 


[N.  Y.  Med.  Joub. 


wit)i  Specimen,  by  Dr.  W.  K.  Simpson,  of  New  Yorlv ;  also  a  discussion 
on  Diphtheria,  its  Prophyhixis  and  Treatment,  to  be  opened  by  Dr. 
JIulhall  and  Dr.  Robinson. 

Dr.  Dujardin-Beaumetz's  Treatment  of  Obesity. — "  For  tiie  treat- 
ment of  obesity  in  a  person  whose  heart  and  arteries  are  sound,"  says 
the  Zancefs  Paris  correspondent,  "  the  above-named  physician  recom- 
mends the  following  method  :  Every  morning  a  general  body-sponging 
with  hot  eau  de  Cologne  and  water,  followed  by  dry  rubbing  and  mas- 
sage. A  tumlilerful  of  purgative  water  is  then  administered.  At  the 
end  of  each  meal  a  dessertspoonful  of  the  following  solution  is  swal- 
lowed :  Fifteen  grammes  of  iodide  of  potassium  and  250  grammes  of 
water.  The  undermentioned  regimen  is  to  be  rigorously  observed : 
First  meal  at  8  a.  m.,  a  cup  of  chocolate  and  20  grammes  of  bread. 
Second  meal,  2  eggs,  or  100  grammes  of  meat;  100  grammes  of  green 
vegetables  or  salad ;  15  grammes  of  cheese,  a  little  fruit,  50  grammes 
of  bread,  a  glass  and  a  half  of  liquid  (a  light  white  wine  with  Vichy 
water).  Third  meal  at  *?  p.  m.,  no  soup,  100  grammes  of  meat,  100 
grammes  of  green  vegetables  or  salad,  15  grammes  of  cheese,  fruit, 
50  grammes  of  bread,  a  glass  and  a  half  of  liquid  (white  wine  with 
Vichy  water).  No  drmking  between  meals,  no  tea,  coffee,  cognac,  or 
other  alcoholic  beverage.    Plenty  of  exercise  in  the  open  air." 

The  Philadelphia  Society  of  Philosophy. — The  Gazette  midlcale  de 
Parix  putilishes  a  communication  from  the  University  of  Paris  to  the 
Philadelphia  Society  of  Philosophy,  on  the  occasion  of  the  society's 
centennial  festival,  which  may  be  translated  as  follows  :  "  The  Univer- 
sity of  Paris  takes  pleasure  in  saluting  your  society,  which  is  so  suc- 
cessfully cultivating  the  philosophical  sciences  in  a  country  that  Europe 
too  often  looks  upon  as  wholly  given  over  to  industrial  and  commercial 
affairs.  It  was  fitting  that  the  State  which  counted  among  its  citizens 
such  a  practical  philosopher  as  Franklin  should  hold  aloft  and  steady 
the  banner  of  philosophy  in  the  United  States  of  America.  France 
does  not  forget  that  Pennsylvania  sent  her  that  great  j)atriot,  who 
linked  your  young  nation  and  old  France  in  bonds  of  affection,  or  that 
it  was  on  the  outskirts  of  Philadelphia  that  La  Fayette,  in  his  first 
battle,  sealed  with  his  blood  that  nascent  and  imperishable  friendship. 
We  are  fond  of  remembering,  too,  that  Franklin  not  only  won  for  his 
country  the  sympathies  of  France,  but,  by  the  simple  dignity  of  his 
life,  by  his  words,  and  by  his  writings,  prepared  us  for  liberty  by  show- 
ing us  that  a  great  nation  could  govern  itself.  These  ineffaceable 
memories  assure  you,  gentlemen,  of  the  sincerity  of  our  wishes  for  your 
society  and  for  the  great  republic  ot  the  United  States  of  America." 

The  New  York  Academy  of  Medicine. — The  special  order  for  the 
meeting  of  Thursday  evening,  May  18  th,  was  a  paper  on  The  Organiza- 
tion and  Efiuipment  of  the  Division  of  Disinfection,  New  York  Health 
Department,  and  the  Method  of  Work,  by  Dr.  H.  M.  Biggs. 

At  the  next  meeting  of  the  Section  in  Laryngology  and  Rhinology, 
on  Wednesday  evening,  the  24th  inst.,  papers  are  to  be  read  as  follows : 
On  Internal  Massage  of  the  Nose,  by  Dr.  W.  Freudenthal ;  and  Tulier- 
culosis  of  the  Pharynx  and  Larynx,  by  Dr.  F.  S.  Crossfield,  of  Hart- 
ford, Conn.  Dr.  Phillips  will  show  a  new  electrical  head-illuminator, 
and  Dr.  F.  E.  Hopkins  will  give  the  history  of  an  unusual  case  of  tuber- 
culosis, and  show  the  larynx. 

The  late  Dr.  Charles  Carroll  Lee. — At  a  meeting  of  the  faculty  of 
the  New  York  Post-graduate  Medical  School,  held  May  12,  1893,  the 
following  resolutions  were  unanimously  adopted : 

"  The  directors  and  faculty  of  the  New  York  Post-graduate  Medical 
School  and  Hospital  wish  to  record  their  keen  sense  of  the  great  loss 
they  have  sustained  in  the  death  of  Charles  Carroll  Lee,  M.  D.,  LL.  D., 
one  of  their  professors  of  diseases  of  women. 

"  Dr.  Lee  was  a  teacher  of  the  highest  rank,  being  able  to  intently 
interest  his  hearers,  and  to  convey  to  them  a  clear  sense  of  his  views 
upon  the  cases  in  his  very  important  department. 

"  Dr.  Lee  was  a  ('hristian  gentleman  who  bound  himself  to  his  asso- 
ciates and  to  those  who  were  instructed  by  liiin  l)y  the  most  affection- 
ate ties. 

"  We  deplore  the  great  loss  we  have  suffered.  W e  shall  ever  count 
it  an  honor  that  for  so  many  years  he  was  one  of  the  faculty  of  the 
New  York  Post-graduate  Medical  School  and  Hospital,  and  we  respect. 


fully  present  to  his  family  our  earnest  sympathy  in  their  supreme  be- 
reavement. 

[Signed.]  "  D.  B.  St.  .John  Roosa,  Frexident. 

"  Ci.AKKNCK  C.  Rice,  Secretary." 

The  late  Dr.  Frank  H.  Ingram. — At  a  meeting  of  the  board  of 
pathologists  of  the  New  York  city  asylums  for  the  insane,  held  April  4, 
1893,  the  following  resolution  was  adopted  : 

Wliereaa,  Death  has  deprived  this  board  of  one  of  its  most  valued 
members  and  each  personally  of  an  esteemed  and  worthy  professional 
brother,  Dr.  Frank  H.  Ingram ;  therefore  be  it 

liesolved,  That  the  members  of  this  board  express  their  regret  at 
the  untimely  termination  of  his  promising  career,  and  that  they  extend 
to  his  family  the  expression  of  their  deep  sympathy  with  them  in  this 
great  affliction. 

Frederick  Peterson,  M.  D.,  )  y, 
rSioTied  1  -  Committee. 

L»igneQ.j  J  p  jicGowAN,  M.  D.,  i 


To  Contributors  and  Correspondents. —  The  attention  of  all  wJw  purpose 
fiii'orlng  us  with  commu/iuatiom  is  respectfully  called  to  the  follovj- 
i  mj : 

Authors  of  articles  inlended  for  pidjltcation  wider  the  head  of  "  original 
contributions  "  are  respertfuUy  informed  that,  in  accepting  such  arti- 
cles, we  always  do  so  with  the  understanding  that  the  following  condi- 
tions are  to  he  obsemed  ■■  (i)  when  a  manuscript  is  sent  to  this  jour- 
nal, a  similar  manuscript  or  any  aljstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  llie  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  custotnary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — ire 
can  not  engage  to  publisli  an  article  in  any  specified  issue  ;  (3)  any 
conditions  vihich  an  author  wislies  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  he  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  addnss,  not  necessarily  for  publication.  No  at- 
tention will  be  paid  to  anonymous  comnmnicutions.  Herea  fter ,  cor- 
respondents asking  for  in  formation  that  we  are  capable  of  givi7ig, 
and  thai  can  properly  be  given  in  this  journal,  viill  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  he  looked  for.  All  communicaiions  not  intended /or  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  iis  in- 
formed of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi- 
cations of  tnatters  that  are  expected  to  come  up  at  particular  meet- 
ings will  be  inserted  vjhen  they  are  received  in  time. 

Newspapei-s  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  tis  information  of  matters  of  inlerest 
to  our  readers  will  be  considered  as  doing  them  and  ns  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  .fub.itance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
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THE  JN^EW  YORK  MEDICAL  JOURl^AL,  May  27,  1893. 


©riginal  Contmxtnications. 


GASTEIC  ANACIDITY. 
By  ALLEN  A.  JONES,  M.  D., 

INSTRUCTOR  IN  PRACTICE,  AND  CLINICAL  INSTRUCTOR  IN  MEDICINE, 
MEDICAL  DEPARTMENT,  UNrVER8ITT  OF  BUFFALO. 

Gastric  anacidity  designates  that  condition  of  the  stom- 
ach in  which  its  contents  are  habitually  neutral  or  alkaline 
in  reaction  at  a  time  when  they  ought  to  be  acid.  Before 
the  contents  of  the  stomach  were  systematically  studied  this 
condition  escaped  notice.  The  importance  of  this  disorder 
lies  in  the  fact  that  gastric  digestion  is  not  carried  on,  and 
therefore  the  organism  is  deprived  of  one  of  its  greatest 
sources  of  nutrition.  Furthermore,  the  whole  task  of  di- 
gestion is  imposed  upon  the  intestine,  which  soon  becomes 
incapable  of  performing  it  perfectly.  The  general  health 
necessarily  suffers,  and  the  greater  its  impairment,  the  less 
perfectly  can  the  digestive  apparatus  perform  its  functions, 
and  the  less  perfectly  such  functions  are  performed  the  more 
profound  becomes  the  general  debility ;  thus  a  vicious  cycle 
of  morbid  events  results  from  disturbed  primary  digestion, 
and  the  conditions  will  not  be  bettered  except  by  striking 
at  the  primary  disturbing  element. 

Etiology. — Gastric  anacidity  may  occur  as  a  secretory 
neurosis,  just  as  may  hyperacidity  occur ;  or  it  may  be 
brought  about  by  depression  of  the  vitality  from  chronic 
disease  in  other  parts  of  the  body.  It  is  sometimes  the  di- 
rect result  of  atrophy  of  the  gastric  tubules  depending  upon 
chronic  gastric  catarrh,  or  upon  some  general  malnutrition, 
and,  indeed,  whenever  anacidity  is  obstinately  present  such 
atrophy  probably  exists.  I  have  found  it  present  not  infre- 
quently with  malignant  disease  of  the  stomach.  In  several 
cases,  two  of  which  are  reported  below,  persistent  anacidity 
existed  with  extensive  gastrectasia.  I  have  found  anacidity 
in  very  corpulent  and  in  thin  persons.  It  is  a  disorder  most 
commonly  found  in  middle  and  advanced  life,  and  in  females 
more  frequently  than  in  males.  Prolonged  hard  work  and 
worry  seem  occasionally  to  induce  it. 

Symptoms. — The  symptoms  accompanying  gastric  ana- 
cidity are  not  characteristic.  They  are  in  some  cases  lo- 
cated in  or  about  the  stomach,  while  in  other  cases  remote 
symptoms — such  as  ansemia,  backache,  headache,  languor, 
and  weakness — are  complained  of.  The  symptoms  alone  often 
arouse  a  suspicion  of  some  totally  different  intragastric  con- 
dition. In  some  cases  paroxysms  of  gastralgia  occur,  inde- 
pendently of  the  time  of  eating.  Anorexia  is  not  usually 
present  in  this  state  ;  on  the  contrary,  there  frequently  ex- 
ists a  morbid  craving  for  food,  which,  however,  is  curbed 
by  the  patients,  who  fear  that  food  will  cause  pain  or  some 
other  distressing  symptom.  Gastric  flatulency  is  occasion- 
ally very  prominent  in  this  disease.  Nausea  and  vomiting 
sometimes  occur.  Burning,  fullness,  weight,  and  indefinite 
distress  are  more  often  complained  of  than  any  other  symp- 
toms. In  some  cases  chronic  diarrhoea  exists.  The  graver 
forms  of  the  disease  entail  serious  failure  of  the  general 
health  and  render  patients  pale,  weak,  thin,  and  wretched 
year  after  year. 


Diagnosis. — External  examination  with  a  view  of  deter- 
mining the  size,  shape,  and  position  of  the  stomach  in  a  pro- 
portion of  the  cases  of  anacidity  reveals  marked  gastrec- 
tasia. The  existence  of  dilatation  is  confirmed  by  the  direct 
examination,  but  by  repeated  investigations  these  dilated 
stomachs  are  often  found  comparatively  sufficient  as  regards 
motion.  Direct  examination  also  reveals  the  true  state  of 
gastric  digestion.  If  the  gastric  contents  are  examined 
three  hours  after  a  meal  of  meat,  bread,  and  potato,  the 
foods  are  found  practically  unchanged,  simply  watersoaked, 
and  floating  or  sinking  in  the  wash  water.  They  show  no 
signs  of  having  been  acted  upon  by  solvents  ;  they  are  not 
dissolved  or  disintegrated  sufficiently  to  stain  the  wash 
water.  The  reaction  of  the  contents  is  usually  neutral,  al- 
though slight  alkalinity  may  be  present.  Mucus  may  or 
may  not  be  present ;  usually  it  is  not  present  in  large  quan- 
tities. On  the  whole,  the  contents  appear  as  though  they 
had  been  lying  for  a  few  hours  in  a  rubber  bag  or  in  a 
bladder. 

Chemical  examination  shows  that  no  gastric  digestion 
has  taken  place.  The  contents  are  anacid,  and  the  filtrate 
contains  at  best  but  a  little  dissolved  albumin.  No  synto- 
nin,  none  of  the  albumoses,  no  peptone  are  present.  Ren- 
net is  usually  absent.  The  starch  in  solution  is  sometimes 
partially  changed,  as  is  shown  by  the  erythrodextrin  reaction 
(purple  with  Lugol's  solution),  or  the  dissolved  starch  not 
uncommonly  present  unchanged. 

These  intragastric  conditions  are  found  every  day  for 
weeks  and  every  week  for  months  and  every  month  for 
years ;  so  there  is  no  question  as  to  the  reality  of  gastric 
anacidity  which,  so  studied,  conveys  to  our  minds  not  only  an 
absence  from  the  stomach  of  HCl  and  lactic  acid,  but  a  state 
of  complete  and  permanent  abeyance  of  gastric  digestion. 
The  bearing  of  such  a  condition  upon  the  general  health  is 
of  paramount  importance.  The  following  four  cases  of  this 
disease  consulted  Dr.  Charles  G.  Stockton,  and,  as  I  had  the 
privilege  of  treating  them,  by  his  courtesy  I  am  able  to  re- 
port them. 

Cask  I. — Mrs.  H.,  aged  forty-three,  married  ;  mother  of  two 
healthy  children  ;  occupation  housewife.  Family  history  nega- 
tive. The  patient  was  always  healthy  until  four  years  ago,  when 
she  had  a  severe  attack  of  retching  and  vomiting.  Since  that 
time  she  has  had  at  irregular  periods  paroxvsms  of  intense  gas- 
trulgia  lasting  several  hours  and  simulating  biliary  colic.  The 
bowels  are  always  sore  for  about  two  weeks  after  an  attack. 
She  has  never  found  any  gall- stones.  The  gastralgia  is  accom- 
panied by  vomiting  with  great  restlessness  and  nervous  excite- 
ment. She  screams  repeatedly  while  in  pain  and  manifests  a 
neurotic  state  in  many  ways.  She  sleeps  poorly  if  in  dread  of 
pain,  and  can  not  lie  down  when  it  is  present.  Anaesthesia  of 
the  conjunctivae  and  hyperaesthesia  over  the  abdomen  are  present. 
Motion  is  slow,  and  the  face  expresses  melancholy.  The  heart 
is  weak ;  blood-vessels  not  diseased ;  liiugs  normal ;  appetite 
good  during  the  intervals  between  the  attacks  of  pain.  Nervous 
belching  at  times  persistent.  Tongue  small  and  slightly  cya- 
nosed,  with  a  univei'sal  thin,  white  coat.  Bowels  very  regular. 
Skin  thick,  muddy,  moist,  and  relaxed.  Urine  hyperlitluiric. 
Weight,  two  hundred  pounds. 

Direct  examination  of  the  stomnch  in  this  case  twelve  times 
in  two  months  always  revealed  anacidity  and  suspension  of  gas- 


574 


JOKES:   GASTRIC  ANACIDITY. 


[N.  Y.  Mkd.  Jock., 


trie  digestion.  On  July  23,  1891,  two  hours  and  a  lialf  after  a 
roll  and  coffee,  I  found  the  former  present  entirely  unchanged, 
with  the  contents  neutral  in  reaction,  no  mucus,  no  syntonin,  no 
albumoses,  no  peptone,  no  rennet,  dissolved  starch  undergoing 
transformation  under  continued  salivary  action. 

On  July  24,  1891,  the  stomach  was  empty  two  hours  after 
half  a  pint  of  peptonized  milk,  and  the  first  water  was  neutral  in 
reaction. 

Anacidity  was  found  at  all  the  subsequent  examinations.  I 
never  found  any  evidence  that  gastric  digestion  had  taken 
place.  The  motion  was  sometimes  active,  sometimes  sluggish. 
The  treatment  consisted  in  the  administration  of  IICl,  predi- 
gested  foods,  mistura  asafcBtidse,  plain  mixed  diet,  cold  spinal 
douches,  and  the  application  of  the  constant  current  within  the 
stomach.  Great  relief  followed,  and  the  patient  experienced 
no  gastralgia  until  January  of  this  year  (1893),  when  I  was 
called  to  see  her  suffering  with  the  old  pain  and  manifesting  the 
old  nervous  symptoms.  I  again  prescribed  nervines  and  hydro- 
therapy, which  were  followed  by  relief. 

Case  II. — Mrs.  C,  aged  thirty-six.  Married  and  had  two 
healthy  children.  Had  diarrhoea  for  several  years.  External 
examination  of  the  stomach  showed  the  lower  border  on  a  level 
with  the  umbilicus ;  splashing  was  readily  elicited.  Numerous 
direct  examinations  of  the  stomach,  extending  over  a  period  of 
several  months,  invariably  showed  the  food  present  unchanged 
and  mixed  with  more  or  less  mucus.  The  contents  were  neu- 
tral in  reaction ;  no  albumoses,  no  peptone,  were  ever  found. 
Eennet  was  occasionally  present.  Starches  were  incompletely 
changed.  In  this  case  the  motion  was  usually  sufficient  to 
empty  the  stomach  in  about  five  hours,  and  thus  tax  the  intes- 
tine with  the  whole  labor  of  digestion.  Eye-strain  in  this 
case  existed  to  the  extent  of  the  following  refractive  error: 
E, +0-75  D.  3 +  0-50  D.  c.  ax.  70,  V.f.  L.  — 0-25  D.C 
1-25  D.  c.  ax.  105,  V.  f  Snellen. 

Case  III. — Mr.  H.,  aged  fifty.  Eight  years  ago,  while  in 
Egypt,  had  a  severe  attack  of  vertigo  and  nervousness.  Since 
that  time  has  suffered  repetitions  of  the  same.  December  20, 
1892,  appetite  poor,  eructations  complained  of;  no  other  direct 
gastric  symptoms.  Bowels  usually  regular.  External  examina- 
tion shows  lower  border  of  tlie  stomach  about  four  inches  be- 
low umbilicus ;  clapotage  marked.  I  made  direct  examination 
of  the  stomach  two  hours  and  a  half  after  oatmeal,  cream,  rolls, 
baked  apples,  and  coffee.  All  the  food  was  entirely  undigested, 
lying  in  a  water-soaked  condition.  The  contents  were  neutral 
in  reaction ;  a  good  deal  of  tenacious,  ropy  mucus  was  present. 
No  evidences  of  gastric  digestion  were  discovered,  as  the  albu- 
moses and  peptone  were  absent,  the  dissolved  starch  was  not 
changed,  and  rennet  was  not  present.  I  have  since  made 
many  examinations  of  the  stomach  contents,  but  always  with 
results  similar  to  the  above.  The  stouiach  usually  emptied 
itself  into  the  duodenum  in  from  five  to  six  hours  sifter  meals. 
The  flesli,  blood,  and  strength  of  this  patient  were  very  much 
lowered. 

Case  IV. — Mrs.  A.,  aged  thirty-seven.  Married.  Decem- 
ber 20,  1892,  is  much  emaciated  and  very  pale.  Complains 
chiefly  of  gastric  flatulence  with  fainting  spells  when  the  gas 
distends  the  stomach.  Bowels  regular.  Lower  border  of  the 
stomach  three  or  four  inches  below  the  umbilicus;  no  gastrop- 
tosis.  1  witlidrew  the  stomach  contents  December  21st  by  the 
ordinary  means,  three  hours  and  three  quai'ters  after  a  break- 
fast of  beefsteak,  bread  and  butter,  coffee  with  cream  and  sugar. 
The  food  was  unchanged,  contents  neutral,  no  biuret  reaction, 
rennet  absent,  dissolved  starch  digested.  Repeated  examina- 
tions of  the  stomach  contents  at  periods  varying  from  two  to 
six  hours  after  eating,  and  after  various  test  meals,  failed  to  re- 
veal the  slightest  evidence  of  gastric  digestion  of  albuminoids. 


The  stomach  usually  emptied  itself  from  five  to  six  hoars  after 
meals. 

The  urine  in  Case  I  was  hyperlithuric  ;  in  Case  II,  nega-; 
five;  in  Case  III,  negative;  in  Case  IV,  somewhat  supe 
acid,  otlierwise  negative. 

Prognosis. — If  the  affection  is  due  to  a  purely  reflex 
disturbance  of  innervation  and  the  patient  is  young,  the 
prognosis  is  most  favorable.  On  the  other  hand,  if  the  pa- 
tient is  middle-aged  or  old,  and  has  passed  through  great 
physical  and  mental  hardships,  and  if  the  condition  per- 
sists for  montlis  without  amelioration  despite  the  best 
remedial  efforts,  probably  atrophy  of  the  gastric  tubules 
has  occurred  and  the  prognosis  is  very  unfavorable  so  far 
as  restoration  of  gastric  digestion  is  concerned.  Life  is  not 
endangered  by  this  disease  except  in  so  far  as  it  renders  the 
organism  less  resisting  to  other  diseases. 

Treatment. — When  a  diagnosis  of  gastric  anacidity  has 
been  made  the  therapeutic  indications  are  clear.  We 
should  try  to  re-establish  gastric  digestion  by  giving  HCl 
in  copious  doses,  and  if  no  peptonization  takes  place  under 
its  influence,  pepsin  ought  to  be  given  with  it,  as  atrophy  of 
the  gastric  tubules  may  exist.  Papain  may  be  used,  as  it 
sometimes  digests  nitrogenous  foods  in  a  neutral  medium. 
Large  doses  of  nux  vomica  or  strychnine  and  physostigma 
are  useful  both  for  their  general  and  local  effects.  Certain 
direct  local  stimulants  are  sometimes  useful ;  for  instance, 
salt,  capsicum,  mustard,  horseradish,  Belfast  ginger  ale, 
etc.,  given  with  or  before  meals  in  moderate  doses.  Ex- 
tract of  malt  affords  great  benefit  if  given  for  a  long  time. 
Quassin,  quinine,  and  other  vegetable  bitters  with  arsenic 
are  useful  in  some  cases.  It  is  a  mistake,  however,  to  give 
too  much  medicine  in  this  condition,  as,  indeed,  it  is  in 
almost  every  disease. 

If  the  patient  is  neurotic,  as  in  the  first  of  the  four 
cases  above  reported,  phosphorus,  sumbul,  asafoetida,  vale- 
rian, electricity,  and  hydrotherapy  are  indicated.  Massage, 
Swedish  movements,  Emersonian  exercises,  vapor  baths  are 
all  to  be  chosen  in  preference  to  shotgun  prescriptions.  Pe- 
ripheral irritations,  such  as  ovarian  disease  or  eye-strain, 
should  be  corrected  at  the  outset. 

The  environment  of  the  patient  should  be  investigated, 
and  overwork,  worry,  grief,  unhappiness,  or  undue  excite- 
ment should  be  obviated  if  possible.  Prolonged  change  of 
scene  and  climate  sometimes  brings  improvement.  The 
diet  should  consist  of  predigested  foods,  as,  for  instance, 
peptonized  milk  and  peptonized  beef.  These  preparations 
afford  extra  nutriment  to  the  patient,  as  they  are  largely 
absorbed  from  the  stomach.  All  rich  mixed  dishes,  such  as 
mince  pies  and  plum  pudding,  should  be  proscribed  ;  while 
plain  puddings,  such  as  bread,  rice,  sago,  tapioca,  and  corn- 
staich,  may  be  allowed.  The  succulent  fruits  are  very 
grateful,  and  the  acid  juices  of  orange,  grape-fruit,  and 
lemon  seem  to  exert  a  favorable  effect  upon  the  stomach. 
Lime  juice  and  acid  phosphate  also  may  be  given.  The 
major  part  of  the  food  should  consist  of  milk,  eggs,  tender 
meats,  stale  bread,  zwieback,  oysters,  salt  and  fresh  fish, 
well-cooked  mashed  potatoes,  the  succulent  vegetables,  etc. 
Salt  fish  and  salt  meats  should  be  eaten  freely,  as  the  chlo- 
rides contained  in  them  favor  the  development  of  HCl 


Alay  27,  1893.] 


FBIEDENWALD:  DETERMINATION  OF  HTDROCHLORIG  ACID. 


575 


ill  the  stomach.  Common  salt  should  be  used  freely  at 
table. 

The  direct  treatment  of  the  stomach  is  very  important. 
Lavage  ought  to  be  practiced  once  or  twice  a  week  for 
many  months,  perhaps,  at  intervals,  for  years.  Lovventhal  * 
recommends  the  use  of  a  0'6-per-cent.  solution  of  sodium 
chloride  at  a  temperature  of  104°  F.  for  lavage  in  these 
cases.  I  have  been  in  the  habit  of  using  a  weak  saline  solu- 
tion for  lavage  in  cases  of  hypochlorhydria,  and  in  the 
treatment  of  anacidity  I  adopt  the  same  plan. 

The  contents  should  be  examined  each  week  as  to  their 
reaction,  which  if  acid  should  prompt  the  tests  for  HCl  and 
lactic  acid.  Not  infrequently,  in  several  cases  of  gastric 
anacidity  not  reported  in  this  paper,  I  have  found  the  re- 
appearance of  lactic  acid,  and  in  a  few  cases  the  re-estab- 
lishment of  UCl  secretion.  Electricity,  interrupted  and 
continuous  currents,  I  use  directly  applied  to  the  mucous 
membrane  of  the  stomach  by  means  of  the  Stockton  elec- 
trode, and,  in  our  experience,  no  measure  yields  better  re- 
sults. Dr.  Einhorn  f  and  I  J  have  shown  that  the  faradaic 
and  galvanic  currents  will  each  stimulate  the  secretion  of 
HCl  in  healthy  and  in  some  diseased  stomachs.  Therefore 
I  use  them  both  with  a  view  of  exciting  the  secretions  of 
gastric  juice,  while  I  use  the  faradaic  current  to  stimulate 
gastric  peristalsis.  If  atrophy  of  the  gastric  glands  has 
taken  place,  no  therapeutic  measure  can  renew  their  func- 
tion, but  we  ought  to  work  with  the  hope  that  atrophy  has 
not  occurred.  In  the  last  three  of  the  cases  above  reported 
I  believe  atrophy  existed,  because  after  months  of  treat- 
ment the  reappearance  of  gastric  digestion  was  not  noticed, 
although  the  motions  of  the  stomach  increased  appreciably. 
436  Franklin  Stkkkt. 


A  REVIEW  OF  THE  MORE  IMPORTANT  METHODS  FOR  THE 

QUANTITATIVE  DETERMINATION  OF  THE 
HYDROCHLORIC  ACID  OF  THE  GASTRIC  JUICE. 
By  JULIUS  FRIEDENWALD,  A.  B.,  M.  D., 

DEMONSTRATOR  OP  PATHOLOGY,  COLLBOE  Or  PHYSICIANS  AND  SURGEONS, 
BALTIMORE. 

Since  the  chemical  examination  of  the  gastric  secretion 
has  assumed  such  importance  in  the  diagnosis  and  treat- 
ment of  diseases  of  the  stomach  quite  a  number  of  new 
qualitative  and  quantitative  methods  have  been  introduced 
to  determine,  with  more  or  less  accuracy,  the  acidity  of  this 
secretion.  Of  the  quantitative  methods,  we  must  distinctly 
separate  those  which  are  merely  approximate  in  their  value 
and  which  are  intended  for  mere  diagnostic  and  therapeutic 
purposes  from  those  which  are  more  scientific  in  their  aims, 
more  difficult  to  carry  out,  and  from  which  we  expect  exact 
values.  An  hour  after  a  trial  breakfast  after  the  manner 
of  Ewald-Boas  *  the  contents  of  the  stomach  are  obtained 
by  the  aid  of  a  stoinach-tubc  and  filtered,  and,  after  tlie 


*  Med.  Week,  January  6,  1898. 

j-  Medical  Record,  May  0,  1801,  January  :{()  and  February  (i,  1892. 
X  Ibid.,  January  13,  1891. 

*  Thirty-five  to  seventy  gjrainine.s  of  white  bread  and  300  to  40(1 
c.  c,  of  water. 


filtrate  has  been  qualitatively  examined  and  its  entire  acid- 
ity determined  by  the  use  of  phenolphthalein  *  as  an  indi- 
cator, one  of  the  three  following  approximate  methods  may 
be  employed  for  the  quantitative  determination  of  the  free 
hydrochloric  acid : 

Mintz's  Method.  \ — Mintz  has  tested  the  phloroglucin- 
vanillin  reagent  J  of  Giinzburg,  and  has  determined  that  its 
limit  of  accuracy  is  0"0036  per  cent,  of  the  hydrochloric  acid. 
The  examination  is  thus  carried  out :  To  10  c.  c.  of  gastric 
filtrate  one-tenth  normal  sodium  hydrate  *  is  added  until  a 
reaction  can  no  longer  be  got  by  testing  with  Giinzburg's 
reagent.  (A  few  drops  of  this  reagent  are  placed  in  a 
small  porcelain  dish,  together  with  an  equal  quantity  of  gas- 
tric filtrate,  to  which  the  one-tenth  normal  sodium  hj'drate 
has  been  added,  and  carefully  heated  to  dryness  over  a  small 
flame.  If  free  IICl  is  present,  a  carmin-red  mirror  is 
formed.)  If  with  1*2  c.  c.  normal  alkali  a  reaction  can  be 
got,  but  with  1-3  c.  c.  none,  then  the  quantity  of  free  HCl 
is  12  -|-  1  c.  c.  one-tenth  normal  NaOII — that  is,  the  acidity 
for  free  HCl  is  13,  which,  multiplied  by  0-00365,  =  0-0474, 
the  absolute  percentage  of  free  hydrochloric  acid  in  100 
c.  c.  of  gastric  secretion.  This  method  has  been  recently 
tested  by  Martins  and  Liittke,  ||  and  found  to  give  suffi- 
ciently reliable  but  approximate  results. 

Boas's  Method. — A  weak  watery  solution  of  Congo  red 
is  prepared,  which  is  used  as  an  indicator.  To  10  c.  c.  of 
gastric  filtrate  sufficient  is  added  until  a  distinctly  blue  color 
is  obtained,  and  then  titrated  with  one  tenth  normal  NaOH 
until  the  original  red  of  the  Congo  solution  is  got.  If,  for 
instance,  5  c.  c.  of  the  one  tenth  normal  NaOU  has  been 
used,  the  percentage  of  free  hydrochloric  acid  in  a  hundred 
grammes  of  gastric  secretion  will  be  50  X  0-00365  =  0-18 
per  cent.  This  method  gives  not  only  the  percentage  of  free 
hydrochloric  acid,  but  also  of  free  organic  acids.  However, 
the  very  small  quantities  of  organic  acids  which  are  usu- 
ally present  in  the  gastric  filtrate  after  a  trial  breakfast  do 
not  materially  vitiate  the  results  ;  if  larger  quantities  are 
present,  they  must  first  be  removed  by  agitating  with  ether. 
I  have  had  frequent  occasion  to  employ  this  method  in 
Boas's  laboratory,  and  have  always  found  it  convenient 
and  satisfactory  for  practical  purposes. 

Luttke''s  Method.^ — Liittke  has  recently  recommended 
the  use  of  tropseolin  O  O  as  indicator,  instead  of  Congo 
dissolved  in  dilute  alcohol ;  the  yellowish  hue  of  tropseolin 
is  changed  to  red  by  the  addition  of  free  acids.  This  re- 
agent is  employed  in  a  manner  similar  to  that  given  above 
for  Congo. 

*  Ten  c.  c.  of  the  gastric  filtrate  is  titrated  with  a  one-tenth  nor- 
mal sodium-hydrate  solution  (one  to  two  drops  of  one-per-cent.  phenol- 
plithalein  solution  having  been  previously  added  to  the  filtrate)  until  a 
reddish  hue  is  obtained. 

\  Mintz.  Einc  einfache  Methode  zur  quantitativen  Bestimmung  der 
freien  Salzsaure  im  Mageninhalt.  Wiener  klin.  Wochcmchrift,  1889, 
No.  20. 

\  Phlorogluciii,  2  ;  vanillin,  1  ;  absolute  alcohol,  30. 

*  One-tenth  normal  sodium-hydrate  solution  is  one  which  contains 
0-004  gramme  NaOH  in  each  cubic  centimetre ;  every  cubic  centimetre 
of  this  solution  corresponds  exactly  to  0-00365  HCl. 

II  Martius  und  Liittke.    Die  Magemtaure  dcx  Memchcn,  p.  91. 
^  Martius  und  Liittke.    Loc.  cU.,  p.  67. 


576 


FRIEDENWALD:  DETERMINATION  01  HYDROCHLORIC  ACID.       [N.  Y.  Mbd.  Joob., 


Among  the  more  scientific  methods  which  may  be  em- 
ployed for  the  determination  of  hydrochloric  acid  may  be 
mentioned  those  of  Heyner-Seemann,  Sjoqvist,  Liittke,  and 
Leo.  They  are  intended  for  the  estimation  not  only  of  free 
HCl,  but  likewise  for  that  part  of  the  HCi  combined  with 
inorganic  as  well  as  organic  bases,  so  that  they  may  be  em- 
ployed during  any  stage  of  digestion,  even  before  hydro- 
chloric acid  has  been  set  free.  It  must  be  stated  in  advance 
that  none  of  these  methods  is  devoid  of  certain  errors,  and 
that  as  yet  no  perfectly  accurate  and  reliable  method  is 
known.* 

The  Heyner-Seemann  Method, \  also  known  as  Braun^s.\ 
— If  to  a  certain  quantity  of  gastric  filtrate  a  definite 
quantity  of  one-tenth  normal  NaOH  is  added,  and  the 
whole  evaporated  to  dryness  over  a  water  bath  and  then 
charred  in  a  flame,  the  organic  material  is  converted  into 
carbon  dioxide,  which  escapes,  so  that  from  the  remaining 
free  alkali  the  percentage  of  hydrochloric  acid  is  easily 
calculated.  Example :  Ten  c.  c.  of  gastric  filtrate  is  ex- 
actly neutralized  with  one-tenth  NaOH  (say,  8  c.  c.)  ;  it 
is  now  evaporated  and  charred,  and  the  ash  dissolved  in 
water,  filtered,  and  exactly  the  same  quantity  of  one-tenth 
normal  IICl  is  added  to  the  filtrate  as  normal  NaOH  was 
added  before  (8  c.  c).  A  few  drops  of  phenolphthalein 
are  added,  and  the  whole  titrated  with  one-tenth  normal 
NaOH  ;  if  3  c.  c.  would  now  be  required  for  neutralization, 
30  multiplied  by  0-00365  would  give  0-1095  per  cent,  free 
HCI.    This  method  is  recommended  by  Leube.|| 

Sjoqvisfs  Method.^ — If  a  gastric  filtrate  to  which  ba- 
rium carbonate  has  been  added  is  evaporated  to  dryness,  all 
the  acids  are  changed  into  barium  salts;  now,  by  charring 
the  mass  the  barium  salts  of  the  organic  acids  are  converted 
into  barium  carbonate,  while  the  barium  chloride  remains 
unchanged  ;  a  watery  extract  is  then  made  ;  barium  car- 
bonate is  insoluble  in  water,  while  the  chloride  passes  over ; 
the  quantity  of  barium  chloride  is  determined  by  titration, 
from  which  the  HCl  is  calculated.  The  method  is  most 
conveniently  carried  out  according  to  Bourget's  ^  modifica- 
tion, which  Boas  |  has  still  further  simplified.  Ten  c.  c.  of 
filtered  gastric  secretion  to  which  a  small  quantity  of  pure 
pulverized  barium  carbonate  has  been  added  is  evaporated 

*  Boas.  Allgemeine  Diagnostik  und  Therapie  der  Magenkranklieiten, 
Zweite  Auflage,  p.  139. 

^  Seemann.  Uel)er  das  Vorliandensein  freier  Salzsaure  im  Magen. 
Zeitschr.f.  klin.  Med.,  Bd.  v,  S.  272. 

\  Leo.  Diagnostik  der  Krankheiten  der  Verdauungsorgane,  1890, 
p.  113. 

*  One-tenth  normal  HCl  is  one  which  contains  0-00365  gramme 
HCl  in  each  cubic  centimetre.  Each  cubic  centimetre  of  a  one-tenth 
normal  acid  neutralizes  exactly  the  same  quantity  of  a  one-tenth  normal 
alkali. 

|{  Leube.  Spccielle  Diagnose  der  inneren  Krankheiten,  Dritte  Auf- 
lage,  p.  241. 

^  Sjoqvist.  Einc  neue  Methode  freie  Salzsaure  im  Mageninhalte 
quantitativ  zu  bestimmen.  Zeitsch.  f.  physiol.  Chemie,  Bd.  xiii,  S.  1, 
1888. 

0  Bourget.  Nouveau  proccd6  pour  la  recherche  et  la  dosage  de  I'acide 
chlorhydrique  dans  le  liquide  stomacal.  Arch,  de  mid.  exper.,  1889,  No. 
6,  p.  844. 

J  Boas.  Ceniralblait  fur  klin.  Medicin,  1891,  No.  2 ;  also  Allgemeine 
Diagnostik  und  Tlierapie,  p.  144. 


in  a  silver  crucible  over  a  water  bath  to  dryness.  The  mass 
is  then  washed  in  the  flame,  allowed  to  cool,  and  then  re- 
peatedly extracted  in  warm  water  and  filtered  until  the  fil- 
trate reaches  50  c.  c.  The  filtrate  now  contains  the  chloride 
of  barium  alone,  while  the  carbonate  of  barium  has  been  left 
back  on  the  filter.  To  the  filtrate  a  saturated  solution  of 
sodium  carbonate  is  now  added  ;  a  precipitate  of  barium  car- 
bonate is  formed.  This  is  then  filtered  and  washed  until 
the  filtrate  no  longer  reacts  alkaline.  The  filter  with  its  con- 
tents is  then  removed,  placed  in  a  beaker  glass  in  water, 
rubbed  into  pieces,  and  then  sufficient  one-tenth  normal  HCl 
added  until  all  barium  carbonate  has  passed  into  solution 
and  reacts  acid  to  litmus ;  after  boiling  to  get  rid  of  all  CO2 
a  few  drops  of  phenolphthalein  are  added,  and  the  whole 
titrated  with  one-tenth  normal  NaOH  ;  if  10  c.  c.  of  the  one- 
tenth  normal  HCl  has  been  used  and  on  titration  with  the 
one-tenth  normal  NaOH  say  4,  then  we  have  6  c.  c.  one- 
tenth  normal  HCl  in  every  10  c.  c.  of  the  gastric  filtrate,  or  60 
in  every  hundred,  which,  multiplied  by  0-00365,  =  0-02190 
per  cent.  Until  very  recently  this  method  was  considered 
quite  accurate,  but  Kossler  *  has  demonstrated  that  even 
this  method  has  sources  of  error.  He  has  shown  that  by 
the  action  of  calcium  chloride  on  acid  potassium  phosphates 
(and  phosphates  are  always  present  in  a  trial  breakfast)  HCl 
is  set  free  and  escapes  according  to  the  following  formula : 
CaCls  -f  KH2PO4  =  CaHP04  +  KCl  -f  HCl.  Accordin 
to  him,  an  error  of  from  twenty  to  forty  per  cent,  may  be 
made  in  this  way.  Martius  and  Liittke  f  have  also  for  other 
reasons  found  this  method  inaccurate. 

Lattice'' s  Method. \ — This  method  is  a  modification  of  that 
given  by  Vulhard  for  the  determination  of  the  chlorides  in 
the  urine.  When  to  the  gastric  contents  a  strongly  acidu- 
lated silver-nitrate  solution  is  added  in  excess,  a  precipitate 
of  chloride  of  silver  is  formed  ;  if  the  chloride  of  silver  is 
now  filtered  and  the  quantity  of  uncombined  silver  deter- 
mined, the  quantity  of  chlorides  can  easily  be  calculated. 
If,  for  instance,  20  c.  c.  of  one-tenth  normal  AgNOs  solu- 
tion has  been  added  to  10  c.  c.  of  gastric  secretion  and  after 
filtration  only  10  c.  c.  of  one-tenth  normal  AgNOs  remains 
uncombined,  then  the  other  10  c.  c.  of  silver  solution  must 
have  been  used  up  in  combining  with  the  chlorine.  The 
chlorides  combined  with  inorganic  bases  can  be  similarly 
determined  after  evaporation  and  charring  of  the  gastric 
contents ;  the  ash  is  then  extracted  with  water  and  the  chlo- 
rides determined  by  adding  an  excess  of  one-tenth  normal 
silver  solution.  The  determination  of  the  excess  of  AgNOs 
rests  upon  the  following  principle  :  If  to  a  solution  of  silver 
nitrate  strongly  acidulated  and  containing  some  ferric  sul- 
phate a  solution  of  sulphocyanide  of  ammonium  is  added, 
a  precipitate  of  sulphocyanide  of  silver  is  occasioned  and 
a  blood-red  color  is  produced  when  the  last  of  the  silver  is 
precipitated.    The  sulphate  of  iron  thus  acts  as  an  indi- 


*  Kossler.  Zeitschrift  fur  physiologisclie  Chemie,  Bd.  xvil,  p.  107, 
1892. 

f  Martius  und  Liittke.    Loc.  cit.,  p.  84. 

I  J.  Liittke.  Eine  neue  Methode  zur  quantitativen  Bestimmung 
der  Salzsaure  im  Mageninhalt.  Deutsche  med.  Wochenschrift,  1891, 
No.  49 ;  and  Die  Alagensdure  des  Menschen.  Martius  und  Liittke, 
p.  101. 


May  27,  1893.J 


JUDSON:   THE  MANAGEMENT  OF  HIP  DISEASE. 


577 


cator  and  serves  to  show  when  all  the  silver  has  been  pre- 
cipitated. 

(A)  Determination  of  all  chlorides :  Ten  c.  c.  of  well- 
agitated  unfiltered  gastric  secretion  are  placed  in  a  100  c.  c. 
flask  ;  20  c.  c.  one-tenth  normal  silver  solution  *  are  added  ; 
the  flask  is  then  well  shaken  and  allowed  to  stand  for  ten 
minutes,  and  filled  up  to  100  c.  c.  with  distilled  water,  agi- 
tated, filtered  through  a  dry  filter  into  a  dry  beaker  glass. 
Fifty  c.  c.  of  the  filtrate  are  then  titrated  with  a  one-tenth 
normal  sulphocyanide-of-aiiimonium  f  solution.  The  num- 
ber of  cubic  centimetres  of  sulphocyanide  solution  multi- 
plied by  two  and  subtracted  from  twenty  (the  quantity  of 
silver  used)  gives  the  entire  quantity  of  chlorides  present  in 
one  hundred  grammes  of  gastric  contents. 

(B)  Determination  of  inorganic  chlorides  :  Ten  c.  c.  of 
well-agitated  gastric  secretion  are  evaporated  to  dryness  over 
a  water  bath  ;  after  evaporation  the  mass  is  charred  in  the 
direct  flame,  the  charring  being  kept  up  until  the  ash  no 
longer  burns  with  a  bright  flame.  The  ash  is  then  extracted 
with  100  c.  c.  of  hot  water  and  filtered.  The  entire  filtrate 
is  then  placed  in  a  beaker,  precipitated  with  10  c.  c.  one- 
tenth  silver  solution,  and  titrated  with  one- tenth  sulpho- 
cyanide-of-ammonium  solution.  The  calculation  of  the  in- 
organic chlorides  is  made  by  a  subtraction  of  the  number  of 
cubic  centimetres  of  sulphocyanide-of-ammonium  solution 
from  the  number  of  cubic  centimetres  of  silver  solution 
utilized  (10  c.  c).  The  calculation  of  hydrochloric  acid  is 
made  by  a  subtraction  (A — B) — that  is,  the  value  obtained 
for  the  inorganic  chlorides  from  that  of  the  entire  chlorides ; 
this  gives  the  value  for  HCl  in  each  10  c.  c.  of  gastric  secre- 
tion, which,  multiplied  by  0"0365,  gives  the  per  cent,  of 
HCl  in  100  c.  c,  of  the  gastric  contents. 

Although  this  method  of  Lilttke's  is  but  a  few  months 
old,  it  has  not  failed  to  receive  severe  criticism.  Both 
Ewald  J  and  Boas  *  have  called  attention  to  the  fact  that 
no  practical  advantage  is  gained  by  utilizing  unfiltered  gas- 
tric secretion.  Ewald  believes  that  the  error  which  Kossler 
has  found  for  Sjoqvist's  method  must  also  be  taken  into 
consideration — namely,  that  by  the  evaporation  with  cal- 
cium salts  and  acid  potassium  phosphate  HCl  is  set  free 
and  escapes  (calcium  salts  and  phosphates  are  always  to  be 
found  in  the  gastric  contents). 

Leo's  Metkod.\\ — This  method  rests  upon  the  principle 
th^t  free  acids,  such  as  IICI,  are  fully  neutralized  by  the 
addition  of  calcium  carbonate  even  at  low  temperatures, 
while  solutions  of  acid  phosphates  or  other  salts  of  sodium 
or  potassium  retain  their  acidity. 

*  A  one-tenth  normal  silvcr-nitiate  solution  is  one  which  contains 
seventeen  grains  of  AgNOs  to  the  litre ;  the  indicator  ferric  sulphate 
and  sulphuric  acid  must  be  added. 

•f  A  one  tenth  normal  sulphocyanideof-ammonium  solution  is  one 
which  contains  7'C  grammes  CNSNlIj  to  the  litre.  For  special  directions 
for  preparing  this  solution,  as  well  as  the  silver  solution,  see  Martius  and 
Luttke,  Die  Magensdure  dcs  Afcnsc/tcn,  j).  105. 

J  Ewald.  Berliner  Minische  Wochcnschrift,  Nov.  21,  18'.)2,  No. 
i1,  p.  1199. 

*  Boas.    Zcilschrifl  fiXr  klinische  Medicin,  Bd.  xxi,  H.  3  u.  4. 

I  Leo.  Eine  neue  Methode  zur  Siiurebestimraung  im  Mageninhalt, 
Cenlralhlatt  fur  d.  tncd.  Wmenxch.,  1889,  No.  26;  and  Leo,  Diagnostik 
der  KrankheUen  der  Vcrdauunysorgane,  p.  11 4. 


To  10  c.  c.  gastric  filtrate  5  c.  c.  concentrated  calcium- 
chloride  solution  are  added,  and  a  few  drops  of  a  solution 
of  alcoholic  phenolphthalein  and  then  titrated  with  a  one- 
tenth  NaOH  solution  (A).  An  additional  quantity  of  gas- 
tric filtrate  (15  c.  c.)  is  precipitated  with  about  one  gramme 
pure  powdered  CaCOg,  agitated,  and  then  filtered  through  a 
dry  filter.  Ten  c.  c.  of  this  filtrate  are  removed  and  air 
passed  through  *  so  as  to  remove  all  carbon  dioxide.  To 
this  5  c.  c.  CaClj  and  a  few  drops  of  alcoholic  phenolphtha- 
lein are  added,  and  the  acidity  determined  by  titration 
with  one-tenth  normal  sodium  hydrate  (B).  A  —  B  corre- 
sponds to  the  free  acids ;  if  fatty  and  lactic  acids  are  not 
present  the  result  would  correspond  to  HCl ;  should  fatty 
acids  or  lactic  acid  be  present  in  the  gastric  filtrate,  they 
must  first  be  removed — the  fatty  acids  by  distillation,  the 
lactic  acid  by  agitation  with  ether.  Of  all  the  scientific 
methods,  Leo's  seems  the  most  accurate  and  is  preferred  by 
Kossler  f  and  Ewald. J  It  must  be  remembered  that  none 
of  the  methods  known  give  absolute  but  merely  relative 
values,  and  that  a  perfectly  reliable  method  for  the  deter- 
mination of  free  as  well  as  bound  HCl  is  as  yet  unknown. 
Berlin,  March  27,  1893. 


THE  MANAGEMENT  OF  HIP  DISEASE* 
By  a.  B.  JUDSON,  M.  D., 

ORTHOP.15DIC  StTRGBON  TO 
THE  ODT-PATIENT  DEPARTMENT  OP  THE  NEW  YORK  HOSPITAI,. 

Probably  from  the  beginning  of  surgery  hip  disease 
has  been  the  cause  of  serious  and  anxious  thought  to  the 
practitioner.  The  many  and  wonderfully  various  means  of 
treatment  in  vogue  in  the  past,  and  especially  at  present, 
are  sufficient  evidence  that  the  subject  has  been  faithfully 
and  ingeniously  studied.  To  my  mind,  an  evidence  that 
real  progress  has  been  made  in  late  years  is  found  not  so 
much  in  new  methods  of  treatment  as  in  a  juster  appreci- 
ation of  what  can  be  accomplished  by  treatment.  Of  late 
years  we  speak  of  the  management  of  hip  disease  rather 
than  its  treatment.  Are  we  not  right  in  agreeing  that  a 
case  of  this  insidious  and  terrible  afl^ection  is  to  be  managed 
in  such  a  way  that  the  natural  cure,  which  is  almost  in- 
variably the  rule,  shall  come  as  speedily  and  with  as  lit- 
tle ultimate  disability  as  possible  ?  Would  that  it  were 
possible,  by  an  incisive  and  brilliant  operation,  to  cut 
short  the  disease  and  leave  symmetry  and  unimpaired 
ability  !  Unfortunately,  the  hip  patient  can  not  be  treated 
and  cured  as  if  he  had  a  calculus,  or  an  appendicitis,  or  an 
aneurysm.  And  yet  the  management  of  such  a  case  is  far 
from  being  an  instance  of  expectant  treatment.  It  is  a 
field  in  which  excellent  service  may  be  rendered  to  the 
sufferer  and  in  which  there  is  abundant  opportunity  for  the 
exercise  of  skill  and  devoted  attention. 

*  This  is  best  accomplished  by  passing  air  through  by  means  of  a 
double-bulbed  syringe  to  one  end  of  which  a  piece  of  glass  tubing  is 
attached. 

f  Kossler.    Zcitschrift filr  phi/siologishe  Chemic,  Bd.  xvii,  p.  107. 
\  In  his  lectures  to  physicians,  March,  1893. 

*  Read  before  the  Fifth  Distiict  Branch  of  the  New  York  State 
Medical  Association,  Brooklyn,  May  23,  1893. 


578 


JUD80N:   THE  MANAGEMENT  OF  HIP  DISEASE. 


[N.  Y,  Med.  Jouh., 


The  most  obvious  thing  to  do  is  to  relieve  the  joint 
from  the  work  of  supporting  the  weight  of  the  body  which 
falls  on  it  in  standing  and  walking.  In  ISS?  Brooklyn  lost 
by  death  one  of  her  foremost  surgeons,  a  man  of  sterling 
character  and  positive  convictions.  I  refer  to  Dr.  Joseph 
C.  Hutchison.  He  saw  so  clearly  the  necessity  of  removing 
this  kind  of  traumatism  from  the  joint  that,  discarding  all 
other  apparatus,  he  prescribed  simply  a  pair  of  crutches, 
with  a  high  sole  on  the  sound  foot.  What  was  the  effect 
of  this  treatment,  or  management  ?  Obviously  to  make  the 
affected  limb  pendent,  like  the  arm,  and  to  remove  it  en- 
tirely from  the  labor  of  walking.  And  that  is  perhaps  the 
principal  function  of  the  hip  splint,  no  matter  how  elabo- 
rately it  may  be  constructed  with  the  design  of  producing 
traction,  or  extension,  or  abduction,  or  adduction,  or  fixa- 
tion, or  motion  without  friction,  or  relief  from  articular 
pressure,  or  counteraction  of  the  circumarticular  muscles. 
These  various  things  may  or  may  not  be  of  value  at  cer- 
tain stages ;  but  the  object  sought  by  the  use  of  crutches 
and  obtained  by  the  hip  splint  is  the  relief  of  the  joint 
from  the  traumata  which  attend  locomotion.  These  inflic- 
tions cease,  of  course,  when  the  recumbent  position  is 
taken,  but  by  Dr.  Hutchison's  crutches,  or  the  ischiadic 
crutch  of  the  hip  splint,  they  are  nullified,  and  yet  the 
patient  is  up  and  about.  The  patient  is  up  while  the  limb 
is  in  bed.  A  European  writer  on  hip  disease  exclaims  : 
"  But  can  the  body  maintain  the  erect  position  for  months, 
touching  the  ground  with  but  one  foot  ?  Certainly  not. 
It  is  not  in  the  range  of  human  possibility."  He  adds 
with  an  access  of  hope  :  "  The  future,  however,  holds  many 
a  surprise.  What  is  to-day  impossible  may  on  the  mor- 
row be  an  accomplished  fact."  *  This  was  written  two 
years  after  Dr.  Fayette  Taylor  had  described  the  hip 
splintjf  and  to-day  we  see  thousands  of  children  running 
about  for  months  and  years  resting  on  one  foot  only,  and 
thus  giving  Nature  her  best  opportunity  to  resolve  inflam- 
mation and  secure  symmetry  and  locomotor  ability,  and 
recovering,  some  of  them,  with  no  deformity  and  perfect 
motion  in  the  joint. 

A  few  years  ago  I  compiled  from  the  published  reports 
of  the  orthopaedic  institutions  of  New  York  city  for  a  given 
year  a  table  showing  the  relative  frequency  of  cases  of  hip- 
joint  disease  and  shoulder-joint  disease.^  There  were  five 
hundred  and  sixty-four  of  the  former  and  only  nine  of  the 
latter.  These  figures  are  suggestive  in  the  extreme.  They 
indicate  that  the  mechanical  environment  of  the  hip  pre- 
vents the  resolution  of  inflammation,  while  the  more  favor- 
able situation  of  the  shoulder  promotes  early  resolution. 
Similar  statistics  and  inferences  apply  to  corresponding 
affections  in  the  knee  and  elbow,  the  ankle,  and  the  wrist. 
Shall  we  turn  away  from  a  lesson  so  plainly  taught,  or 
ought  we  not  at  the  earliest  moment  to  make  the  affected 
or  suspected  limb  pendent  for  the  weeks,  or  months,  or 
years  required  by  the  nature  of  the  case  ? 

Let  us  further  inquire  whether,  in  the  usually  tedious 
course  of  this  affection,  something  more  is  not  required 

*  Arch,  'jen.,  Januaiy,  1869,  p.  64. 

f  Medical  Record.,  Sept.  1,  186*7. 

X  New  York  Medical  Journal,  June  5,  1886,  p.  626. 


beyond  protecting  the  joint.  There  are  periods  in  which 
motion,  however  slight,  causes  the  severest  pain.  In  the 
words  of  Sir  Charles  Bell :  *  "It  is  remarkable  how  the 
slightest  degree  of  movement  in  another  part  of  the  body 
is,  as  it  were,  necessarily  accompanied  with  a  motion  of  the 
surfaces  of  those  bones  which  compose  the  hip  joint.  If 
ever  you  should  see  a  patient  suffering  with  acute  inflam- 
mation of  the  hip  you  will  see  the  proof  of  this,  for  every 
motion  of  the  body  gives  extreme  pain,  and  proves  an  ad- 
ditional source  of  excitement  and  inflammation.  It  is  this 
consideration  which  leads  us  to  understand  the  difficulty  of 
curing  the  disease."  Mr.  Henry  Hancock,  arguing  in  favor 
of  exsection,  gives  the  following  description :  \  "  Look  at  a 
patient  wasted  to  a  shadow,  confined  to  his  bed,  not  for 
months  only,  but  for  five  years,  in  constant  pain  and  in  the 
last  stage  of  exhaustion  from  long-continued  discharge,  his 
hands  employed  night  and  day  incessantly  maintaining  a 
fixed  position  of  the  limb,  and  endeavoring  to  prevent  the 
intense  agony  which  occurs  on  the  slightest  movement. 
Often  have  I  seen  the  poor  hip-joint  patient,  when  all  others 
have  slept,  still  wakeful  and  anxiously  engrossed  with  the 
one  and  monotonous  task  of  steadying  the  knee  and  pre- 
venting movement." 

The  pictures  thus  graphically  drawn  but  recall  scenes 
too  common  in  the  past  and  present.  Happy  those  of  us 
who  have  also  seen  the  ease  and  comfort  and  the  relief 
from  pain  and  the  assurance  of  sleep,  and  in  the  day  time 
the  ability  to  walk,  which  are  obtained  by  the  gentle  trac- 
tion exerted  by  the  hip  splint. 

In  one  of  our  general  hospitals,  several  years  ago,  the 
hip  splints  which  were  in  use  experimentally  were  not  equal 
in  number  to  the  patients  in  the  children's  ward  who  need- 
ed them.  Therefore  it  was  unfortunately  necessary  some- 
times to  remove  a  splint  from  a  child  and  apply  it  to  one 
whose  need  was  greater.  It  was  a  cruel  necessity,  and  was 
always  furiously  resented  by  the  little  one,  who  had  learned 
by  experience  that  comfort  and  a  greater  ability  to  play  had 
come  to  him  when  the  splint  was  applied. 

How  can  we  properly  estimate  the  benefit  which  the 
management  of  a  case  of  hip  disease  in  this  way  secures  to 
the  patient  ?  Locally  we  have  fixation  and  protection  from 
trauma,  and  generally  we  have  comfortable  sleep  and  activi- 
ty out  of  doors.  Can  we  place  the  affected  bone  in  a  more 
favorable  environment,  or  better  fortify  the  natural  powers 
to  take  up  and  carry  on  the  work  of  repair,  or  make  a  bet- 
ter defense  against  intercurrent  diseases  ? 

There  are  many  details  which  may  well  be  considered 
on  other  occasions.  I  have  tried  to  make  a  response  to  the 
kind  invitation  of  our  secretary  by  presenting  these  thoughts 
of  every-day  practical  interest. 


lodozone, — At  the  meeting  of  the  Academic  den  snences  on  the  21st 
of  March,  M.  Robin  described  iodozone,  a  liquid  compound  produced  by 
tlie  combination  of  iodine  and  ozone.  It  is  a  clear,  innocuous  liquid, 
void  of  any  irritating  properties;  a  powerful  disinfectant;  forms  a  use- 
ful application  to  ulcers,  and  may  be  used  as  a  mouth  wash. — Dublin 
Journal  of  Medical  Science. 


*  London  Medical  Gazette,  Jan.  12,  1828,  p.  138. 
t  Lancet,  June  1,  1872,  p.  620. 


May  27,  1893.] 


BOZEMAN:  AN  AIR  AND  WATER  IRRIGATOR  AND  DRAIN. 


579 


AN  AIR  AND  WATER  IRRIGATOR  AND  DRAIN 
FOR  PROLONGED  DOUCHING  IN  DEEP  CAVITIES. 
By  NATHAN  G.  BOZEMAN,  Ph.  B.,  M.  D. 

The  author  published  in  the  New  York  Medical  Jour- 
nal for  June  1,  1889,  a  description  of  his  new  system  of 
continuous  vaginal  irrigation  and  drainage.  The  main  fea- 
tures of  it  are  the  introduction  of  sterilized  air  with  the 
hot  water  into  the  vagina  and  the  withdrawal  of  the  same 
by  slight  suction  before  it  can  accumulate  there  in  sufficient 
quantities  to  flow  over  the  perinaeum  and  wet  the  patient's 
clothing  and  the  bedding.  The  mixture  of  air  and  water 
in  the  afferent  tube  is  obtained  by  means  of  an  intermittent 
siphon.  The  suction  or  rarefaction  of  air  in  the  efferent 
tube  is  produced  by  a  modified  filter  pump,  which  has  al- 
ready been  described.  The  system  was  invented  to  drain 
off  the  escaping  urine  from  artificial  vesico-vaginal  fistu- 
lae,  but  it  is  equally  applicable  for  douching  in  any  deep 
cavity. 

The  perfected  apparatus  does  not  differ  in  principle 
from  the  original.  It  is  simple  and  inexpensive  and  acts 
automatically.  The  quantity  of  flow  from  the  reservoir  for 
the  irrigation  and  the  production  of  suction  is  constant  and 
is  regulated  by  natural  laws. 

The  reservoir  is  an  ordinary  glass  filter  bottle,  having 
any  desired  capacity.    A  tightly  fitting  cork  with  two  per- 
forations is  in  the  neck, 
and  into  the  nozzle  a 
tube  passes  which  ex- 
tends to  the  neck  and 
communicates  there 
with  the  air ;   by  its 
side  is  another  open 
tube.     The   fluid  es- 
capes from  the  bottle 
by  the  circular  aper- 
ture at   a,  when  the 
stopcock  is  open  ;  and 
the  flow  is  constant, 
provided  the  level  of 
the  fluid  is  not  below 
the  end  of  the  vertical 
tube.    The  quantity  of 
efl[lux   is  proportional 
to  the  square  root  of 
the  height  between  the 
end  of  the  vertical  tube 
and  the  circular  open- 
ing, and  is  proportion- 
al to  the  area  of  the 
latter.   Since  this  aper- 
ture is  in  the  wall  of  a 
large  empty  tube,  the  algebraic  formula  for  the  weight  of 
water,  W,  which  flows  out  of  the  bottle  in  a  given  time,  t,  is 
W  =  A  a  t^/2gh.    Practically,  when  one  fluidounce  of  water, 
W,  escapes  in  one  minute,  t,  the  area,  A,  of  the  circular 
aperture  is  0-003316  square  inch  (diameter  0-0649  inch), 
and  the  height,  h,  between  the  latter  and  the  lower  end  of 
the  vertical  tube  is  half  an  inch ;  a  is  the  coefficient  of 


efflux.  The  reason  why  the  flow  from  the  bottle  is  con- 
stant has  been  explained  by  Mariotte,  a  celebrated  French 
physicist.  As  the  water  flows  out  of  the  bottle,  air  enters 
by  the  vertical  tube  bubble  by  bubble  and  takes  its  place. 

The  suction  tube  is  a  series  of  glass  coils  suspended  in 
a  vertical  position  ;  it  widens  at  its  upper  extremity  and  is 
closed  by  a  thin  disc  with  a  central  perforation.  This  is 
shown  of  half  size  in  the  illustration.  The  water  which 
escapes  from  the  reservoir  fills  the  vertical  tube  beyond  the 
stopcock  up  to  the  nipple  in  its  side.  This  column  of 
water  has  a  constant  level,  because  as  fast  as  the  fluid  ac- 
cumulates above  the  nipple  it  flows  into  the  intermittent 
siphon,  and  the  sudden  emptying  of  this  draws  air  down 
the  tube  which  passes  through  the  bottle.  The  height  of 
this  column  for  practical  use  is  two  inches,  and  the  area  of 
the  circular  aperture  in  the  disc  upon  which  it  rests  is 
0-000829  square  inch  (diameter  0-0325  inch),  and  half  an 
ounce  of  water  for  aspirating  purposes  flows  through  it 
into  the  suction  tube  in  one  minute.  It  will  be  seen  that 
this  is  the  half  of  the  entire  quantity ;  the  rest  supplies  the 
intermittent  siphon,  and  every  time  it  empties  itself  air 
which  has  been  sterilized  by  filtering  through  the  antisep- 
tic gauze  wound  about  the  neck  of  the  bottle  is  drawn  into 
the  afferent  tube. 

For  continuous  irrigation  the  bottle  is  filled  with  hot 
sterilized  water  and  placed  on  a  table  near  the  bed  of  the 
patient,  the  end  of  the  suction  tube  falling  into  a  vessel  on 
the  floor.  The  perforated  loop  of  soft-rubber  tubing, 
stiffened  by  a  wire  inside  and  shaped  so  as  to  be  self-re- 
taining, is  introduced.  The  stopcock  is  then  opened. 
The  air  in  the  drainage-tube  being  partially  exhausted  by 
the  vertically  falling  water,  the  intermittent  siphon  empties 
itself ;  then  short  columns  of  water  separated  by  air  follow 
one  another  in  quick  succession  along  the  drainage-tube,  the 
suction  tube,  and  into  the  vessel  on  the  floor.  The  tissues 
which  come  in  contact  with  the  drainage-tube  are  bathed 
in  the  irrigating  fluid,  and  the  secretions  are  carried  oft' 
with  it.  There  is  no  overflow,  and  the  patient's  clothes 
and  bedding  are  kept  dry.  The  apparatus  may  be  obtained 
from  the  well-known  firm  of  George  Tiemann  &  Co. 
9  West  Thirtt-first  Street. 


INGROWN  TOE  NAIL; 

ITS  SURGICAL  TREATMENT. 
By  WILLIAM  R.  HOWARD,  M.  D., 


POUT  WORTH,  TEXAS. 


Inorown  toe  nails  have  long  been  a  source  of  trouble 
and  annoyance  to  the  surgeon  as  well  as  to  the  patient,  and 
many  methods  of  treatment  have  been  practiced  with  in- 
different success.  The  causes  are  many.  Trimming  the  cor- 
ners of  the  nail  back  too  close  to  the  fleshy  union,  hard 
shoes,  too  short  or  too  narrow  across  the  toes,  too  high  heels, 
and  congenital  soft  nails,  are  the  most  common  causes. 

The  application  of  caustic  potash  to  the  nail  to  soften 
it,  and  stuffing  cotton  under  the  corners,  may  be  success- 
ful if  done  early.  Scraping  the  nail  in  the  center  and  lift- 
ing the  corners  with  an  elastic  band  has  been  reconunended, 


580 


HOWARD:  INGROWN  TOE  NAIL. 


[N.  Y.  Med.  Jons., 


and  may  succeed  if  done  in  time.  I  have  used  strips  of 
rubber  adhesive  plaster  applied  to  the  flesh  at  the  edge  of 
the  nail  and  passed  around  beneath  the  toe  diagonally  back- 
ward, drawing  the  soft  parts  away  from  the  nail  and  treat- 
ing the  corners  as  above  mentioned,  with  fair  success  in 
selected  cases.  The  corners  of  the  nail  should  be  allowed 
to  grow  out  past  the  end  of  the  toe,  which  will  always  suc- 
ceed as  a  remedy,  except  where  the  nail  is  so  soft  and  brittle 
that  it  breaks  off  back  to  the  fleshy  union,  and  this  is  seldom 
seen  except  in  the  congenital  soft  nail. 

Removal  of  the  entire  nail  gives  only  temporary  relief, 
and  the  trouble  returns,  usually,  tenfold  worse  than  before ; 
for  when  the  nail  grows  out  again  it  is  thick  and  deformed, 
often  the  distal  end  of  the  matrix  is  destroyed,  and  the 
nail  of  sharper  incurve  than  before,  both  shortening  and 
thickening  it. 


FlQ.  1. 


Dr.  Cotting  published,  a  few  years  ago,  a  method  which 
has  met  with  favor  with  most  surgeons  as  the  best  and 
most  satisfactory  cure — that  of  slicing  off  the  side  of  the 
toe  from  the  edge  of  the  nail,  removing  all  of  the  inflamed 
part,  cutting  away  the  whole  side  of  the  toe  and  treating  it 
antiseptically,  allowing  the  wound  to  cicatrize  over  the  cut 
surface,  the  contraction  of  the  cicatrix  drawing  the  soft 
parts  away  from  the  nail. 

Another  method  recommended  is  to  remove  the  nail 
and  destroy  the  matrix  with  caustics ;  this  is  unwarrant- 
able in  all  cases  that  I  have  ever  seen,  and  will  almost  al- 
ways be  unsuccessful,  resulting  in  the  return  of  the  nail  or 
parts  of  the  nail,  where  the  matrix  has  not  been  destroyed, 
in  the  form  of  little  round,  hard  knots,  more  troublesome 
than  the  ingrown  nail,  requiring  subsequent  operations 
which  must  be  very  painful. 


Fig. 


A  method  which  to  me  is  new,  and  has  only  been  prac- 
ticed by  myself  so  far  as  I  know,  is  simple,  rational,  and, 
in  my  hands  in  more  than  a  score  of  cases,  has  been  suc- 
cessful, giving  satisfaction  in  every  case.  Fig.  1  shows  the 
condition  of  the  toe  with  ingrown  nail,  also  the  cut  made  for 


the  operation.  Commencing  about  three  sixteenths  of  an 
inch  from  the  edge  of  the  nail,  passing  the  knife  directly 
toward  the  bone,  not  going  deep  enough  to  wound  the  peri- 


FiG.  3. 


osteum,  make  the  cut  from  the  center  in  front,  horizontal 
to  the  plantar  surface,  around  and  back  to  a  line  a  little 
beyond  the  proximal  end  of  the  nail ;  next  begin  at  the 
same  place  as  before,  pass  the  knife  in  a  semicircular  man- 
ner, ending  with  the  proximal  end  of  the  first  cut,  remov- 
ing an  elliptical  wedge-shaped  section  by  bringing  the  cuts 
together  at  their  deepest  angle.  A  piece  three  eighths  of 
an  inch  in  width  is  often  sufficient  to  draw  the  soft  parts 
away  from  the  nail  when  closed.  Bring  the  edges  together 
with  deep  silk  sutures,  as  in  Fig.  2,  dress  antiseptically,  and 
immediate  union  will  take  place.  On  the  fourth  day  the 
sutures  may  be  removed  and  the  wound  dressed  as  in  any 
other  case.  In  from  a  week  to  ten  days  a  shoe  may  be 
worn  with  perfect  comfort. 


Fio.  4. 


The  operation  is  rendered  nearly  bloodless  by  placing  a 
small  rubber  band  around  the  toe,  which  is  allowed  to  re- 
main till  the  wound  is  closed.  The  time  taken  is  less  than 
ten  minutes  after  the  patient  is  thoroughly  anaesthetized. 
It  may  be  asked.  Why  not  use  cocaine  or  some  local  anaes- 
thetic ?  I  have  noticed  that  in  all  cases  of  plastic  surgery 
where  these  local  anaesthetics  have  been  used  they  have 
operated  against  perfect  immediate  union,  upon  which  the 
success  of  the  operation  so  often  depends. 

This  operation  may  be  varied  to  suit  the  case ;  for  in- 
stance, where  both  corners  are  ingrown,  or  where  the  nail 
has  been  removed  and  is  short  and  sharply  incurved,  and  al- 
lows the  end  of  the  toe  to  rise  all  around  above  the  nail,  as 
in  P'ig.  3,  the  cut  should  be  made  around  the  entire  end  of 
the  toe  (Fig.  4),  and  a  piece  sufficiently  large  removed  to 
bring  the  nail  above  the  surrounding  soft  parts  (Fig.  5). 

Often  the  second  toe  overrides  the  deformed  great  toe 
(Fig.  3,  dotted  lines) ;  in  such  cases  we  usually  find  that 
the  deformity  consists  in  a  bag,  so  to  speak,  containing 
fragments  of  hypertropliied  nail  which  keeps  up  the  irrita- 


May  27,  1893.] 


CALDWELL:   OBSTRUCTION  OF  TEE  NASAL  DUCT. 


581 


tion,  maintaining  an  abscess,  often  encysted,  causing  hyper- 
trophy of  the  soft  parts.  These  must  be  carefully  and 
certainly  removed.  In  all  cases  endeavor  to  preserve  the 
matrix,  especially  along  the  edges  and  around  the  distal 
end  of  the  nail. 


Fio.  5. 


There  is  naturally  a  great  difference  in  the  degrees  of 
firmness  of  toe  nails — some  are  soft  and  brittle  and  will  not 
bear  any  bending  without  breaking,  while  others  will  bear 
any  amount  of  manipulation  safely.  Where  we  have  trouble 
with  these  soft  nails,  the  corners  usually  break  off  and  the 
soft  parts  are  wont  to  overlap  and  cause  inflammation 


Fio.  6. 


around  the  edges  (Fig.  6).  When  tight  shoes  with  high 
heels  are  worn  there  is  very  little  that  can  be  done  to 
benefit  them.  An  operation  which  has  for  its  object  .the 
removal  of  the  greater  part  of  the  toe,  making  the  cut  en- 
tirely around  the  end,  extending  it  back  nearly  to  the  dis- 
tal joint,  will  relieve  these  cases,  if  followed  by  wearing  a 
shoe  with  broad  toe  and  low  flat  heel.  The  application  of 
one  part  of  paraffin  and  two  parts  of  tallow  will  tend  to 
toughen  the  nail  and  to  hold  the  soft  parts  away  from  the 
nail.  Many  cases  may  be  relieved  by  this  application  alone, 
properly  applied  at  the  onset  of  the  trouble. 


TWO  NEW  OPERATIONS  FOR 
OBSTRUCTION  OF  THE  JMASAL  DUCT, 

WITH  PRESERVATION  OF  THE  CANALICULI, 
AND  AN  INCIDENTAL  DESCRIPTION  OF  A  NEW  LACRYMAL  PROBE. 

By  G.  W.  CALDWELL,  M.  D., 

LATE  RESIDENT  SURGEON,  NEW  AMSTERDAM  EYE  AND  EAR  HOSPITAL  ; 
INSTRUCTOR  IN  OPHTUALMOLOGY  AND 
ASSISTANT  IN  RHINOLOGY  AND  LARY   OOLOGY  IN  THE  NEW  YORK  POLTOLINIO; 
OPHTHALMIC  AND  AURAL  SURGEON  TO 
THB  CONVENT  AND  SCHOOL  OP  THE  SISTERS  OP  ST.  DOMINIC. 

With  the  treatment  by  slitting  a  canaliculus  and  slow 
dilatation  with  probes,  obstruction  of  the  lacrymal  duct  is 
notoriously  obstinate  and  painful.  It  has  even  been  held 
by  a  prominent  oculist  that  a  perfect  cure  never  occurs, 
and  that  in  many  cases  the  last  condition  is  worse  than  the 
first.  Recent  studies  have  demonstrated  the  existence  of 
circular  and  triangular  muscular  fibers  about  the  canaliculi. 


which,  assisted  by  the  contractions  of  the  orbicularis  and 
the  capillarity  of  the  tubes,  are  sufficient  to  effect  the  nor- 
mal drainage  of  the  conjunctival  sac.  By  slitting  the 
canaliculus  this  physiological  process  is  supplanted  by  a 
simple  gravity  drain,  and  drainage  is  never  thereafter  quite 
perfect,  even  if  the  nasal  duct  is  dilated  to  such  a  size  that 
were  it  a  matter  of  simple  drainage  a  gallon  of  tears  might 
flow  through  in  an  hour.  In  health  the  capillary  tubes  of 
the  canaliculi  are  sufiicient  to  carry  away  the  tears,  yet  if 
one  of  them  is  destroyed  by  slitting,  it  is  usually  thought 
necessary  to  dilate  the  nasal  duct  to  many  times  its  normal 
size  in  order  to  secure  any  sort  of  drainage.  It  is  reasona- 
ble to  suppose  that  the  preservation  of  normal  function  of 
the  canaliculi  is  of  far  greater  importance  than  an  excessive 
capacity  of  the  nasal  duct.  While  it  may  be  true  that  a 
few  dry  skulls  have  bony  nasal  ducts  large  enough  to  admit 
the  larger  Theobald  probes,  it  is  certainly  a  fact  that  scarcely 
any  membranous  ducts  can  admit  them  ;  and  forcing  them 
through,  as  advised  by  Theobald,  "  even  if  it  fractures  the 
bony  canal,"  must  be  considered  barbarous  to  say  the  least. 
That  many  false  passages  are  made,  every  oculist  who  also 
examines  the  nose  will  be  ready  to  admit.  Gentleness  is 
imperative  in -dealing  with  all  membranous  canals.  This 
is  as  true  of  the  lacrymal  ducts  as  of  the  urethra,  although 
ill  treatment  may  not  be  so  dangerous  to  life.  By  bruising 
a  congested  nasal  duct  a  functional  stricture  may  be  changed 
into  an  organic  one,  and  to  that  extent  rough  treatment  is 
worse  than  no  treatment.  Haemorrhage  from  the  nose 
should  never  follow  simple  probing  of  the  nasal  duct. 
Each  time  it  occurs,  another  contracting  cicatrix  is  added 
to  the  stricture. 

Many  slight  cases  of  epiphora  require  only  dilatation  of 
the  canaliculi  up  to  No.  3  probe,  with  possibly  its  passage 
through  the  nasal  duct  from  the  upper  canaliculus  without 
slitting.  Usually,  however,  it  is  necessary  to  reach  the 
nasal  duct  with  larger  instruments  than  the  canaliculus  can 
admit.  In  order  to  avoid  the  destruction  of  the  canaliculus, 
which  has  so  important  a  function  in  the  drainage  of  the 
conjunctival  sac,  and  for  other  reasons  which  will  be  ap- 
parent, I  have  operated  with  very  gratifying  results  in  the 
following  manner :  A  small  probe  being  passed  through 
the  upper  canaliculus  well  into  the  sac  and  held  in  position 
by  an  assistant,  the  tissues  at  the  innc-r  canthus  are  made 
taut  by  pressure  against  the  side  of  the  nose,  and  a  small 
incision  is  made  from  the  inner  extremity  of  the  inner  can- 
thus  inward  and  backward  directly  into  the  sac  upon  the 
probe.  A  suture  should  be  taken  through  the  wall  of  the 
sac  and  the  inner  margin  of  the  wound,  the  ends  being  left 
long  for  traction  to  facilitate  the  entrance  of  instruments 
into  the  sac  in  the  subsequent  manipulations.  The  nasal 
duct  may  now  be  explored,  and  the  caliber,  length,  character, 
and  position  of  strictures  determined  by  means  of  the 
probes  which  I  will  describe  further  on.  A  stricture  being 
found,  it  should  be  divided  at  once  by  any  narrow  probe- 
pointed  knife.  If  the  edge  be  made  rather  dull,  its  service 
can  be  better  limited  to  the  stricture.  Two  or  three  nicks 
are  better  than  one  deeper  cut.  Dilatation  is  carried 
directly  up  to  No.  12  if  the  duct  will  admit  it  with  gentle 
pressure,  and  the  duct  irrigated  with  antiseptic  solution,  as 


582 


JARVIS:   MUMPS  AT  FORT  APACHE,  ARIZONA. 


[N.  y.  Mkd.  Joob., 


boric  acid.  If  the  stricture  is  slight,  the  sac  may  be 
allowed  to  close  at  once ;  if  not,  the  wound  should  be  pre- 
vented from  closing  by  the  insertion  of  an  obturator  made 
of  a  fragment  of  rubber  tissue,  while  the  stricture  is  dilated 
every  three  or  four  days  until  the  wound  in  the  duct  has 
healed,  when  the  sac  wound  may  be  freshened  and  closed 
by  catgut  sutures.  The  operation  is  done  without  pain 
under  cocaine,  a  few  minims  of  a  four-per-cent.  solution 
being  injected  into  the  point  in  the  inner  canthus  where 
the  incision  is  to  be  made  and  used  freely  in  the  duct.  In  a 
few  cases,  when  the  inferior  turbinated  is  small  and  high, 
it  is  possible  to  explore  and  dilate  the  nasal  duct  by  way  of 
the  lower  opening  in  the  inferior  meatus  of  the  nose. 

)The  probe  referred  to  above  is  made 
according  to  my  design  by  Tiemann  &l 
Co.,  and  consists  of  a  wire  staff  eleven 
centimetres  in  length,  with  a  central 
plate  for  convenience  in  handling.  On 
each  end  is  a  bullet- shaped  tip  one  centi- 
metre long,  with  conical  pomt,  parallel 
sides,  and  abrupt  shoulder.  The  tips  are 
graded  in  size,  as  are  Theobald's  probes, 
in  successive  numbers,  each  unit  of 
which  represents  one  quarter  millimetre 
of  diameter.  The  shoulders  are  intended 
to  emphasize  the  qualities  of  an  obstruc- 
tion, while  the  length  is  sufficient  to  al- 
low it  to  be  retracted  into  and  held  by  a 
stricture  for  the  purpose  of  dilatation. 
A  complete  set  comprises  seven  double- 
ended  probes  numbered  from  1,  the  staff 
alone,  to  No.  14,  the  largest  size.  The 
advantages  which  I  assert  for  this  probe 
are  that,  while  for  the  purpose  of  dilata- 
tion it  possesses  all  the  essential  prop- 
erties of  Bowman's  or  Theobald's,  it  also 
affords  the  additional  advantage  that 
with  it  a  diagnosis  of  the  location, 
length  (allowance  being  made  for  the 
length  of  the  tip),  caliber,  and  character 
of  an  obstruction  may  be  accurately 
made.  The  small  size  of  the  staff  avoids 
traction  at  the  inner  canthus  and  there- 
by lessens  the  pain.  The  entrance  of 
the  probe  into  the  open  space  between 
the  inferior  turbinated  body  and  the  outer  wall  is  immedi- 
ately indicated  by  the  loss  of  resistance.  It  is  not,  there- 
fore, necessary  to  carry  it  to  the  floor  of  the  nose  to  be 
assured  it  is  in  the  nasal  space. 

In  preparing  wet  anatomical  specimens  I  have  observed 
that  not  infrequently  the  inferior  turbinated  body  rolls 
upon  itself  in  such  a  manner  as  to  be  in  the  course  of  a 
probe  projected  through  the  nasal  duct.  When  we  re- 
member that  the  nasal  duct  is  only  a  half  to  three  quarters 
of  an  inch  in  length,  the  reasonable  suspicion  must  arise 
that  this  anatomical  arrangement  may  possibly  account  for 
some  of  those  "  very  firm  strictures  which  are  occasionally 
encountered  at  the  lower  extremity  of  the  duct,"  to  over- 
come which  probes  of  such  extraordinary  strength  and 


length  have  been  advised.  In  other  cases  the  antral  wall 
encroaches  so  far  on  the  nasal  space  that  an  ordinary  probe 
in  its  downward  course  impinges  upon  the  outer  wall  at  an 
acute  angle,  when,  if  the  force  is  continued,  the  periosteum 
is  lacerated  and  pockets  formed,  which  complicate  the  case. 
These  accidents  can  hardly  occur  in  the  use  of  this  probe, 
as  its  escape  from  the  duct  is  immediately  indicated,  and 
we  need  not  be  seriously  concerned  about  what  the  probe 
may  encounter  farther  down.  The  accompanying  sketch 
gives  a  fair  representation  of  the  instrument. 

In  those  cases  where,  in  sjjite  of  or  on  account  of  the 
long- continued  passage  of  tremendous  probes,  the  duct  has 
become  hopelessly  closed  by  fibrous  or  bony  growths,  and 
in  fractures,  caries,  and  persistent  dacryocystitis,  and  in  all 
cases  in  which  obliteration  of  the  sac  is  usually  practiced, 
it  will  be  found  that  by  tapping  the  nasal  duct  in  the  mid- 
dle meatus  the  function  of  the  tear  duct  may  be  preserved. 
This  is  best  done  by  the  electric  burr  after  passing  a  probe 
into  the  duct  as  far  as  the  stricture.  The  opening  should 
be  made  at  the  seat  of  stricture  as  indicated  by  meas- 
urements, and  enlarged  upward  as  far  as  necessary.  In  the 
two  cases  of  bony  closure  in  which  I  have  employed  this 
operation  a  complete  cure  has  resulted.  The  operation  is 
so  evidently  preferable  to  ablation  or  obliteration  of  the  sac 
that  no  argument  is  necessary  in  its  support. 


MUMPS  AT  FORT  APACHE,  ARIZONA. 
By  Oaptain  N.  S.  JARVIS, 

ASSISTANT  SXTROEON,  U.  S.  ARMY. 

(Published  by  autJwrity  of  the  Surgeon  General,  U.  S.  Army.) 

On  the  6th  of  February  of  this  year  Private  C.  D.,  Com- 
pany I,  Eleventh  Infantry,  was  admitted  to  the  post  hos- 
pital at  Fort  Apache  suffering  from  an  uncertain  enlarge- 
ment of  the  right  parotid  gland.  On  careful  inquiry  it 
was  learned  that  this  Indian  soldier  had  recently  visited 
some  of  his  band  at  San  Carlos,  Arizona,  where  mumps 
was  epidemic.  A  few  days  afterward  the  occurrence  of  a 
second  and  third  case  left  no  doubt  as  to  the  diagnosis. 

Of  the  forty  patients  that  have  been  under  observation, 
twenty-eight  were  members  of  Company  I  (Apaches),  one 
a  white  mountain  scout,  one  a  negro  ex-soldier,  and  ten 
white  men  from  Companies  F  and  H,  Eleventh  Infantry, 
and  Troop  D,  First  Cavalry. 

For  about  a  month  the  disease  confined  itself  to  the 
Indian  company,  showing  that  in  overcrowded  and  poorly 
ventilated  barracks  the  contagion  has  a  fertile  field  for  its 
extension.  The  first  white  soldier  attacked  was  a  nurse. 
The  disease  then  gradually  spread  to  the  other  organiza- 
tions. The  small  percentage  of  whites  affected  indicated 
probable  immunity  by  a  previous  attack ;  and  as  the 
Apaches  had  hitherto  led  more  of  an  open-air  existence, 
they  had  probably  escaped  the  disease  until  domiciled  in 
crowded  barracks.  Both  parotids  were  affected  in  seven- 
teen cases,  the  right  only  in  eleven,  the  left  only  in  twelve 
cases,  thus  barely  maintaining  the  predilection  in  favor  of 
the  left  parotid.  The  testicles  were  attacked  in  thirteen 
cases  (33*;3  per  cent.) — the  left  in  three  ;  the  right  in  seven  ; 


May  27,  1893.] 


BATES: 


CHRONIC  DEAFNESS  FROM  ADENOIDS. 


583 


both  in  three ;  the  right,  as  usual,  in  the  larger  percentage 
of  cases.  Of  these  thirteen  cases,  atrophy  resulted  in  three 
instances  (7"5  percent.) — in  the  right,  one;  in  the  left,  two. 
It  is  probable,  however,  that  other  instances  of  atrophy  may 
be  added  to  this  list  when  time  has  elapsed  to  permit  the 
gland  to  contract.  The  cases  in  which  atrophy  occurred 
were  by  no  means  the  most  severe  as  to  general  symptoms 
or  local  manifestations.  Two  patients  without  orchitic 
complications  had  for  several  days  a  temperature  ranging 
from  102°  to  105°  F.,  with  considerable  prostration,  stupor, 
abdominal  pain,  and  some  constitutional  depression.  In 
the  majority  of  those  in  whom  orchitis  supervened  an  in- 
terval of  from  two  to  five  days  elapsed,  the  metastatic 
complication  being  ushered  in  by  chill,  headache,  fever, 
and  tenderness  of  the  gland.  In  one  case  no  parotid  en- 
largement had  been  observed.  The  swollen  testicle  pre- 
sented a  characteristic  feel  upon  examination.  In  the  ma- 
jority of  instances  it  was  hard  and  tense,  the  tunica 
albuginea  apparently  offering  an  unyielding  wall  against 
the  more  elastic  and  cedematous  contents  of  the  sac.  Im- 
mediately above  and  back  of  the  body  of  the  gland  was  a 
small  mass  hard  to  the  touch,  of  about  the  size  and  shape  of 
a  marble,  situated  at  the  anatomical  site  of  the  globus  major ; 
it  seemed  completely  isolated  from  the  testicle  proper.  I 
have  seen  many  cases  of  orchitis  from  various  causes,  acute 
and  chronic  indurations  of  the  gland  and  epididymis,  but 
in  no  other  variety  of  testicular  inflammation  have  I  ob- 
served this  peculiar  type  of  swelling.  Symptoms  of  cere- 
bral hyperajmia,  such  as  tinnitus  aurium,  photophobia, 
epistaxis,  and  vomiting,  were  not  infrequent.  Qidema  and 
congestion  of  the  pharynx  was  another  complication,  and 
in  one  case  oedema  and  obstruction  of  the  nasal  mucous 
membrane.  The  average  Apache  Indian,  when  swollen 
with  the  mumps,  is  by  no  means  a  prepossessing  spectacle, 
and  I  regret  now  that  I  did  not  photograph  some  of  the 
more  typical  patients. 

The  treatment  in  the  majority  of  cases  consisted  at  first 
in  free  purgation  with  magnesia  or  Seidlitz  powders,  and  then 
in  the  use  of  antipyretics,  with  sedatives  when  indicated,  and 
local  applications  of  lead  and  opium  to  the  swollen  parotids. 
My  chief  source  of  anxiety  was  the  testicular  complication 
and  its  possible  result — atrophy.  To  avoid  this,  patients 
were  closely  confined  and  cautioned  against  exposure  to 
cold.  That  the  intense  oedema  held  down  by  the  rigid 
tunica  albuginea  has  much  to  do  with  subsequent  contrac- 
tion I  am  confident.  In  some  cases  where  rapid  subsidence 
does  not  follow  the  usual  methods  of  treatment,  I  think 
that  puncturing  the  gland  with  needles  at  several  points, 
under  proper  antiseptic  precautions,  would  reduce  the  in- 
flammation quickly  and  lessen  the  risk  of  subsequent 
atrophy.  I  found  that  considerable  relief  of  pain  followed 
the  use  of  a  poultice  of  flaxseed  and  tobacco ;  but  the 
oedema  did  not  subside  under  this  treatment,  and,  although 
many  practitioners  prefer  a  stereotyped  course  of  warm 
poultices  or  fomentations,  the  question  arises  as  to  whether 
lieat  should  not  be  employed  with  some  caution  in  view  of 
its  tendency  to  increase  oedema. 

Considering  such  severe  symptoms  as  I  have  reported, 
the  possibility  of  atrophy   of  the  testicle,  the  loss  of 


service,  and  expense  to  the  Government,  I  feel  confirmed  in 
the  opinion  that  a  case  of  mumps  in  a  garrison  demands 
isolation  and  every  effort  to  prevent  further  spread.  More- 
over, the  disease  has  wide  limits  in  its  intensity,  and  we 
can  never  predict,  when  it  appears,  what  type  it  may  assume. 
Von  Ziemssen  mentions  an  epidemic  in  a  French  garrison  in 
which  twenty-three  cases  of  orchitis  with  subsequent  atro- 
phy resulted  in  eighty-seven  affected  soldiers  (twenty-six 
per  cent.). 


A  CASE  OF  CHRONIC  DEAFNESS 
caused  by  adenoid  vegetations  in  the  nasopharynx. 
By  W.  H.  bates,  M.  D., 

ASSISTANT  SURGEON,  NBW  TOBK  EYE  AND  BAR  INPIRMART. 

The  patient  was  very  deaf  with  that  form  of  middle- 
ear  catarrh  which  is  not  usually  benefited  by  treatment. 
The  case  is  interesting  on  account  of  the  great  improve- 
ment in  the  hearing  which  followed  after  the  adenoid 
vegetations  were  removed. 

On  .January  14,  1893,  Mr.  M.,  aged  twenty-nine,  presented 
himself  for  treatment.  With  the  right  ear  he  can  not  hear 
loud  conversation ;  neither  the  watch  nor  a  loud-ticking  clock 
can  be  heard  when  pressed  against  the  ear;  tlie  tuning  fork  is 
lieard  better  by  bone  conduction  than  by  air  conduction.  With 
the  left  ear  he  can  hear  loud  conversation  at  four  feet;  the 
watch  is  heard  ^ ;  the  tuning  fork  is  heard  equally  well  by 
bone  or  air  conduction.  Inflation  with  the  Politzer  air  bag  is 
easy  and  the  hearing  is  not  improved  in  either  ear.  The  pa- 
tient has  no  tinnitus  aurium. 

He  gave  the  history  of  progressive  hardness  of  hearing  for 
more  than  four  years.  His  mother  and  a  brother  are  also  deaf. 
He  has  been  treated  by  inflation  for  tliree  months,  and  his 
hearing  was  worse  after  the  treatment.  A  number  of  com- 
petent otologists  in  Philadelphia  and  New  York  have  examined 
him  and  told  him  that  he  could  not  be  benefited  by  treatment. 
The  patient  states  that  his  hearing  is  usually  worse  when  he 
has  a  cold  in  his  head.  At  present  there  is  no  nasopharyngeal 
catarrh.  The  nose  appears  perfectly  normal.  The  adenoid 
tissue  in  the  vault  of  the  pharynx  does  not  interfere  with  nasal 
breathing.  There  are  adhesions  of  the  Eustacliain  tubes  to 
the  vault  of  pharynx.  The  patient  complains  of  some  diffi- 
culty in  swallowing. 

The  removal  of  the  adenoid  tissue  in  the  nasopharynx  was 
accomplished  with  great  difficulty.  The  patient's  throat  was 
very  sensitive.  At  first  the  tongue  depressor  was  sufficient  to 
excite  gagging.  The  rhinoscopic  examination  was  made  after 
many  failures.  The  throat  became  quite  tolerant  after  a  few 
days,  and  this  result  was  brought  about  by  the  perseverance  of 
the  patient,  who  introduced  his  finger  frequently  into  his  throat 
until  gagging  seldom  occurred.  During  the  operations  for  the 
removal  of  the  adenoids  no  cocaine  was  used,  because  the  pa- 
tient said  that  he  felt  no  pain  from  the  cutting.  The  removal 
of  tissue  from  the  center  of  the  vault  was  followed  by  slight 
improvement  in  the  hearing.  The  removal  of  tissue  from  above 
aud  behind  the  Eustachian  tubes  was  followed  by  the  greatest 
improvement  in  the  hearing.  It  was  only  possible  to  reach  the 
locality  of  the  Eustachian  tubes  when  the  patient  relaxed  his 
throat  completely;  the  forceps  had  to  be  forced  upward  and 
outward  and  strongly  pressed  bacikwnrd  against  tiie  bone  in 
order  to  cut  through  the  hypertrophied  tissue  in  this  region. 
The  quantity  of  tissue  removed  was  more  than  half  a  cubic 
inch.    The  forceps  was  introduced  into  the  vault  behind  the 


684 


HEYL:  WOUND 


OF  THE  HEART. 


[N.  Y.  Med.  Jocb., 


palate  more  than  fifty  times,  and  frequently  it  could  not  remove 
any  of  the  tissue  on  account  of  the  gagging,  which  forced  it  to 
the  median  line.  The  patient  was  not  exhausted  by  the  great 
number  of  operation?.  Not  all  of  the  adenoid  vegetations  were 
removed. 

January  22d. — The  patient  liears  right  watch  left  watch 
«§•  With  both  ears  open  he  appears  to  hear  ordinary  conver- 
sation at  more  than  twenty  feet.  He  hears  whispered  words 
behind  his  back  at  more  than  ten  feet. 

The  patient  left  the  city  for  his  home. 

February  16th. — He  writes  that  his  hearing  has  remained 
good. 

1.31  West  Fifty-sixth  Strket. 


WOUND  OF  THE  HEART: 

DEATH  AT  THE  END  OF  THREE  DAYS. 
By  ASHTON  B.  HEYL,  M.  D., 

l,rEUTENANT  AND  ASSISTANT  SUBGEON,  V.  8.  ARMY,  FORT  NIOBRARA,  NEBRASKA. 

(Published  by  authority  of  the  Surgeon  General.) 

About  noon,  March  19,  1893,  Private  E.  P.  W.  was  stabbed 
with  a  pocketknife  over  the  upper  margin  of  the  fifth  rib  in 
the  fourth  interspace,  the  knife  penetrating  the  chest  wall  three 
inches  to  the  left  of  the  median  line  and  three  quarters  of  an 
inch  below  and  slightly  to  the  right  of  the  left  nipple.  At  first 
shock  was  profound,  there  being  scarcely  any  pulse  at  the 
wrist.  As  soon  as  received  at  the  hospital  he  began  to  vomit, 
and  also  had  involuntary  evacuations  from  the  rectum.  A  hypo- 
dermic of  ether  was  given,  under  which  he  soon  recovered 
sufBciently  to  be  conscious  and  answer  questions.  The  wound 
was  not  explored,  but  simply  occluded.  His  condition  seemed 
to  improve  up  to  the  day  before  death,  when  the  temperature 
rose  to  102'.5°,  and  he  complained  for  the  first  time  of  pain  in 
the  left  lung  and  dyspnoea.  He  was  unable  to  retain  food ;  alco- 
holic stimulants  were  given  at  intervals  to  combat  impending 
cardiac  failure.  On  the  morning  before  death  a  pleuritic  fric- 
tion r41e  was  heard  over  the  left  lung  near  the  apex,  rapidly 
increasing  until  it  spread  over  the  whole  lung.  A  few  moments 
before  death  he  requested  that  his  head  be  lowered.  At  this 
time  the  heart's  action  was  so  weakened  that  there  was  no 
pulse  at  the  wrist.    He  died  at  2-16  p.m.,  March  22,  1893. 

Post-mortem  examination  twenty-four  hours  after  death: 
External  wound  as  above  stated.  Upon  ojjening  the  chest  cav- 
ity there  was  an  escape  of  sero-sanguinolent  liquid  from  the 
pericardium,  which  presumably  had  been  held  in  by  the  sur- 
rounding tissues,  for  as  soon  as  the  chest  wall  was  lifted  the 
fluid  poured  through  the  puncture  made  in  the  pericardium. 
There  were  evidences  of  plastic  pericarditis  and  of  pleuritis.  The 
heart  had  the  appearance  of  having  been  macerated  in  the 
liquid,  so  shrunken  was  the  external  muscular  structure.  The 
puncture  extended  not  more  than  an  eighth  of  an  inch  into  the 
heart  muscle,  at  a  point  corresponding  to  the  rhaphe  between 
the  ventricles  and  one  third  the  distance  from  the  apex  to  the 
ba.se.  The  puncture  in  the  pericardium  was  larger  than  the 
external  wound,  probably  due  to  stretching  by  the  heart's  ac- 
tion or  by  pressure  from  the  liquid  within.  The  whole  of  the 
left  lung  was  ojdematous  and  the  pleural  sac  was  filled  with 
fluid  similar  to  that  in  the  pericardium.  The  interior  of  the 
pericardial  sac  was  covered  with  plastic  exudation,  as  was  also 
the  pleural  sac,  which  latter  showed  adhesions  to  the  chest 
walls. 


The  Death  of  Dr.  Johann  Schnitzler,  of  Vienna,  is  unnounced  in 
the  hdernationale  Iclinische  Jiundschau  for  May  7th. 


THE  VALUE  OF  GALVANIC  ELECTRICITY 
APPLIED  WITHIN  THE  RECTUM. 
By  JOHN  V.  SHOEMAKER,  A.M.,  M.  D., 

PHILADELPHIA. 

In  a  host  of  morbid  processes  characterized  by  devia- 
tions from  the  normal  nutritive  type,  electricity  is  the  most 
powerful  remedial  agent  at  our  command.  It  is  also  in 
many  cases  the  most  rapidly  efficient.  The  physical,  physio- 
logical, and  therapeutical  effects  of  this  force  demand,  there- 
fore, the  closest  study.  The  action  of  the  different  forms 
of  electricity  and  the  modes  in  which  they  are  applied  are 
subjects  upon  which  we  should  seek  to  enlarge  our  knowl- 
edge and  obtain  precision  of  opinion. 

Electricity  exerts  a  remarkably  stimulating  influence 
upon  the  functions  of  the  nervous  system.  Consecutive  to 
this  effect  it  benefits  the  muscular  and  glandular  tissues, 
the  action  of  which  depends  so  closely  upon  the  condition 
of  the  nerves  by  which  they  are  animated.  Both  voluntary 
and  involuntary  muscles  are  invigorated.  A  languid  circu- 
lation is  strengthened,  and  cellular  nutrition  is  therefore 
directly  and  indirectly  improved.  Muscular  vigor  is  in- 
creased, secretory  processes  become  more  active,  digestion 
and  absorption  are  therefore  promoted,  and  the  work  of 
elimination  is  facilitated.  The  general  absorbent  system  is 
also  stimulated,  and  inflammatory  products  are  removed  un- 
der the  influence  of  this  agent. 

For  all  these  reasons  electricity  is  peculiarly  adapted  to 
the  treatment  of  a  wide  range  of  disorders.  All  those  de- 
pendent upon  or  associated  with  anomalies  of  secretion, 
feebleness  of  the  circulation,  or  depressed  nutrition  are  eflS- 
caciously  treated  by  means  of  electricity.  On  account  of 
its  effects  upon  arterioles,  capillary  and  absorbent  vessels, 
it  is  likewise  valuable  in  chronic  inflammations.  In  every 
sphere  of  medical  art  conditions  occur  which  will  receive 
their  most  effective  treatment  by  means  of  electricity. 

Atony  of  the  unstriped  muscular  fibers  of  the  intestine 
and  bladder  is  particularly  liable  to  occur.  Neglectful 
habits  as  regards  diet,  manner  of  eating,  carelessness  as  re- 
gards the  punctual  evacuation  of  the  bowels,  engender  a 
habit  of  constipation  which  has  a  natural  tendency  to  be- 
come worse  with  advancing  years.  The  intestinal  secre- 
tions diminish  ;  peristaltic  action  is  sluggish ;  a  mass  of 
hard,  dry  excrementitious  material  constantly  occupies  the 
lower  portion  of  the  colon  ;  the  wall  of  the  gut,  accustomed 
to  be  kept  on  the  stretch,  loses  its  elasticity  and  grows  lax. 
Its  propulsive  force  is  absolutely  lessened.  Cause  and  effect 
act  and  interact  upon  each  other  to  perpetuate  the  morbid 
condition. 

This  habitual  retention  of  refuse  material  within  the 
large  intestine  can  not  be  otherwise  than  detrimental  to  the 
general  health.  Waste  products  are  eliminated  by  the 
glandular  system  of  the  bowel,  microbes  are  constantly  pres- 
ent, toxic  products  are  absorbed,  the  blood  is  vitiated,  and 
general  nutrition  suffers.  A  condition  is  finally  induced 
which  Sir  Andrew  Clarke  has  described  as  "faical  anajmia." 
The  obstruction  of  the  rectal  circulation  results  in  the  for- 
mation of  internal  and  external  haemorrhoids,  with  their 
concomitant  disadvantages.   Chronic  constipation  produces 


May  27,  1893.]   SHOEMAKER:   GALVANIC  ELECTRICITY  APPLIED  WITHIX  THE  RECTUM. 


585 


headache,  dullness  of  mind,  depression  of  spirit,  palpitation 
of  the  heart,  and  languor  of  bodj'. 

Atony  of  the  bladder  is  brought  about  by  distention. 
Unavoidable  circumstances  may  sometimes  prevent  evacua- 
tion of  the  urine  and  lead  to  its  accumulation  within  the 
bladder.  This  stretching  of  the  muscular  coat  of  the  organ 
is  deleterious,  and  may  lay  the  foundation  of  persistent 
atony.  Such  a  cause  is  far  more  frequently  operative  in  fe- 
males, whose  delicacy  will  often  prevent  a  prompt  obedience 
to  the  calls  of  Nature.  In  the  vast  majority  of  cases,  how- 
ever, a  weakened  bladder  is  in  men  consecutive  to  obstruc- 
tion to  the  exit  of  urine  by  reason  of  an  enlarged  prostate 
or  old  urethral  stricture.  The  vesiculae  seminales  also  some- 
times become  enlarged  in  consequence  of  gonorrhoea!  infec- 
tion. A  chronic  inflammation  of  the  prostatic  urethra  ex- 
cites prostatorrhcea,  spermatorrhoea,  and  sexual  incapacity, 
together  with  a  long  train  of  bodily  and  mental  ills  depend- 
ent upon  an  abnormal  condition  of  the  generative  appiira- 
tus.  In  all  these  cases  electricity  is  an  admirable  remedial 
agent. 

I  have  long  been  in  the  habit  of  treating  these  disor- 
ders by  means  of  the  continuous  current  applied  within  the 
rectum.  The  intrarectal  rheophore,  attached  to  the  nega- 
tive pole,  is  introduced  within  the  bowel,  while  the  sponge- 
covered  rheophore  representing  the  positive  pole  is  adjust- 
ed by  the  patient  upon  the  perinaeum.  The  constant  cur- 
rent passes  directly  through  the  prostate  gland.  The  pa- 
tient is  able  to  exactly  graduate  the  intensity  of  the  current 
by  means  of  more  or  less  pressure  upon  the  rheophore. 
The  strength  of  the  current  should  be  about  that  of  one 
milliamp6re,  rather  less  than  more,  and  the  patient  is  at 
first  unconscious  of  its  passage.  Gradually,  however,  he 
perceives  the  rectal  electrode  becoming  heated  to  a  point  at 
which  it  can  be  comfortably  borne.  I  think  that  the  slow 
and  steady  increase  in  the  strength  of  the  current,  some- 
times from  one  to  ten  or  twelve  milliamperes,  is  of  value  in 
producing  the  result.  It  was  in  the  course  of  treating 
prostatic  disease  in  this  manner  that  I  discovered  the  rapid 
laxative  ellect  of  the  galvanic  current.  The  secretion  from 
the  mucous  membrane  is  stimulated,  as  well  as  peristaltic 


as  examples  cases  which  have  been  entirely  cured  by  gal- 
vanism applied  in  the  manner  indicated.  The  procedure 
has  been  so  simplified  that  it  can  with  the  greatest  ease  be 
practiced  by  the  subject  of  any  of  the  affections  which  I 
have  named.  The  "  prostatic  electrolyzer "  consists  of  a 
rectal  rheophore  corresponding  to  the  negative  pole.  The 
rectal  limb  of  the  instrument  has  a  movement  in  the  verti- 
cal plane,  and  in  adjusting  is  pressed  downward  toward 
the  sponge- covered  moistened  pole.    The  olive-shaped  bulb 


Pig.  1. 

action.  In  the  course  of  a  few  minutes  the  patient  ex- 
periences the  desire  to  go  to  stool.  In  describing  *  the  use 
of  the  galvanic  current  as  a  laxative,  I  expressed  the  opin- 
ion that  the  application  might,  by  repetition,  be  made  to 
have  constitutional  effects  in  the  relief  or  removal  of  chionic 
constipation.  This  surmise  has  been  amply  confirmed  by 
the  results  of  subsequent  experience,  and  I  am  able  to  cite 

*  Medical  Bulletin,  1890,  pp.  198  and  275. 


Fig.  2. 

pole  having  been  oiled,  the  instrument  is  passed  under  the 
perinseum.  The  front  handle  is  allowed  to  fall  away  ;  the 
bulb  is  passed  into  the  rectum.  The  sponge- covered  positive 
pole,  which  works  upon  a  hinge,  is  then  placed  upon  the 
perinaeum.  This  instrument  is  now  made  by  the  E.  A.  Yar- 
nall  Company,  of  Philadelphia, 
in  such  a  form  that  it  can  be 
attached  to  a  small,  portable,  in- 
expensive battery.  The  outfit 
can  be  advantageously  employed 
by  those  persons  who  may  be,  for 
various  reasons,  unable  to  place 
themselves  under  the  continued 
supervision  of  a  physician. 
As  illustrative  of  the  benefits  which  accrue  from  the  ad- 
ministration according  to  this  method,  the  following  his- 
tories are  selected  from  many  others  of  similar  kind  occur- 
ring in  the  practice  of  the  writer : 

Case  I.  Constipation. — An  nnniarried  man,  twentj-seveu 
years  of  age,  had  for  two  years  sniTered  from  indigestion.  The 
difficulty  was  consecutive  to  what  tlie  patient  denominated  as 
"inflammation  of  the  bowels."  The  symptoms  were  flatulence, 
water-brasli,  pain  in  the  epigastrium,  palpitation  of  the  heart, 
and  eructations,  lie  was  likewise  afflicted  with  constipation 
and  internal  liajmorrhoids.  The  action  of  the  heart  was  rapid 
but  regular,  and  there  were  no  adventitious  sounds.  To  compli- 
cate the  case  the  man  had  been  excessively  addicted  to  mastur- 
bation, and  was  troubled  with  spermatorrhoea.  The  application 
of  galvanism  very  speedily  overcame  the  constipation.  The 
change  was  not  merely  temporary  but  continued.  The  digestive 
functions  gradually  improved,  and  finally  the  morbid  and  ex- 


580 


SHOEMAKER:   OALVANIG  ELECTRICITY  APPLIED  WITHIN  THE  RECTUM.    [N.  Y.  Med.  Joch., 


cessive  seminal  losses  were  restrained.  Eventually  the  man  was 
discharged  entirely  cured. 

Case  II. — A  woman,  fifty-nine  years  of  age,  had  been  dys- 
peptic for  years,  but  her  symptoms  had  for  several  preceding 
months  been  aggravated.  She  was  subject  to  heartburn,  flatu- 
lence, and  eructations.  She  often  suffered  from  a  feeling 
of  nausea,  although  she  seldom  vomited.  She  had  lately  been 
troubled  by  sensations  of  faiutness  coming  on  after  meals.  She 
never  swooned,  however,  nor  did  she  become  dizzy.  Her  diet 
and  habits  were  regulated,  and  she  was  given  some  tonics  and 
digestive  ferments.  This  internal  medication  was  regarded  as  en- 
tirely subsidiary  to  the  course  of  galvanism  which  was  immedi- 
ately instituted.  She  improved  apace.  The  constipation  van" 
ished,  and  was  followed  by  the  other  evidences  of  imperfect 
digestion.  The  appetite  grew  keen,  the  lady  gained  in  weight 
and  strength,  and  reported  herself  as  feeling  better  than  she 
had  for  ten  years.  When  dismissed  she  thought  that  her  di- 
gestive powers  were  as  good  as  they  had  ever  been. 

Case  III.— A  man,  aged  twenty-seven  years,  was  subject  to 
sick  headaches.  He  vomited  and  retched,  and  after  an  at- 
tack was  destitute  of  appetite.  His  bowels  were  always  consti- 
pated. 

This  patient  did  not  need  much  treatment.  His  bowels  be- 
came regular  after  a  few  seances,  and  while  he  was  under  obser- 
vation he  was  free  from  headache.  As  the  patient  has  not 
reported  for  a  year  or  more,  the  presumption  is  that  the  im- 
provement has  been  permanent. 

Case  IV. — A  woman,  fifty-five  years  of  age,  suffered  from 
flatulent  distention  of  the  abdomen,  nausea,  and  sometimes 
vomiting,  irrespective  of  the  food  taken.  She  would  not  infre- 
quently retch  violently  when  nothing  had  been  recently  eaten. 
She  suflFered  also  from  headache,  but  not  from  vertigo.  She 
had  but  little  appetite.  Her  bowels  were  habitually  consti- 
pated, but  twice  during  the  preceding  six  months  she  had  had 
a  pseudo-dysenteric  attack,  attended  by  rather  frequent  passages 
of  mucus,  sometimes  mixed  with  blood,  the  illness  being  un- 
marked by  chill  or  fever.  There  was  no  oedema.  The  lady 
never  had  fainting  fits,  and  although  she  was  somewhat  short 
of  breath,  she  had  not  been  especially  troubled  with  dyspnoea. 
She  suffered  also  from  considerable  pain  in  the  abdomen  and 
had  lost  some  flesh.  She  had  never  vomited  blood,  there  was 
no  abdominal  tumor,  she  was  not  an  alcoholic  subject,  and 
there  was  no  albumin  in  the  urine.  The  normal  area  of  he- 
patic dullness  was  unchanged.  The  symptoms  had  first  made 
their  appearance  several  years  ago,  but  had  been  increasing  in 
severity  during  the  preceding  year.  The  patient  had  never  had 
syphilis. 

Notwithstanding  the  rather  suspicious  nature  of  the  history, 
amendment,  though  not  so  rapid  as  in  some  of  the  other  cases, 
gradually  progressed  until  the  patient  regarded  herself  as  en- 
tirely cured.  At  the  end  of  about  three  months  appetite,  di- 
gestion, and  bowels  were  in  perfect  activity,  and  the  mental 
condition  had  correspondingly  improved.  Whereas  she  had 
been  listless,  peevish,  and  despondent,  her  spirits  rose,  and  she 
was  again  able  to  extract  some  enjoyment  from  life.  Anti- 
spasmodic powders  with  powdered  charcoal  were  sometimes 
administered  to  this  patient  in  the  beginning  of  the  treatment, 
and  certainly  afforded  a  certain  amount  of  relief.  That  they 
did  not,  however,  influence  the  cause  of  her  malady  was  evi- 
denced by  the  fact  that  they  had  been  previously  employed 
with  only  temporary  benefit,  and  that,  as  she  began  to  improve 
under  the  use  of  galvanism,  the  powders  were  altogether  aban- 
doned. 

Case  V. — -A  woman,  twenty-three  years  of  age,  had  lately 
been  annoyed  by  flatulence  after  eating  and  pain  in  the  stom- 
ach.   II(!r  appetite  was  poor  and  her  bowels  habitually  consti- 


pated. There  was  no  nausea  or  vomiting.  She  often  had  head- 
ache, and  had  lost  flesh  and  color.  Her  menses  had  always 
been  regular  until  within  the  last  period,  when  an  interval  of 
only  two  weeks  elapsed.  She  had  had  some  lencorrboea  of  late. 
The  effects  of  treatment  need  not  be  given  in  detail.  Suffice  it 
to  say  that  in  six  weeks'  time  this  patient  went  home  with  a 
good  appetite,  excellent  digestion,  and  regular  bowels.  The 
leucorrhoea  also  had  disappeared.  She  had  appreciably  gained 
in  flesh,  and  her  com])lexion  had  lost  its  dull  ])allor  and  exhibited 
a  more  healthy  hue. 

Case  VI. — A  woman,  forty-seven  years  of  age,  hou.sekeeperi 
had  for  six  months  experienced  great  distress  after  eating. 
Her  principal  troubles  were  extreme  flatulence  and  palpitation 
of  the  heart.  The  flatulence  appeared  very  soon  after  eating 
and  continued  for  several  hours — often  as  many  as  six  or  eight. 
The  palpitation  occurred  at  irregular  times,  and  was  often  pres- 
ent, but  not  every  day.  She  had  no  colicky  pains,  but  there 
was  generally  a  feeling  of  soreness  over  the  stomach  on  pres- 
sure. The  gaseous  distention  chiefly  concerned  the  stomach, 
which  became  enormously  swollen  and  outlined  in  the  epigas- 
trium and  hypochondriac  region.  Some  houi's  after  a  meal  the 
swelling  usually  descended  to  the  lower  abdominal  regions. 
There  was  no  evidence  of  hepatic  disturbance.  She  had  never 
been  of  a  "bilious"  liabit.  Her  bowels  were,  and  long  had 
been,  extremely  constipated.  She  seldom  had  nausea  and 
never  vomited.  She  did  suffer  from  headache  or  vertigo,  but 
had  fallen  into  the  habit  of  brooding,  and  was  very  melancholy 
and  nervous.  She  did  not  sleep  well  on  account  of  her  nerv- 
ousness. She  occasionally  had  sour  stomach.  She  had  not 
much  appetite  for  the  morning  or  evening  meal,  but  had  a  taste 
for  a  midday  dinner,  although  she  almost  dreaded  to  eat  be- 
cause she  suffered  so  much  from  indigestion.  She  was  not 
able  to  determine  that  her  symptoms  depended  especially  upon 
any  particular  kind  of  food.  She  lived  upon  a  mixed  diet,  but 
had  abandoned  the  use  of  fried  food,  pastry,  and  coffee.  This 
patient  led  a  very  monotonous  indoor  life. 

In  the  management  of  this  case  pepsin  was  given  for 
a  while  in  order  to  assist  digestion,  and  the  galvanic  current  was 
used  within  the  rectum  for  the  relief  of  the  constipation.  The 
result  was  all  that  could  be  desired.  The  bowels  became  active 
and  the  various  symptoms  of  indigestion  ameliorated  after  a 
few  applications.  In  comparison  with  the  chronicity  of  the  case 
the  improvement  was  remarkably  rapid.  The  patient  was  dis- 
charged at  the  end  of  three  months.  The  bowels  were  then 
moving  regularly  once  in  the  twenty-four  hours,  which  previous 
to  the  treatment  they  had  not  done  for  a  number  of  years. 
The  woman  had  regained  her  natural  spirits,  no  longer  sat 
brooding  alone  all  day,  but  was  pleased  to  make  and  receive 
neighborly  calls. 

Case  VII. — A  woman,  aged  fifty  years,  had  mild  dyspeptic 
symptoms,  but  had  a  dirty  tongue,  had  dull  headache  much  of 
the  time,  and  often  experienced  a  sense  of  suffocation.  Her 
bowels  were  very  sluggish  and  hard  to  move  by  the  aid  of  pur- 
gative medicine.  She  had  been  in  this  condition  for  many 
years.  She  was  soon  cured  solely  by  the  use  of  galvanism  ap- 
plied in  the  manner  described. 

Case  VIII. — A  man,  aged  fifty-eight  years,  who  suffered 
from  extreme  flatulence  and  constipation,  was  entirely  relieved 
by  the  same  plan  of  treatment. 

Case  IX. — A  young  girl,  aged  eighteen  years,  who  had  long 
been  subject  to  frequent  attacks  of  headache  and  vertigo,  had 
an  irregular  and  capricious  appetite  with  a  very  weak  digestion. 
There  was  a  good  deal  of  flatulence  after  eating,  and  from  time 
to  time  she  experienced  exacerbations  of  dyspepsia,  upon  which 
occasions  the  vertigo  was  always  aggravated.  The  girl  was 
very  constipated. 


May  27,  1893.]   SHOEMAKER:   GALVANIC  ELECTRICITY  APPLIED  WITHIN  THE  RECTUM. 


587 


The  constipation  was  soon  relieved  and  the  digestion  bene- 
fited by  applications  of  galvanism.  The  attacks  of  pain  in  the 
head  and  dizziness  became  less  frequent  and  less  severe. 

Case  X.  Internal  Hcemorrhoids. — A  man,  aged  thirty-five 
years,  had  been  troubled  with  piles  for  fifteen  months.  They 
had  caused  him  more  or  less  annoyance,  but  had  not  given  rise 
to  much  suffering  until  within  the  preceding  month.  For  two 
days  past  they  had  been  paining  him  exceedingly,  so  that  he 
had  no  comfort  in  any  position  and  could  not  sleep  well  at 
night.  At  times  they  had  bled,  occasionally  quite  freely.  The 
bleeding  always  gave  him  temporary  relief.  Examination 
showed  several  large  protruding  masses  surrounding  the  margin 
of  the  anus,  of  a  purple  color  and  very  sensitive.  He  was  able 
to  return  them  himself,  but  they  would  not  remain  in  position. 
The  man  was  ordered  to  remain  in  bed  for  two  days,  and  an  oint- 
ment composed  of  tannic  acid  and  stramonium  was  kept  ap- 
plied. The  pain  was  by  this  means  alleviated  and  the  tumors 
reduced  in  size.  I  then  began  to  use  the  constant  current.  The 
treatment  at  first  caused  some  pain,  but  this  grew  less  at  each 
re[)etition  and  the  tumors  demonstrably  lessened  in  size, 
until  at  the  end  of  a  month  tliey  could  no  longer  be  detected. 

Case  XI. — A  woman,  aged  fifty  years,  had  for  years  been 
subject  'to  constipation  and  also  to  occasional  protrusion  of 
piles.  The  latter  had  not  given  her  much  pain  or  trouble  until 
within  |the  preceding  week.  Occasionally,  at  long  intervals, 
they  would  relieve  themselves  by  bleeding,  after  which  they 
became  smaller  and  ceased  to  protrude  or  cause  pain. 

One  week  before  she  came  to  me  they  again  began  to  pro- 
trude in  consequence  of  straining  at  stool.  Although  at  times 
the  tumors  wei-e  not  so  large  as  at  others,  yet  they  had  re- 
mained down  all  the  time.  They  caused  her  excessive  pain, 
restlessness,  nervousness,  and  sleeplessness.  The  patient  lost 
appetite,  had  nausea,  and  sometimes  vomited.  The  bowels  were 
obstinately  constipated.  The  pain  was  of  a  throbbing  char- 
acter and  very  severe,  compelling  her  to  assume  many  diflferent 
positions,  although  she  obtained  no  decided  relief  from  any 
change.  The  pain  seemed  equally  intense  whether  she  was  sit- 
ting, standing,  or  lying.  The  tumors  had  not  bled  any  during 
this  attack. 

Upon  examination,  I  found  at  the  anus  a  large  mass  of  about 
the  size  of  a  pigeon's  egg,  composed  of  an  aggregation  of  sev- 
eral tumors.  They  were  very  much  swollen,  extremely  sensi- 
tive to  the  lightest  touch,  and  seemed  to  be  on  the  verge  of 
strangulation,  being  oedematous  in  some  spots  and  of  a  livid  hue 
in  other  places.  The  base  was  firmly  constricted  by  the  ex- 
ternal sphincter  ani.  The  mucous  membrane  was  highly  in- 
jected though  not  eroded.  The  patient  had  tried  to  replace  the 
tumors,  but  had  not  succeeded.  As  it  would  have  been  almost 
impossible  to  return  them  without  the  aid  of  an  anjesthetic,  I 
ordered  an  ointment  of  cocaine  hydrochloride  together  with  a 
purgative.  After  the  bowels  had  been  well  opened,  a  few  doses 
of  morphine  were  administered  at  intervals  in  order  to  control 
the  pain.  Two  days  later  the  piles  were  considerably  smaller, 
less  vascular,  and  decidedly  less  tender  upon  pressure.  The 
bowels  operated  without  pain,  she  was  able  to  sleep  without 
the  aid  of  morphine,  and  her  api)etite  was  beginning  to  im- 
prove. Ten  days  after  I  tirst  saw  her  I  was  able  to  insert  the 
rectal  pole  and  begin  a  course  of  galvanism.  The  hajmorrhoidal 
tumors  steadily  diminished  in  size.  The  treatment  created  no 
pain,  evacuations  from  the  bowels  became  regular,  and  the  pa- 
tient was  finally  discharged  cured. 

Case  XII. — A  woman,  aged  fifty-five  years,  had  suffered 
from  internal  hasmorrhoids  for  more  than  live  years.  They 
had  occasioned  great  i)aiii,  tenesmus,  and  prolapse  of  the  rectum. 
At  times  they  liad  bled.  They  were  very  much  inflamed,  the 
mucous  membrane  was  abraded  in  spots,  and  a  fissure  of  the 


anus  had  formed.  After  a  preliminary  treatment  similar  to 
that  of  the  preceding  case,  galvanism  was  made  use  of  with  the 
same  happy  result. 

Case  XIII. — A  woman,  aged  twenty  years,  had  suffered 
from  haemorrhoids  ever  since  a  confinement  eight  months 
previously.  They  had  gradually  grown  worse  and  had  become 
very  painful.  They  protruded  and  bled.  Her  bowels  were 
habitually  constipated.  The  constant  current  effected  a  com- 
plete cure. 

Case  XIV. — A  man,  aged  twenty-eight  years,  had  been  for 
three  or  four  days  passing  blood  at  stool.  He  did  not  suf- 
fer pain  then  or  at  any  other  time.  He  was  the  subject  of 
chronic  constipation.  About  a  year  previously  he  had  been 
troubled  with  piles,  but  they  did  not  bleed  and  disappeared 
without  treatment.  Examination  revealed  a  small  bunch  ot 
hfemorrhoids  protruding  when  he  strained,  and  a  small  quantity 
of  blood  escaped  at  the  same  time  from  the  anal  orifice.  Digital 
exploration  detected  a  protuberance  of  the  mucous  membrane, 
just  above  the  internal  sphincter,  on  the  anterior  surface  of  the 
gut  and  somewhat  tender  to  pressure.  This  man  suffered  from 
palpitation  due  to  a  "tobacco  heart."  The  cardiac  action  was 
irregular.  Galvanism  checked  the  hemorrhage,  caused  the 
tumors  to  shrink,  and  also  corrected  the  irregularity  of  the 
heart.    He  was  directed  to  abstain  from  the  use  of  tobacco. 

Case  XV.  Relaxation  of  the  Sphincter  Vesica. — A  woman, 
aged  forty-five  years,  complained  that  for  two  or  three  years 
past,  whenever  she  coughed,  sneezed,  vomited,  or  by  any  strain 
brought  the  abdominal  muscles  into  play,  or  whenever  she  was 
jarred,  as  in  descending  from  a  step,  a  gush  of  urine  escaped. 
This  had  become  so  great  a  trouble  to  her  that  she  was  con- 
stantly kept  wet  and  chafed.  She  had  a  very  irritable  stomach 
and  had  a  cough  much  of  the  time.  She  suffered  from  headache, 
dizziness,  and  dimness  of  vision  on  suddenly  rising.  She  was 
habitually  constipated.  The  lips  and  tongue  were  pale.  The 
patient  had  within  the  period  mentioned  lost  a  great  deal  of 
flesh.  There  were  no  symptoms  of  cystitis.  There  was  a  small 
external  haamorrhoid.  Neither  nephritis  nor  tuberculosis  ex- 
isted. The  galvanic  current  was  passed  in  taginam  and  the 
sphincter  of  the  bladder  gradually  recovered  its  tone.  Consti- 
pation vanished. 

In  chronic  affections  of  the  prostate  gland  galvanism, 
applied  according  to  the  method  detailed  in  this  paper, 
affords  more  satisfactory  results  than  any  other  plan  of 
treatment.  I  wish  to  allude,  in  the  first  place,  to  the 
gradual  hypertrophy  of  the  gland,  which  is  so  frequently 
observed  in  persons  of  advancing  years.  The  obstinacy  of 
this  affection  to  every  form  of  medical  or  surgical  treat- 
ment is  due  to  the  histological  character  of  the  growth. 
We  are  not  concerned  here  with  a  mere  organization  of  in- 
flammatory products  or  proliferation  of  interstitial  connec- 
tive tissue,  but  with  an  actual  increase  in  the  normal  con- 
stituents of  the  organ.  The  prostate  is  composed  of  un- 
striped  muscular  fibers  inclosing  true  gland  cells.  In  senile 
hypertrophy  we  find  an  increase  of  both  the  muscular  and 
cellular  elements.  Hence  the  difficulty  in  effecting  any  re- 
duction of  size.  I  am  able,  however,  from  abundant  ex- 
perience, to  assert  that  the  constant  current  is  able  to  ac- 
complish exactly  what  is  desired — viz.,  to  limit  the  new 
production  of  tissue  and  to  bring  about  a  diminution  in  the 
size  of  the  organ.  Surgical  intervention  has  proved  of  no 
avail  in  this  condition.  We  now  possess  in  galvanic  electri- 
city the  only  efficient  means  of  reducing  an  hypertrophied 
prostate  approximately  to  its  normal  size.   Were  the  current 


588  SHOEMAKER:   GALVANIC  ELECTRICITY  APPLIED  WITHIN  THE  RECTUM.    [N.  Y.  Mkd.  Joup., 


restricted  in  its  therapeutic  efficiency  to  this  single  r6h,  it 
would  be  impossible  to  overestimate  its  efEect  upon  human 
life  and  happiness.  The  slow  but  sure  progress  of  hyper- 
trophy of  the  prostate  is  accompanied  by  ills  which  make 
life  a  burden  long  before  the  patient  is  released  by  death 
from  his  sufferings.  At  first  the  obstruction  to  the  uretliral 
channel  simply  renders  the  act  of  micturition  somewhat 
laborious  and  ineffectual.  Imperfect  evacuation  necessitates 
more  frequent  acts  of  urination.  The  difficulty  progres- 
sively increases,  and  after  a  time  it  is  very  difficult  to  empty 
the  bladder.  The  latter  organ  hypertrophies.  Its  mucous 
membrane  becomes  the  seat  of  inflammation.  The  urine 
then  alters  in  character ;  it  becomes  alkaline  in  reaction, 
turbid,  and  mixed  with  ropy  mucus.  It  readily  undergoes 
decomposition,  not  infrequently  even  before  it  is  passed. 
Recourse  must  eventually  be  had  to  the  catheter.  The 
thickened  bladder  becomes  atonic.  Obsti'uction  in  front, 
loss  of  propulsive  power  behind,  an  intiamed  bladder,  an 
acrid  urine — all  co-operate  to  produce  a  most  distressing 
condition.  Haemorrhoids  and  prolapse  of  the  rectum  are 
common  sequelae,  and  finally  the  ureters  and  kidneys  become 
involved.  This  frightful  train  of  consequences  may  be 
averted  by  the  institution  as  early  as  possible  of  judicious 
treatment. 

Case  XVI. — A  man,  aged  sixty- six  years,  came  to  me  in 
great  distress  about  eleven  o'clock  one  night,  complaining  that 
he  could  not  pass  water.  He  had  urinated  last  at  6  p.  m.,  had 
drunk  several  glasses  of  beer  during  the  evening,  and,  upon 
preparing  to  go  to  bed,  found  himself  unable  to  void  his  urine. 
He  soon  began  to  suffer  pain  from  the  retention,  became  alarmed 
and  very  nervous.  This  was  the  first  occasion  when  he  had 
been  incapable  of  relieving  his  bladder.  A  catheter  was  passed 
and  about  two  quarts  of  urine  withdrawn.  Digital  examina- 
tion per  rectum  revealed  hypertrophy  of  the  prostate. 

This  was  a  favorable  case  for  treatment.  The  enlargement 
was  moderate  in  extent;  it  had  not  previously  given  rise  to 
noteworthy  symptoms;  the  urine  was  clear;  the  general  con- 
dition good.  At  my  advice  the  man  placed  himself  under 
systematic  treatment.  He  had  no  recurrence  of  retention,  the 
tumor  gradually  diminished  in  volume  until  it  was  scarcely  ap- 
preciable, and  the  patient  considered  himself  entirely  onred. 
The  relief  has  been  permanent  to  the  present  time — a  period  of 
more  than  two  years. 

Case  XVII. — A  man,  aged  sixty  years,  exemplified  a  more 
advanced  stage  of  the  affection.  He  had  for  two  or  three  years 
been  conscious  of  increasing  difiiculty  in  the  act  of  micturition. 
He  was  obliged  to  strain  a  good  deal  when  he  endeavored  to 
pass  urine:  he  experienced  the  desire  quite  frequently  and  was 
generally  forced  to  rise  two  or  three  times  during  the  night. 
At  times  he  suffered  from  pains  at  the  head  of  the  penis  and 
smarting  sensations  along  the  course  of  the  urethra.  The  urine 
contained  some  mucus,  but  was  free  from  the  ropy,  viscid  sedi- 
ment characteristic  of  chronic  cystitis.  Treatment  by  means  of 
the  prostatic  electrolyzer  was  followed  by  notable  amelioration 
of  the  symptoms.  The  act  of  evacuation  became  less  difficult 
and  less  frequent,  he  was  freed  from  the  necessity  of  rising  at 
night,  the  uneasy  sensations  in  the  urethra  vanished,  and  digital 
exploration  assured  me  that  the  gland  had  been  reduced  almost 
to  its  normal  size. 

Case  XVIH. — The  case  of  a  man  aged  seventy-four  years 
excellently  illustrates  the  final  period  with  consecutive  renal 
disease.    The  history  of  his  difficulty  ran  back  for  ten  years. 


The  steps  by  which  it  had  progressed  need  not  be  rehearsed. 
When  I  first  sawi;him  he  had  long  been  dependent  upon  the  cathe- 
ter. The  urine  was  alkaline  and  contained  much  ropy  mucus. 
It  emitted  a  decided  ammoniacal  odor.  He  suffered  from  an 
uneasy  sensation  of  fullness  in  the  rectum,  his  general  health 
had  sensibly  declined,  he  was  weak  and  obliged  to  remain  in 
bed  a  good  part  of  his  time.  There  was  great  hypertrophy 
of  the  prostate,  involving  both  lateral  and  the  middle  lobe.  The 
case  was  unpromising,  but,  in  addition  to  remedies  adapted  to 
alleviate  the  cystitis,  I  resolved  to  make  use  of  galvanism  in  the 
hope  that  it  might,  render  urination  less  difficult.  The  effect 
was  better  than  I  expected.  The  desire  to  pass  water  became 
less  frequent,  the  patient  obtained  more  rest,  his  general  condi- 
tion improved,  and  the  character  of  the  urine  changed  for  the 
better.  The  mucus  became  decidedly  less  abundant  and  lost  its 
ammoniacal  odor.  It  was  too  late  to  effect  a  decided  reduction 
of  the  enlarged  gland,  and  indeed  the  kidneys  had  become  dis- 
eased. The  galvanic  current,  however,  mitigated  the  old  man's 
sufferings,  rendered  his  last  year  of  life  less  intolerable,  and,  [ 
am  satisfied,  prolonged  his  existence  for  some  months. 

Prostatorrhoea,  Spermatorrhoea,  Impotence. — If  enlarged 
prostate  renders  life  a  burden  to  the  aged,  disease  of  the 
prostatic  urethra,  its  symptoms  and  consequences,  destroys 
the  happiness  of  the  young  and  middle-aged.  The  mental 
effects  in  this  class  of  cases  are  even  more  serious  than  the 
physical  ills.  A  most  wretched  state  of  mind  is  engen- 
dered. The  patients  have  generally  abused  themselves  in 
youth,  and  an  exaggerated  estimate  of  the  damage  which 
the  practice  is  capable  of  producing,  together  with  a  spirit 
of  self-accusation  or  remorse,  renders  life  miserable.  Vari- 
ous refiex  nervous  phenomena  are  also  observed  in  these 
patients.  Medicinal  treatment  is  of  comparatively  little 
avail.  Distention  of  the  prostatic  urethra  by  large-sized 
steel  sounds  is  a  serviceable  procedure,  but  I  have  found 
the  intrarectal  use  of'the  constant  current  even  more  bene- 
ficial. I  will  cite  a  few  cases  in  which  this  method  proved 
effectual. 

Case  XIX. — A  youth,  nineteen  years  of  age,  had  mastur- 
bated from  the  age  of  fourteen,  and  had  not  yet  succeeded  in 
freeing  himself  from  the  habit.  For  some  time  past,  however, 
he  had  endeavored  to  do  so  and  seldom  deliberately  indulged  in 
the  practice.  But  he  was  troubled,  and  had  been  for  some 
years,  with  involuntary  nocturnal  emissions.  Going  to  bed 
without  thought  of  indulgence,  or  at  least  with  a  determina- 
tion to  abstain,  he  had,  at  some  time  during  the  night,  an  erotic 
dream  and  awoke  to  find  himself  handling  his  penis.  An  emis- 
sion then  took  place  or  was  provoked.  Occasionally  an  emission 
would  take  place  without  awakening  him,  and  he  only  learned 
of  the  fact  by  observing  a  stain  upon  the  bed-clotliing.  Noc- 
turnal pollutions  occurred,  on  an  average,  about  once  a  week. 
On  the  following  day  he  felt  languid  and  had  backache.  He 
had  no  pain  over  the  abdominal  rings  or  in  the  testicles.  He 
suffered  at  such  times  from  a  dull  frontal  headache.  He  had 
no  urethral  or  prostatic  discharge.  He  had  never  cohabited. 
The  lad's  general  health  was  good,  his  appetite  was  fair,  and  his 
bowels  were  regular.  He  had  not  noticed  any  irregularity  as  re- 
gards urination.  Examination  demonstrated  that  the  prostatic 
urethra  was  noticeably  sensitive.  The  patient  was  completely 
cured  within  three  months.  He  persevered  in  his  efforts  to  ab- 
stain from  self-abuse.  The  abnormal  sensibility  of  the  urethra 
lessened  and  finally  disappeared ;  erotic  dreams  and  nocturnal 
emissions  became  less  frequent  and  ceased  to  be  followed  by 
languor  or  pain. 


May  27,  1893.J 


LEADING 


ARTICLES. 


589 


Case  XX. — An  unusually  robust  man,  aged  twenty-five 
years,  was  greatly  troubled  in  mind  by  frequent  erotic  dreams 
and  emissions.  He  had  long  been  a  masturbator,  although  he 
averred  that  he  had  abandoned  the  practice.  This  patient  had 
a  very  shy  and  self-conscious  air,  and  was  very  anxious  that  his 
sexual  functions  should  be  restored,  as  he  was  desirous  to  marry. 
Seminal  losses  occurred  once  or  twice  a  week  and  left  some 
feeling  of  weakness  on  the  following  day.  lie  had  backache, 
but  there  were  no  prominent  reflex  phenomena.  Here  again  I 
found  the  prostatic  urethra  tender.  The  individual  made  a 
rapid  recovery,  married,  lost  his  morbid  fears,  and  in  the  course 
of  a  year  begot  a  child. 

Case  XXI. — A  well-developed  man,  aged  thirty-two  years, 
had  for  five  years  been  afl:ected  with  premature  ejaculations  in 
coition.  The  difficulty  was  growing  worse.  He  had  originally 
been  of  a  strongly  amorous  disposition,  and  indulged  freely  in 
social  intercourse.  He  had,  however,  become  so  afflicted  that 
he  scarcely  more  than  efi^ected  entrance  before  ejaculation  oc- 
curred. The  patient  had  consequently  become  apprehensive 
of  his  sexual  capacity.  He  had  no  pain  in  the  back,  testicles, 
or  head  ;  no  form  of  neuralgia  ;  had  a  good  appetite  and  diges- 
tion. The  man  seldom  suflered  from  an  involuntary  nocturnal 
emission.  He  ascribed  his  trouble  to  an  attack  of  gonorrhoea. 
His  sexual  vigor  had  never  since  been  the  same.  A  redundant 
prepuce  was  retrenched.  After  the  wound  had  healed  he  was 
subjected  to  a  galvanic  course  and  soon  regained  his  original 
sexual  vigor. 

There  is  still  another  difficulty  in  which  I  found  this 
method  of  applying  the  galvanic  current  within  the  rectum 
of  advantage.  I  refer  to  inflammation  of  the  seminal  vesi- 
cle, or  gonecystitis.  This  is  an  affection  of  which  very  little 
is  said  in  the  text-books.  No  doubt  it  is  of  rare  occur- 
rence, and  yet,  judging  by  ray  own  experience,  it  is  more 
common  than  is  generally  supposed.  At  any  rate,  I  meet 
from  time  to  time  with  such  a  case  as  the  following : 

Case  XXIF. — A  man,  twenty-four  years  of  age,  six  months 
previously  had  acquired  gonorrhoea.  No  unusual  manifesta- 
tions were  presented  until  in  the  third  week,  when  the  urethral 
discharge  was  declining.  The  patient  then  began  to  suffer  from 
pain  situated  low  down  in  the  rectum.  The  pain  was  intensi- 
fied when  the  bowels  were  moved.  Urination  was  difficult. 
The  symptoms  had  subsided,  but  had  never  entirely  disap- 
peared. He  still  suffered  at  times  from  pain  in  the  rectum  and, 
occasionally,  from  painful  erections.  A  slight  urethral  dis- 
charge had  also  lingered.  Spermatozoa  could  be  detected  in 
the  discharge  when  examined  under  the  microscope.  Upon  ex- 
ploring the  rectum,  I  found  an  oval  swelling  behind  the  pros- 
tate gland  which  was  unaltered.  The  tumor  corresponded  to 
the  position  of  the  right  seminal  vesicle.  It  was  hard,  of  irregu- 
lar outline,  and  somewhat  sensitive  to  pressure.  Under  the  in- 
fluence of  galvanism  the  tenderness  gradually  diminished  and 
the  swelling  was  reduced  in  size. 

This  lesion  usually  occurs  upon  one  side  only,  but  excep- 
tionally both  vesiculae  seminales  are  involved.  In  the  acute 
stage  it  gives  rise  to  severe  suffering,  and  at  times  to  noctur- 
nal emissions  containing  a  mixture  of  semen,  pus,  and  blood. 

I  have  in  this  paper  limited  myself  to  an  enumeration 
of  the  advantages  derived  from  the  use  of  galvanism  ap- 
plied within  the  rectum  by  means  of  a  special  instrument. 
I  have  consequently  avoided  reference  to  the  value  of  elec- 
tricity in  the  treatment  of  urethral  stricture.  The  effect  of 
the  current  upon  the  caliber  of  the  rectum  I  have  described 
in  former  papers  to  which  1  have  made  allusion. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frahk  P.  Fosteb,  M.  D. 


NEW  YORK,  SATURDAY,  MAY  27,  1893. 


THE  TREATMENT  OF  MYXEDEMA. 

The  Edinburgh  Medical  Journal  for  May  contains  a  paper 
on  the  use,  during  the  past  two  years,  of  thyreoid  extract  in 
myxoedema  and  allied  conditions,  by  Dr.  Robert  A.  Lundie. 
From  1878,  when  Dr.  Ord  made  his  original  contribution  to  the 
subject  of  myxoedema,  to  1891,  there  had  been  only  palliative 
treatment  brought  to  light  in  respect  to  that  disease.  A  care- 
ful regard  for  the  patient's  personal  hygiene,  massage,  a  change 
of  environment,  or  a  milder  climate  had  been  known  to  benefit 
a  few  patients ;  others  had  improved  slightly  and  transiently 
under  the  use  of  such  drugs  as  jaborandi,  nitroglycerin,  arsenic, 
and  strychnine.  In  Dr.  Ord's  article  on  this  disease,  written 
for  Quain's  Dictionary  oj  Medicine  about  ten  years  ago,  that 
author  stated  that  not  much  hope  of  improvement  could  be 
predicated  of  drugs  ;  he  said  :  "  The  progress  of  the  disease  is 
not  readily  affected  by  any  remedy,  and  the  prognosis  is  alto- 
gether unfavorable."  Now,  however,  thanks  to  the  plan  of 
treatment  instituted  in  1891  by  Dr.  G.  R.  Murray,  of  Newcastle, 
England,  and  confirmed  by  others  in  the  same  year  and  in  1892, 
there  are  few  abnormal  conditions  that  are  so  certainly  amelio- 
rated by  treatment.  Dr.  Murray's  plan  consisted  in  the  subcu- 
taneous injection  of  a  sterilized  extract  of  the  thyreoid  of  the 
sheep.  Two  glands  and  a  half  were  used  in  the  first  case,  in 
the  space  of  three  months  ;  afterward  he  used  a  manufactured 
glycerin-extract  in  doses  averaging  twenty-five  minims  every' 
two  weeks.  In  later  oases  the  same  physician  has  used  the  ex- 
tract in  doses  of  from  twelve  to  twenty-five  minims  weekly,  also 
in  daily  doses  of  ten  minims  when  they  are  taken  by  the  mouth. 
In  cases  where  thymus  extract  was  used,  the  reported  results 
were  far  from  being  satisfactory. 

The  subcutaneous  method  of  treatment  continued  in  vogue 
during  the  greater  part  of  1892,  and  was  followed  by  most  grati- 
fying improvement  in  nearly  every  instance.  Dr.  Lundie  pre- 
sents a  tabular  statement  of  thirty-two  cases  thus  treated  dur- 
ing 1892,  and  of  only  two  of  these  is  it  stated  that  no  improve- 
ment occurred.  As  these  two  exceptional  cases  occurred  in  the 
practice  of  the  same  physician,  there  is  room  for  a  belief  that 
the  size  of  the  dose  or  the  method  of  procedure  was  at  fault. 
Of  the  results  that  have  been  recorded  as  favorable  wc  find  a 
wide  range  in  regard  to  the  extent  of  the  improvement ;  one 
patient  is  reported  "  practically  cured,"  another  "immensely 
improved,  another,  a  maniac,  "improved  both  physically  and 
mentally,"  another  "slightly  improved."  One  patient  recov- 
ered pari  passu  from  myxoedema  and  from  melancholia ;  and 
another  patient  having  a  severe  nephritis  improved  decidedly 
in  that  respect  as  well  as  in  the  more  serious  malady.  Dr» 


590 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jodb., 


Byrom  Bramwell  has  seen  amenorrhoea  and  albuminuria  disap- 
pear quite  early  in  the  course  of  thyreoid  feeding ;  but  in  cases 
of  myxcedenia  occurring  in  elderly  people,  where  the  albumin 
is  present  in  consequence  of  an  associated  cirrliosis  of  the  kid- 
ney, the  albuminuric  symptom  may  not  be  expected  to  clear  up 
in  the  same  manner  as  in  younger  patients.  One  of  Dr.  Dun- 
lop's  cases,  reported  in  the  same  journal  that  contains  Dr.  Luu- 
die's  paper,  was  remarkable  as  an  example  of  myxcedema  fol- 
lowing a  recovery  from  goitre,  with  atrophy  of  the  tliyreoid 
gland  as  a  consequence  of  that  recovery.  This  was  a  case  of 
myxcedema  having  a  more  distinct  organic  origin  than  is  ordi- 
narily the  case.  It  is  true  that  there  is  wasting  of  the  gland  as 
the  malady  progresses,  but  it  seems  to  be  a  feature  of  develop- 
ment rather  than  of  origin,  as  in  this  instance.  The  recovery 
in  this  case  was  so  marked  that  the  rejiorter  writes:  "Tiiis  case 
is  a  good  example  of  the  rapidity  with  which  improvement 
takes  place,  all  the  symptoms  having  yielded  to  treatment  in  a 
couple  of  months." 

The  administration  of  thyreoid  gland  by  the  mouth  was  be- 
gun by  three  or  more  physicians,  independently  of  one  another, 
in  difiFerent  towns  and  countries  nearly  simultaneously,  in  the 
latter  part  of  1892.  The  gland  was  variously  used — raw, 
cooked  (parboiled  or  fried),  extracted  in  glycerin,  and  in  the 
form  of  a  dry  powdered  extract.  These  methods  of  prepara- 
tion have  all  been  found  about  equally  efl5cacious,  except  when 
too  much  heat  has  been  applied  in  the  process  of  cooking  the 
gland  ;  from  which  it  seems  probable  that  the  physiological 
constituent  of  the  gland  that  is  potent  against  myxcedema  is  de- 
stroyed by  heat. 

The  thyreoid  of  the  sheep  has  generally  been  used,  but  that 
of  other  animals,  such  as  kine,  calves,  and  swine,  has  also  been 
used  with  good  results.  Care  must  be  taken  that  the  glands 
are  in  a  healthy  state,  since  it  has  been  pointed  out  by  Dr.  Na- 
pier, in  the  Lancet,  that  not  more  than  half  the  thyreoids  of 
sheep  are  free  from  abnormal  changes.  The  preparation  known 
as  Brady  and  Martin's  extract  was  employed  in  eleven  of  the 
forty-six  cases  included  in  Dr.  Lundie's  tables,  and  also  in  five 
other  cases  not  included  in  those  tables,  but  rejiorted  in  the 
same  number  of  the  Edinhurgh  Medical  Journal.  Solid  ex- 
tracts have  been  used  by  Dr.  Arthur  Davies,  Dr.  Vermehren, 
and  others.  Mr.  Edmund  White,  of  St.  Thomas's  nospital,  has 
prepared  a  powder  of  thyreoid  of  which  the  dose  is  three  grains, 
equivalent  to  one  eighth  of  a  gland  ;  and  an  enterprising  Lon- 
don manufacturer  has  quite  recently  introduced  tabloids  of  com- 
pressed dry  gland-powder,  each  tabloid  containing  five  grains 
of  healthy  sheep's  thyreoid.  It  is  stated  that  Mr.  White's  pow- 
der has  been  found  efficient  in  several  cases  of  myxcedema. 

Deterioration  or  tendency  to  relapse  is,  as  a  rule,  noted  after 
a  few  weeks,  if  the  thyreoid  feeding  is  suspended;  which  is  an- 
other way  of  saying  that  the  treatment  is  not  competent  to  re- 
move the  morbid  tendency,  but  is  eflScient  to  counteract  it  arti- 
ficially. And  Dr.  Lundie  suggests  that  a  smaller  initial  dosage 
may,  in  the  future,  be  found  to  yield  more  permanent  results, 
at  the  expense  of  a  brilliant  initial  improvement.  In  more  than 
ofie  case  the  ill  effects  of  an  overdose  of  extract  were  made 


promptly  manifest  in  cardiac  depression,  pain  in  the  head  and 
other  parts,  nausea,  or  profuse  perspiration.  Two  of  I)r.  Mur 
ray's  f)atient's  died  from  cardiac  syncope ;  but,  as  they  were 
both  persons  of  advanced  age  and  feeble  and  as  no  autopsy  was 
lield,  there  is  considerable  doubt  as  to  how  far  the  treatment 
contributed  to  the  unexpected  termination.  Dr.  Byrom  Bram- 
well has  pointed  out  that,  in  cases  of  old  persons  whose  arteries 
are  atheromatous  and  whose  heart-muscle  has  degenerated,  the 
thyreoid  feeding  should  be  conducted  with  very  great  care  and 
the  remedy  given  in  very  minute  doses  until  the  effect  has 
been  accurately  measured  and  recorded  in  regard  to  each  in- 
dividual. Dr.  Lundie,  at  the  outset  of  all  thyreoid  treatments, 
warns  the  patient  of  the  risk  attendant  upon  sudden  or  unusual 
exertion. 

In  the  same  number  of  the  KiUnbnrgh  Medical  Journal  a 
case  that  was  fatal  soon  after  the  beginning  of  a  thyreoid  treat- 
ment for  myxcedema  is  reported  by  Dr.  .John  Thomson,  to- 
gether with  a  full  description  of  the  necropsy.  The  case  is  an 
important  one,  but  it  can  not  be  clearly  adduced  as  one  of  fatal 
result  due  to  thyreoid  administration.  It  teaches  caution,  how- 
ever, in  the  employment  of  the  hitherto  despised  gland.  There 
appear  to  be  no  recorded  results  in  case  of  persons  in  good 
health. 

Another  paper  in  the  same  journal,  by  Dr.  John  Thomson, 
recites  the  clinical  history  of  a  case  of  sporadic  cretinism  treated 
by  thyreoid  feeding.  That  the  results  in  this  case  were  re- 
markable is  shown  by  tiiis  one  fact :  The  patient,  a  lad  aged 
eighteen,  was  at  the  beginning  of  the  treatment  thirty-three 
inches  and  a  half  in  height ;  at  the  end  of  two  weeks  of  treat- 
ment the  height  had  increased  two  inches,  whereas  in  the  four- 
teen years  preceding  the  stature  had  increased  little  if  at  all. 
This  growth  has  been  only  one  of  several  indications  of  the 
marked  benefit  of  the  treatment.  The  history  of  the  case  should 
be  consulted  for  the  full  details. 

In  the  same  number  of  the  Edinburgh,  Medical  Journal  there 
are,  in  all,  six  papers  bearing  on  thyreoid  treatment  and  the 
two  diseases,  myxcedema  and  sporadic  cretinism.  They  were 
brought  out  at  or  in  connection  with  a  discussion  of  thyreoid 
feeding,  before  the  Medico-chirurgical  Society  of  Edinburgh,  at 
meetings  held  on  two  successive  evenings  in  February  last. 
The  names  of  the  physicians  who  took  part  in  that  discussion 
are  Dr.  Byrom  Bramwell,  Dr.  R.  A.  Lundie,'y)r.  Melville  Dun- 
lop,  Dr.  John  Thomson,  Dr.  W.  W.  Ireland,  Dr.  W.  S.  Green- 
field, Dr.  Olouston,  and  Dr.  Stalker.  The  latter  speaker  stated, 
in  regard  to  the  apparent  increase  of  myxcedema  in  recent  years, 
that  he  knew  of  not  fewer  than  twenty-one  cases  of  that  disease 
in  the  comparatively  small  town  of  Dundee.  Dr.  George  Mur- 
ray, of  Newcastle,  the  now  famed  inaugurator  of  the  thyreoid 
hypodermic  method,  was  also  present  by  invitation  and  advo- 
cated the  use  of  small  daily  doses  and  the  systematic  enforce- 
ment of  quiet  during  the  early  stages  of  the  treatment.  It  was 
a  frequent  remark  by  the  participants  in  the  discussion  that  ex- 
ophthalmic goitre  was  not  materially  relieved  by  thyreoid 
feeding. 


May  27,  1898.] 


MINOR  PARAGRAPHS. 


591 


MINOR  PARAGRAPHS. 

THE  EXTERNAL  USE  OF  GUAIACOL  IN  PYREXIA. 

AocoBuiNQ  to  the  Medical  Week  for  April  14tli,  Dr.  S. 
Sciolla  has  reported  that  the  application  of  from  thirty  minims 
to  two  draohms  and  a  half  of  tincture  of  guaiacol  to  the  skin 
of  the  abdomen,  back,  chest,  or  extremities  is  followed  by  the 
rapid  absorption  of  that  remedy  and  by  its  antipyretic  effect  in 
all  febrile  diseases.  Its  action  is  accelerated  when  the  part  to 
which  it  is  applied  is  enveloped  in  gauze  covered  with  gutta. 
percha  tissue.  Defervescence  is  often  accompanied  by  profuse 
perspiration,  but  there  is  no  cyanosis  or  other  alarming  mani- 
festation. Administered  in  this  way,  guaiacol  is  eliminated  by 
the  kidneys  in  the  form  of  guiaco-sulphuric  ether,  that  appears 
in  the  urine  about  an  hour  after  the  skin  has  been  painted. 
The  application  may  be  repeated  several  times  in  the  twenty- 
four  hours. 


THE  HITCHCOCK  MEMORIAL  HOSPITAL. 

The  Hanover,  N.  II.,  town  authorities  have  received  the 
gift  of  a  new  hospital  from  Mr,  Hiram  Hitchcock,  of  New  York. 
It  is  a  pavilion  institution  of  four  buildings.  The  exterior  of 
the  buildings  is  of  Pompeiian  brick  with  terra  cotta  ornamenta- 
tion. The  domed  roofs  have  red  Spanish  tiles,  and  vitrefied 
tiles  are  largely  used  for  the  ceilings  and  floors  of  the  wards. 
The  intent  of  the  donor  has  been  to  erect  a  memorial  to  his  late 
wife  and  to  establish  a  means  of  clinical  instruction  for  the 
medical  students  who  pursue  their  studies  at  the  Dartmouth 
College  medical  department.  The  presentation  ceremonies  took 
place  on  May  3d. 


IODIZED  COLLODION  IN  THE  TREATMENT  OF  TINEA 

TONSURANS. 

At  the  fourth  annual  meeting  of  the  French  Society  of  Der- 
matology and  Syphilography,  according  to  the  report  pubhshed 
in  the  Revue  generale  de  medecine,  de  cMrurgie  et  d'ohstetrique, 
Dr.  Butte  extolled  the  value  of  iodized  collodion  in  tinea  ton- 
surans. He  employs  a  solution  of  forty-eight  parts  of  seventy- 
five-per-cent.  alcohol  and  three  parts  of  iodine,  with  the  addi- 
tion of  a  hundred  and  forty  parts  of  collodion,  six  parts  of 
Venice  turpentine,  and  twelve  parts  of  castor  oil.  Two  or  three 
coatings  are  applied  daily  for  three  or  four  days.  A  fortnight 
later  the  coating  is  removed  and  the  patch  is  washed  with  a 
one-to-five-hundred  solution  of  corrosive  sublimate. 


THE  HARVARD  MEDICAL  SCHOOL  ASSOCIATION. 

The  fourth  number  of  the  Bulletin  of  the  Harvard  Medical 
School  Association,  dated  May,  1893,  fully  sustains  the  promise 
given  in  the  earlier  numbers.  In  a  prefatory  note  it  is  stated 
that  whether  or  not  the  Bulletin  becomes  a  regular  publication 
will  depend  entirely  upon  the  reception  that  it  meets  with 
among  the  graduates  of  the  school,  for  whose  information  in 
regard  to  certain  new  methods  of  teaching  that  have  arisen  in 
various  departments  of  the  school  it  is  designed.  It  is  to  be 
expected  that  their  esprit  de  corps  will  lead  them  to  favor  it 
with  conditions  conducive  to  its  permanency. 


UNNECESSARY  OOPHORECTOMIES. 

At  the  recent  annual  meeting  of  the  Georgia  State  Medical 
Association,  as  reported  in  the  Journal  of  the  American  Medi- 
cal Association,  Dr.  McIIatton,  of  Macon,  read  a  paper  entitled 
Four  Women  who  refused  Oophorectomy,  and  their  Subse- 
quent Histories.    He  declared  that  in  a  practice  of  twelve  years 


he  had  had  occasion  to  recommend  the  removal  of  the  uterine 
appendages  once,  leaving  out  of  account  cases  of  ovarian  tumor, 
and  that  case  had  proved  to  be  one  of  pyosalpinx.  Several  of 
his  patients  had  drifted  into  other  hands  and  had  oophorectomy 
performed,  but,  so  far  as  ho  could  learn,  they  had  all  been  dis- 
appointed in  the  result. 


THE  INFLUENCE  OF  THE  GENERAL  HEALTH  ON  THE 
CURABILITY  OF  PITYRIASIS  VERSICOLOR. 

In  a  statistical  review  of  the  cases  of  skin  disease  observed 
at  the  clinic  of  the  Bordeaux  Faculty  of  Medicine  during  the 
years  1889  to  1892,  by  Professor  Arnozan,  published  in  the 
March  number  of  the  Archives  cliniques  de  Bordeaux,  the  author 
remarks  upon  the  rebelliousness  of  pityriasis  versicolor,  not- 
withstanding the  superficial  habitat  of  the  parasite.  He  thinks 
it  must  be  that  a  good  deal  depends  upon  the  nature  of  the  soil 
on  which  it  effects  a  lodgment.  Particularly,  he  mentions  tu- 
berculosis and  dyspepsia  as  playing  a  considerable  part. 


THE  NEW  YORK  JOURNAL  OF  GYNECOLOGY  AND 
OBSTETRICS. 

This  journal,  edited  by  Dr.  J.  D.  Emmet  and  Dr.  A.  H.  Buck- 
master,  is  evidently  winning  its  way  to  the  favor  of  the  profes- 
sion. The  May  number  opens  with  an  interesting  article  by  Dr. 
Thomas  Addis  Emmet,  entitled  Reminiscences  of  the  Founders 
of  the  Woman's  Hospital  Association,  illustrated  with  portraits 
of  the  late  Dr.  J.  Marion  Sims,  the  late  Dr.  Valentine  Mott,  the 
late  Dr.  Francis  Delafield,  Mrs.  Doremus,  the  late  Dr.  Alexander 
H.  Stevens,  the  late  Dr.  John  W.  Francis,  the  late  Dr.  Horace 
Green,  and  the  venerable  nurse,  Margaret  Brennan. 


ISOLATION  HOSPITALS. 

The  need  of  these  institutions  is  one  that  we  have  often  and 
urgently  insisted  on.  It  has  lately  been  illustrated  in  Philadel- 
phia by  the  case  of  a  child  affected  with  diphtheria  who  was 
denied  admi.^sion  into  the  Children's  Hospital.  In  consequence, 
as  we  learn  from  the  Medical  News,  the  hospital  has  incurred 
newspaper  censure — unmerited,  because  the  child's  admission, 
even  temporarily  until  the  Municipal  Hospital  ambulance  could 
be  obtained,  would  have  been  contrary  to  positive  orders  from 
the  board  of  health. 


A  FUND  FOR  THE  LATE  DR.  LAURENCE  JOHNSON'S 
CHILDREN. 

We  are  glad  to  learn  that  an  effort  is  being  made  to  raise 
by  subscriptions  on  the  part  of  the  medical  profession  in  New 
York  a  fund  for  the  benefit  of  the  young  children  left  orphans 
by  the  death  of  Dr.  Johnson  and  that  of  Mrs.  Johnson.  Dr, 
Johnson  will  be  remembered  as  untiring  in  his  efforts  to  ad- 
vance the  interests  of  the  profession,  and  we  look  to  see  a  sub- 
stantial recognition  of  the  value  of  his  labors  in  the  shape  of 
handsome  subscriptions  to  the  fund. 


THIOSLNAMINE  IN  LUPUS. 

The  Lancet  for  May  6th  makes  brief  tnention  of  Dr.  H.  von 
Ilebra's  experience  in  the  employment  of  allylsulphocarbamide, 
or  thio.sinamine,  as  a  remedy  for  lupus.  It  is  administered  sub- 
cutaneously,  and  produces  a  local  but  not  a  general  reaction. 
Under  its  influence  the  cicatricial  tissues  are  said  to  soften  and 
become  pliable,  enlarged  glands  to  become  reduced,  and  cor- 
neal opacities  to  clear  up. 


592 


ITEMS. 


[N.  T.  Med.  Jouh., 


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  May  23,  1893 : 


DISEASES. 

Week  ending  May  16. 

Week  ending  May  23. 

Cases. 

Deaths. 

Cases. 

Deaths. 

21 

3 

9 

G 

9 

6 

15 

3 

206 

18 

159 

15 

Cerebro-spinal  meningitis. . .  . 

23 

IT 

23 

14 

187 

5 

143 

4 

122 

29 

97 

39 

8 

5 

9 

1 

The  American  Surgical  Association. — The  annual  meeting  will  be 
held  in  Buffalo,  in  the  new  Alumni  Hall  of  the  Medical  Department  of 
the  University  of  Buffalo,  on  Tuesday,  Wednesday,  and  Thursday,  May 
30th  and  31st  and  June  1st,  under  the  presidency  of  Dr.  Nicholas  Senn, 
of  Chicago,  besides  whose  address,  on  A  New  Method  of  Direct  Fixa- 
tion of  Fragments  in  Compound  and  Ununited  Fractures  (to  be  discussed 
by  Dr.  Roswell  Park,  Dr.  F.  S.  Dennis,  and  Dr.  De  Forrest  Willard),  the 
programme  announces  an  address  of  welcome,  by  Dr.  Matthew  D.  Mann, 
of  Buffalo,  and  the  following  papers  : 

Pneumotomy  for  the  Removal  of  a  Horseshoe  Nail  from  the  Right 
Lung  of  a  Child,  by  Dr.  W.  T.  Briggs,  of  Nashville  ;  Hypertrophies  and  De- 
generations of  Cicatrices  and  Cicatricial  Tissue,  by  Dr.  J.  Collins  War- 
ren, of  Boston  (discussion  by  Dr.  C.  H.  Mastin,  Dr.  G.  R.  Fowler,  and 
Dr.  W.  H.  Carmalt) ;  The  Surgery  of  the  Gall-bladder,  by  Dr.  M.  H. 
Richardson,  of  Boston  (discussion  by  Dr.  J.  Ewing  Mears,  Dr.  A.  Vander 
Veer,  Dr.  W.  H.  Carmalt,  and  Dr.  T.  A.  McGraw) ;  The  Surgical  Treat- 
ment of  Cervical,  Thoracic,  and  Abdominal  Aneurysm,  by  Dr.  C.  B. 
Nancrede,  of  Ann  Arbor ;  The  Surgery  of  the  Rectum,  by  Dr.  A.  G. 
Gerster,  of  New  York  (discussion  by  Dr.  L.  S.  Pilcher,  Dr.  H.  H.  Mudd, 
and  Dr.  L.  McLane  Tiffany) ;  The  Surgery  of  the  Prostate,  by  Dr.  J. 
William  White,  of  Philadelphia  (discussion  by  Dr.  Hunter  McGuire,  Dr. 
T.  F.  Prewitt,  Dr.  R.  F.  Weir,  and  Dr.  F.  H.  Gerrish) ;  and  The  Treat- 
ment of  Carbuncle,  by  Dr.  F.  Lange,  of  New  York  (discussion  by  Dr. 
Robert  Abbe,  Dr.  J.  B.  Roberts,  and  Dr.  J.  S.  Wight). 

In  addition  to  these,  the  following  papers  are  volunteered  and  will 
be  read,  as  opportunity  offers,  at  the  end  of  each  day's  programme : 

Unreduced  Dislocations  of  the  Astragalus,  by  Dr.  Stephen  Smith, 
of  New  York ;  Clinical  Reports  (Two  Cases  of  Primary  Sarcom  of  the 
Tonsil,  with  Operation ;  Cases  of  Operation  upon  Meckel's  and  the  Gas- 
serian  Ganglia  ;  Malignant  Polyp  springing  from  the  Base  of  the  Skull 

 Attempt  to  make  the  Operation  Bloodless  after  Senn's  Suggestion),  by 

Dr.  Roswell  Park,  of  Buffalo  ;  and  The  Importance  of  the  Colon  Bacillus 
to  the  General  Surgeon,  by  Dr.  Roswell  Park. 

The  late  Dr.  Charles  Carroll  Lee. — The  Medical  Society  of  the 
County  of  New  York  has  adopted  the  following  preambles  and  resolu- 
tions : 

Whereas,  It  has  pleased  Divine  Providence  in  its  inscrutable  wis- 
dom to  take  from  us  in  the  prime  of  his  manhood  and  the  fullness  of  his 
usefulness,  our  colleague,  the  president  of  this  society ;  and 

Whereas,  We,  the  officers  and  fellows  of  the  Medical  Society  of  the 
County  of  New  York,  desire  to  place  upon  record  our  estimate  of  the 
character  of  our  deceased  brother,  be  it 

Resolved,  That  in  the  death  of  Charles  Carroll  Lee  this  society  has 
lost  a  devoted,  able,  and  faithful  officer,  whose  earnestness  of  purpose 
and  loftiness  of  motive  peculiarly  fitted  him  for  the  office  which  he 
adorned. 

Resolved,  That  the  loss  which  we  thus  mourn  is  by  no  means  limited 
to  our  society,  our  city,  or  even  our  country.  Wherever  the  profession 
of  medicine  is  to-day  practiced  as  a  science,  there  will  the  death  of  Lee 
be  recognized  as  a  misfortune ;  there  will  the  silence  of  his  voice  and 
the  stillness  of  his  pen  arouse  a  sorrow  responsive  to  our  own. 

Resolved,  That  to  his  family,  in  tliis  bitter  hour  of  bereavement  and 
sorrow,  we  most  respectfully  and  sincerely  extend  our  heartfelt  sympa- 


thy, wishing  for  them  that  consolation  which  is  the  legitimate  outcome 
of  the  contemplation  of  his  noble  life  and  the  bright  record  which  he 
leaves  behind  him. 

Resolved,  That  a  draft  of  these  resolutions  be  spread  upon  the  min- 
utes of  this  society,  that  duplicates  be  sent  to  the  medical  and  daily  press 
of  this  city,  and  that  a  copy  be  transmitted  to  the  family  of  our  deceased 
friend. 

The  Chicago  College  of  Physicians  and  Surgeons. — In  order  to  en- 
courage graduates  of  literary  and  scientific  schools  to  undertake  the  study 
of  medicine,  the  College  of  Physicians  and  Surgeons  offers  ten  scholar- 
ships, each  of  which  is  valued  at$100  a  yearforthree  years,  to  such  ap- 
plicants as  present  evidence  of  the  best  qualifications  for  medical  study. 

The  New  York  Academy  of  Medicine. — The  programme  for  this 
week's  meeting  of  the  Section  in  Obstetrics  and  Gynaecology,  on  Thurs- 
day evening,  included  a  paper  on  Haematoma  of  the  Vulva,  by  Dr.  G. 
P.  Murray,  and  one  on  Uranalysis  in  Gynajcology,  by  Dr.  Howard  A. 
Kelly,  of  Baltimore. 

The  New  York  Post-graduate  Medical  School. — At  a  meeting  of 
the  board  of  directors  held  on  May  17th,  Dr.  A.  Palmer  Dudley  was 
elected  professor  of  diseases  of  women.  Dr.  George  M.  Edebohls  pro- 
fessor of  diseases  of  women,  and  Dr.  George  T.  Jjlliot  professor  of  dis- 
eases of  the  skin.  Dr.  J.  West  Roosevelt  has  resigned  his  position  as 
professor  of  clinical  medicine. 

The  American  Gyn2ecological  Society. — At  the  recent  annual  meet- 
ing, held  in  Philadelphia  on  the  16th,  17th,  and  18th  inst.,  officers  for 
the  ensuing  year  were  elected  as  follows :  President,  Dr.  William  T. 
Lusk,  of  New  York ;  vice-presidents.  Dr.  Samuel  C.  Busey,  of  Wash- 
ington, and  Dr.  Bache  McE.  Emmet,  of  New  York  ;  secretary.  Dr.  Henry 
C.  Coe,  of  New  York ;  treasurer.  Dr.  Matthew  D.  Mann,  of  Buffalo. 
It  was  decided  to  hold  the  next  meeting  in  Washington,  in  May,  1894. 

The  New  York  Dermatological  Society. — At  the  annual  meeting, 
held  on  Tuesday,  the  23d  inst.,  officers  for  the  ensuing  year  were  elected 
as  follows  :  President,  Dr.  Charles  W.  Allen  ;  secretary  and  treasurer. 
Dr.  Hermann  G.  Klotz  ;  other  members  of  the  executive  committee.  Dr. 
George  T.  Elliot,  Dr.  .John  A.  Fordyce,  and  Dr.  S.  Lustgarten. 

The  Medical  Department  of  Tulane  University. — The  veteran 
teacher.  Dr.  Joseph  Jones,  has  been  relieved  from  chnical  duty  after 
twenty-six  years  of  this  service.  His  chair  will  hereafter  be  that  of 
chemistry  and  medical  jurisprudence.  Dr.  Albert  B.  Miles  has  been  in- 
ducted into  the  chair  of  surgery,  as  successor  to  the  late  Dr.  Samuel 
Logan.  Dr.  L.  F.  Rennaud  succeeds  Dr.  Miles  in  the  branch  of  materia 
medica  and  therapeutics. 

The  New  York  State  Quarantine. — Certain  improvements  in  the 
station  recently  provided  for  include  a  three- story  house  for  detained 
immigrants,  which,  it  is  said,  is  to  be  built  within  sixty  days.  In  addi- 
tion, the  piers  at  Hoffmann  Island  are  to  be  enlarged  and  the  disinfect- 
ing appliances  improved. 

St.  Mary's  Hospital,  Brooklyn. — It  is  announced  that  the  twenty- 
fifth  anniversary  of  the  establishment  of  the  hospital  will  be  celebrated 
by  a  garden  party  on  the  6th,  7th,  and  8th  of  June. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Offieers  serving  in  the  Medical  Department,  United  States 
Army,  from  Mag  ?  to  May  20,  1893  : 

Taylor,  Blair  D.,  Captain  and  Assistant  Surgeon,  will  report  in  person 
to  Lieutenant-Colonel  Dallas  Bache,  Deputy  Surgeon  General,  presi- 
dent of  the  examining  board  convened  at  Omaha,  Neb.,  at  such 
time  as  he  may  be  required  by  the  board  for  examination  as  to  his 
fitness  for  promotion. 

A  board  of  officers — to  consist  of  Alexander,  Charles  T.,  Colonel  and 
Assistant  Surgeon  General ;  Sternberg,  George  M.,  Lieutenant  Colo- 
nel and  Deputy  Surgeon  General ;  and  Hoff,  John  Van  R,,  Major  and 
Surgeon — is  appointed  to  meet,  at  the  call  of  the  president  thereof, 
at  New  York  city  for  the  examination  of  such  officers  as  may  be 
ordered  before  it,  with  a  view  to  determining  their  fitness  for  pro- 
motion. 


May  27,  1893.J 


ITEMS.— LETTERS  TO  THE  EDITOR. 


503 


PiiioE,  Curtis  E.,  Captain  and  Assistant  Surgeon,  is  ordered  to  report  in 

person  to  tlie  president  of  the  examining  board  at  New  Yorlc  city 

for  examination  for  promotion. 
{{KNiiAM,  RouKiiT  B.,  Captain  and  Assistant  Surgeon,  is,  by  direction  of 

the  Secretary  of  War,  granted  leave  of  absence  for  six  niontlis  on 

account  of  sickness. 
Johnson,  Rkhari)  W.,  Captain  and  Assistant  Surgeon,  is  relieved  from 

duty  at  Fort  Bowie,  Arizona,  and  ordered  to  duty  at  Washington 

Barracks,  D.  C. 

Wakeman,  William  J.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  Fort  Bidwell,  California,  and  ordered  to  Fort  Thomas,  Ken- 
tucky, for  duty. 

MuNN,  Curtis  E.,  Major  and  Surgeon,  is  hereby  granted  leave  of  ab- 
sence for  twenty  days,  to  commence  about  May  24,  1893. 

McCaw,  Walter  D.,  Captain  and  Assistant  Surgeon,  is  granted  leave 
of  absence  for  one  month,  to  take  effect  June  1,  1893. 

Breche.min,  Louis,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  the  Presidio  of  San  Francisco,  Cal.,  and  ordered  to  Colum- 
bus Barracks,  Ohio,  for  duty. 

W iLLCOX,  Charles,  First  Lieutenant  and  Assistant  Surgeon,  is  relieved 
from  temporary  duty  at  Angel  Island,  California,  and  ordered  to  the 
Presidio  of  San  Francisco,  Cal.,  for  duty. 

Spencer,  William  G.,  Captain  and  Assistant  Surgeon.  The  leave  of 
absence  granted  on  surgeon's  certificate  of  disability  is  extended 
four  months  on  account  of  disability. 

WoRTHiNGTON,  James  C,  Captain  and  Assistant  Surgeon,  ordered  to  re- 
port in  person  to  Colonel  Charles  T.  Alexander,  Assistant  Surgeon 
General,  president  of  the  examining  board,  appointed  to  meet  at 
New  York  city,  N.  Y.,  at  such  time  as  he  may  be  required  by  the 
board,  for  examination  as  to  his  fitness  for  promotion. 

HoRTON,  Samuel  M.,  Major  and  Surgeon,  San  Diego  Barracks,  Cal.,  is 
granted  leave  of  absence  for  one  month  on  surgeon's  certificate  of 
disability. 

Promotion. 

Middleton,  Johnson  V.  D.,  Major  and  Surgeon,  to  be  Deputy  Surgeon 
General  with  the  rank  of  Lieutenant  Colonel,  May  8,  1893. 

Casualty. 

McClellan,  Ely,  Lieutenant  Colonel  and  Deputy  Surgeon  General,  died 
May  8,  1893,  at  Chicago,  111. 

Appointments. 

To  be  Assistant  Surgeons  with  the  rank  of  First  Lieutenant,  May  12, 
1892:  Stark,  Alexander  N.,  of  Virginia;  Lynch,  Charles,  of  New 
York  ;  Kulp,  John  S.,  of  Pennsylvania ;  Munson,  Edward  L.,  of 
Connecticut ;  Flagg,  Charles  E.  B.,  of  South  Carolina ;  Kennedy, 
James  M.,of  South  Carolina;  Godfrey,  Guy  C.  M.,of  Ohio;  Lewis, 
William  F.,  of  North  Carolina. 

Society  Meetings  for  the  Coming  Week: 

Tuesday,  May  30th  :  Medical  Societies  of  the  Counties  of  Queens  (an- 
nual— Miueola)  and  Rockland  (annual),  N.  Y. ;  Boston  Society  of 
Medical  Sciences  (private). 

Wednesday,  May  31st :  Medical  Society  of  the  County  of  Monroe  (an- 
nual— Rochester),  N.  Y.  ;  Auburn,  N.  Y.,  City  Medical  Association ; 
Berkshire,  Mass.,  District  Medical  Society  (Pittsfield). 

Thursday,  June  1st:  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). 

Friday,  June  2d :  Practitioners'  Society  of  New  York  (private) ;  Balti- 
more Clinical  Society. 

Satvrd AY,  June  3d :  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.  JfiT. — "  Inflammation  of  the  bowels "  is  a  popular  term  for 
peritonitis. 

No.  Jf08. — We  have  no  knowledge  of  the  person  or  of  the  alleged 
transaction. 


fetters  to  the  debitor. 


THE  CHICAGO  POST-GRADUATE  MEDICAL  SCHOOL. 

Kansas  City,  Mo.,  May  13,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal  : 

Sir  :  In  the  announcement  of  the  summer  course  of  lectures 
at  the  Chicago  Post-graduate  Medical  School  by  Mr.  Lawson 
Tait,  of  Birmiugham,  Mr.  Reginald  Harrison,  of  London,  Pro- 
fessor Schauta,  of  Vienna,  Dr.  Price,  of  Philadelpliia,  and  oth- 
ers, by  an  unfortunate  mistake  of  the  printer's  I  am  placed  as  a 
resident  of  New  York,  and  my  subject  is  not  mentioned.  The 
topics  discussed  by  myself  will  be  embraced  in  the  title  Some 
Achievements  in  Intracranial  Surgery,  and  my  remarks  will  be 
based  almost  entirely  upon  my  personal  experience,  which  in 
number  and  variety  of  cases  is  more  extensive  than  that  of  any 
other  American  surgeon.  Inasmuch  as  this  work  has  been  done 
in  Kansas  City,  may  I  not  ask  you  to  kindly  make  a  note  of  cor- 
rection as  to  my  field  of  labor?       Emory  Lanpiiear,  M.  D. 


NEWSPAPER  MEDICINE. 

New  York,  May  1893. 
To  the  Editor  of  the  New  York  Medical  Journal  : 

Sir  :  My  attention  has  only  to-day  been  called  to  a  letter 
published  in  your  esteemed  journal  of  the  date  of  April  1st 
quoting  an  item  from  a  newspaper  in  regard  to  a  patient  under 
my  care.  The  anonymous  author  of  this  letter,  "  San  Grado  " 
he  signs  himself,  after  commenting  in  a  sarcastic  manner  upon 
the  case  and  after  quoting  some  ridiculous  statements  of  the 
newspaper  reporter  in  which  my  name  is  used,  remarks  in  con- 
clusion, "  Comment  seems  unnecessary." 

Well,  it  seems  to  me  that  several  comments  are  necessary. 

If  San  Grado's  idea  is  to  inveigh  against  "  newspaper  medi- 
cine," I  heartily  agree  with  him,  but  no  one  can  read  his  letter 
without  perceiving  that  a  personal  reflection  is  intended.  If 
otherwise,  why  does  he  not  sign  his  name  to  the  letter? 

I  desire  to  say,  in  the  first  place,  that  I  never  saw  the 
newspaper  slip  quoted  prior  to  reading  it  in  your  journal,  nor 
am  1  in  any  sense  directly  or  indirectly  responsible  for  it,  nor 
have  1  been  instrumental  in  its  appearance.  I  have  steadfastly 
refused  to  be  interviewed  time  and  time  again  about  this  pa- 
tient, as  well  as  about  others  of  public  fame.  I  am  not  there- 
fore responsible  for  the  statements  made,  as  most  certainly 
would  appear  from  San  Grado's  letter. 

An  anonymous  letter  in  a  public  journal  can  seldom  be 
other  than  a  despicable  thing,  especially  when  it  contains 
innuendoes  against  persons.  If  San  Grado  has  any  charges  to 
make  against  me,  I  invite  him  to  come  out  openly  into  the  arena 
of  your  pages  and  make  them,  rather  than  conceal  himself  be- 
hind a  fictitious  signature.  W.  J.  Morton,  M.  D. 

A  FROG  IN  THE  STOMACH. 

Cypress  River,  Manitoba,  May  12,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  A  case  of  more  than  ordinary  interest  came  under  my 
observation  in  this  place.  A  Mr.  Ruston,  farmer,  aged  about 
sixty,  was  engaged  one  day  in  September,  1891,  in  bringing 
water  to  a  thrashing-machine  engine.  The  water  was  taken 
from  a  slough  and,  the  day  being  warm,  Mr.  R.  drank  freely  of 
it.  That  night  he  was  taken  ill.  Day  by  day  he  continued 
getting  worse.  He  had  a  peculiar,  indescribable  feeling  in  the 
region  of  the  stomach.    This  feeling  would  at  times  bo  followed 


594 


LETTERS  TO  THE  EDITOR.— BOOK  NOTICES. 


[N.  y.  Med.  Jocb., 


by  a  sensation  of  "  a  lump  rising  in  his  throat  and  choking 
him."  After  some  time  he  called  in  a  medical  man,  who  told 
him  that  he  did  not  understand  his  ailment,  and  that  he  thought 
nothing  could  be  done  for  him.  Then  a  second  doctor  was  sent 
for.  After  his  second  visit  he  diagnosticated  it  as  cancer  of  the 
liver.  A  third  doctor  was  called  in  later.  He  found  the  liver 
enlarged,  but  did  not  think  that  would  account  for  the  patient's 
condition.  After  some  time  he  told  the  patient  he  could  do 
nothing  for  him.  At  this  time  he  was  so  low  that  no  one  ex- 
pected he  could  recover.  But  about  the  1st  of  March,  1892,  he 
began  to  rally,  and  ere  long  was  able  to  move  around,  though 
up  to  this  date  he  has  not  been  strong  enough  to  do  any  work. 

In  November,  1892,  I  was  called  to  see  him.  At  this  time 
he  had  an  attack  of  acute  bronchitis.  While  making  an  exami- 
nation I  discovered  that,  in  addition  to  his  other  ailment,  he  had 
cardiac  trouble.  After  recovering  from  the  attack  of  bronchitis 
he  went  to  visit  his  old  home  in  Ontario.  While  there  he  was 
taken  very  ill.  Two  doctors  attended  him,  both  of  whom  told 
him  that  he  had  serious  heart  trouble.  On  his  return  home  in 
March  last  he  sent  for  me.  At  that  time  he  complained  of  both 
the  gastric  and  the  cardiac  affections.  I  directed  my  treatment 
mainly  to  the  heart  at  first.  He  improved  considerably,  but  still 
was  unable  to  work.  His  gastric  trouble  still  remained.  Dur- 
ing the  first  days  of  this  month  he  suflered  more  than  usual. 
On  the  8th  he  "felt  as  if  he  were  going  to  die."  During  one  of 
those  choking  spasms  he  made  a  strong  attempt  to  clear  his 
throat  of  the  "  lump."  He  was  more  than  usually  successful, 
for  along  with  other  things  came  a  lively  little  frog.  Its  body 
is  about  an  inch  and  a  quarter  to  an  inch  and  a  half  long.  At 
first  it  was  of  a  pale,  gelatinous  appearance,  but  now  it  has  quite 
a  natural  color.  On  hearing  of  it  I  drove  to  see  for  myself  if 
the  report  was  really  true,  and  I  had  the  pleasure  of  seeing  His 
Frogship.  Mr.  R.  keeps  it  in  a  bottle  containing  a  little  water, 
and  says  that  he  will  not  part  with  it  for  any  money.  He  feels 
decidedly  more  comfortable  since  he  ejected  his  "little  boarder." 

R.  W.  MacChaeles,  M.  D.,  C.  M. 


PRIORITY  IN  THE  TREATMENT  OF  SPRAINED  ANKLE. 

717  Eleventh  Street,  N.  W.,  Washington,  D.  C, 

May  16,  1893. 
To  the  Editor  of  the  Neic  York  Medical  Journal: 

Sib:  Your  current  editorial  on  The  Treatment  of  Sprained 
Ankle  is  both  timely  and  valuable,  for  in  my  experience  sprains 
are  more  serious  in  their  ultimate  results  than  fractures. 

And,  while  concurring  in  the  main  with  the  statements  made 
by  Dr.  V.  P.  Gibney,  yet  I  am  not  prepared  to  admit  that  Mr. 
Cotterell's  method  of  treatment  is  entirely  new.  Twenty- five 
years  ago,  when  a  student  at  the  Medical  Department  of  the 
University  of  Louisville.  1  well  remember  that  Professor  D.  W. 
Yandell,  one  of  the  best  all-round  teachers  of  surgery  in  Amer- 
ica and  a  perfect  master  of  the  bandage,  taught  us  the  identical 
principles  now  claimed  as  of  English  origin.  Moreover,  in  the 
early  seventies,  the  late  Dr.  R.  O.  Cowling,  of  Louisville,  Ky., 
contributed  several  valuable  articles  to  the  American  Prdcti- 
tioner  on  the  treatment  of  fractures  and  sprains,  advocating  the 
use  of  manilla  paper,  etc.,  as  a  dressing,  and  substantially  rec- 
ommending the  same  line  of  treatment  taught  by  Dr.  D.  W. 
Yandell.  Furthermore,  while  I  was  attending  Bellevue  Hospi- 
tal Medical  College  in  1877,  it  is  my  impression  that  Professor 
Lewis  A.  Sayre  treated  sprained  ankles  with  adlie.«ive-pl;ister 
dressings  and  secured  admirable  results.  The  greatest  master 
of  the  bandage  in  his  day  and  generation  was  Dr.  Benjamin 
Dudley,  of  Lexington,  Ky.,  and  his  legatee,  in  thi?  respect,  is 
Dr.  D.  W.  Yitndell,  uf  the  same  State. 

William  E.  Beanut,  M.D.,  Ph.  1). 


PRENATAL  MEASLES. 

SAi.iSBCRy,  Mo.,  May  9,  1893. 
To  the  Editor  of  the  New  York  Medical  JourrMl  : 

SiE  :  An  item  was  clipped  from  the  New  York  MedicalJour- 
nal  by  one  of  our  Western  journals  recently  in  regard  to  a  case 
of  prenatal  measles  reported  at  a  meeting  of  the  Edinburgh  Ob- 
stetrical Society. 

By  notice  being  given  in  such  a  high  place  I  presume  such 
cases  rarely  occur,  which  is  my  apology  for  reporting  to  you  a 
case  which  came  under  my  care.  The  mother,  while  suffering 
with  measles,  was  delivered  of  an  eight-months  child  which 
had  the  eruption  fully  established  all  over  it  from  head  to  foot. 
I  have  never  reported  the  case  to  any  journal,  as  I  thought 
there  was  nothing  unusual  about  it  in  times  of  epidemic. 

F.  B.  Philpott,  M.  D. 


NEWSPAPER  ACCOUNTS  OF  DEATHS  FROM  ETHER. 

Albany,  N.  Y.,  May  19,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sie:  My  attention  has  just  been  called  to  an  article  in  the 
Medical  News  for  April  29th,  and  in  your  Journal  of  May  6, 
1893,  which  has  given  me  much  annoyance,  and  I  hasten  to 
make  some  reply.  I  certainly  never  made  any  such  statement 
as  is  attributed  to  me.  I  have  too  much  confidence  in  Dr. 
McBurney  to  in  any  way  doubt  his  treatment  of  Col.  Shepard's 
case.  Beyond  a  doubt  everything  was  done  that  was  possible 
in  the  case,  and  done  well  and  properly. 

DwiGHT  A.  Lawrence. 


Human  Anatomy.  A  Complete  Systematic  Treatise  by  Various 
Authors,  including  a  Special  Section  on  Surgical  and  Topo- 
graphical Anatomy.  Edited  by  Henet  Mobeis,  M.  A.  and 
M.  B.  Lond.,  Surgeon  to  and  Lecturer  on  Surgery,  formerly 
Lecturer  on  Anatomy  at  the  Middlesex  Hospital,  etc.  Illus- 
trated by  791  Woodcuts,  214  of  which  are  printed  in  Colors 
from  Drawings  made  expressly  for  this  Work  by  Special 
Artists.  Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1893.  Pp. 
xxxiii-17  to  1286.    [Price,  $7.50.] 

The  past  few  years  have  been  prolific  in  the  production  of 
treatises  on  human  anatomy.  In  England,  Macalister  has 
brought  out  an  excellent  manual  and  Qaain^s  Anatomy  has  been 
almost  wholly  rewritten.  In  Germany,  Gegenbaur's  masterly 
treatise  has  run  rapidly  through  five  editions,  Rauber  has  re- 
written Hoffmann's  work,  Toldt  has  rewritten  Langer,  Stieda 
has  rewritten  Pansch,  and  an  excellent  compendium  of  topo- 
graphical anatomy  has  been  issued  by  Gerlach,  while  more  ex- 
tensive works  in  the  same  department  have  been  undertaken 
by  Joeseel  and  Merkel.  In  France,  Testut  has  undertaken  a 
treatise  in  three  volumes  illustrated  in  the  most  elaborate  man- 
ner, Debierre  has  given  another  in  two  volumes,  and  Poirier 
has  just  begun  two  works — one  descriptive,  the  other  topo- 
graphical. In  this  country  the  Nestor  of  American  anatomists, 
Dr.  Leidy — now,  alas!  no  more — has  revised  and  rewritten  his 
manual ;  Dr.  Harrison  Allen  has  written  a  large  work,  and  Dr. 
McClellan  has  produced  a  finely  illustrated  topographical 
anatomy. 

The  reason  for  this  unprecedented  activity  is  found  not  so 


May  27,  1893.] 


BOOK  NOTICES. 


596 


niucli  in  new  discoveries,  thougli  these  have  been  many  and 
important,  as  in  the  general  feeling  on  the  part  of  anatomists 
that  the  older  books  are  faulty  in  plan  and  that  something 
better  can  be  devised.  The  great  impulse  given  to  biological 
sciences  by  the  epoch-making  theory  of  evolution  has  profound- 
ly influenced  all  anatomical  studies,  and  this,  though  not  always 
expressed,  has  given  rise  to  a  discontent  with  the  treatises  that 
satisfied  the  preceding  generation. 

The  present  magnificent  volume  is  the  latest  attempt  to  meet 
the  modern  requirements.  It  is  a  compilation  contributed  by 
various  authors,  each  an  acknowledged  authority  in  his  branch, 
under  the  editorsiiip  of  an  anatomist  who  has  already  had  some 
experience  as  a  writer.  His  work  on  the  Anatomy  of  the  Joints, 
published  some  years  ago,  forms  the  basis  for  the  section  which 
he  now  contributes  to  this  volume.  The  illustrations  are  many 
and  various,  a  considerable  number  of  them  being  new,  and  all 
of  them  executed  with  such  care  and  fidelity  as  to  make  an  ex- 
ceedingly attractive  and  showy  volume.  The  external  apf)ear- 
ance  and  typographical  execution  of  the  book  are  admirable. 
From  the  publishers'  point  of  view  it  leaves  little  to  be  desired. 
Under  such  auspices  it  is  not  strange  that  in  some  respects  it  is 
a  decided  improvement  over  any  treatise  yet  published.  The 
section  on  Osteology,  by  J.  Bland  Sutton,  F.  R.  C.  S.,  and  that 
on  the  Organs  of  Digestion,  by  Frederick  Treves,  F.  R.  G.  S., 
are  especially  to  be  commended.  We  have  nowhere  seen  a 
more  satisfactory  account  of  the  development  of  the  perito- 
nfeum  than  is  given  in  the  latter  article. 

Many  deficiencies  are,  however,  to  be  noted.  Every  anato- 
mist will  find  some  and  will  rate  them  according  to  his  own 
estimate  of  the  scope  of  the  science.  It  would  seem,  for  ex- 
ample, that  in  a  comprehensive  work  like  this  space  could  have 
been  found  for  a  succinct  account  of  the  varieties  of  human 
crania  and  of  craniological  terms  and  methods.  No  one  who 
has  followed  our  recent  advances  in  the  knowledge  of  joints  is 
likely  to  be  satisfied  with  Morris's  too  meager  classification, 
and  still  less  will  the  scientific  myologist  favor  the  retention  of 
the  worn-out  nomenclature  of  muscles  of  the  back,  now  aban- 
doned by  all  continental  authorities.  Had  Dr.  Walsham  seen 
his  way  to  a  scientific  discussion  of  the  causes  of  variation  in 
the  vascular  system  he  would  have  assisted  the  student  greatly. 

These  maybe  thought  to  be  but  minor  matters ;  unfortu- 
nately, they  arise  from  the  peculiar  attitude  taken  by  the  editor 
toward  his  work,  an  attitude  which  we  can  but  think  seriously 
cripples  its  value  as  an  exposition  of  existing  anatomical  knowl- 
edge. In  the  pi'eface  he  says:  "Histology  and  development — 
except  the  mode  and  dates  of  the  development  of  the  bones,  and 
in  a  few  other  instances — are  not  included,  as  it  is  felt  that 
these  subjects  are  more  appropriately  dealt  with  in  books  on 
physiology  than  they  can  conveniently  be  in  works  on  anato- 
my." Truly  this  is  a  most  surprising  statement  to  be  made  in 
these  days  when  the  departments  referred  to  are  considered  as 
the  corner-stones  of  proper  scientific  anatomy.  It  is  much  as 
if  a  treatise  on  chemistry  should  confine  itself  to  describing  the 
sensible  properties  of  substances,  referring  all  questions  of 
atomic  constitution  and  chemical  theory  to  some  other  branch; 
or  as  if  a  treatise  on  geology  should  confine  itself  to  a  descrip- 
tion of  the  actual  relations  of  strata,  without  considering  either 
their  constitution  or  how  they  came  to  be  deposited. 

This  capital  fault  obscures  greatly  what  is  otherwise  a  very 
valuable  work.  For  want  of  the  clews  which  histology  and  em- 
bryology might  give,  the  student  must  often  wander  in  a  hope- 
less maze.  This  is  very  notable  in  the  section  on  the  nervous 
system,  contributed  by  the  able  hand  of  H.  St.  John  Brooks, 
demonstrator  of  anatomy  to  the  Dublin  University.  Not  one 
word  is  said  here  of  the  marvelous  discoveries  of  recent  times 
relating  to  the  structure  and  relations  of  the  nerve  cells,  and 


hardly  anything  about  the  nerve  tracts  found  in  the  brain  and 
spinal  cord.  We  might  almost  believe  that  anatomy  had  re- 
treated to  the  time  of  Gall,  when  the  brain  was  supposed  to  be 
composed  of  a  series  of  conical  "  organs"  having  their  apices  at 
the  medulla  and  their  bases  at  the  periphery.  When  we  con- 
sider that  the  Dublin  University  is  one  of  the  most  active  ana- 
tomical centers  in  Europe,  and  that  the  anatomy  of  the  brain 
has  received  special  attention  there  under  the  able  guidance  of 
Dr.  D.  J.  Cunningham,  it  is  hard  to  understand  how  Dr.  Brooks 
could  have  permitted  himself  to  be  drawn  into  a  work  so  shorn 
of  its  just  scope. 

This  erroneous  point  of  view  is  a  very  common  one,  and  it 
is  not  difficult  to  see  how  it  comes  to  be  adopted.  Busy  men, 
crowded  with  practice,  constantly  facing  practical  problems, 
finally  cease  to  interest  themselves  in  the  principles  of  the  sci- 
ence which  they  are  daily  using.  The  civil  engineer  who  is 
working  in  daily  routine  with  embankments  and  trusses,  strains 
and  levels,  soon  prefers  to  use  his  table  of  logarithms  and  other 
means  of  ready  calculation,  and  forgets  the  step-by- step  meth- 
ods of  logical  thought  by  which  was  built  up  the  science  of 
mathematics  that  made  these  tables  possible.  Yet,  let  a  new 
case  present  itself  and  the  routine  engineer  is  lost,  he  becomes 
a  common  draughtsman ;  while  the  truly  scientific  expert  can 
proceed  to  apply  his  principles  and  make  new  deductions.  In 
civil  engineering  it  has  never  been  maintained  that  the  Engi- 
neer's PoclcethooTc  was  an  adequate  treatise  on  the  science,  yet  a 
contention  somewhat  similar  is  constantly  made  in  anatomy. 

In  what  other  science,  let  us  ask,  is  a  student  plunged  at 
once  into  the  subject  without  some  definition  of  its  nature,  its 
relation  to  other  sciences,  and  the  terms  which  it  uses?  Yet, 
when  we  open  the  treatise  before  us,  expecting  to  find  an  intro- 
duction explaining  the  scope  of  anatomy,  its  divisions,  and  some 
preliminary  definitions,  we  find  on  the  first  page — "Osteology. 
The  Skeleton.  The  skeleton  contains  206  distinct  bones."  As 
to  what  anatomy  is,  what  osteology,  what  the  skeleton,  the 
pupil  may  search  the  book  through  and  he  will  find  no  direct 
information.    The  same  fault  exists  in  other  departments. 

We  are  aware  that  it  is  no  light  task  to  prepare  a  work  on 
anatomy  that  shall  comprise  all  the  branches  of  that  vast  sci- 
ence and  yet  be  of  a  convenient  size.  Sappey's  work  is  in  four 
volumes;  Luschka,  Henle,  Testut,  and  the  new  Quain  each  has 
three.  Debierre,  Rauber,  and  Gegenbaur  have  two,  containing, 
however,  no  more  matter  than  Morris's  single  volume.  The 
works  of  HyrtI,  Pansch,  Danger,  Brosike,  and  Leidy,  each  in  a 
single  volume  of  moderate  size,  are  rather  compendiums  than 
exhaustive  treatises.  An  editor  might  easily  complain  of  lack 
of  space,  yet  we  believe  that  it  is  quite  possible  to  compress  the 
necessary  matter  within  the  limits  here  assigned  by  giving  a 
diiferent  treatment  to  the  letterpress  and  the  illustrations.  Some 
of  the  latter  are  unnecessarily  large,  and  much  space  is  lost  in 
paragraphing  and  leading  the  heads.  This,  of  course,  adds  to 
the  appearance  of  the  book,  but  at  what  cost?  The  student 
who  wishes  to  equip  himself  properly  must  at  once  purchase  a 
treatise  on  embryology  and  another  on  histology  to  supply 
what  ought  to  be  found  in  this,  properly  correlated  with  the 
other  matter. 


Investigations  into  the  Nature,  Causation,  and  Prevention  of 
Texas  or  Southern  Cattle  Fever,  made  under  the  Dfrection 
of  Dr.  D.  E.  Salmon,  Chief  of  the  Bureau  of  Animal  Indus- 
try. By  TnEOBAi.D  Smith,  Ph.  B.,  M.  D.,  and  F.  L.  Kil- 
BOENE,  B.  Agr.,  B.  V.  S.  Published  by  Anihority  of  the 
Secretary  of  Agriculture.  Washington:  Government  Print- 
ing Office,  1893.    Pp.  301. 

These  investigations  have  been  carried  on  since  1888  by  the 
Bureau  of  Animal  Industry,  and  the  investigators  conclude 


596 


BOOK  NOTICES. 


[N.  Y.  Mkd.  Joub.) 


that  thi8  fever  is  a  haemic  disease,  characterized  hy  destruction 
of  red  corpuscles.  The  symptoms  are  partly  due  to  the  in- 
duced anaemia  and  partly  to  the  debris  in  the  blood.  The  red 
corpuscles  are  destroyed  by  an  intracorpuscular  micro-organ- 
ism belonging  to  the  Protozoa.  Cattle  from  a  permanently  in- 
fected territory  carry  the  parasite  in  their  blood,  though  ap- 
parently healthy,  and  direct  inoculation  of  such  blood  into  a 
susceptible  animal  will  produce  the  fever.  Ordinarily  the  fever 
is  transmitted  from  infected  to  healthy  animals  by  the  cattle 
tick  {Boophilus  hovis),  and  the  fever  is  more  fatal  to  adult  than 
to  young  cattle.  Two  mild  attacks  or  one  severe  attack  will 
probably  prevent  a  subsequent  fatal  one.  The  authors  find 
that  sheep,  rabbits,  guinea-pigs,  and  pigeons  are  insusceptible 
to  direct  inoculation  of  infected  blood.  They  advise  that  in 
making  the  diagnosis  in  the  living  animal  the  blood  should  al- 
ways be  examined  microscopically. 


Human  Monstrositien.  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  IV.  Il- 
lustrated with  Ten  Photographic  Reproductions  and  Forty- 
six  Woodcuts.  Philadelphia:  Lea  Brothers  &  Co.,  1893. 
Pp.  iv-151  to  220. 

This,  the  final  part  of  an  elaborate  and  exhaustive  work, 
continues  the  subject  of  composite  monsters.  There  are  descrip- 
tions and  illustrations  of  the  dicephalus,  i?chiopagus,  and  pygopa- 
gus;  of  the  terata  anadidyma,  the  dipygus,  syncephalus,  and 
craniopagns ;  and  of  the  terata  anakatadidyma,  the  prosopo- 
thoracopagus, the  sternopagus,  and  the  xiphopagus.  Among 
those  of  double  parasitic  monsters  there  are  descriptions  of 
beterotypus,  of  heteralius,  of  polymelus,  of  endocyma,  of  di- 
prosopus  parasiticus,  of  dicephalus  parasiticus,  of  ischiopagus 
parasiticus,  of  dipygus  parasiticus,  of  syncephalus  parasiticus, 
of  craniopagns  parasiticus,  of  thorocopagus  parasiticus,  of  poly- 
gnathus, of  epiguathus,  and  of  the  endocyma.  A  final  section 
on  triple  monsters  completes  the  volume.  There  is  a  bibliog- 
raphy of  journal  references  and  monographs  on  teratology. 
The  index  might  have  been  made  more  complete,  as  the  reader 
looks  in  vain  for  atlodidymus,  derodidymus,  psodymus,  and 
hepatodymus,  and  he  may  not  think  that  these  are  varieties  of 
the  dicephalus. 

All  that  we  have  said  in  commendation  of  this  work  is  jus- 
tified by  the  final  part,  and  the  four  parts  constitute  a  monu- 
ment to  American  scientific  research. 


The  Recrudescence  of  Leprosy  and  its  Causation.  A  Popular 
Treatise.  By  William  Tebb.  With  an  Appendix.  Lon- 
don :  Swan,  Sonnenschein  &  Co.,  1893.  Pp.  20-21  to  412. 
This  work  is  the  result  of  a  generous  collection  of  excerpta 
on  leprosy  from  medical  and  lay  publications,  assisted  by  much 
travel  to  countries  in  which  that  disease  is  more  or  less  fre- 
quently encountered.  The  author  has  assumed  that  leprosy 
has  greatly  increased  during  the  last  half  century — an  assump- 
tion that  is  without  warrant,  absolutely  disregarding  as  it  does 
that  the  onvs  prohandi  rests  upon  the  assertor.  To  this  major 
of  the  increase  of  leprosy  is  added  the  minor  premise  that 
leprosy  is  irioculable,  and  the  conclusion  is  reached  tha',  as  the 
most  frequent  opportunities  of  inoculating  the  virus  of  leprosy 
are  afforded  in  the  practice  of  inoculating  vaccine,  therefore 
vaccination  is  a  true  cause  of  the  diffusion  of  leprosy.  One  of  the 
fundamental  i)rinciples  of  logic  is  that  in  nn  extensive  categori- 
cal syllogism  the  assumption  must  be  definite,  and,  as  the  last 
rule  affecting  the  same  principle  is  tliat  the  conclusion  must 
correspond  in  quality  with  the  assumption,  Mr.  Tebb's  argu- 


ments fall  to  the  ground  on  account  of  the  fallibility  of  hie 
major  premise.  He  himself  concedes  that  there  is  no  informa- 
tion that  shows  how  far  vaccination  has  determined  the  amount 
of  leprosy  in  recent  times,  and  yet  he  subsequently  states  that 
the  increase  of  leprosy  in  the  Sandwich  Islands,  the  West  Indies, 
the  Unites  States  of  Colombia,  British  Guiana,  South  Africa, 
and  New  Caledonia  has  followed  pari  passu  with  the  introduc- 
tion and  extension  of  vaccination,  which  in  nearly  all  these 
places,  without  previous  inquiry  or  demand  from  the  inhabit- 
ants, has  been  made  compulsory.  The  Scotch  verdict  "Not 
proven"  must  be  the  voice  of  the  jury  on  Mr.  Tebb's  volume, 
and  the  shade  of  Cervantes  must  weep  in  contemplating  the 
futility  of  applying  the  lesson  of  Don  Quixote. 


Ueher  die  TrunksucTit  und  Versuche  ihrer  Behandlung  rail 
Strychnin.  Von  Gustav  Beldau.  Jena :  Gustav  Fischer, 
1892.    Pp.  47. 

TuE  author  believes  that,  inasmuch  as  most  of  the  experi- 
ments with  nitrate  of  strychnine  in  cases  of  alcoholism  have  re- 
mained unknown  to  the  medical  world  at  large,  from  the  fact  of 
their  having  been  chiefly  recorded  in  the  Russian  language,  he 
is  rendering  a  good  service  to  science  in  compiling  the  works  of 
such  men  as  Parzewski,  Korona,  Pombrak,  Luton,  and  Dobron- 
rawow.  From  these  works  he  deduces  several  conclusions : 
That  the  treatment  of  drunkenness  with  nitrate  of  strychnine  is 
productive  of  more  or  less  favorable  fesults;  that  strychnine  is, 
in  a  certain  way,  the  physiological  antagonist  of  alcohol ;  that 
the  effects  produced  by  this  medication  seem  variable  according 
to  the  mode  of  administration,  whether  by  the  stomach  or  by 
subcutaneous  injections,  and  are  proportional  to  the  dose  and 
length  of  treatment;  that  better  results  are  obtained  with  dip- 
somaniacs than  with  chronic  drunkards ;  and  that  drunkards 
are  extremely  tolerant  of  large  doses  of  strychnine,  which  do 
not  seem  to  produce  a  cumulative  effect.  It  is  credible,  he 
thinks,  that  drunkards  subjected  to  the  influence  of  strychnine 
no  longer  feel  their  previous  irresistible  impulse  to  drink,  bat 
doubtful  if  they  are  really  averse  to  drinking. 


The  Creation  of  God.  By  Dr.  Jacob  Haetmann,  New  York 
New  York :  The  Truth  Seeker  Company,  1893.  Pp.  viii-9 
to  432. 

We  trust  that  Dr.  Hartraann  is  better  qualified  to  labor  in 
his  profession  than  in  the  field  upon  which  he  has  trespassed  in 
this  volume.  Revamping  Voltaire,  Paine,  Volney,  et  id  omne 
genus  may  fit  the  author  for  the  epigram — 

Tliy  writings  are  immortal,  0  my  friend. 
For  he  who  reads  them  reads  them  to  no  end. 

BOOKS,  ETC.,  RECEIVED. 

Diseases  of  the  Rectum  and  Anus,  their  Pathology,  Diagno- 
sis, and  Treatment.  By  Charles  B.  Kelsey,  A.  M.,  M.  D.,  Pro- 
fessor of  Diseases  of  the  Rectum  at  the  New  Y'ork  Post-gradu- 
ate Medical  School  and  Hospital,  etc.  Fourth  Edition,  revised 
and  enlarged.  With  Two  Ohromo-lithographs  and  One  Hun- 
dred and  Sixty-two  Illustrations.  New  York :  William  Wood 
&  Company,  1893.    Pp.  x-490.    [Price,  $4.] 

A  Treatise,  Practical  and  Theoretic,  on  Cancers  and  the  Can- 
cer Process.  By  Herbert  Snow,  M.  D.  (Lond.),  etc.,  Surgeon  to 
the  Cancer  Hospital.  London:  J.  &  A.  Churchill,  1893.  Pp 
xiii-384.    [Price,  15  shillings.] 

Appendicitis  and  Perityphlitis.  By  Charles  Talamon,  M.  D., 
Physician  to  Tenon  Hospital,  Paris,  France.  Translated  by  E. 
P.  Hurd,  M.  D.  Detroit :  George  S.  Davis,  1893.  Pp.  iv-210 
[The  Physician'' s  Leisure  Library. '\    [Price,  25  cents.] 


May  27,  1893. J 


MISCELLANY. 


597 


The  Surgical  Anatomy  and  Surgery  of  the  Ear.  By  Albert 
H.  Tuttle,  M.  D.,  S.  B.  (Harv.),  of  Catnbridge,  Mass.  With 
Twenty-eight  Original  Illustrations,  reproduced  from  the  Writ- 
er's Drawings  from  Nature.  Detroit:  George  S.Davis,  1893. 
Pp.  vii-109.  {Tke  Phtjuician's  Leisure  Library.}  [Price,  25 
cents.] 

A  Practical  Treatise  on  Materia  Medica  and  Therapeutics, 
with  Especial  Reference  to  the  Clinical  Application  of  Drugs. 
By  John  V.  Shoemaker,  A.  M.,  M.  D.,  Professor  of  Materia 
Medica,  Pharmacology,  Therapeutic?,  and  Clinical  Medicine,  and 
Clinical  Professor  of  Diseases  of  the  Skin  in  the  Medico-chi- 
rurgical  College  of  Philadelphia.  Second  Edition,  thoroughly 
revised.  In  Two  Volumes.  Volume  I.  Devoted  to  Pharmacy, 
General  Pharmacology,  and  Therapeutics,  and  Remedial  Agents 
not  properly  classed  with  Drugs.  Pp.  xi-354.  Volume  II.  An 
Independent  Volume  upon  Drugs.  Pp.  vi-355  to  1046.  Phila- 
delphia and  London  :  The  F.  A.  Davis  Co.,  1893. 

On  Lupus.  By  J.  L.  Milton,  Senior  Surgeon  to  St.  John's 
Hospital  (or  Diseases  of  the  Skin.  [Reprinted  from  the  Edi7i- 
burgh  Medical  Journal.] 

Acute  Rhinitis  with  Retention  of  Secretion.  By  C.  E.  Per- 
kins, M.  D.,  Sandusky,  Ohio.  [Reprinted  from  the  Medical  and 
Surgical  Beportcr.] 

Idiopathic  Muscular  Atrophy.  By  J.  T.  Eskridge,  M.  D., 
Denver,  Col.  [Reprinted  from  the  Journal  o/ Nervous  amd  Men- 
tal BMease.] 

Chronic  Meningo-myelitis.  By  J.  T.  Eskridge,  M.  D.,  Den- 
ver, Col.    [Reprinted  from  the  Denver  Aledical  Times.] 

Vegetable  Plates  in  Bowel  and  Stomach  Surgery  ;  a  Discus- 
sion of  the  Proper  Technique.  By  Robert  II.  M.  Dawbarn, 
M.  D.,  of  New  York.    [Reprinted  from  the  Annals  of  Surgery.] 

Legislative  Restriction  of  the  Practice  of  Medicine.  By  W. 
P.  Munn,  M.  D.,  Denver,  Col.  [Reprinted  from  the  Pittsburgh 
Medical  Review.] 

The  Third  Annual  Report  of  the  Eye,  Ear,  Nose,  and  Throat 
Hospital,  New  Orleans,  La. 

Ueber  Diabetes  raellitus.  Von  Dr.  A.  Kallay,  Brunnenarzt 
in  Karlsbad.  [Separatabdruck  aus  der  Wiener  medizinischen 
Woehenschrift.] 

Diphtheria — a  Clinical  Study.  By  William  P.  Munn,  M.  D., 
of  Denver,  Col.    [Reprinted  from  the  Medical  News.] 


lit  i  s  r  1 1 1  a  n  g , 


Treatment  by  Drugs. — "  It  is  a  significant  sign  of  the  attitude  of 
the  medical  profession  toward  the  question  of  treatment  of  disease," 
Bays  the  Lancet,  "  that  an  outspoken  belief  in  the  efficacy  of  drugs  is 
not  now  an  uncommon  thing.  It  is  not  a  great  many  years  since  medi- 
cal science  emerged  from  that  mass  of  empiricism  which  had  grown 
round  it.  in  the  middle  ages,  and  perhaps  no  more  interesting  or  amus- 
ing occupation  can  be  found  than  in  trying  to  arrive  at  the  reasons 
which  in  those  old  days  prompted  or  suggested  tlie  use  of  certain  drugs 
under  certain  conditions  and  to  effect  certain  objects.  With  this  emer- 
gence from  empiricism,  biiuging  with  it  as  it  did  the  foreshadowing  to 
some  extent  of  rational  treatment,  there  came  tlie  natural  and  inevitable 
skepticism  as  to  the  efficacy  of  drugs,  leading  too  often  to  a  bold  nega- 
tion of  their  usefulness  under  any  and  every  circumstance.  But,  as 
history  is  said  to  repeat  itself  without  ever  evoking  exactly  the  same 
condition  of  things,  so  treatment  by  drugs  at  the  present  time  bids  fair 
to  assume  its  ancient  importance  and  to  occupy  much  of  the  attention 
of  every  one  who  has  sufficient  courage  to  confront  our  pathological 
conceptions  of  disease  with  some  remedy  for  the  use  of  which  there  is 
a  rational  foundation.    No  doubt  the  reason  for  this  lies  in  the  great 


advance  that  has  taken  place  in  two  different  directions.  In  the  first 
place,  many  diseases  are  now  recognized  as  the  effect  of  toxic  sub- 
stances, using  the  word  '  toxic '  in  its  very  widest  sense.  Many  of  these 
toxic  substances  are  of  the  nature  of  chemical  compounds,  and  it  is 
scarcely  surprising,  considering  the  enormous  strides  which  scientific 
chemistry  has  recently  made,  that  a  hope  should  be  born,  that  anti- 
dotes for  some  of  the  poisons  may  be  discoverable,  or  that  something 
may  be  found  the  application  of  which  may  render  the  morbid  process 
impossible.  In  the  same  direction  also  is  the  search  for  some  remedy 
for  combating  those  probably  disturbed  internal  conditions  which  under- 
lie many  of  what,  for  want  of  a  better  name  and  more  exact  knowdedge, 
we  term  '  functional '  diseases,  and  it  is  significant  to  find  an  autliority 
of  the  high  standing  of  the  latest  Fothergillian  medalist  declaring  his 
gi'owing  belief  in  the  efficacy  of  drugs  in  the  treatment  of  disease.  We 
can  not  do  better  than  quote  some  of  his  own  words :  '  I  have  been 
surprised,'  he  says,  '  at  the  amount  of  good  that  has  been  done  in  affec- 
tions commonly  looked  upon  as  intractable — relief,  arrest,  and  restora- 
tion. With  each  successive  year's  experience  it  seems  to  me  greater 
and  more  distinct  and  to  elicit  more  gratitude  from  the  patients  to 
whom  it  is  applied.'  These  words  are  very  encouraging,  and  we  have 
no  doubt  that  during  the  next  few  years  there  will  be  discovered  even 
more  potency  in  the  weapons  already  at  our  disposal,  as  most  certainly 
new  ones  will  be  revealed." 

Arsenical  Neuritis. — At  a  recent  meeting  of  the  Johns  Hopkins 
Hospital  Medical  Society,  the  proceedings  of  which  are  given  in  the 
Johns  Hopkins  Hospital  Bulletin  for  April,  Dr.  Osier  said  : 

"On  October  25,  1892,  the  patient  before  you  was  admitted  to  my 
ward  with  Hodgkin's  disease,  the  cervical,  axdlary,  and  inguinal  groups 
being  involved.  Having  had  under  observation  for  now  nearly  four 
years  a  case  of  this  disease,  which  has  been  remarkably  benefited  by 
the  prolonged  use  of  Fowler's  solution  taken  at  intervals,  we  naturally 
placed  this  man  upon  the  same  drug.  The  details  of  his  case,  so  far 
as  they  relate  to  the  lymphatic  disorder,  do  not  concern  us.  The  ar- 
senic was  begun  on  October  27th,  given  as  Fowler's  solution,  and  gradu- 
ally increased.  He  took  it  on  the  first  occasion  for  ten  days  ;  it  was 
then  resumed  on  November  14th,  and  in  two  weeks  the  dose  reached 
fifteen  minims  three  times  a  day.  Toward  the  end  of  November  it  was 
noted  that  his  skin,  which  was  naturally  of  a  somewhat  dark  color,  had 
a  much  deeper  tint,  and  that  of  the  abdomen  was  very  distinctly  bronzed. 
Throughout  the  month  of  December  he  did  not  do  well.  The  arsenic 
was  stopped  on  the  19th  and  begun  again  on  the  27th.  From  the  out- 
set the  patient  has  had  that  interesting  feature  in  many  cases  of  Hodg- 
kin's disease,  an  intermittent  pyrexia,  and,  as  may  be  seen  by  his  last 
week's  chart,  the  temperature  rises  every  afternoon  and  evening  to 
about  104°.  The  pigmentation  seemed  to  increase  throughout  Decem- 
ber. Twice  during  the  first  two  months  of  his  stay  in  hospital  there 
was  slight  diarrhoea,  which  was  attributed  to  the  arsenic.  About  the 
middle  of  January  it  was  noticed  that  he  was  tender  to  the  touch  and 
walked  somewhat  stiffly.  He  is  a  Pole,  speaking  no  English,  and,  as 
there  was  no  one  in  the  ward  to  interpret  for  him,  these  symptoms 
did  not  perhaps  at  first  attract  the  attention  they  deserved.  The 
most  striking  feature  at  this  time  was  the  sensitiveness  on  pressure. 
The  skin  itself  did  not  appear  to  be  painful,  but  if,  for  example,  the 
arm  was  grasped,  or  the  pectoral  muscle  lifted,  or  the  thigh  pinched, 
he  winced  and  tears  came  into  his  eyes.  By  the  end  of  January  he 
walked  with  much  difficulty  and  could  scarcely  go  from  his  bed  to  the 
closet.  He  has  natmally,  in  the  course  of  his  disease,  wasted  a  good 
deal,  but  the  legs  seem  to  have  become  distinctly  flabby  wiihiu  the 
past  two  or  three  weeks.  The  knee-jerks,  which  were  present  on  Janu- 
ary 10th,  are  at  present  absent. 

"  On  February  2(1  Dr.  Hoch  reported  the  faradaic  excitability  of  the 
nerves  of  the  leg  was  diminished,  the  galvanic  also  to  a  slight  extent. 
In  the  muscles  the  diminution  to  both  currents  was  more  marked,  and 
the  contraction  following  the  galvanic  stimulation  was  decidedly  slower, 
and  the  anode,  if  not  larger,  was  at  least  equal  to  the  K.  C.  C.  The 
muscular  power  in  the  arm  is  not  so  strikingly  diminished,  though  the 
grasp  is  feeble  in  comparison  with  what  it  was.  The  hypersensitive- 
ness  of  the  muscles  does  not  appear  to  be  at  all  diminished. 

Between  the  27th  of  October  and  the  10th  of  January  thia  patimi; 


598 


MISCELLANY. 


[N.  Y.  Med.  Jodb., 


took  §431illl8of  the  liquor  potassii  arsenitis,  equivalent  to  16^  (ca.) 
grains  of  areenious  acid.  During  these  seventy-five  days  there  were 
fourteen  days  in  which  the  drug  was  omitted.  The  marked  sensory 
changes,  the  gradual  impairment  of  muscular  power,  and  the  progress- 
ive character  indicate  very  clearly  the  peripheral  and  neuritic  nature 
of  the  affection,  and  though  he  has  a  chronic  cachexia,  in  which,  as  in 
cancer  or  tuberculosis,  peripheral  neuritis  might  develop,  yet  it  seems 
more  rational  to  attribute  it  to  the  somewhat  prolonged  use  of  the  ar- 
senic, more  particularly  as  he  has  had  also  another  striking  feature  of 
arsenical  poisoning — namely,  pigmentation  of  the  skin." 

The  Chinese  Movement  Cure. — In  the  March  installment  of  Dr. 
John  C.  Thomson's  article  on  Surgery  in  China,  published  in  the  China 
Medical  Missionary  Journal,  the  following  passage  occurs  : 

"The  sixth  operation  of  surgery,  which  I  have  rendered  'shampoo- 
ing,' is  worthy  of  more  than  passing  notice,  since  in  addition  to  the 
general  idea  of  massage  it  has  developed  into  a  science  resembling  in 
some  respects,  and  rivaling  iu  detail  at  least,  the  now  famous  Swedish 
movement  cure.  Massage  in  its  simpler  form,  consisting  of  tapping, 
kneading,  pinching,  chafing,  and  pommeling  the  body  all  over,  is  widely 
used  as  a  remedy  for  muscular  fatigue,  nervousness,  headache,  paraly- 
sis, pelvic  disorders,  labor,  etc.,  and  also  as  a  simple  luxury,  the  barbers 
being  the  operators  and  concluding  their  daily  shaving  and  dressing 
operations  with  a  sound  pommeling  to  the  back  and  limbs  of  such  of 
their  patrons  as  can  afford  to  pay  for  it. 

"  This,  as  well  as  the  more  complicated  system  of  massage  com- 
bined with  air-swallowing  and  muscular  exercise,  is  of  great  age,  being 
traced  not  to  the  usual  Hwang  Ti  (2697  b.  c),  legendary  though  that 
emperor  be,  but  some  twelve  centuries  beyond  him.  Into  the  history 
of  the  system,  however,  I  shall  not  here  enter,  referring  for  that  and 
for  a  full  description  of  its  theory  to  a  paper  on  the  subject  by  D.  J. 
Macgowan,  M.  D.,  WSnchow,  in  the  Customs  Medical  Report,  No.  29, 
1884— '86  ;  and  here  passing  directly  to  a  brief  account  of  the  frictions 
and  movements  themselves  taken  from  that  paper. 

"  The  period  of  air-swallowing  and  friction  exercises  is  to  be  di- 
vided into  three  parts  of  one  hundred  days  each.  After  certain  pre- 
liminary carefully  described  inhalations  of  the  sun's  air  on  the  first  of 
the  moon,  and  of  the  moon's  air  at  the  full  moon,  all  is  ready  for  a 
commencement  being  made.  During  the  first  month  friction  is  to  be 
made  by  two  youths,  each  on  alternate  days,  they  rubbing  the  patient's 
abdomen  with  the  right  hand  and  from  right  to  left,  at  first  lightly, 
but  gradually  increasing  the  pressure,  and  this  for  an  hour  three  times 
daily.  By  the  end  of  the  first  month  the  services  of  the  youths  may  be 
dispensed  with,  when  a  form  of  shampooing  is  to  be  practiced  by  the 
patient  himself,  thumping  his  ribs  with  a  bag  filled  with  water-worn 
pebbles,  weighing  a  pound,  three  times  daily.  During  the  third  month 
a  pestle  about  six  inches  long,  or  a  round  bat  somewhat  longer,  is  to  be 
employed  for  pounding  the  abdomen  three  times  a  day  ;  they  are  to  be 
made  of  hard  wood,  and  their  form  is  to  be  as  shown  in  the  illustration. 
Meanwhile  friction  and  pounding  the  ribs  is  to  be  continued.  During 
the  fourth  month  the  bat  and  pestle  are  to  be  alternately  used  along 
with  friction,  and  this  completes  the  first  period  of  one  hundred  days. 

"From  the  fifth  month  of  the  exercises  the  bag  of  pebbles  is  to  be 
used  continually  till  the  close  of  the  eighth  month,  which  closes  the 
second  period  of  a  htmdred  days.  During  the  third  period  the  back  is 
to  be  pounded  in  like  manner.  During  the  whole  three  hundred  days 
it  is  directed  that  continence  be  maintained  except  once  between  the 
hundred-day  periods ;  and  ever  afterward,  except  once  in  fifty  days. 

"  On  completing  these  exercises  muscular  movements  are  to  be 
commenced,  of  which  there  are  twelve  kinds,  namely : 

"I.  Stand  erect  and  firmly,  retain  the  breath,  bring  the  flexed  hands 
together  on  the  chest,  knuckles  meeting,  keeping  the  mind  at  absolute 
rest. 

"  II.  Stand  on  the  toes  and  extend  the  arms  laterally,  with  eyes 
fixed,  mouth  closed,  and  mind  perfectly  quiescent. 

"  III.  Maintaining  the  tijjtoe  posture,  raise  the  arms  above  the  head 
and  bring  the  hands  together  with  palms  turned  upward,  joints  closed, 
tongue  pressing  roof  of  mouth ;  clinch  the  fists  and  bring  the  arms 
/irmly  and  slowly  down. 

"  TV,  Raise  one  arm  above  the  head,  palm  hollowed,  eyes  directed 


toward  it,  inhahng  through  nostrils,  and  forcibly  and  slovrly  bringing 
down  the  arm.    Rejieat  with  the  other  arm. 

"  V.  As  if  pulling  the  tails  of  nine  bulls,  stand  on  one  foot  bent  and 
extended  forward,  the  other  extended  backward ;  cause  the  air  of  the 
pubic  region  to  move  forcibly,  thrusting  one  arm  forward,  the  other 
backward,  eyes  fixed  on  the  clinched  fist.    Repeat,  reversing  the  legs. 

"  VI.  Extend  the  arms  forward,  as  if  pushing  out  and  drawing  in, 
seven  times. 

"VII.  Head  inclined,  with  a  hand  stretched  behind  the  neck.  Re- 
peat with  other  hand.    Maintain  erect  posture,  with  gentle  breathing. 

"  VIII.  Sit  with  legs  wide  apart,  pressing  the  hands  on  the  floor, 
and  forcibly  raise  them,  eyes  fixed,  mouth  closed ;  rise  and  bring  the 
feet  together. 

"  IX.  Turn  the  arms  alternately  across  the  chest,  fixing  eyes  on  the 
hands,  the  mind  meantime  settled. 

"  X.  Assume  the  posture  of  the  '  crouching  tiger,'  one  knee  bent, 
the  other  stretched  backward,  head  turned  upward,  palms  resting  on 
the  ground. 

"  XI.  Bend  forward,  placing  the  hands  at  the  back  of  the  head,  so 

as  to  cover  the  ears ;  close  the  teeth,  press  roof  of  mouth  with  tongue. 

"  XII.  Finally,  keeping  legs  erect,  bend  forward,  with  fixed  eyes 
and  upturned  head,  the  hands  clasped  on  the  ground  ;  rise ;  stamp 
twenty-one  times,  and  stretch  the  arms  alternately  seven  times ;  then 
sit  cross-legged,  each  leg  in  turn,  with  closed  eyes. 

"  The  above  exercises  are  to  be  performed  three  times  daily  for  an 
indefinite  period,  and  with  them  are  to  be  gone  through  certain  supple- 
mentary exercises  for  the  development  of  individual  groups  of  muscles, 
which  Dr.  Macgowan  describes  in  detail.  Exercise  is  recommended  to 
be  taken  in  the  open  or  in  woods,  and  it  is  again  and  again  provided 
that  in  going  through  the  exercises  there  is  to  be  no  thinking :  the 
mind  must  be  absolutely  quiescent. 

"In  conclusion,  regret  is  expressed  that  owing  to  the  business  voca- 
tions or  inconsiderateness  of  youth  this  means  of  averting  disease  is 
deferred  till  old  age,  when  it  can  be  of  no  avail." 

Erasistratus  and  the  Diagnosis  of  Love. — In  one  of  Dr.  James  Fin- 
layson's  bibliographical  demonstrations,  entitled  Herophilus  and  Erasis- 
tratus, published  in  the  May  number  of  the  Glasgow  Medical  Journal, 
we  find  the  following : 

"  When  discussing  Galen's  works  on  a  previous  occasion,  I  brought 
under  your  notice  his  recognition  of  the  illness  of  the  wife  of  Justus  as 
being  due  to  love  (Kiihn's  edition,  torn,  xiv,  p.  630) ;  Galen  in  that 
passage  refers  to  a  somewhat  similar  diagnosis  made  by  Erasistratus, 
which  is  evidently  the  celebrated  one  narrated  by  various  authors.  I 
give  the  account  as  contained  in  Plutarch's  Li  fe  of  Demetrius  (Lang- 
horne's  translation): 

"  '  He  [Demetrius]  was  informed  too  that  his  daughter,  who  had 
been  married  to  Seleucus,  was  now  wife  to  Antiochus,  the  son  of  that 
prince,  and  declared  queen  of  the  barbarous  nations  in  Upper  Asia. 
Antiochus  was  violently  enamored  of  the  young  Stratonice,  though  she 
had  a  son  by  his  father.  His  condition  was  extremely  unhappy.  He 
made  the  greatest  efforts  to  conquer  his  passion,  but  they  were  of  no 
avail.  At  last,  considering  that  his  desires  were  of  the  most  extrava- 
gant kind,  that  there  was  no  prospect  of  satisfaction  for  them,  and  that 
the  succors  of  reason  entirely  failed,  he  resolved,  in  his  despair,  to  rid 
himself  of  life,  and  bring  it  gradually  to  a  period,  by  neglectmg  all  care 
of  his  person  and  abstaining  from  food ;  for  this  purpose  he  made  sick- 
ness his  pretense.  His  physician,  Erasistratus,  easily  discovered  that 
his  distemper  was  love ;  but  it  was  diflicult  to  conjecture  who  was  the 
object.  In  order  to  find  it  out,  he  spent  whole  days  in  his  chamber ; 
and  whenever  any  beautiful  person  of  either  sex  entered  it,  he  observed 
with  great  attention  not  only  his  looks,  but  every  part  and  motion  of 
the  body  which  corresponds  most  with  the  passions  of  the  soul.  When 
others  entered  he  was  entirely  unaffected,  but  when  Stratonice  came  in, 
as  she  often  did,  either  alone  or  with  Seleucus,  he  showed  all  the  symp- 
toms described  by  Sappho,  the  faltering  voice,  the  burning  blush,  the 
tumultuous  pulse,  and  at  length,  the  passion  overcoming  his  spirits,  a 
dciiquium  and  mortal  paleness. 

"  '  Erasistratus  concluded  from  these  tokens  that  the  prince  was  in 
love  with  Stratonice,  and  perceived  that  he  intended  to  carry  the  secret 


May  27,  1893.] 


MISCELLANY. 


599 


with  him  to  the  grave.  He  saw  the  ditHculty  of  brealiing  the  matter  to 
Seleucus ;  yet  depending  upon  the  affection  which  the  king  liad  for  liis 
son,  he  ventured  one  day  to  tell  him  "  that  the  young  man's  disorder 
was  love,  but  love  for  which  there  was  no  remedy."  The  king,  quite 
astonished,  said,  "  How  !  love  for  which  there  was  no  remedy  !  "  "  It 
is  certainly  so,"  answered  Erasistratus,  "  for  he  is  in  love  with  my 
wife."  "  What,  Erasistratus  !  "  said  the  king,  "  would  you,  who  are  my 
friend,  refuse  to  give  up  your  wife  to  my  son  when  you  see  us  in  danger 
of  losing  our  only  hope  ?  "  "  Nay,  would  you  do  such  a  thing,"  an- 
swered the  physician,  "  though  you  are  his  father,  if  he  was  in  love 
with  Stratonice  ?  "  "  O  my  friend,"  rejilied  Seleucus,  "  how  happy 
should  I  be  if  either  (Jod  or  man  could  remove  his  affections  thither ! 
I  would  give  up  ray  kingdom,  so  I  could  but  keep  Antiochus."  He 
pronounced  these  words  with  so  much  emotion,  and  such  a  profusion  of 
tears,  that  Ei  asistratus  took  him  by  the  hand  and  said :  "  Then  there  is 
no  need  of  Erasistratus.  You,  sir,  who  are  a  father,  a  husband,  and  a 
king,  will  be  the  best  physician  too  for  your  family."  Upon  this  Seleu- 
cus summoned  the  people  to  meet  in  full  assembly,  and  told  them  it 
was  his  will  and  pleasure  that  Antiochus  should  intermarry  with  Stra- 
tonice, and  that  they  should  be  declared  King  and  Queen  of  the  Upper 
Provinces.' " 

"  This  story  is  given  by  so  many  authorities  that  we  may  conclude 
that  it  is  essentially  true,  particularly  as  the  marriage  of  Antiochus  and 
Stratonice  is  authenticated  in  other  ways.  Curiously  enough,  however, 
some  very  similar  stories  are  reported  regarding  other  physicians. 

"  For  the  cure  of  the  young  prince  Erasistratus  is  reported  by  Pliny 
to  have  received  a  fee  of  100  talents  {Hist.  A^at,  lib.  xxix,  cap.  i), 
which  is  calculated  as  amounting  to  nearly  £25,000  sterling.  Another 
passage  in  Pliny  (lib.  vii,  cap.  x.xxvii)  records  a  fee  to  Cleombrotus  of 
the  same  amount,  but  it  is  supposed  that  this  is  simply  an  error,  and 
that  Erasistratus  is  the  name  really  intended." 

Candor  in  Prognosis. — In  the  last  number  of  his  Asdepiad  Dr.  Ben- 
jamin Ward  Richardson  says  : 

"  The  author  or  authoress  of  the  remarkable  modern  work  entitled 
Gossip  of  a  Century  observes,  in  speaking  of  the  relationships  of  doctor 
and  patient,  that  '  faith  in  his  medical  attendant  and  faith  in  his  recov- 
ery are  the  sick  man's  staff,  and  will  often  save  him  when  treatment 
fails  ;  the  greatest  Physician  told  his  patient  in  so  many  words  it  "  was 
faith  that  made  him  whole,"  and  every  doctor  who  is  worth  his  shilling, 
to  say  nothing  of  the  gold  coin,  knows  the  power  of  imagination.' 

"  The  opinion  thus  expressed  is  a  lesson  drawn  from  the  observation 
of  its  writer  on  effects  which  have  been  supposed  to  follow  the  com- 
munications, in  the  form  of  prognosis,  which  sometimes  pass  between 
the  patient  and  physician.  The  case  of  Balzac  is  quoted,  and  the  idea 
is  conveyed  that  '  the  too  conscientious  physician  often  takes  away  the 
patient's  last  chance.  Let  him  (the  patient)  read  the  word  "  hopeless  " 
in  the  doctor's  face,  and,  however  brave,  he  is  lost ;  a  dose  of  poison 
would  not  be  more  effectual.' 

"  I  look  back  over  a  long  period  of  practical  experience  as  I  study 
these  statements.  I  ask.  Is  perfect  candor  in  prognosis  really  so  bad  ? 
The  conclusion,  the  only  conclusion  I  can  arrive  at,  is  that  candor  in  re- 
gard to  good  or  bad  effects  turns  entirely  on  diagnosis.  If,  though  symp- 
toms may  seem  urgent,  the  physician  be  absolutely  certain  there  is  no 
organic  change  of  structure  in  the  sick  man,  change  involving  life,  then 
prognosis  of  hope  and  persistence  in  favorable  prognosis  is  a  good  and 
curative  procedure  ;  and  faith  plays  its  splendid  part  with  the  greatest 
credit.  But  when  there  is  sure  and  certain  evidence  of  organic  disease 
of  vital  organ  or  organs,  then  all  the  faith  in  the  world  will  never  make 
whole.  It  is  in  these  last-named  conditions  that  prognosis  is  so  dillicult 
and  delicate  a  subject.  It  is  at  the  moment  when  the  physician  is  cer- 
tain that  declaring  the  worst  can  have  no  material  effect  on  the  condi- 
tion of  his  patient  that  candid  prognosis  is  thought  to  be  so  doubtful  by 
lookers-on.  But  suppose  in  such  a  crisis  the  physician  speaks  hopefully 
and  looks  unconcernedly,  knowing  the  deceit  he  is  carrying  out,  what 
can  he  expect  to  get  but  merciless  criticism  when  the  near  and  inevita- 
ble event  has  occurred  ?  His  whole  reputation  is  at  stake  if  he  deceive 
a  dying  man  and  a  dying  man's  friends. 

"  Candor  in  prognosis  is  right,  let  the  consequences  be  what  they 
may,  when  it  rests  sn  assured  diagnosis  ;  and  so  far  from  having  a  bad. 


it  often  has  a  good,  effect.  The  foreknowledge  of  the  worst  brings  to 
most  miuds,  even  the  most  timorous,  resignation  in  place  of  despair.  It 
makes  way  for  preparations  of  various  kinds  ;  and  when  it  is  properly 
led  up  to,  it  has  nothing  whatever  to  do  with  curative  faith.  Faith  never 
healed  an  aneurysm,  restored  a  cavernous  lung,  removed  a  tibrLnous  plug 
from  the  heart,  brought  back  to  natural  function  a  malignant  gland,  or 
dispersed  a  stone  in  the  kidney,  ureter,  or  bladder ;  and  when  any  final 
deathly  arbitration  is  present,  the  wisest  physician's  word  or  look  can 
be  of  no  vital  consequence  to  the  fate  in  store  for  the  sick  man.  On  the 
contrary,  firm  and  candid  statements  are  the  best  that  can  be  offered^ 
I  recall  well  the  case  of  an  important  official  of  the  state  during  a  period 
of  great  political  crisis.  This  gentleman  was  within  a  few  weeks  of 
death  from  an  incurable  disease.  He  was  under  the  care  of  Dr.  Daniel 
Noble,  Sir  Thomas  Watson,  Dr.  Arthur  Wilson,  Dr.  George  Budd,  and 
myself.  His  family  pressed  us  '  to  hold  out  hopes  of  his  recovery.'  We 
declined.  Another  physician  was  summoned  who,  entirely  replacing  us, 
held  out  such  hopes  that  a  public  announcement  of  a  speedy  recovery 
and  return  to  official  duties  went  forth.  In  three  weeks  the  death  of 
that  patient  took  place,  by  what  might  well  be  called  natural  necessity, 
and  the  confusion  that  followed,  the  dismay,  the  disgust  for  the  false 
prognosis,  it  is  impossible  to  describe.  No !  let  the  outside  world  say 
what  it  may,  candor  in  prognosis,  founded  on  solid  diagnosis,  is  the  right 
course,  both  for  patient  and  friends  ;  it  can  not  kill  a  man  stricken  with 
organic  disease;  it  can  not  weaken  a  brave  man,  and  it  may  give  to  one 
esteemed  a  coward  resignation  amounting  to  resolution,  since  death  at 
some  time  is  sure.  For  my  own  part,  I  should  detest  no  man  more  thor- 
oughly than  that  man  who,  seeing  me  lie  hopelessly  stricken  at  his  feet, 
conveyed  the  idea  by  false  word  or  look  that  my  days  or  hours  were  not 
numbered." 

Contemplated  Postponement  of  the  International  Medical  Congress. 

— In  a  letter  dated  May  Ist,  the  Lancet's  correspondent  in  Rome  says: 
"  I  have  to  make  the  rather  serious  announcement  that  the  Interna- 
tional Medical  Congi-ess,  arranged  to  hold  its  sittings  from  September 
24th  till  October  1st,  may  possibly  have  to  be  postponed.  No  actual 
decision  has  yet  been  taken,  but  at  recent  meetings  of  the  organizing 
committee  a  section  of  that  body  was  of  opinion  that  '  in  sequito  alle 
condizioni  sanitarie  di  alcune  regioni  d'  Europa'  (in  consequence  of 
the  sanitary  state  of  some  parts  of  Europe)  it  would  be  advisable  to 
hold  the  congress  at  another  season.  It  was  feared  that,  on  account  of 
the  '  condizioni  sanitarie '  referred  to,  many  physicians  and  health  offi- 
cers whose  presence  at  the  sittings  was  of  supreme  importance  might 
be  unable  to  attend.  The  postponement  of  the  congress  would  equally 
involve  that  of  the  '  Esposizione  Internazionale  di  Medicina  ed  Igiene  ' 
to  be  held  at  the  same  time.  This,  as  I  have  said,  would  be  a  rather 
serious  step  to  take,  and  next  week  I  hope  to  be  able  to  announce  that  the 
fears  that  have  suggested  it  are  so  far  unfounded  and  that  the  postpone- 
ment in  question  will  not  be  carried  out.'  Arrangements,  like  those  already 
completed,  of  a  complicated  kind  and  on  a  world-wide  scale,  are  not  to 
be  lightly  set  aside,  unless  by  the  force  majeure  of  exceptionally  grave 
and  quite  unforeseen  circumstances — circumstances  which  do  not  seem 
to  have  occurred,  as  yet  at  least,  in  any  of  the  great  centei  s  of  European 
population.  Certainly  the  full  and  carefully  authenticated  reports  of 
the  public  health  of  Great  Britain  and  the  continent,  given  in  the  Lan- 
cet of  the  2flth  ult.,  furnish  no  ground  for  alarm  at  the '  condizioni  sani- 
tarie '  of  any  part  of  Europe  in  the  immediate  present.  Meanwhile  the 
'  adesioni '  of  representatives  of  foreign  medical  schools  and  official 
sanitary  boards  continue  to  reach  the  organizing  committee.  The  Uni- 
versity of  Madras  announces  its  cordial  alacrity  to  intervene  at  the  con- 
gress, reserving  till  a  future  date  the  name  of  its  delegate.  The  French 
Societe  de  la  medecine  legale,  whose  headquarters  are  in  Paris,  has 
forwai'ded  an  anuouncement  to  the  same  effect,  while  the  Antwerp  As- 
sociation of  Medicine  has  nominated  its  representative  in  the  per.sou  of 
Professor  Leroy.  The  medical  school  of  that  city  will  further  have  a 
delegate  appointed  by  the  Minister  of  Public  Instruction.  Railway  and 
steamboat  companies,  in  addition  to  those  already  enumerated,  have 
intimated  their  readiness  to  convey  the  '  congressisti '  to  and  fi-oni 
Rome  at  reduced  fares,  and  Signer  Martini,  the  Minister  of  Public  In- 
struction in  the  Italian  Government,  has,  in  concert  with  the  directors 
of  the  national  museums  and  galleries  of  archaology,  sculpture,  and 


600 


MISCELLANY. 


[N.  Y.  Med.  Joub. 


painting,  provided  the  members  of  the  congress  with  special  facilities 
for  visiting  the  same.  The  excavations  now  in  progress  at  Pompeii 
will  also  be  thrown  open  to  members  on  simply  producing  their  con- 
gress ticket.  Considering  the  maturity  that  these  and  a  thousand  other 
arrangements  for  the  convenience  of  the  '  congressisti '  have  already 
reached,  to  say  nothing  of  the  fact  that  delegates  from  the  Antipodes 
are  already  on  the  eve  of  starting  for  Rome  or  have  adjusted  their  en 
gagements  ad  hoc,  it  seems  hardly  fair  to  contemplate  the  postpone- 
ment referred  to,  except  on  grounds  of  greater  gravity  and  precision 
than  those  just  indicated." 

Menthol  in  Pruriginous  Affections  of  the  Skin. — In  the  May  num- 
ber of  the  Brilixh  Journal  of  DcrinatoJoijy  there  is  an  abstract  of  an 
article  by  Dr.  Colombini,  published  in  the  Giornale  italiaiio  delle  malaHie 
veneree  e  dclla  pelle  for  March.  Dr.  Colombini  gives  his  experiences 
with  menthol  in  forty-four  cases.    He  divides  these  into  three  groups: 

(1)  Dermatoses  in  vihich  prurittis  is  a  consequence  of  the  eruption 
or  of  the  cause  of  the  eruption — e.  g.,  eczema  and  the  pruritus  persist- 
ing in  scabietics  after  destruction  of  the  acarus ;  in  all,  twenty-six 
cases. 

(2)  Dermatoses  in  which  pruritus  is  the  substantive  disease  with- 
out any  visible  skin  lesion — e.g.,  pruritus  nervosus;  in  all,  nine  cases. 

(3)  Dermatoses  in  which  the  cutaneous  lesions  are  either  wholly  or 
partly  the  result  of  scratching — e.  g.,  urticaria  and  certain  forms  of 


eczema  ;  in  all,  nine  cases. 

He  used  the  following  formulae  : 

1.  3  Menthol   5-10  parts. 

Spiritus  vini  rectificati   100  " 

M.    Sig. :  Lotio. 

2.  5  Menthol   10  parts. 

Olei  amygdalae  dulcis   100  " 

M.    Sig. :  Applicatio. 

3.  5  Zinci  oxidi, 

Amyli  pulveri  sati  aa  50  parts. 

Menthol   1-6  " 

Paraffini  mollis   100  " 

M.    Sig.:  Pasta. 

4.  3  Zmci  oxidi, 

Bismuthi  subnitratis  aa  10  parts. 

Menthol   1-3  " 

Amyli  pulverisati   30  " 


M.  Sig. :  Pulvis  aspersorius. 
As  regards  Group  I,  the  results  were  remarkable,  all  the  cases  of 
eczema  being  relieved  almost  immediately,  and  consequently  cure  was 
greatly  expedited ;  even  in  a  case  of  prurigo  Hebras,  in  a  child  aged 
twelve,  unbroken  sleep  was  obtained.  Ichthyol  had  been  previously 
tried  in  the  form  of  paste,  but  with  no  great  benefit  in  any  of  these 
cases. 

Of  the  nine  cases  forming  Group  II,  three  were  completely  cured 
[pruritus  cutaneus,  two ;  pruritus  hiemalis  (Duhring),  one] ;  four  were 
considerably  relieved  [pruritus  cutaneus  dorsi  et  crurum,  one ;  pruritus 
cutaneus  diffusus,  one  ;  pruritus  senilis,  one  ;  pruritus  cutaneus,  one]  ; 
and  two  remained  obstinate.  Other  pastes — e.  g.,  /3-naphthol  and  ich- 
thyol— had  been  previously  used.  In  some  of  these  cases  the  sensation 
of  cold  was  complained  of  after  the  application  of  menthol ;  it,  how- 
ever, passed  off. 

Of  the  nine  cases  included  in  Group  III,  the  efficacy  of  menthol 
was  incontestable.  All  were  cured.  [Eczema  scroti,  two ;  eczema 
pruriginosum  diflfusum,  three ;  urticaria,  three ;  eczema  post  scabiem, 
one.] 

In  conclusion.  Dr.  Colombini  considers  menthol  should  always  be 
used  in  cases  where  pruritus  is  the  chief  symptom  and  its  cause  a 
nervous  one.  The  solution  of  menthol  in  oil  is,  as  a  rule,  to  be  pre- 
ferred to  that  in  spirit. 

The  Massachusetts  Medical  Society  will  hold  its  one  hundred  and 
twelfth  annual  meeting  in  Boston  on  Tuesday  and  Wednesday,  June  13th 
and  14th,  under  the  presidency  of  Dr.  James  C.  White,  of  Boston.  In 
the  Section  in  Medicine,  papers  will  be  read  on  The  Influence  of  College 
Life  on  Health,  by  Dr.  (Jrace  A.  Preston,  of  Northampton,  Dr.  Edwin 
Famham,  of  Cambridge,  and  Dr.  R.  W.  Greenleaf,  of  Boston ;  and  on 


The  Treatment  of  Pneumonia,  by  Dr.  F.  C.  Shattuck,  of  Boston.  In 
the  Section  in  Surgery,  Dr.  A.  G.  Gerster,  of  New  York,  will  read 
a  paper  entitled  How  should  the  General  Practitioner  deal  with 
Strangulated  Hernia  V  The  Shattuck  Lecture,  on  Tuberculous  Pleurisy, 
will  be  delivered  by  Dr.  William  Osier,  of  Baltimore.  At  the  general 
meeting,  Dr.  C.  W.  Galloupe,  of  Boston,  will  read  a  paper  entitled  A 
Consideration  of  Erysipelas  occurring  during  the  Puerpcrium  ;  and  Dr. 
F.  11.  Williams,  of  Boston,  will  read  one  on  Diphtheria  and  Other  Mem- 
branous Affections  of  the  Throat.  The  annual  discourse  will  be  de- 
livered by  Dr.  J.  T.  G.  Nichols,  of  Cambridge. 

A  Powder  for  Hyperidrosis  ( Union  mid.). 

R  Washed  sulphur   gr.  xxx ; 

Powdered  arrowroot.   1  ; 

Salicylic  acid   gr.  vii. 

Sig. :  To  be  dusted  over  the  feet  and  between  the  toes. — British 
Journal  of  Dermatology. 


To  Contributors  and  Correspondents. —  The  attention  of  all  wIm  purpose 
favoring  us  with  communications  is  respectfully  called  to  t/ie  follow, 
ing: 

Authors  of  articles  intended  for  ptiblication  under  the  head  of  "original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti- 
cles, we  ahoays  do  so  with  the  understanding  that  the  following  condi- 
tions are  to  be  observed  ■■  (1)  when  a  manuscript  is  seiU  to  this  jour- 
nal, a  similar  manuscript  or  any  abstract  thereof  mmt  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  specif  ed  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  typesetters'  haiuis.  We  are  often  constrained  to  dcctiiu 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  mitable  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  aru>nymous  communications.  Hereafter,  cor- 
respondents asking  for  in  formation  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  7Wte 
is  to  be  looked  for.  All  communications  not  intended  _for  publication 
under  the  author's  name  are  treated  as  strictly  confdential.  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  m  in- 
formed of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi- 
cations of  matters  that  are  expected  to  come  up  at  particular  meet- 
ings will  be  inserted  when  they  are  received  in  time. 

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

All  commumcniioiis  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. 

Contributors  who  wish  to  order  REPRINTS  of  their  articles  should  do 
so  on  a  blank  prepared  for  that  purpose,  which  wid  he  sent  to  them 
by  the  publishers  on  receipt  of  a  request  to  that  effect.  The  order 
sliould  be  sent  to  the  publishers,  and  not  to  t/u  editor. 


THE  JSTEW  YORK  MEDICAL  JOURlSrAL,  Jtoe  3,  1893. 


Original  Communications. 


THE  PATHOLOGY  AND  TEEATMENT  OF 
GRAVES'S  DISEASE  * 
By  W.  H.  THOMSON,  M.  D., 

PR0PES80B  OF  MATERIA  JIEDICA  AND  OP  NERVOUS  DISEASES, 
UNIVERSITY  OP  THE  CITY  OF  NEW  YORK  ; 
PHYSICIAN  TO  BELLEVUE  AND  ROOSEVELT  HOSPITALS. 

The  progress  of  pathiology  often  illustrates  the  disad- 
vantage of  the  premature  naming  of  diseases  after  some  of 
their  common  or  prominent  symptoms,  for  further  knowl- 
edge may  show  the  disease  to  have  much  wider  relation- 
ships than  at  first  suspected,  and  in  some  cases  to  exist  with- 
out these  symptoms  being  present.  If  such  be  the  case, 
the  symptomatic  name  may  then  operate  to  prevent  a  cor- 
rect diagnosis.  Locomotor  ataxia  is  a  good  example  of  the 
concealing  power  of  such  names,  for  I  have  known  of  an 
elaborate  diagnosis  being  made  of  a  tumor  in  the  optic 
thalamus  to  account  for  the  optic  atrophy  of  a  tabetic  pa- 
tient who,  though  wholly  blind,  yet  had  no  ataxic  gait, 
while  in  other  patients  with  this  disease  the  significance 
of  paina  or  of  gastric  crises  has  been  similarly  misinter- 
preted, because  the  motor  symptoms  were  so  little  devel- 
oped. In  like  manner  the  name  exophthalmic  goitre  has 
had  much  the  same  influence  in  preventing  the  recognition 
of  Graves's  disease  in  many  instances,  and  still  more  in 
confusing  the  views  of  its  pathology.  In  reading  the  nu- 
merous contributions  on  the  pathology  of  this  interesting 
affection,  it  is  striking  to  note  how  predominantly  the  con- 
ception of  some  textural  lesion  in  the  nervous  system  that 
would  account  for  the  exophthalmia  and  the  goitre  has  di- 
rected either  the  investigation  or  the  speculation,  in  seeming 
forgetfulness  of  the  fact  that  these  symptoms  are  not  essen- 
tial to  the  affection,  because  they  may  be  both  present  with 
Graves's  disease  absent,  or  both  absent  with  Graves's  dis- 
ease present. 

The  safest  rule  to  follow  in  pathological  problems  is  to 
seek  first  for  the  most  constant  characteristics  of  a  given 
complaint,  rather  than  for  the  most  obtrusive  ones,  for, 
when  the  latter  are  found  to  be  wanting  in  some  real  cases 
of  a  given  affection,  they  sink  at  once  from  the  rank  of 
a  primary  to  that  of  an  accessory  relationship  to  its  true 
pathology.  Having  found  the  most  constant  characteristic 
of  the  disease,  we  must  even  then  keep  to  what  is  most 
constant  about  the  characteristic  itself  when  we  come  to 
analyze  it,  lest  we  be  again  turned  aside  from  the  right 
course  by  non-essential  accompaniments.  Thus  the  most 
uniform  condition  in  Graves's  disease  is  what  may  be  cor- 
rectly described  as  a  state  of  marked  agitation.  In  many 
instances  it  is  for  long  a  purely  physical  state,  not  involving 
the  mind  or  the  spirits,  and  yet  the  patient  acts  as  if  great- 
ly alarmed  about  something.  This  has  led  many  writers  to 
pronounce  fright  to  be  a  leading  cause  of  the  disease,  and 
how  far  this  hypothesis  may  be  pushed  is  illustrated  by  Dr. 
Hector  W.  Mackenzie,  in  his  excellent  lectures  on  Graves's 


*  Read  before  the  New  York  Neurological  Society,  March  17,  1893. 


disease  {Lancet,  September,  1890),  when  he  sums  up  its  pa- 
thology by  saying  that  if  we  can  not  show  in  each  case  that 
the  patients  themselves  have  so  started  from  a  fright,  yet 
some  of  their  ancestors  may  once  on  a  time  have  been  greatly 
terrified,  and  thus  laid  the  foundation  for  Graves's  disease 
in  a  descendant  by  what  he  terms  an  unconscious  heredi- 
ary  memory.  We  are  thus  at  the  outset  diverted  from  the 
study  of  a  truly  characteristic  condition  to  that  of  a  most 
occasional  element  in  the  clinical  history  of  the  affection, 
and  which  is  then  made  to  do  duty  as  a  guide  to  its  true 
pathology.  The  parallel  instance  of  chorea,  where  fright 
is  so  often  spoken  of  as  a  cause  of  the  disease,  naturally 
suggests  the  desirability  of  a  new  technical  meaning  of  the 
term  "  cause "  in  medicine.  It  would  be  a  great  gain  to 
restrict  its  use  only  to  some  element,  discovered  or  to  be 
discovered,  in  the  aetiology  of  a  disease  without  whose 
presence  the  disease  would  not  exist,  while  for  all  variable 
factors  to  employ  some  such  term  as  occasion.  Thus  fright 
may  be  the  occasion  of  the  first  manifestation  of  chorea  or 
of  Graves's  disease,  a  blow  the  occasion  of  the  development 
of  a  mammary  cancer,  a  chill  from  exposure  to  cold  the 
occasion  for  the  development  of  a  croupous  pneumonia  or 
of  a  pulmonary  phthisis,  but  it  is  only  a  hindrance  to  our 
progress  toward  a  correct  pathology  of  either  of  these  dis- 
eases to  put  down  any  one  of  the  very  varying  occasions  of 
its  first  manifestation  as  its  cause.  It  would  be  better  to 
defer  rating  anything  that  is  occasional  in  a  disease  until  its 
proper  and  quite  subordinate  place  is  settled  by  the  due 
precedence  being  determined  of  the  few  constant  over  the 
many  occasional  elements.  This  is  particularly  the  case 
with  such  a  convenient  cause  to  allege  as  fright  in  nervous 
patients,  for  not  infrequently  it  may  prove  on  examination 
that  the  patients  had  been  for  months  in  a  state  of  true 
physical  agitation  before  the  accident  of  a  mental  impres- 
sion occurred  which  they  describe.  In  my  last  eight  con- 
secutive cases  of  Graves's  disease  in  private  practice  not 
one  of  them  would  ascribe  the  initiation  of  the  complaint 
either  to  fright  or  to  any  other  emotional  cause.  Of  course 
it  is  impossible  to  say  what  may  have  happened  to  their 
ancestors,  but  I  think  that  a  much  nearer  source  of  their 
bodily  agitation  may  be  found  in  their  present  living  frames 
than  in  the  dead  past. 

The  first  of  the  above-mentioned  patients  presented  at  her 
first  visit  a  complete  picture  of  the  constant,  in  distinction 
from  the  occasional,  symptoms  of  Graves's  disease.  I  had 
known  her  well  for  some  time,  from  having  attended  other 
members  of  her  family,  but  she  had  always  been  healthy  be- 
fore, so  that  I  had  not  seen  her  for  some  months.  She  showed 
no  sign  of  either  exophthalmia  or  goitre,  but,  as  she  now  began 
her  story,  she  seemed  as  if  about  hesitatingly  to  divulge  some 
great  cause  of  mental  distress.  Her  voice  trembled  as  if  choked 
with  emotion,  her  hands  trembled,  and  her  respiration  was  hur- 
ried and  catching.  She  said,  however,  tluit  she  had  had  noth- 
ing to  make  her  so  nervous,  nor  could  she  imagine  why  she  was 
so,  except  that  she  had  had  diarrhoea  all  summer,  but  that  other 
people  had  diarrhoea  without  being  as  nervous  as  she  was.  As 
soon  as  I  examined  her  pulse,  which  was  over  140,  with  a  nor- 
mal temperature,  and  noted  that  the  muscular  tremor  was  so 
extensive,  I  felt  assured  that  she  had  Graves's  disease,  though 


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it  was  not  till  long  afterward  tliat  she  showed  any  enlargement 
of  the  thyreoid,  and  never  up  to  her  death  from  this  disease, 
three  years  afterward,  did  she  show  any  exophtlialmia. 

The  second  and  third  patients  were  sisters,  the  second  a  young 
unmarried  woman  with  very  rapid  action  of  the  heart  and  con- 
siderable enlargement  of  the  thyreoid,  but  no  exophthalmia.  She 
entirely  recovered.  Her  sister  was  married  and  some  fifteen 
years  older.  She  had  no  marked  goitre  and  but  a  very  slight 
exophthalmia,  but  she  had  rapid  heart  action,  with  very  ex- 
tensive throbbing  of  the  arteries,  and  complained  of  frequent 
abdominal  pains.  She  quite  recovered  for  four  years  and  then 
had  a  relapse,  from  which  she  has  again  improved.  Both  these  pa- 
tients had  suffered  from  rheumatism,  and  the  elder  had  a  perma- 
nent hip  lameness  from  it.  They  were  both  poor  and  hard- 
worked,  but  otherwise  had  no  cause  of  mental  depression  or 
shock. 

The  fourth  patient  found  her  nervousness  a  mystery  to  her. 
She  had  naturally  a  lively  disposition  and  she  bad  contracted  a 
fortunate  marriage,  so  that  she  felt  contented  with  everything  in 
her  life,  when  without  apparent  reason  she  became  unaccount- 
ably nervous.  She  developed  goitre  and  exophthalmia  very 
rapidly,  and  with  voc  Graefe's  symptoms  very  distinct,  and  she 
became  both  anamic  and  emaciated.  The  heart's  action  was  vio- 
lent and  accompanied  by  loud  systolic  murmurs  at  the  base  and 
apex.  After  a  year  of  most  serious  symptoms  she  gradually  im- 
proved and  is  now  in  a  fair  state  of  health,  with  but  moderate 
exophthalmia  or  goitre. 

The  fifth  patient,  a  very  accomplished  lady  and  a  happy  wife 
and  mother,  came  complaining  that  she  lacked  the  repose  of 
strength.  She  is  a  prominent  advocate  of  the  rights  of  women, 
and  hence  felt  humiliated  at  finding  herself  turning  into  a 
weak,  trembling,  nervous  creature.  She  had  enlargement  of 
the  right  side  of  the  thyreoid,  but  no  exophthalmia  on  either 
side.  She  had  suffered  from  both  rheumatism  and  chorea  in 
childhood,  and  has  now  two  children — daughters — who  are  be- 
ginning with  choreic  symptoms.  Under  treatment  she  wholly 
recovered. 

The  sixth  case  was  peculiar  in  that  the  symptoms  first  de- 
veloped when  the  patient  was  about  sixty-five  years  of  age.  She 
had  thyreoid  enlargement  and  was  subject  to  suffocative  noctur- 
nal attacks  like  laryngeal  crises.  She  had  rather  persistent  albu- 
menuria  for  six  months,  and  during  the  course  of  Graves's  dis- 
ease she  was  extremely  nervous  and  much  troubled  with  in- 
somnia. She  wholly  recovered  for  four  years  from  all  her 
symptoms,  finally  dying  from  pneumonia  during  the  epidemic 
of  influenza  of  April,  1891,  at  the  age  of  seventy-four.  She  had 
a  marked  family  history  of  rheumatism. 

This  lady,  however,  had  a  daughter,  now  about  thirty-five 
years  of  age,  who,  after  some  years  of  delicate  health,  began  to 
show  a  uniform  enlargement  of  the  uterus,  which  in  about  two 
years  continued  to  increase  until  it  reached  the  umbilicus.  My 
friend  Dr.  Robert  Watts  examined  her  with  me  and  pro- 
nounced it  a  myxomatous  hypertrophy  of  the  uterus,  similar  to 
a  case  which  we  both  had  together  in  the  Roosevelt  Hospital 
some  years  before,  and  in  which  afterward  the  late  Dr.  Peaslee 
performed  hysterectomy  at  the  Woman's  Hospital.  The  inter- 
est of  the  present  case  is  that,  without  any  other  symptom  of 
myxoedema,  she  has  gradually  become  very  enfeebled  in  mind, 
and  presents  an  appearance  of  pseudo-exophthalmia,  due  to 
emaciation  without  retraction  of  the  eyeballs.  She  has  fre- 
quent movements  of  the  lower  jaw  of  a  choreic  character.  Her 
pulse  is  slow  and  weak  and  her  general  condition  the  reverse 
of  Graves's  disease,  as  she  is  listless  and  apathetic.  The  thyreoid 
gland  seems  to  be  wholly  atrophied.  Her  case  is  interesting  as 
one  of  cachexia  thyreoidopriva  in  the  daughter,  with  Graves's 
disease  in  the  mother. 


The  seventh  case  of  Graves's  disease  is  tliat  of  a  young  mar- 
ried lady  who  developed  goitre  without  an  exophthalmia  and 
with  rather  severe  tachycardia.  She  improved,  but  had  not  re- 
covered, when  she  became  pregnant.  This  did  not  seem  to  affect 
the  disease  one  way  or  the  other.  She  gave  birth  to  a  child  at 
term,  but  it  lived  only  a  few  hours.  She  is  now,  at  the  expira- 
tion of  a  year,  improved,  but  not  fully  restored.  No  mental 
shock  of  any  kind  had  ever  occurred  to  this  patient,  who,  on 
the  contrary,  is  of  a  very  equable  temperament,  without  nerv- 
ousness, so  to  speak,  in  spite  of  persistent  palpitation. 

The  eighth  patient,  a  married  lady  aged  forty-four,  I  saw  in 
consultation  with  Dr.  Emil  Mayer,  of  this  city,  into  whose  care 
she  had  come  after  suffering  for  eighteen  months  with  lancinat- 
ing pains  in  both  legs,  persistent  headaches,  insomnia,  and 
muscular  tremors;  then  persistent  diarrhoea  with  emaciation, 
losing  forty-eight  pounds  in  weight,  with  progressive  weak- 
ness till  she  could  not  leave  her  bed.  Meantime  her  heart  ac- 
tion was  140  and  there  was  general  arterial  throbbing.  Va- 
rious diagnoses  had  been  made  in  her  case,  including  general 
tuberculosis,  but  because  she  presented  no  sign  of  either  goitre 
or  of  exophthalmia,  Graves's  disease  had  not  been  suspected. 
I  diagnosticated  her  case  as  such,  and  under  the  treatment 
for  that  affection,  including  galvanism,  her  diarrhoea  soon 
stopped  and  her  improvement  was  progressive,  so  that  on  see- 
ing her  two  months  ago  she  had  regained  her  flesh  and  color 
and  her  pulse  was  70. 

Now,  in  neither  one  of  these  eight  cases  was  fright  or 
any  other  emotion  an  element  of  the  clinical  history.  With 
the  exception  of  the  two  sisters  mentioned,  they  were,  on 
the  contrary,  more  than  usually  free  from  causes  of  men- 
tal strain  or  depression  in  their  life  environment  or  ex- 
perience, and  so  far,  therefore,  they  indicate  that  mental 
factors  are  accidental  rather  than  essential  elements  in  the 
aetiology  of  the  complaint. 

Of  these  eight  cases,  both  exophthalmia  and  goitre  were 
wholly  absent  in  one.  Exophthalmia  alone  was  absent  in 
five.  Goitre  was  absent  in  one,  and  was  present  slightly 
and  only  late  in  the  disease,  just  before  death,  in  one_ 
Both  exophthalmia  and  goitre  were  marked  only  in  one. 
But  in  all  there  was  the  same  pronounced  tachycardia  and 
muscular  tremor,  and  in  each  there  was  emaciation — moder- 
ate in  five  and  very  pronounced  in  three.  In  four,  imper- 
fect inspiratory  power  was  noted,  but  not  so  particularly  as 
I  shall  look  for  it  hereafter  after  reading  Dr.  Louise  Fiske 
Bryson's  observations  of  this  symptom  in  Graves's  disease. 

I  have  chosen  these  eight  cases  from  my  private  practice 
notes  because  they  sufficiently  illustrate  the  familiar  fea- 
tures of  the  disease  which  I  wish  to  dwell  upon  as  most 
related  to  its  pathology.  One  peculiar  case  I  will  only 
further  mention,  that  of  a  patient  who  was  sent  to  me  by 
her  physician  four  months  ago,  and  who  presented  remarka- 
ble aneurysmal  dilatations  of  the  systemic  arteries.  There 
were  several  on  the  radial  and  on  the  right  external  carotid. 
The  story  was  that  they  were  transient  in  character.  She 
had  suffered  a  great  deal  from  palpitation  and  tachycardia, 
but  had  no  goitre  or  exophthalmia.  Shortly  after  her  visit 
she  died  suddenly  with  symptoms  of  hemiplegia. 

The  fact,  therefore,  that  Graves's  disease  may  exist  even 
in  a  fatal  degree  of  severity,  as  illustrated  by  the  first  pa- 
tient in  my  list,  without  either  exophthalmia  or  goitre, 
should  be  emphasized  from  the  liability  to  the  disease  not 


June  8,  1893.J         THOMSON:  PATHOLOGY  AND  TREATMENT  OF  GRAVES'S  DISEASE. 


603 


being  diagnosticated,  owing  to  the  absence  of  these  symp- 
toms, as  actually  occurred  in  the  case  of  the  eighth  patient. 
The  enlargement  of  the  thyreoid  is  mentioned  by  all  writers 
as  very  variable  in  degree  and  in  duration,  even  in  the  same 
patient,  and  it  is  equally  noted  that  the  rapid  action  of  the 
heart  often  both  precedes  the  goitre  and  persists  after 
its  subsidence,  it  and  the  muscular  tremor  being  the  first 
symptoms  to  develop  and  the  last  to  disappear,  and  together 
constituting  the  most  invariable  elements  of  the  disease. 
Our  attention,  therefore,  should  be  particularly  directed  to 
them  as  the  most  related  to  its  pathology,  and,  moreover, 
the  most  important  practically,  as  the  earlier  the  recogni- 
tion of  the  disease  the  better  for  its  treatment.  As  to  pa- 
thology, a  paralytic  lesion  involving  the  common  nucleus  of 
the  glossopharyngeal,  vagus,  and  spinal  accessory  nerves, 
and  extending  to  the  neighboring  vaso-motor  center  in  the 
medulla  oblongata,  would  account  for  the  whole  group  of 
symptoms  which  make  up  the  picture  of  Graves's  disease. 
In  the  first  place,  it  should  be  noted  that  simple  irritation 
of  the  lower  branches  of  the  glossopharyngeal  and  of  the 
superior  laryngeal  nerves  is  sometimes  accompanied  by 
general  muscular  tremor.  I  once  saw  this  amusingly  illus- 
trated by  a  stalwart  young  German  butcher  who  came  into 
my  office  trembling  like  a  leaf  because  he  had  a  fish  bone 
stuck  in  his  throat.  He  said  in  a  husky  voice  that  he  was 
not  frightened,  but  that  he  could  not  help  shaking.  With 
the  laryngoscope  I  saw  the  bone  directly  across  the  chink 
of  the  glottis,  and  as  soon  as  it  was  removed  his  shaking 
stopped.  In  experimental  thyreoidectomy  on  monkeys 
and  dogs  the  commonest  immediate  result  is  stated  to  be 
general  muscular  tremor,  which  lasts  for  many  weeks.  I 
regard  this  symptom  as  the  direct  effect  of  injury  to 
branches  of  the  superior  and  recurrent  laryngeal  nerves, 
which,  according  to  Lindemann,  are  the  only  nerves  which 
supply  the  thyreoid,  rather  than  due  to  the  effects  of  the 
removal  of  the  gland  itself  upon  the  blood,  for  the  tremor 
is  much  too  immediate  upon  the  operation  to  be  so  ex- 
plained. 

Now,  such  a  bulbar  lesion  as  we  have  supposed  would 
also  produce  the  other  great  oonstant  feature  of  Graves's 
disease — namely,  the  tachycardia  and  the  universal  relaxa- 
tion and  throbbing  of  the  systemic  arteries.  It  would  also 
explain  the  interference  with  the  inspiratory  expansion.  It 
would  not  account,  however,  for  the  mechanism  of  the  ex- 
ophthalmia  or  of  the  goitre,  though  for  the  latter  condition 
we  have  another  cause  to  be  mentioned  presently.  When 
we  turn  to  pathological  anatomy,  however,  we  have  no  con- 
stant evidence  of  any  textural  lesion  in  the  medulla, 
whether  of  the  above-mentioned  centers  or  of  other  parts. 
The  experiments  of  Fileline,  recently  repeated  with  con- 
firmatory results  by  Seeligmiiller  and  by  Bienfait,  in  which 
lesions  of  the  restiform  body  produced  increased  pulse-rate 
and  corresponding  unilateral  exophthalmia  with  muscular 
tremors,  are  open  to  the  objection  that  it  is  diflScult  to  per- 
form such  experiments  without  affecting  contiguous  bulbar 
centers.  On  the  other  hand,  autopsies  after  Graves's  dis- 
ease have  not  shown  any  constant  distinctive  changes  in 
the  restiform  bodies  any  more  than  in  the  cervical  sym- 
pathetic, which  was  once  supposed  to  be  the  anatomical 


seat  of  the  affection.  These  theories,  moreover,  share  in 
common  the  objection  that  the  enlargement  of  the  thyreoid 
and  the  exophthalmia  are  supposed  to  be  the  chief  elements 
of  the  disease,  which,  as  we  have  seen,  is  quite  incorrect. 

As  pathological  anatomy,  therefore,  has  so  far  not  re- 
vealed any  truly  characteristic  change  which  can  be  causally 
associated  with  the  genesis  of  Graves's  disease,  the  ques- 
tion arises  whether  we  can  look  elsewhere  than  to  the  nerv- 
ous system  for  the  fons  et  origo  of  the  malady.  Here  I 
think  that  clinical  experience  may  afford  some  significant 
intimations. 

In  the  case  of  tlie  first  patient  above  mentioned  I  tried  a 
great  variety  of  remedies  which  I  found  recommended  as  service- 
able in  the  treatment  of  this  complaint.  Belladonna,  arsenic, 
nitrate  of  silver,  the  bromides,  digitalis,  and  the  iodides  were 
prescribed  in  succession,  without  satisfactory  results.  The 
diarrhoea  continued  for  many  weeks  unchecked  by  astringents, 
and  the  emaciation  increased,  with  the  rapid  pulse  and  excessive 
nervousness  and  insomnia.  At  last  I  prescribed  a  complete 
change  of  diet,  and  ordered  that  the  patient,  who  was  now  con- 
fined to  her  bed  by  her  weakness  and  tremor,  should  be  fed  ex- 
clusively with  matzoon  and  stale  bread.  The  change  for  the 
better  upon  this  diet  was  surprisingly  rapid  and  progressive. 
The  diarrlioea  stopped  without  medicines,  both  her  nervous- 
ness and  sleeplessness  improved,  and  finally  the  pulse  became 
remarkably  lessened.  Iron  then  seemingly  began  to  improve 
her  anremia,  when  before  it  appeared  to  aggravate  her  symp- 
toms, and  in  the  course  of  two  months  she  seemed  to  be  getting 
quite  well.  After  four  months  she  had  so  much  improved  that, 
contrary  to  my  advice,  she  discontinued  the  matzoon  and  began 
to  resume  a  meat  diet,  for  which  she  was  always  very  fond. 
Two  months  after  this,  on  her  return  from  the  country,  I 
found  that  all  her  former  symptoms  bad  recurred,  including  the 
diarrhoea.  She  again  was  put  on  matzoon  and  again  she  im- 
proved, and  this  time  she  continued  the  milk  for  about  six 
months,  with  such  a  gain  in  flesh  and  color  that  she  felt  that 
she  was  well.  She  then  went  back  to  her  ordinary  diet,  and  I 
did  not  hear  from  her  for  some  time,  when  I  was  called,  to  find 
her  now  worse  than  ever,  because  of  the  development  of  mental 
symptoms  of  both  irritability  and  obstinacy  which  she  had  not 
shown  before.  She  declared  that  she  would  rather  die,  than 
take  the  matzoon,  and  nothing  would  persuade  her  to  try  milk 
in  any  form.  One  day  I  was  sent  for  to  see  her  because  she 
seemed  to  be  so  low.  I  found  her  pulse  to  be  with  difficulty 
countable,  and  she  was  in  a  state  of  delirium  with  hallucinations. 
While  I  had  my  finger  on  the  pulse,  trying  again  to  count  it,  it 
suddenly  stopped,  her  pupils  dilated,  and  the  patient  was  dead 
with  scarce  a  perceptible  struggle. 

Now,  in  this  case  a  change  of  diet  effected  what  drugs 
had  quite  failed  to  do  ;  and  then  a  first  return  to  a  meat 
diet  brought  back  a  return  of  the  disease  ;  then  to  be  again 
and  unmistakably  arrested  by  discontinuing  meat  and  re- 
suming milk ;  and,  lastly,  a  second  return  to  meat  brought 
back  a  fatal  return  of  the  disorder.  This  case  has  led  me 
ever  since  that  date  (1880)  to  rely  mainly  on  the  dietetic 
treatment  of  (Jraves's  disease,  with  such  favorable  results, 
both  in  hospital  and  private  practice,  that  1  have  now  little 
doubt  that  a  specific  disorder  of  intestinal,  in  distinction 
from  gastric,  digestion  is  a  primary  factor  in  the  genesis  of 
this  affection.  It  is,  of  course,  a  familiar  fact  that  diet 
has  much  to  do  with  the  therapeutics  of  functional  nervous 
diseases,  but  until  within  recent  years  our  practice  in  this 


604 


THOMSON:  PATHOLOGY  AND  TREATMENT  OF  GRAVES'S  DISEASE.    [N.  Y.  Med.  Jouh., 


respect  has  been  based  wholly  upon  empirical  grounds.  In 
such  an  instance  as  this,  however,  it  is  difficult  not  to  infer 
a  causal  relation  between  the  food  taken  and  the  resultant 
symptoms.  The  meat  diet  seemed  to  be  not  only  a  con- 
tributing but  a  direct  cause  of  diarrhoea,  tremor,  and  rapid 
heart  action — as  direct  as  we  find  in  any  other  seemingly 
immediate  connection. 

That  we  have  now  more  than  empirical  grounds  for 
inferences  about  the  relation  of  auto-infection  to  the  gene- 
sis of  many  of  the  derangements  of  functional  nervous  dis- 
eases is  as  well  settled  as  any  of  the  recent  advances  of 
pathology.  In  the  processes  of  normal  intestinal  digestion 
it  is  claimed,  on  apparently  well-ascertained  facts,  that  the 
healthy  system  is  constantly  producing  organic  poisons, 
which  are  as  capable  of  causing  injury  as  any  of  the  prod- 
ucts of  retrogressive  metabolism  in  the  body  at  large.  We 
may  therefore  have  specific  disturbances  occur  from  these 
organic  poisons  in  either  of  two  ways  :  First,  by  their  ex- 
cessive generation,  or,  secondly,  by  a  failure  in  the  normal 
functions  of  the  body  which  are  protective  against  them,  from 
deficiency  in  the  protecting  functions  of  the  organs  them- 
selves, or  from  a  greater  virulence  in  the  poison  generated  than 
they  can  counteract.  An  effect  from  diet,  therefore,  in  nerv- 
ous disorders,  one  way  or  the  other,  would  be  explicable  on 
chemical  principles  rather  than  on  nervous  textural  changes, 
and,  from  my  experience  in  the  treatment  of  functional 
nervous  diseases,  I  am  becoming  more  and  more  persuaded 
that  we  have  in  this  direction  greater  promise  of  progress, 
both  in  theory  and  in  practice,  than  in  hypotheses  of  irri- 
tative nervous  lesions  as  the  source  of  many  functional  dis- 
orders, Graves's  disease  included.  On  this  point  Dr.  Fagge 
well  remarks :  "  Some  writers  have  endeavored  to  account 
for  all  the  phenomena  of  the  [Graves's]  disease  on  a  theory 
of  irritation.  But  it  is  a  sufficient  objection  to  such  a  view 
that  a  primary  irritation  of  a  nerve  center,  lasting  for  months 
or  years  unchanged,  is  as  yet  unknown  to  pathology." 

On  the  other  hand  we  may  say  that,  while  a  structural 
lesion  in  the  medulla  which  would  account  for  the  phe- 
nomena of  Graves's  disease  is  almost  inconceivable  without 
its  sooner  or  later  involving  all  the  vital  functions  of  that 
seat  of  life,  yet  particular  functional  derangements  pro- 
duced by  toxic  agents  are  just  what  might  be  expected,  for 
nothing  is  more  characteristic  than  the  narrowly  selective 
operation  of  functional  nervous  poisons,  which  may  go  on 
for  years,  as  in  the  case  of  opium,  affecting  certain  functions 
without  producing  either  progressive  changes  in  them  or 
extension  to  other  functions. 

The  chief  hindrance  to  committing  ourselves  to  the 
toxic  in  distinction  from  the  structural  aetiology  of  such 
diseases  is  the  considerable  change  which  it  involves  in  our 
views  of  the  pathology  of  functional  nervous  diseases  in 
general.  It  seems  to  offer  too  tempting,  because  too  easy, 
a  solution  of  many  of  the  most  obscure  problems  of  prac- 
tical medicine.  That  its  advocates  are  often  carried  away 
by  its  far-reaching  conclusions  is  undeniable,  and  many  of 
their  deductions  are  open  to  criticism  on  the  score  both  of 
haste  and  of  hobby-riding.  But  just  the  same  may  be  said 
of  bacteriology — namely,  that  it  is  too  much  like  a  blazing 
comet  passing  through  the  medical  sky,  with  a  nucleus  of 


fact  surrounded  by  a  cloud  of  seemingly  mere  gas,  carry- 
ing a  tail  of  still  more  tenuous  inferences  stretching  out  to 
infinity.  We  need  not,  however,  surrender  our  nucleus  of 
facts,  nor  legitimate  inferences  based  upon  them,  because 
everything  can  not  be  demonstrated  at  once  in  a  newlv  dis- 
covered field. 

Certainly  there  is  one  fact  in  Graves's  disease  which 
points  much  more  distinctly  to  a  digestive  disorder  than  to 
a  structural  nervous  lesion,  and  that  is  its  occurrence  in 
women  about  ten  times  as  often  as  in  men.  We  can  hardly 
imagine  that  this  difference  is  due  to  a  difference  in  the 
medulla  between  the  two  sexes.  That  the  digestive  appa- 
ratus in  women,  however,  is  subject  to  special  disorders  is 
notorious.  Many  years  ago  I  published  in  the  Transactions 
of  the  Medical  Society  of  the  State  of  New  York  the  case  of  a 
girl  who,  after  a  suppression  of  the  menses  from  a  wetting 
in  a  thunder  shower,  had  first  an  obstinate  constipation, 
which  was  attributed  by  the  late  Dr.  White,  Professor  of 
Obstetrics  in  Buffalo,  and  for  a  time  also  in  Bellevue  Hos- 
pital Medical  College,  to  intestinal  obstruction,  as  she  had 
developed  stercoraceous  vomiting.  In  the  further  progress 
of  her  case,  however,  her  bowels  were  made  to  act,  but  the 
dejecta  showed  a  total  absence  of  coloring  matter.  She 
then  had  sudden  suppression  of  urine,  which  was  soon  fol- 
lowed by  profuse  salivation  and  lacrymation,  but  which 
stopped  after  five  days,  when  the  kidneys  started  secretion 
again,  and  this  alternation  between  the  flow  from  the  blad- 
der and  from  the  mouth  continued  at  intervals  till  her 
death,  about  three  months  after  the  beginning  of  her  affec- 
tion. Such  a  case,  however,  only  illustrates  in  an  extreme 
way  what  derangements  in  the  secretions  and  in  the  chem- 
istry of  the  products  of  the  blood-making  and  of  the  blood- 
purifying  glands  can  take  place  from  nervous  disorders  in 
the  splanchnic  system  of  women,  and  hence  renders  the  sur- 
mise probable  that  if  auto-infection  from  the  intestine  can 
take  place  at  all,  it  may  be  looked  for  in  women  with  spe- 
cial frequency.  I  may  mention,  therefore,  in  this  connec- 
tion, that  I  have  not  yet  seen  a  case  of  severe  Graves's  dis- 
ease in  which  diarrhoea  was  not  sooner  or  later  a  prominent 
symptom. 

On  the  other  hand,  it  may  be  asked,  if  the  symptoms  of 
Graves's  disease  are  to  be  ascribed  to  toxic  infection  of  the 
blood  by  intestinal  poisons,  what  relation  has  that  fact  to 
the  common  implication  of  the  thyreoid  in  this  affection  ? 
To  this  it  may  be  replied  that  the  facts  of  both  sporadic 
myxoedema  and  the  cachexia  following  thyreoidectomy,  in 
both  man  and  in  animals,  point  much  more  to  a  metabolic 
function  of  the  thyreoid  than  to  a  secreting  one.  It  may 
be  questioned  whether  such  be  not  the  main  function  of  the 
ductless  blood  glands — that  is,  that  they  produce  changes 
in  the  blood  passing  through  them  that  may  free  the  blood 
of  otherwise  toxic  products,  rather  than  that  they  add  par- 
ticular secretions  of  their  own  to  it.  The  interesting  ex- 
periments of  Griitzner  seem  to  support  this  conclusion  as 
regards  the  thyreoid,  for  he  found  that  the  blood  of  an  ani- 
mal from  which  the  thyreoid  had  been  removed,  when  in- 
jected into  the  veins  of  another  animal,  caused  symptoms  in 
it  similar  to  those  observed  by  Kocher  in  operative  myxoe- 
dema in  man. 


June  3,  1893.] 


SALICRUP: 


SMALL-POX  AND  VACCINATION. 


605 


The  phenomena  of  Graves's  disease,  however,  are  those 
of  excessive  action  of  the  thyreoid,  rather  than  those  of  the 
contrasting  symptoms  of  thyreoid  atrophy  ;  as  if  the  gland 
were  overstimuiated  by  some  ingredient  in  the  blood  which 
it  can  not  sufficiently  neutralize,  for  it  is  noticeable  that  the 
thyreoid  is  found  in  many  cases  not  so  much  diseased  after 
death  as  that  its  proper  tissue  is  apparently  hypertrophied. 
Certainly  it  often  seems  so  to  act  in  these  patients  during 
life,  presenting  a  variation  in  bulk  which  causes  it  to  resem- 
ble an  erectile  tissue  in  its  alternate  enlargement  and  subsi- 
dence, so  different  from  endemic  or  ordinary  goitre.  This 
appears  to  me  a  much  more  probable  explanation  than  the 
view  of  Chevalier,  who  ascribes  Graves's  disease  to  an  in- 
toxication of  the  nervous  system  by  products  of  the  thyre- 
oid, because  it  is  rather  removal  or  atrophy  of  the  thyreoid 
which  is  most  constantly  followed  by  signs  of  an  intoxica- 
tion due  to  the  absence  of  its  preservative  functions. 

As  to  the  relation  of  a  meat  diet  to  disorders  of  the 
thyreoid,  I  will  only  cite  for  what  they  are  worth  some  ref- 
erences to  published  observations.  L.  Breisacher,  of  Leip- 
sic,  finds  that  meat  and  meat  extractives  exert  a  poisonous 
influence  on  dogs  after  thyreoidectomy.  Ewald  and  Rock- 
well are  quoted  in  Sajous's  Annual  of  the  Universal  Medical 
Sciences,  1891,  as  finding  the  removal  of  the  thyreoid  in 
pigeons  to  exert  no  perceptible  influence  on  their  health. 
They  chose  pigeons  as  pure  vegetable  feeders,  to  corrobo- 
rate the  earlier  observations  of  Ewald,  in  which  he  ascribed 
the  difference  in  the  effects  of  thyreoidectomy  between  dogs 
and  rabbits  to  the  difference  in  their  diet.  Charcot,  in  his 
lectures  on  Graves's  disease,  lays  special  stress  on  the  benefit 
to  be  derived  from  a  milk  diet. 

Now  that  examination  of  the  urine  includes  so  much 
more  than  tests  for  albumin  or  sugar  or  the  proportion  of 
urea,  there  is  much  to  be  hoped  for  in  researches  of  its  com- 
position in  cases  of  functional  nervous  diseases.  The  chem- 
istry of  the  urine,  however,  is  evidently  not  an  easy  subject 
either  in  health  or  in  disease.  The  existence  of  alkaloidal 
poisons  in  it  is  very  variously  reported,  but  meantime  there 
is  no  reason  to  be  incredulous  that  much  light  is  yet  to  be 
thrown  upon  the  relation  of  toxic  ingredients  in  this  secre- 
tion to  the  clinical  facts  of  a  great  variety  of  morbid  condi- 
tions. As  regards  Graves's  disease,  I  find  a  reference  in  Sa- 
jous's Annual,  1892,  to  researches  by  Boinet  and  Silbert, 
reported  in  the  Marseille  medical,  who  profess  to  have  found 
three  principal  varieties  of  ptomaines  in  the  urine  of  a  case 
of  exophthalmic  goitre.  One  possesses  a  convulsive  action 
and  produces  arrhythmia,  weakens  the  systole  and  arrest  of 
the  heart  in  diastole,  while  another  causes  a  primary  increase 
in  systolic  energy  and  afterward  enfeeblement  and  arrest  in 
diastole.  Such  observations,  however,  of  urinary  ptomaines 
in  disease  are  not  yet  sufficiently  uniform  or  distinctive  to 
claim  much  authority. 

My  treatment  of  Graves's  disease  is  mainly  based  upon 
its  supposed  relation  to  digestive  disorders.  In  the  first 
place,  it  seems  to  me  that  a  meat  diet  is  to  be  as  much  re- 
stricted in  these  patients  as  a  starchy  diet  in  diabetics. 
Fresh,  undiluted  milk  also  is,  in  my  experience,  not  to  be 
allowed,  from  its  indigestibility  with  most  healthy  adults. 
It  is  a  significant  fact  that  races  like  the  Tartars,  the  Be- 


douins, and  the  Guachos  of  South  America,  who  have  to  live 
upon  milk,  have  all  found  by  experience  that  it  has  to  be 
fermented  first  before  it  can  become  a  staple  and,  as  with 
them,  about  their  only  daily  diet.  All  the  world  over  the 
ferment  for  this  purpose  is  the  same — namely,  the  yeast 
plant.  With  fresh,  good  milk  fermented  every  day,  as  it  is 
by  the  Arabs  and  the  peoples  of  western  Asia,  and  now  sold 
here  pretty  extensively  under  the  Turkish  name  of  matzoon, 
I  have  relieved  more  cases  of  vomiting  from  organic  diseases 
of  the  stomach  than  by  any  other  one  article.  In  Graves's 
disease  it  has  in  my  experience,  as  above  mentioned,  proved 
especially  beneficial. 

Medicinally,  I  think  it  is  well  to  begin  treatment  by 
a  mercurial  purgative,  as  the  ordinary  blue  pill,  to  be  re- 
peated occasionally  from  time  to  time.  In  some  patients 
this  will  be  found  particularly  useful  against  the  diarrhoea. 
Then,  three  or  four  times  a  day,  I  prescribe  in  capsule  five 
grains  of  equal  parts  of  bismuth  subcarbonate  and  powdered 
calumba,  with  four  grains  of  salol  and  five  of  benzoate  of 
sodium  ;  or  capsules  of  ten  grains  of  bismuth  salicylate  with 
two  of  /3-naphthol  and  two  of  ichthyol.  The  best  time  for 
these  intestinal  antiseptics  to  be  taken  is  an  hour  after 
meals. 

As  a  vaso-motor  tonic,  I  now  rely  chiefly  on  ten-drop 
doses  of  tincture  of  strophanthus  half  an  hour  before  meals. 


SMALL-POX 

AND  THE  VALUE  OF  VACCINATION  AS  A  PREVENTIVE.* 
By  PEDRO  JOSE  SALICRUP,  M.  D.. 

EX-MEMBER  OP  THE  ROYAL  SFBLBGATION  OP  THE  BOARD  OP  HEALTH 
OP  PUERTO  RICO. 

The  disease  which  constitutes  the  subject  of  my  paper 
this  evening  has  lost  a  great  deal  of  its  importance  in  this 
country  by  the  persistent  and  careful  practice  of  vaccina- 
tion, made  compulsory  by  law. 

In  spite  of  this,  however,  the  disease  makes  its  occa- 
sional appearance  among  the  inhabitants  of  the  crowded 
tenement-house  districts,  generally  imported  by  emigrants 
from  other  countries.  But  the  cases  that  occur  are,  as  a 
rule,  of  the  modified  or  mild  variety  of  the  disorder.  In 
this  city,  as  in  many  others  in  this  country  and  in  Europe, 
where  they  possess  a  well- organized  board  of  health  with 
ample  means  for  the  isolation  of  cases  and  disinfection,  the 
epidemics  are  checked  at  the  outset  by  the  prompt  and 
efficient  measures  adopted  by  the  said  boards.  This  is  not, 
however,  the  case  in  many  other  countries  where  vaccina- 
tion is  not  so  generally  and  carefully  practiced,  sanitary 
measures  are  not  properly  enforced,  and  means  of  isolation 
and  disinfection  are  deficient  or  altogether  wanting,  where 
the  disease  continues  to  be  a  dreadful  scourge,  carrying 
away  many  victims  and  leaving  many  others  more  or  less 
injured  and  marked  for  life  with  its  periodical  ravages. 

Ihis  is  especially  the  case  in  tropical  countries  where 
people  belonging  to  colored  races  are  abundant,  for  whom 
this  disease  seems  to  have  an  especial  predilection,  and 

*  Read  before  the  New  York  County  Medical  Association,  April  17, 
1893. 


606 


SALIC RUP:  SMALL-POX  AND  VACCINATION. 


[N.  Y.  Med.  Joub., 


who  are  generally  very  careless  about  cleanliness  and  sani- 
tary measures  and  much  prejudiced  against  vaccination. 

In  one  of  these  countries  (Puerto  Rico)  I  have  prac- 
ticed medicine  for  twenty-two  years ;  there  I  made  my 
first  acquaintance  with  the  disease,  in  the  treatment  of 
which  I  have  had  a  rather  extensive  experience.  I  have 
also  in  my  capacity  of  public  vaccinator,  which  office  I 
held  there  for  many  years,  practiced  vaccination  extensively 
by  direct  inoculation  with  bovine  and  humanized  vaccine 
virus,  and  from  arm  to  arm,  and  can  testify  to  the  benefi- 
cial eflEects  of  this  operation  in  the  shortening  of  epidemics 
and  rendering  subsequent  ones  less  severe,  especially  since 
the  facilities  for  obtaining  pure  and  reliable  vaccine  virus 
have  been  increased  by  the  foundation  of  an  institute  for 
the  cultivation  of  bovine  vaccine  virus  to  supply  the 
country. 

I  am  sorry,  Mr.  President,  not  to  be  able  to  produce 
some  statistics  which  would  prove  my  assertion  and  make 
this  paper  interesting,  but  I  could  not  procure  them  in  the 
short  time  at  my  disposal  to  prepare  this  paper. 

I  do  not  pretend  to  bring  to  your  notice  in  this  paper 
any  new  facts  in  connection  with  the  disease,  but  simply  to 
call  your  attention  to  the  severity  which  its  epidemics  still 
have  in  many  countries,  especially  the  West  Indies,  and  to 
make  a  plea  to  bacteriologists  and  workers  in  the  field  of 
infectious  diseases  in  f^vor  of  research  and  investigation  of 
the  causes  and  pathogenesis  of  this  disease,  which  has 
been  little  attended  to,  with  the  object  of  finding,  if  possi- 
ble, a  more  efiicient  measure  to  prevent  its  occurrence, 
either  by  devising  other  means  of  producing  immunity 
from  it  or  devising  new  means  of  treatment  in  man,  or 
by  improving  the  present  measure  of  preventive  inocula- 
tion, "  vaccination,"  having  more  extensive  and  precise 
knowledge  of  the  germ  which  causes  it,  and  its  habits 
and  peculiarities,  as  is  the  case  in  other  diseases  of  the 
kind. 

The  history  of  small-pox  dates  from  very  far  back.  It 
is  said  to  have  existed  as  a  scourge  in  China  and  Hindostan 
one  thousand  years  before  the  birth  of  Christ,  and  to  have 
made  its  way  through  Arabia  and  Egypt  into  Europe, 
where  it  was  introduced  by  the  crusaders.  It  was  un- 
known on  this  continent  before  the  arrival  of  the  European 
conquerors  and  new  settlers,  who  imported  it  into  this  and 
other  newly  discovered  lands.  It  was  a  much- dreaded 
scourge  all  over  the  world  until  the  wonderful  discovery  of 
Jenner  in  1796  came  to  deprive  it  of  a  great  deal  of  its  hor- 
rible and  deadly  cliaracter  in  countries  where  this  operation 
is  regularly  and  persistently  practiced.  The  discovery  of 
Jenner  was  met  by  a  great  opposition  at  the  beginning 
among  a  number  of  practitioners  and  lay  people,  and  even 
at  the  present  time  organized  anti-vaccination  societies  are 
in  existence  in  England  and  other  countries  to  attest  what 
prejudice  and  ignorance  can  do  even  with  the  most  useful 
and  successful  discoveries  in  our  art. 

I  will  not  tire  you  by  giving  a  minute  and  elaborate  de- 
scription of  the  disease,  its  clinical  history,  etc.  I  will 
simply  make  a  hurried  sketch  of  the  disorder,  its  varieties, 
and  dilferent  stages,  making  some  remarks  on  its  compli- 
cations, sequelae,  and  treatment,  with  reference  to  my  ex- 


perience with  it  in  the  different  epidemics  which  I  have 
observed  in  Puerto  Rico. 

Small-pox  or  variola  is  a  contagious  and  infectious  dis- 
ease of  the  blood,  characterized  by  a  peculiar  eruption  of 
the  skin  and  inflammation  of  the  mucous  membranes  of  the 
body,  accompanied  by  fever. 

According  to  the  present  views,  like  all  other  infectious 
diseases,  it  ought  to  be  caused  by  the  introduction  into  the 
body  of  some  kind  of  microbe  or  germ  which,  by  its  pres- 
ence in  the  blood,  produces  the  poison,  toxalbumin  or  tox- 
ine,  which  gives  rise  to  the  grave  symptoms  and  general 
dyscrasia  of  the  blood  sometimes  observed.  But  so  far  bac- 
teriologists have  not  found  any  special  germ,  and  only  the 
common  pus  coccus  has  been  found  in  the  pustules. 

The  first  cases  of  variola  that  appear  in  a  locality  can 
always  be  traced  to  contagion  if  properly  investigated,  and 
the  disease  has  always  a  tendency  to  spread  as  an  epidemic 
if  not  promptly  checked  by  appropriate  means. 

It  is  often  preceded  by  other  exanthemata,  especially 
measles,  and  whether  there  is  any  relation  between  the 
agents  causing  these  diseases  or  whether  it  is  owing  merely 
to  the  epoch  of  the  year  at  which  they  occur  being  favora- 
ble for  their  development  in  the  human  system,  I  am  not 
prepared  to  say.  As  to  its  primitive  origin,  some  authorities 
believe  that  it  first  originated  in  the  horse  and  cattle  and 
from  thence  was  acquired  by  man,  and  others  hold  the 
opposite  view.  Variola  is  most  conveniently  divided,  in 
regard  to  its  severity,  into  benignant,  malignant,  and  modi- 
fied ;  as  regards  distribution  of  the  eruption,  into  discrete, 
semi-confluent,  confluent,  and  corymbose  or  clustered. 

The  course  of  the  disease  is  generall}'  divided  into  five 
periods  or  stages,  which  indicate  the  different  phases  which 
the  disease  assumes  before  its  termination,  as  follows :  In- 
cubation, invasion  or  primary  fever,  eruption,  secondary  or 
suppurative  fever,  and  incrustation  and  decrustation  or  des- 
quamation. 

In  the  modified  variety  all  these  stages  are  not  perfectly 
developed,  and  so  we  will  take  a  typical  case  of  true  variola 
for  our  description.  The  period  of  incubation  includes  the 
space  of  time  which  intervenes  between  exposure  to  the 
affection  or  contagion  and  invasion  of  the  disease.  This 
period  may  be  shorter  or  longer  according  to  the  severity 
of  the  case  to  follow,  but  the  limit  generally  assigned  to  it 
by  most  authorities  is  from  five  to  twenty  days.  There  are 
no  appreciable  symptoms  in  this  stage. 

The  period  of  invasion,  or  primary  fever,  is  marked  by 
symptoms  which  indicate  serious  constitutional  disturbance. 
It  commences  with  lassitude,  chills,  pains  of  the  head, 
loins,  and  limbs,  and  hot  skin.  Conjunctivae  suffused  ;  rapid 
pulse  and  respiration.  There  are  thirst  and  loss  of  appetite, 
with  a  white  and  coated  tongue,  dotted  with  red  papillae, 
nausea,  and  often  vomiting,  constipation,  pain  and  heat  in 
the  epigastrium,  restlessness,  and  general  prostration.  To 
this  may  follow  oppression  of  breathing,  cough,  lethargy, 
and  in  some  cases  delirium  and  coma.  The  tongue,  which 
at  the  beginning  of  this  stage  was  white,  becomes  red,  the 
change  beginning  at  the  point  and  extending  subsequently 
over  its  whole  surface.  In  children  convulsions  frequently 
occur.    There  is  an  exacerbation  of  febrile  symptoms  to- 


June  3,  1893.j 


SALICRUP:  SMALI^POX  AND  VACCINATION. 


607 


ward  night.  These  symptoms  vary  in  intensity  in  different 
cases  according  to  the  confluence  or  discreteness  of  the  en- 
suing case,  being  more  severe  in  the  confluent  and  malig- 
nant types,  especially  vomiting.  The  disease  may,  and 
sometimes  does,  terminate  in  death  in  malignant  cases  in 
this  period. 

The  symptoms  of  invasion  generally  last  forty-eight 
hours  in  ordinary  cases  of  discrete  and  semi- confluent  erup- 
tion, and  only  twenty-four  in  confluent  and  malignant  cases, 
in  which  the  eruption  appears  on  the  second  day.  The 
symptoms  of  this  period  may  be  complicated  with  violent 
and  often  fatal  inflammation  of  the  brain  or  internal  or- 
gans, and  in  the  malignant  type  the  dyscrasia  of  the  blood 
is  such  that  the  patient  may  die  before  the  eruptive  stage 
begins. 

These  symptoms  very  much  resemble  those  of  a  severe 
cold  or  those  of  invasion  of  other  infectious  diseases,  espe- 
cially yellow  fever,  and  it  is  very  important  to  be  able  to 
make  early  a  differential  diagnosis  to  relieve  anxiety  and 
for  other  purposes,  especially  when  the  patient  happens  to 
be  a  foreigner,  as  they  entertain  a  peculiar  dread  for  yellow 
fever,  which  proves  most  fatal  among  them,  while  variola 
is  more  fatal  to  individuals  of  color  races.  Although  a 
differential  diagnosis  is  not  always  possible  in  these  cases, 
the  early  presence  of  vomiting  and  the  peculiar  appearance 
of  the  tongue  may  help  in  the  diagnosis  of  small-pox,  as 
other  symptoms  are  common  to  both. 

To  the  period  of  invasion  the  period  of  eruption  fol- 
lows. With  the  outburst  of  the  eruption  all  the  febrile 
and  other  symptoms  suddenly  and  immediately  disappear, 
and  the  patient  feels  comparatively  comfortable.  The 
eruption  generally  begins  to  appear  on  the  forehead  and 
lips,  and  extends  gradually  to  the  rest  of  the  face,  neck, 
arms,  trunk,  and  inferior  extremity,  and  the  same  order  is 
followed  in  all  its  stages  of  development.  It  first  develops 
as  red  spots  (maculae),  which  soon  become  prominent,  giv- 
ing a  hard  feeling  to  the  touch  (papulae).  In  the  discrete 
variety  they  are  scattered  over  the  body  and  are  distinct  in 
character.  In  the  coherent  variety  they  resemble  the 
patches  of  rubeola  by  their  appearance  in  patches,  and  in 
the  confluent  variety  they  are  close  together  and  so  numer- 
ous as  to  diffuse  a  hardness  over  the  surface.  These  papules 
by  the  second  day  of  eruption  (fourth  of  invasion)  become 
raised  in  small  conical  pimples  with  an  inflamed  base  and 
transparent  vesicular  point.  They  continue  to  increase  to 
the  fifth  day  of  eruption  and  gradually  pass  from  a  conical 
to  a  flattened  and  umbilicated  form.  This  form  is  often 
apparent  in  the  vesicles  from  the  third  day.  Their  con- 
tents, from  being  transparent,  become  opaque  and  milky, 
and  by  the  sixth  day  are  converted  into  pus  (pustules),  and 
by  the  eighth  day  suppuration  is  well  established.  The 
fever,  which  had  disappeared  with  the  outburst  of  the 
eruption,  reappears ;  considerable  pain  and  redness  of  the 
skin  and  great  tumefaction  and  a  distressing  sensation  of 
tension  of  the  integument  occur.  The  eyelids  are  swollen 
and  oedematous,  completely  burying  the  eyes,  and  the  nose 
and  lips  are  enormously  swollen  in  some  cases. 

While  these  changes  are  taking  place  in  the  skin  similar 
changes  occur  in  the  numerous  membranes  ;  the  mucous 


membrane  of  the  mouth  and  respiratory  passages  is  greatly 
inflamed,  as  shown  by  the  presence  of  oppression  of  respi- 
ration, cough,  and  sore  throat.  The  alimentary  canal  S3'm- 
pathizes  with  the  general  irritation,  as  shown  by  the  accom- 
panying diarrhoea.  The  conjunctivae  participate  in  the 
inflammation,  and  in  this  locality,  as  in  the  air  passages, 
pustules  form,  which,  if  not  properly  attended  to,  cause 
ulceration  and  subsequent  opacity  of  the  cornea,  or  staphy- 
loma, with  partial  or  total  loss  of  sight. 

In  some  very  malignant  forms  of  this  disease  and  in 
cachectic  individuals  haemorrhages  occur  in  the  vesicles  and 
pustules,  constituting  what  is  known  as  haemorrhagic  vari- 
ola, or  variola  nigra  ;  and  in  other  cases  still  severer  and 
always  fatal,  the  eruption  does  not  develop  in  its  different 
stages,  but  subcutaneous  haemorrhages  take  place,  giving 
origin  to  ecchymoses  or  petechiae,  which  are  accompanied  by 
other  severe  symptoms  of  decomposition  and  loss  of  plas- 
ticity of  the  blood,  which  is  deficient  in  fibrin. 

In  other  cases  an  arrest  of  development  of  the  vesicles 
and  pustules  occurs  with  absorption  of  their  purulent  con- 
tents, which  results  in  death.  The  period  of  suppuration 
is  accompanied  in  mild  cases  by  moderate  delirium,  but  in 
semiconfluent  and  confluent  cases  the  symptoms  assume  a 
low  typhoid  type  ;  there  are  restlessness,  a  hard  cough,  and 
haemoptysis,  and  in  some  cases  haematuria,  accompanied  by 
other  dangerous  symptoms. 

This  period,  I  have  observed,  can  be  materially  short- 
ened and  its  symptoms  made  less  severe  in  ordinary  cases 
by  the  practice  of  opening  or  cutting  the  pustules  and  ex- 
pression of  their  contents  when  they  are  ripe. 

Desiccation  ordinarily  begins  from  the  eighth  to  the 
ninth  day,  and  is  indicated  by  the  subsidence  of  the  tume- 
faction of  the  skin  and  drying  up  of  the  pus  and  purulent 
discharges  produced  during  the  preceding  period.  It  be- 
gins at  the  face,  and  crusts  are  often  present  in  this  region 
before  pustules  are  fully  matured  in  the  trunk  and  extremi- 
ties. This  stage  is  sometimes  prolonged,  especially  in  the 
lower  part  of  the  trunk,  where  pressure  has  been  exerted 
by  lying  where  clusters  continue  to  suppurate  for  a  long 
time,  and  in  places  where  the  skin  is  thick,  as  on  the  palms 
of  the  hands  and  soles  of  the  feet. 

Decrustation  or  desquamation  commences  generally 
from  the  eleventh  to  the  fourteenth  day  of  eruption,  and 
the  skin  below  is  of  a  deep-red  color,  retaining  this  hue 
for  some  weeks,  and  the  newly  formed  epidermis  is  thrown 
off  by  repeated  desquamation. 

The  cicatrices  become  deeper  as  the  swelling  disap- 
peaj's.  In  the  confluent  variety  the  crust  remains  adherent 
to  the  face  for  ten  or  twelve  days,  and  in  places  where  the 
skin  is  harder,  as  in  the  palms  of  the  hands  and  soles  of  the 
feet,  where  pustules  do  not  develop  well,  the  whole  thick 
epidermis  is  cast  off  in  a  piece,  leaving  the  newly  formed 
epidermis  very  delicate  and  tender,  preventing  the  jiaticnt 
from  walking  for  a  long  time  in  some  cases. 

The  process  of  desiccation  is  accompanied  with  severe 
itching  which  induces  the  patient  to  scratch,  often  tearing 
the  surface  with  his  nails  and  causing  hjemorrhages  in  the 
ulcerated  surfaces  and  blackening  of  the  pustules.  It  is 
also  accompanied  by  a  nauseating  and  t)ffensive  odor,  un- 


«08 


8ALICRUP:  SMALL-POX  AND  VACCINATION. 


[N.  Y.  Med.  Joch., 


bearable  if  proper  means  of  disinfection  have  not  been  ap- 
plied from  the  beginning  of  treatment. 

Some  changes  have  been  observed  in  the  urinary  secre- 
tion in  relation  with  the  various  stages  of  the  disease  as  to 
its  amount,  existence  in  it  of  albumin,  or  excess  of  its  nor- 
mal constituents. 

During  an  epidemic  some  cases  occur  in  which  the 
symptoms  of  the  stage  of  invasion  make  their  appearance 
with  great  intensity,  and  the  disease  abates  with  the  re- 
mission of  the  febrile  symptoms,  no  eruption  appearing 
on  the  skin  or  mucous  membrane.  These  cases  are  known 
as  variola  sine  variolis. 

Many  complications  may  occur  in  cases  of  small -pox 
"which  may  cause  to  prove  fatal  a  case  which  appeared  to 
be  progressing  satisfactorily,  and  they  may  occur  at  any  of 
the  five  stages  already  described,  and  may  have  for  their 
seat  the  blood,  nervous  system,  the  raucous  or  serous  mem- 
branes, the  eyeballs,  tongue,  and  cellular  tissues.  The  stage 
of  invasion  may  be  very  severe,  the  fever  may  run  very 
high,  the  pain  in  the  head,  chest,  and  loins  may  be  so 
severe  that  it  may  lead  to  the  suspicion  of  inflammation  of 
the  organs  situated  in  those  regions,  and  delirium,  convul- 
sions, and  coma  may  occur,  giving  a  dangerous  and  per- 
haps fatal  character  to  the  case,  as  has  been  already  said. 

During  the  period  of  eruption  serious  congestion  of  the 
internal  organs  may  ensue,  and  grave  symptoms  from  the 
brain,  spinal  cord,  and  the  lungs  in  the  shape  of  convul- 
rsions,  bronchitis,  pneumonia,  and  pleurisy.  The  mucous 
membrane  of  the  alimentary  canal  may  be  inflamed  and 
thus  give  rise  to  diarrhcEa,  dysentery,  or  haemorrhage  of  the 
bowels,  and  many  other  complications  may  occur  to  which 
reference  has  already  been  made. 

As  sequelffi  of  small-pox  many  secondary  affections  may 
be  developed,  especially  in  cachectic  individuals,  as  a  con- 
sequence of  variolous  inflammation.  Such  are  chronic  in- 
flammation of  the  various  mucous  membranes,  producing 
•otitis,  deafness,  ophthalmia,  opacity  of  the  cornea,  staphy- 
loma, ulceration  of  the  cornea,  oedema  of  the  glottis,  haj- 
moptysis,  pulmonary  tubercle,  chronic  bronchitis,  pneu- 
monia, pleurisy  and  empyema,  chronic  diarrhoea  and 
glandular  enlargements,  caries  of  the  bones  of  the  face, 
subcutaneous  abscesses,  furuncles,  erysipelas,  gangrene  of 
the  skin  and  genitals,  diseases  of  the  joints,  menorrhagia, 
hsematuria,  abscess  of  the  kidney,  miscarriage,  and  many 
others. 

I  must  remark,  however,  that  I  have  met  in  practice 
with  some  few  persons  who  previous  to  the  attack  of  the 
disease  had  enjoyed  poor  health,  constantly  suffering  from 
skin  diseases,  asthma,  and  other  infirmities,  who  after  a 
severe  attack  of  confluent  small-pox  have  got  rid  of  their 
troubles  and  enjoyed  very  robust  health.  In  these  cases 
the  disease  seems  to  have  had  a  purifying  effect  on  the 
blood  of  those  individuals  (but  yet  I  would  not  advise  any 
person  suffering  from  those  infirmities  to  expose  himself  to 
the  contagion  of  variola). 

I  will  not  occupy  your  valuable  time  by  speaking  of  the 
•diagnosis  and  pathology  of  the  affection,  for  the  latter  varies 
according  to  the  complication  that  causes  death,  and  does  not 
j^enerally  throw  any  light  on  the  point  we  want  to  discuss. 


and  will  therefore  only  mention  the  treatment  which  has 
been  suggested  in  the  different  stages  of  this  disease,  and 
the  plan  which  I  adopted  in  regular  cases,  with  the  varia- 
tions which  the  symptoms  required. 

Various  ectrotic  methods  have  been  suggested  and  em- 
ployed at  different  times  to  arrest  the  development  of  the 
eruption  and  avoid  subsequent  pitting.  The  most  adopted 
have  been  cauterization  of  the  vesicles  after  removing  their 
apex  with  a  stick  of  nitrate  of  silver  (this  is  impracticable 
in  semi-confluent  and  confluent  varieties,  and  is  dangerous 
and  painful).  Another  is  the  application  of  sulphur  oint- 
ment to  the  entire  surface  of  the  skin  ;  another  the  applica- 
tion of  a  mercurial  ointment  also  to  the  surface.  Others 
consist  in  covering  the  face,  or  part  of  the  whole  surface  of 
the  body,  with  some  impermeable  material,  as  gold  or  silver 
leaf,  tissue  paper,  different  plasters,  or,  better,  with  collo- 
dion, so  as  to  prevent  the  access  of  air. 

I  never  used  any  of  these  methods,  because  many  are 
impracticable  and  painful  and  all  dangerous,  as  the  arrest 
of  the  development  of  the  eruption  proves  in  most  cases 
fatal.  As  to  internal  medicines,  many  have  been  used  to 
meet  the  different  symptoms  as  they  appear,  but  I  know  of 
no  special  drug  that  has  had  any  constant  good  results. 
In  the  uncomplicated  and  benign  form  of  the  disease  no 
special  treatment  is  necessary  but  the  attention  to  the  gen- 
eral rules  of  cleanliness,  ventilation,  and  general  hygiene. 
In  complicated,  confluent,  and  malignant  ones  every  indica- 
tion should  be  promptly  met  with  the  proper  means,  and 
great  care  has  to  be  exerted  as  to  cleanliness  and  therapeu- 
tical treatment. 

I  will  mention  the  simple  plan  which  I  adopted  in  the 
majority  of  cases  which  seemed  to  prove  successful  in  most 
of  them,  even  in  many  that  were  expected  to  prove  fatal 
when  I  was  first  called  to  attend  the  patients. 

If  I  saw  the  patient  at  the  very  start  of  the  stage  of  in- 
vasion, I  used  to  prescribe  a  dose  of  calomel  (proportionate 
to  the  age  and  sex  of  the  patient),  followed  four  or  five 
hours  after  by  a  saline  purgative  or  a  dose  of  castor  oil ; 
after  the  effects  of  the  purge  had  passed  I  almost  always 
observed  a  relief  in  the  congestive  symptoms,  and  ordered 
the  patient  to  be  sponged  all  over  the  body  with  a  tepid 
weak  solution  of  carbolic  acid  (two  per  cent.)  the  moment 
the  first  symptoms  of  the  eruption  began  to  show  them- 
selves. As  an  internal  medication  I  prescribed  a  mixture 
containing  carbonate  of  ammonium,  chlorate  of  potassium, 
and  saline  mixture  to  take  all  along.  When  the  swelling  of 
the  skin  began  I  used  to  prescribe  the  external  application 
over  the  whole  surface  of  glycerin  with  essential  oil  of  pep- 
permint, which  is,  like  other  aromatic  plants,  a  powerful  dis- 
infectant and  germicide,  in  the  proportion  of  two  or  three 
drops  to  the  ounce.  This  I  always  found  to  greatly  subdue 
the  swelling,  and  seemed,  in  conjunction  with  the  rest  of  the 
treatment,  to  exert  a  modifying  influence  in  the  develop- 
ment of  the  eruption.  When  the  pustules  were  fully  ripe  I 
advised  them  to  be  cut  with  scissors,  and,  after  pressing  well 
their  contents  and  washing  with  a  weak  solution  of  carbolic 
acid  and  hyposulphite  of  sodium,  smear  the  whole  surface 
with  the  glycerin  and  peppermint-oil  mixture. 

In  nearly  all  cases  that  I  could  fairly  treat  with  this 


June  3,  1898.] 


SALICRUP:  SMALL-POX  AND  VACCINATION. 


609 


plan  the  disease  proved  more  manageable  than  in  others  ; 
no  bad  odor  ever  originated  from  the  patients,  and  they  all 
recovered  in  shorter  time  and  with  less  pitting  than  in 
those  I  was  called  to  attend  when  the  eruption  was  more  or 
less  developed. 

Besides  these  therapeutical  means,  attention  was  di- 
rected to  hygienic  measures  and  appropriate  feeding. 

The  room  was  as  well  ventilated  as  possible,  kept  rather 
dark,  and  all  disturbing  influences  made  to  disappear  as 
much  as  possible. 

Some  of  the  symptoms  that  accompany  the  stage  of  in- 
vasion may  assume  such  a  severe  character  as  to  require 
special  medical  treatment.  The  pains  in  the  head  and  limbs 
and  especially  in  the  loins  (which  is  considered  as  a  pathog- 
nomonic symptom,  and  I  have  noticed  that  its  severity  is 
proportionate  to  the  severity  of  the  attack)  may  be  so  se- 
vere that  the  patient  yells  out  for  relief,  and  external  revul- 
sion and  injections  of  morphine  have  to  be  used  to  relieve 
them.  When  the  eruption  is  tardy  in  its  appearance  the 
symptoms  are  very  much  intensified  and  the  mucous  mem- 
branes much  congested,  and  measures  have  to  be  adopted  in 
the  shape  of  diaphoretics  and  warm  bath  and  revulsives, 
which  last  promptly  act  in  bringing  it  out. 

Wherever  a  mustard  plaster  or  blister  is  applied  the 
eruption  promptly  appears  in  a  confluent  form,  and  one  of 
the  best  means  to  limit  it  is  the  application  of  a  number  of 
blisters  to  the  limbs  and  trunk,  as  the  eruption  in  these  cases 
does  not  appear  anywhere  but  in  the  place  of  the  blisters. 

This  method  works  well  in  some  cases ;  but  sometimes  it 
is  very  difficult  to  heal  these  blisters,  which  continue  to 
suppurate  for  a  long  time,  and  even  gangrene  of  the  skin 
supervenes  in  them  and  deep  and  extensive  cicatrices  follow. 

When  typhoid  symptoms  appear  in  the  suppurative  stage 
stimulants  of  all  kinds  have  to  be  freely  used,  carbonate  of 
ammonium,  cinchona,  and  alcohol  being  the  most  useful,  and 
every  complication  has  to  be  met  with  the  appropriate  thera- 
peutical means. 

Cases  of  the  disease  among  intelligent  and  well-to-do 
people  are  more  successfully  treated  than  among  the  poor, 
as  with  the  former  ample  means  of  ventilation,  seclusion, 
and  other  sanitary  surroundings  are  easily  adopted,  while 
among  the  latter  these  means  are  very  deficient  or  totally 
lacking.  I  have  attended  cases  of  both  kinds,  but  it  has 
been  my  lot  to  attend  during  several  epidemics  hundreds  of 
cases  among  the  poorer  and  most  ignorant  classes,  especially 
of  the  colored  class,  in  which  great  prejudice  existed  against 
all  therapeutical  measures,  and  absolute  absence  of  all  sani- 
tary surroundings  and  material  means  of  every  kind.  I  had 
to  contend  with  all  these  drawbacks  and  to  do  the  best  I 
could  with  the  scarce  means  at  my  dis{)osal. 

Small-pox  has  become  endemic  in  Puerto  Ilico  and  is 
raging  probably  all  the  year  in  one  or  another  of  the  twenty- 
eight  towns  which  form  the  island. 

Epidemics  have  a  very  severe  character,  and  every  year 
hundreds  of  victims  are  carried  away  by  this  disease.  Near- 
ly forty  per  cent,  of  the  inhabitants  bear  marks  of  having 
had  the  disease  in  a  more  or  less  severe  form,  .nd  many  suf- 
fer from  partial  or  total  blindness  and  other  sequelie  of  it, 
especially  among  the  colored  part  of  the  population. 


Sanitary  measures  are  very  imperfectly  carried  on  there, 
and  when  an  epidemic  attacks  a  city  or  town  and  after  it 
has  made  considerable  progress,  temporary  hospitals  are 
built  which  are  really  more  centers  of  infection  than  any- 
thing else,  as  they  lack  every  facility  for  the  proper  treat- 
ment which  a  hospital  should  have. 

Only  poor  patients  are  compelled  to  go  to  such  hospitals, 
and  you  often  find  severe  cases  in  the  most  pitiful  condition 
of  abandonment  and  filth  in  the  very  center  of  a  town  where 
well-to-do  people  inhabit,  and  on  the  ground  floor  of  their 
houses,  in  a  small  room  without  any  means  of  ventilation, 
where  five  or  six  other  sound  persons  sleep.  And  these 
constitute  the  majority  of  the  cases  which  I  have  been  called 
to  treat. 

Vaccination. — The  efliciency  of  the  preventive  power  of 
vaccination  is  proved  by  the  facts  of  the  almost  total  dis- 
appearance of  the  disease  in  countries  and  cities  like  this  in 
which  vaccination  is  persistently  practiced  in  conjunction 
with  isolation  of  cases  at  their  start  and  other  sanitary  meas- 
ures. But  that  by  itself  it  does  not  afford  such  perfect  pro- 
tection from  an  attack  of  the  disease  as  it  was  at  first  en- 
thusiastically believed,  is  also  proved  by  what  happens  in 
countries  where  sanitary  measures  are  defective  and  isola- 
tion of  cases  not  opportunely  practiced.  Persons  who  have 
been  successfully  vaccinated,  if  exposed  to  contagion,  are 
sometimes  attacked  by  the  disease  in  its  worst  form  and 
even  killed  by  it ;  but,  fortunately,  this  is  the  exception,  the 
rule  being  that  those  properly  vaccinated  when  exposed  to 
the  contagion  only  suffer  from  the  modified  variety  of  the 
affection. 

The  protective  agency  of  an  attack  of  variola  against 
subsequent  invasions  of  the  disease  being  known  from  an 
early  period  of  medical  history,  and  with  the  purpose  of  ob- 
taining this  protection,  the  inoculation  of  variola  was  prac- 
ticed as  far  back  as  1673  in  Constantinople,  and  the  prac- 
tice introduced  into  England ;  thence  it  extended  to  the  con- 
tinent of  Europe.  But  this  inoculation,  which  generally 
caused  a  mild  attack  of  the  disease,  sometimes  produced 
serious  symptoms,  which  often  culminated  in  the  death  of 
the  inoculated  person,  and  it  was  substituted  by  the  more 
innocent  method  of  vaccirfation,  when  this  discovery  was 
made  by  the  immortal  Jenner. 

Jenner  was  acquainted  with  the  occurrence  of  a  disease 
in  the  cow,  called  vaccinia,  characterized  by  the  appearance 
of  pustule  in  the  teats  and  udders  of  these  animals,  which 
very  much  resembled  the  pustule  of  small-pox.  He  ob- 
served that  the  men  who  milked  and  handled  cows  affected 
with  the  disease  had  a  similar  eruption  developed  in  their 
hands  and  arms,  and  that  they  enjoyed  a  remarkable  im- 
munity to  the  invasion  of  variola.  On  this  observation  he 
founded  his  great  discovery,  and  the  first  experiment  with 
vaccination  with  cow-pox  was  made  by  him  on  the  14th  of 
May,  1796. 

I  have  already  alluded  to  the  opposition  he  met  with 
among  his  contemporaries  and  which  his  method  still 
meets  with  among  many  prejudiced  persons,  but  the  value 
of  the  method  is  at  present  recognized  by  the  generality, 
and  is  practiced  with  good  success  all  over  the  civilized 
world. 


610 

The  short  space  of  time  allowed  for  the  reading  of  tliis 
paper  does  not  allow  me  to  give  the  subject  of  vaccine  and 
vaccination  the  attention  which  it  deserves,  and  I  have  to 
limit  my  remarks  to  the  most  essential  points  in  connection 
with  it,  passing  in  silence  others  that  I  would  like  to  make 
the  subject  of  discussion  this  evening. 

Among  the  many  arguments  that  have  been  raised 
against  vaccination,  and  one  that  yet  stands  in  the  minds 
of  many,  is  the  possibility  of  inoculating  other  constitu- 
tional diseases  existing  in  the  blood  of  the  person  who  sup- 
plies the  virus  when  the  humanized  one  is  used,  and  another 
is  the  possibility  of  causing  infectious  diseases  of  the  blood 
by  using  impure  or  decomposed  virus. 

To  the  first  it  may  be  answered  that  the  small-pox  pus- 
tule, although  no  peculiar  germ  has  yet  been  discovered 
and  described  by  bacteriologists,  may  be  considered  as  a 
pure  culture  of  the  poison  or  germ  that  produces  the  dis- 
ease, and,  if  only  its  contents  are  used  for  inoculation,  no 
danger  exists  of  anything  but  vaccinia  being  inoculated.  It 
may  be  and  is  considered  by  some  as  possessing  always  its 
peculiar  characteristics,  no  matter  what  the  nature  of  the 
constitution  of  the  individual  in  which  it  grows  or  develops. 
And  so  far  no  facts  have  been  brought  to  clearly  prove  the 
occurrence  of  the  communicability  through  vaccination  of 
any  other  disease,  provided  the  operation  has  been  well 
performed  without  unnecessarily  mixing  the  blood  of  the 
giver  and  recipient  of  the  virus  when  the  operation  is  per- 
formed from  arm  to  arm. 

The  use  of  bovine  virus  has  done  away  with  this  objec- 
tion in  a  great  measure.  To  the  second  objection,  or  the 
possibility  of  causing  blood  poisoning  by  the  introduction 
of  putrid  substances  in  the  blood  (which  accident  may  often 
happen,  and  I  have  seen  a  case  of  such  blood  infection  with 
severe  symptoms  of  inflammation  and  infarction  of  the 
lymphatic  system  of  the  arm  operated  upon,  threatening 
mortification  and  endangering  life,  after  inoculation  with 
bovine  virus),  it  may  be  answered  that,  with  proper  care  in 
the  selection  of  the  virus  employed,  trying  to  use  fresh 
virus  always  when  possible,  no  fear  need  be  entertained  of 
such  accidents  happening.  • 

As  to  the  process  of  development  of  vaccine,  and  the 
way  and  different  methods  of  practicing  the  inoculation,  I 
will  not  speak,  not  to  keep  you  longer. 

I  will  only  remark  as  to  the  method  of  practicing  the 
operation  that  it  is  well  that  every  one  should  adhere  to  the 
process  which  yields  him  the  greatest  amount  of  success, 
and  that  I  believe  that  the  more  bloodless  a  method  the 
safest  it  is  for  the  individual  inoculated  and  the  success  of 
the  operation. 

Time  does  not  allow  me  to  be  more  extensive  on  this 
important  subject ;  but  if  my  remarks  can  bring  forth  a  dis- 
cussion on  the  subject  by  the  more  competent  men  present 
here  and  those  invited  for  the  purpose,  the  object  of  my 
paper  will  be  fulfilled,  and  I  shall  not  have  tired  you  with 
my  long  paper. 

The  New  York  Academy  of  Medicine. — At  the  next  meetinf;  of 
the  Section  in  Surgery,  on  Monday  evening,  the  12th  in.st,  Dr.  W.  W. 
Van  Arsdale  will  read  a  paper  on  The  Treatment  of  Granulating 
Wounds. 


[N.  Y.  Med.  Jour., 

THE  PERITONJ^UM. 
Rt  F.  BYRON  ROBINSON,  B.  S.,  M.  D., 

CHICAGO. 

The  peritonijeum  is  a  great  serous,  lymphatic  sac. 
Embryology,  physiology,  and  comparative  anatomy  have 
shed  a  flood  of  light  on  the  peritonajum  and  its  develop- 
ment during  the  last  decade. 

Embryology  and  comparative  anatomy  have  enabled  in- 
vestigators to  demonstrate  that  most  of  the  parietal  attach- 
ments of  the  peritonseum  are  acquired.  The  only  possible 
method  by  which  a  student  can  realize  the  peritonjcum  and 
its  relations  is  by  means  of  embryology  and  comparative 
anatomy.  He  must  watch  the  development  of  animals ; 
he  must  catch  up  the  thread  as  it  courses  through  evolu- 
tionary processes. 

Comparative  anatomy  seems  to  show  that  man  has  pro- 
portionally the  least  amount  of  periton;eum  of  any  of  the 
mammals.  Actual  dissections  would  appear  to  show  that  the 
peritonaeum  decreases  as  the  scale  of  animal  life  ascends. 
The  peritonaeum  of  the  ape  differs  but  little  from  that  of  man, 
but  passing  to  the  lower  monkeys,  some  difference  arises, 
especially  in  regard  to  a  mesoduodenum.  The  dog  possesses 
a  very  large  mesoduodenum.  In  the  horse  and  ox  the 
cjficum  is  very  large  and  free,  floating  in  the  peritoneal 
cavity.  The  caecum  of  the  ox  will  hold  gallons,  and  no 
doubt  is  the  vestigial  remains  of  an  ancient  stomach.  Her- 
bivorous animals  have  a  liberal  peritonaeum,  as  such  animals, 
from  the  nature  of  their  food,  possess  a  long  digestive 
tract.  Their  abdominal  cavity  is  broad  and  the  extensive 
viscera  require  liberal  coverings. 

The  abdominal  cavity  of  carnivora  is  short  and  narrow, 
and  the  digestive  tract  is  also  short,  which  accords  with  the 
nature  of  their  food.  The  peritonaeum  of  the  carnivora, 
though  more  liberal  than  that  of  man  and  ape,  is  relatively 
less  than  that  of  the  herbivora. 

If  one  could  conceive  of  the  abdominal  cavity  entirely 
empty  and  its  walls  lined  by  a  membrane,  and  then  imagine 
the  various  viscera  budding  out  from  the  dorsal  parietal 
wall  until  they  are  partially,  or  almost  wholly,  enveloped 
by  the  folds  of  peritonaeum,  it  might  aid  in  understanding 
the  complicated  arrangements  of  this  membrane. 

It  is  quite  useless  to  attempt  to  understand  the  perito- 
njeum  as  it  appears  in  the  adult.  It  is  only  through  evolu- 
tionary processes  that  the  peritonaeum  becomes  intelligible. 
From  an  embryological  standpoint  the  peritonaeum  passes 
through  vast  changes.  Two  special  points  should  be  noted 
in  these  changes  which  make  the  folds  of  the  peritonaeum 
difficult  of  comprehension.  One  is  the  rotation  of  the 
loop  of  the  intestines  which  is  fed  by  the  superior  mesen- 
teric artery.  The  rotation  is  from  left  to  right.  The  rota- 
tion of  the  intestinal  loop  over  half  a  circle  makes  the  vasa 
intestini  tenuis  come  off'  from  the  left  side  of  the  superior 
mesenteric  artery  in  the  adult,  while  in  the  embryo  be- 
fore birth  the  vasa  intestini  tenuis  pass  from  the  right 
side  of  the  superior  mesenteric  artery.  This  rotation 
also  drags  on  parts  of  the  peritonaeum  and  thus  en- 
tirely changes  its  original  relations — e.  g.,  the  duodenum 
has  had  its  peritonaeum  entirely  drawn  from  its  posterior 


ROBINSON:    THE  PERITONAilJM. 


Juno  3,  1893.) 


ROBINSON':   THE  PERITONAEUM. 


611 


surface  while  the  caecum  becomes  entirely  covered  by 
peritonaeum. 

A  second  point  which  changes  the  embryotic  perito- 
naeum and  complicates  its  folds  is  the  unequal  growth  of 
organs.  Take,  for  example,  the  appendix  and  ca3cum. 
The  appendix,  from  an  evolutionary  standpoint,  is  fading 
out  of  existence.  The  cascum  grows  to  be  a  vast  receptacle 
in  man  and  in  many  mammals,  such  as  the  ox  and  horse. 
Originally  the  appendix  always  had  a  mesentery,  but  in 
adult  life  it  is  often  found  robbed  of  its  peritoneal  cavity. 
The  growing  caecum  steals  away  the  appendicular  mesentery 
and  appropriates  it  to  cover  its  greater  surface. 

Again,  the  liver  changes  the  original  peritonajum.  At 
birth  the  liver  and  Wolffian  body  are  the  two  chief  organs, 
and  almost  fill  the  entire  cavity.  In  extra-uterine  life  the 
liver  rapidly  lessens  in  size ;  the  other  organs  increase  in 
size,  and  thus  the  peritonaium  is  changed  in  its  relations. 
Rotatio»n  of  the  great  intestinal  loop  and  the  unequal 
growth  of  the  viscera  change  the  entire  peritoneal  attach- 
ments, except  the  original  mesentery  of  one  half  of  the 
transverse  and  descending  colon.  And  even  this  original 
mesentery  is  pushed  from  the  original  middle  line  to  the 
position  of  the  adult  on  the  left  side. 

The  great  omentum  comes  from  a  complicated  process 
in  which  the  stomach  rotates  half  a  circle  from  left  to 
right.  This  rotation  leaves  the  left  vagus  lying  on  the  an- 
terior surface  of  the  stomach  and  the  right  vagus  lying  on 
the  posterior  surface  of  the  stomach.  The  stomach  also 
makes  a  spiral  twist  on  itself,  which  aids  in  producing  the 
great  omentum. 

The  use  of  the  peritonaeum  in  the  economy  of  animal 
life  is  very  important.  Its  first  and  foremost  use  is  to  pre- 
vent friction.  It  allows  viscera  to  move  on  each  other,  to 
alter  their  size,  and  change  their  condition  without  destroy- 
ing their  integrity.  The  peritonaeum  should  be  viewed  as 
a  distinct  joint  membrane.  It  has  all  the  characteristics  of 
a  joint — viz.,  a  synovial  membrane,  muscles  to  move  it,  and 
nerves  to  induce  action  and  sensation.  The  peritonaeum 
resembles  the  pleura,  the  pericardium,  and  the  meninges. 
It  is,  in  fact,  a  synovial  membrane.  The  peritonaeum, 
like  the  pleura,  pericardium,  meninges,  and  serous  mem- 
branes of  joints,  is  liable  to  similar  diseases — e.  g.,  inflam- 
mation and  tuberculosis. 

The  second  use  of  the  peritonseum  is  to  anchor  organs 
in  the  abdominal  cavity.  It  limits  the  movements  of  the 
viscera  so  that  they  do  not  get  entangled.  If  the  anchor- 
age of  the  viscera  becomes  defective,  disaster  soon  follows. 
If  the  mesentery  is  elongated,  volvulus  is  liable  to  occur, 
and  no  inguinal  or  femoral  hernia  can  arise  without  an 
elongated  mesentery.  Should  a  tubule  of  the  parovarium 
enlarge,  its  anchorage  or  mesentery  would  be  changed,  and 
about  twelve  per  cent,  of  such  tumors  rotate  on  their  axes. 

The  anchorage  of  the  peritonanim  divides  itself  into 
that  of  (a)  mesentery,  (/>)  ligaments,  (c)  omenta.  A  mesen- 
tery is  a  double  fold  of  peritonaeum  which  attaches  a  por- 
tion of  the  digestive  tract  to  the  dorsal  parietal  wall.  Be- 
sides holding  the  intestines  to  the  parietal  wall,  the  mesen- 
tery transmits  veins,  arteries,  lymphatics,  and  nerves  to 
the  intestines.    The  mesentery  of  the  small  intestine  covers 


all  the  gut  except  about  one  sixth  of  an  inch.  The  mesen- 
tery of  the  large  gut  covers  the  entire  gut  except  from  half 
an  inch  to  four  inches. 

Treves  noted  in  the  examination  of  one  hundred  fresh 
bodies  that  a  mesentery  was  found  thirty-five  times  in  one 
hundred  cases  on  the  left  side,  and  twenty-five  times  in  one 
hundred  cases  on  the  right  side. 

The  French  surgeon  Amussat  made  his  great  reputa- 
tion by  doing  colotomy  without  opening  the  peritonaeum. 
He  must  have  met  with  cases  with  no  descending  mesocolon. 
He  did  his  first  noted  operation  on  a  princess,  who  recov- 
ered. The  reason  there  is  a  mesentery  oftener  on  the  left 
side  than  on  the  right  is  because  the  left  mesocolon  is  the 
original  mesentery  of  embryological  life,  while  the  right 
mesocolon  is  entirely  acquired. 

It  is  very  evident  that  the  old  surgeons  who  reported 
extraperitoneal  colotomy  penetrated  the  peritonaeum,  con- 
sciously or  unconsciously,  in  performing  colotomy.  It  is 
frequently  asserted  that  one  can  approach  the  appendix  ex- 
traperitoneally,  but  any  one  can  take  the  anatomical  liberty 
of  flatly  contradicting  it,  for  it  can  not  be  done.  The  writer 
has  examined  many  caeca,  and  each  and  every  one  was  en- 
tirely covered  by  peritonaeum. 

A  peritoneal  ligament  is  a  fold  of  peritonaium  which 
holds  solid  organs  to  the  abdominal  wall — as  the  liver,  uter- 
us, and  bladder. 

An  omentum  connects  the  stomach  with  some  other  or- 
gan— as  the  liver,  spleen,  and  colon. 

A  third  use  of  the  peritonaeum  is  to  check  the  invasion 
of  infection.  A  whole  volume  could  be  written  on  this  prac- 
tical subject.  It  is  probable  that  by  evolutionary  processes 
man's  peritonaeum  checks  infectious  invasion  by  throwing 
out  an  exudate  to  stop  the  enemy.  The  exudate  rapid- 
ly surrounds  the  pus,  and  in  many  cases  encapsulates  it 
forever.  It  is  a  very  curious  fact  that  the  peritonaeum  will 
tolerate  any  quantity  of  pus  on  the  outside  surface,  but  the 
moment  the  interior  is  invaded  by  one  drop,  inflammation 
rapidly  spreads.  Another  curious  fact  in  regard  to  the 
peritonaeum  is  that  it  is  so  elastic  that  it  can  be  stretched 
to  enormous  dimensions  if  the  stretching  is  effected  eradu- 
ally. 

A  fourth  use  of  the  peritonaeum  is  to  repair  damaged 
viscera.  The  writer's  experiments  on  dogs  have  proved 
that  in  gunshot  wounds  a  piece  of  omentum  will  actually 
repair  a  hole  in  the  gut. 

A  point  of  interest  in  regard  to  the  peritonaeum  is  that 
the  part  of  the  peritonaeum  which  invests  the  viscera  is 
chiefly  supplied  by  the  sympathetic  nerve.  The  pain  is 
therefore  generally  of  a  dull,  aching  character,  while  that 
part  of  the  peritonaeum  which  lines  the  anterior  parietal  sur- 
face of  the  abdomen  comes  in  close  contact  with  the  ends 
of  the  (spinal)  intercostal  nerves.  This  portion  of  the  peri- 
tonaeum, when  inflaraedj^  is  accompanied  by  shal-p,  cutting 
pains.  There  is  no  doubt  that  by  the  decreasing  of  man's 
peritonaeum  he  is  rapidly  escaping  disease  of  this  sac. 

The  extensive  liberal  folds  of  peritonanim  existing  in  the 
lower  mammals  nuist  induce  disease.  Experiments  would 
show  that  the  resistance  of  man's  peritonaeum  is  much 
greater  than  is  that  of  animals. 


612 


McCONNELL:  NITRATE  OF  STRYCHNINE  IN  ALCOHOLISM. 


[N.  Y.  Med.  Joub., 


Among  animals  the  hog  would  rank  first,  then  the  ape 
and  the  monkey.  From  a  large  number  of  operations  on 
the  peritonteum  of  dogs  the  writer  can  state  that  the  resist- 
ance of  the  peritonajum  of  the  dog  is  about  the  same  as  in 
man.  Veterinary  surgeons  tell  me  that  the  peritona?um 
of  the  horse  is  very  liable  to  fatal  inflammation  ;  but  tliat 
may  be  from  inability  to  control  the  conditions  of  a  sick 
horse. 

So  far  as  the  writer  can  state,  the  resistance  to  disease 
in  the  peritonaeum  of  mammals  does  not  vary  much.  Again, 
the  writer  has  observed  for  some  time  that  peritonitis  in 
male  and  female  is  about  equal  in  amount.  The  aperture 
in  the  female  peritonaeum  from  the  Falloppian  tube  is  re- 
sponsible for  a  large  percentage  of  peritonitis  in  the  female. 
This  is,  however,  about  balanced  by  the  excessive  amount 
of  hernia  and  appendicitis  in  the  male. 

The  peritonaeum  is  highly  supplied  by  a  vast  number  of 
nervous  filaments,  both  spinal  and  sympathetic.  The  reflex 
action  on  distant  organs  is  profound  through  the  sympa- 
thetic. 

A  fifth  use  of  the  peritonaeum  is  as  an  absorbent.  It 
will  rapidly  absorb  fluids.  The  writer  has  often  filled  the 
abdomens  of  dogs  with  water  and  closed  the  wound.  For 
two  or  three  days  the  dog  would  urinate  frequently  and  pro- 
fusely, but  recover  well. 

In  one  of  my  cases  of  repeated  rupture  of  ovarian  cysts, 
in  a  woman  of  twenty-four,  profuse  urination  was  observed 
at  the  time  of  the  rupture  of  the  ovarian  cyst. 

Conclusions. — 1.  The  utility  of  the  peritonaeum  is  to 
prevent  friction. 

2.  It  supports  the  visceral  organs  and  connects  them  to 
the  abdominal  wall,  and  thus  prevents  entanglements  and 
dislocation.  Normal  peritoneal  supports  do  not  allow  her- 
nia or  volvulus. 

3.  It  transmits  veins,  arteries,  Ij-mphatics,  and  nerves  to 
and  from  viscera. 

4.  It  checks  the  invasion  of  infection. 

5.  The  peritonaeum  should  be  viewed  as  a  joint  cavity. 

6.  It  is  an  absorbent  lymph  sac. 

7.  Man,  having  proportionally  the  least  peritonaeum,  is 
the  least  liable  to  disease  in  it. 

8.  It  repairs  damaged  viscera. 

9.  Its  reflexes  are  the  most  profound  on  the  distant 
organs. 

10.  In  peritonitis  the  thighs  are  flexed  on  the  abdomen, 
in  order  to  relax  the  psoas  and  iliacus  muscles. 


NITRATE  OF  STRYCHNINE  IN  ALCOHOLISM.* 
By  J.  BRADFORD  MoCONNELL,  M.  D., 

PROPESSOB  OF  PATHOLOGY  AND  ASSOCIATE  PROFESSOR  OF  MEDICINE, 
UNIVERSITY  OP  BISHOP'S  COLLEGE,  MONTREAL. 

In  Merck'' s  Bulletin  for  August,  1891,  a  brief  notice  of 
Dr.  Portugalow's  experience  with  the  nitrate  of  strychnine 
in  dipsomania  is  given.  He  professed  to  have  cured  four 
hundred  and  fifty-five  cases,  and  asserts  that  he  knows  of 

*  Read  before  the  Medico-chirurgical  Society  of  Montreal,  February 
17,  1893. 


reliable  and  specific  remedies  for  two  affections  only — 
strychnine  for  the  various  forms  of  alcoholism,  and  quinine 
for  malarial  fever.  He  used  a  solution  of  six  decigrammes 
in  fifteen  grammes  of  distilled  water,  giving  a  half  to  a 
quarter  of  a  gramme  hypodermically  once  or  twice  daily, 
ten  to  sixteen  injections  completing  the  treatment.  Similar 
results  were  obtained  by  Dr.  W.  N.  Jergolski  and  others  in 
Russia,  Germany,  and  Italy. 

That  strychnine,  cocaine,  atropine,  capsicum,  cinchona, 
and  other  nerve  tonics  had  been  employed  with  advantage 
in  alcoholism  is  a  fact  generally  known,  but  that  such  bril- 
liant results  could  be  obtained  by  such  a  well-known  remedy 
as  strychnine,  properly  administered,  filled  a  gap  in  the 
therapeutics  of  a  disease  with  which  hitherto  medication 
had  mostly  been  fruitless,  and  which  could  only  be  regarded 
and  hailed  with  grateful  appreciation  by  the  general  practi- 
tioner, who  could  hitherto  do  so  little  for  this  by  no  means 
small  class  of  afilicted  humanity. 

I  have  treated  during  the  last  fifteen  months  some  thirty 
cases,  twenty-five  of  whom  received  the  full  course  of  injec- 
tions. The  results  will,  I  think,  demonstrate  what  benefit  we 
can  obtain  from  it  in  this  form  of  narcomania.  Due  atten- 
tion was  paid  in  each  case  to  the  associated  derangements 
and  the  constitutional  peculiarities.  The  patients  all  came 
to  the  office  for  treatment,  and,  although  recommended  to 
abstain  from  further  drinking,  were  allowed  to  take  liquor 
if  they  desired  it.  The  dose  given  subcutaneously  varied 
from  a  thirtieth  to  a  sixth  of  a  grain  twice  daily  for  ten 
days,  then  once  daily  for  ten  days,  the  highest  dose  being 
reached  about  the  third  or  fourth  day,  and  continued  to  the 
close  of  the  treatment,  this  being  nearly  in  accordance  with 
Spitzka's  experiments,  that  to  maintain  its  action  the  doses 
of  strychnine  must  be  in  the  beginning  increased,  and  later 
the  interval  increased  and  the  doses  lessened.  The  border 
line  of  tolerance  was  reached  in  most  cases  when  one  gramme 
was  used  of  a  soJution  containing  twelve  centigrammes  of 
strychnine  nitrate  to  fifteen  grammes  of  water — that  is, 
about  two  fifteenths  of  a  grain.  Internally,  cinchona,  perox- 
ide of  hydrogen,  and  capsicum  were  frequently  prescribed  in 
combination.  When  bromide  of  sodium  failed  to  procure 
sleep,  paraldehyde  always  succeeded.  In  the  later  cases 
strychnine  in  doses  of  one  twentieth  of  a  grain,  with  elixir 
of  phosphates  and  calisaya  together,  was  ordered  to  be  taken 
once  or  twice  daily  for  four  or  five  weeks  after  ceasing  the 
injections. 

The  following  brief  reports  of  each  case  are  condensed 
from  the  notes  taken  in  detail  during  the  progress  of  the 
treatment. 

Two  solutions  were  used — one  containing  six  centi- 
grammes to  fifteen  grammes  of  water,  and  in  the  later  cases 
one  of  double  the  strength,  equal  to  two  grains  to  the  half 
ounce.  The  weaker  solution  was  used  in  all  cases  unless 
where  the  stronger  is  mentioned. 

Case  I. — November  10,  1891.  Insurance  agent,  aged  fifty; 
has  used  alcohol  since  twelve  years  of  age  and  to  great  excess 
for  twenty  years,  and  more  or  less  continually  during  the  last 
four  years.  Marked  family  history  of  alcoholism.  Patient  is 
small  in  stature,  emaciated,  tongue  thickly  coated,  tremulous; 
has  had  very  little  sleep  for  a  week. 


June  3,  1893.J 


MvGONNELL: 


NITRATE  OF  STRYCHNINE  IN  ALCOHOLISM. 


613 


Gave  a  purgative  and  bromide  of  potassium. 
On  the  11th  bepan  the  injections,  giving  half  a  gramme  twice 
(iaily.  lie  states  that  usually  after  a  prolonged  spree,  during  the 
first  two  or  three  weeks  of  abstinence  he  suffers  from  cramps 
in  the  limbs,  and  for  four  years  has  had  night  sweats.  Had  no 
cramps  after  first  injection,  and  clainmed  to  have  no  desire  for 
liquor  after  the  first  day.  At  the  end  of  the  first  week  of  treat- 
ment he  showed  remarkable  improvement  in  every  respect ;  had 
ravenous  appetite,  slept  well,  no  depression,  and  sanguine  as  to 
the  virtue  of  the  treatment.  During  the  second  week  had  one 
injection  daily.  When  the  treatment  ceased  he  then  professed 
to  enjoy  as  good  health  as  ever  before ;  he  reported  from  time  to 
time  the  entire  freedom  from  desire  for  liquor,  and  remained  so 
for  eleven  months,  during  which  time  he  had  no  regular  work. 
Having  got  a  situation,  after  his  first  pay  he  ventured  a  glass  of 
liquor,  when  the  ardent  crave  was  rekindled  and  a  prolonged  de- 
bauch followed. 

Case  II. — Holder,  aged  fifty ;  is  a  strong,  robust  man.  No 
family  history  of  alcoholism  or  other  neurosis.  Received  a  blow 
on  the  forehead  about  thirty  years  ago,  where  a  depression  still 
exists;  began  his  drinking  habits  after  that;  has  drank  hard  dur- 
ing the  last  fifteen  months,  and  is  now  imbibing  all  he  can  pro- 
cure— sometimes  forty  glasses  of  liquor  daily. 

Had  two  injections  twice  daily  for  a  week  ;  took  no  liquor 
after  the  first  day,  and  after  second  day  claimed  to  have  no  de- 
sire for  liquor.  He  became  ill  with  la  grippe.  Having  received 
ten  injections,  I  heard  from  him  four  or  five  montlis  after,  and 
learned  that  he  had  not  up  to  that  time  partaken  further  of 
spirituous  drinks. 

Case  III. — Insurance  agent,  aged  forty-six ;  has  a  neurotic 
family  history,  there  being  cases  of  alcoholism  and  insanity. 
Has  drank  steadily  for  thirty  years.  I  requested  this  patient 
to  drink  all  he  wished  during  the  treatment.  He  was  poorly 
nourished,  not  having  the  means  to  properly  maintain  himself, 
owing  to  his  habits. 

Drank  twenty  glasses  of  ale  the  first  day  of  treatment,  the 
number  diminishing  daily  until  the  end  of  the  first  week,  when 
his  desire  ceased.  At  the  end  of  the  second  week  he  appeared 
free  from  the  drink  crave,  and  had  improved  very  much  in  his 
physical  condition.  At  the  end  of  two  months  he  again  resumed 
his  drinking  habits;  his  relapse  was  attributed  to  his  unwilling- 
ness to  give  up  his  lifelong  habit  of  ale  at  meals. 

Case  IV. — Advocate,  aged  forty ;  has  drank  inordinately 
for  about  ten  years.  No  hereditary  cause ;  attributes  the  ac- 
quirement of  the  liabit  to  the  treating  custom ;  suffers  from 
gastritis,  with  morning  vomiting  and  sleeplessness;  gave  sodium 
bromide  and  calumba  and  parvules  of  calomel,  one  twentieth  of 
a  grain  every  hour;  gave  first  injection  December  17th  ;  found 
a  tonic  effect  after  first  injection ;  no  vomiting  after  next  morn- 
ing; took  liquor  daily  until  25th;  none  after.  All  the  catarrhal 
symptoms  disappeared  after  the  first  week  of  treatment,  and  also 
the  desire  for  liquor.  Ceased  the  treatment  on  January  1st, 
patient  feeling  quite  restored;  in  a  couple  of  months  he  had  re- 
lapsed into  his  old  condition. 

December  26,  1892. — Came  to  have  another  course  of  treat- 
ment, having  confidence  in  its  power  to  relieve  him  of  his  de- 
sire for  alcohol.  The  gastric  symptoms  were  predominant; 
the  strong  solution  was  used,  beginning  with  five  decigrammes, 
and  increasing  daily  until  ten  were  reached ;  gave  two  injections 
daily  for  ten  days  and  one  daily  for  ten  days  longer.  After 
the  fourth  day  the  gastric  symptoms  were  quite  relieved  and  the 
desire  for  drink  was  gone.  Attempted  a  glass  of  wine  a  day  or 
two  after,  hut  found  it  flat  and  distasteful  while  taking  two  full 
doses  daily.  On  two  occasions  noticed  for  a  few  minutes  invol- 
untary contraction  of  upper  limbs.  Since  end  of  first  week  ap- 
petite and  digestion  have  been  good,  and  he  professes  to  feel 


better  physically  and  mentally  than  for  months.  He,  however, 
will  not  consent  to  total  abstinence  for  the  future,  which  to 
those  who  can  only  drink  immoderately  is  the  only  remedy. 

Case  V. — Printer,  aged  forty,  single,  a  drunkard  for  about 
twenty  years.  No  hereditary  predisposition.  Accustomed  to 
be  off  work  two  or  three  days  each  week.  Began  treatment 
December  30,  1891,  the  ordinary  solution;  had  no  desire  for 
alcohol  after  first  injection,  recovering  in  a  week  his  accus- 
tomed health.  On  inquiry,  I  find  he  remained  well  for  eleven 
months,  when  he  again  resumed  his  drinking  habits. 

Case  VI. — Painter,  aged  fifty,  has  drank  spirituous  liquors 
since  eighteen  years  of  age;  father  was  a  hard  drinker.  He 
can  not  sleep ;  has  no  appetite,  constipated,  tongue  coated, 
smooth  at  tip  and  edges.  Has  an  intense  crave  for  alcohol ; 
drank  a  few  hours  before  beginning  the  treatment.  Took  no 
alcohol  after  first  injection ;  was  at  a  dinner  party  four 
days  after  where  liquor  was  used,  but  bad  no  desire  for 
it  and  took  none.  After  fifteen  injections  he  was  discharged, 
much  improved  in  general  condition  and  changed  in  his  ap- 
pearance. 

Case  VII. — Corset-maker,  aged  thirty-two;  has  used  liquor 
for  fifteen  years,  and  excessively  for  ten  years;  went  on  pro- 
tracted sprees  at  irregular  intervals;  treatment  continued  from 
February  5  to  20,  1892.  Was  drinking  when  the  first  injection 
was  given.  No  desire  for  liquor  after  second  day,  and  steady 
progress  afterward  toward  his  usual  condition  of  health  in  the 
intervals  of  sobriety ;  four  months  after  again  he  resumed  the 
habit. 

Case  VIII. — Druggist,  aged  twenty-nine;  has  used  alcohol 
since  nine  years  of  age.  Had  not  taken  any  for  two  years  previous 
to  three  months  ago.  Had  made  many  attempts  to  give  up  the 
habit,  but  without  success.  No  heredity.  No  insanity  or  nerv- 
ous disease  in  the  family  ;  desire  for  liquor  left  after  second  day  ; 
states  that  he  has  not  experienced  any  of  the  symptoms  of  nerv- 
ousness and  depression  observed  at  other  times  when  breaking 
off.  At  the  end  of  the  two  weeks'  treatment  was  in  good  con- 
dition and  no  desire  for  stimulants.  Some  three  months  after 
learned  that  he  had  relapsed. 

Case  IX. — Auctioneer,  aged  forty-two;  has  drank  intoxi- 
cants for  about  thirty  years,  during  last  six  years  almost  con- 
stantly ;  was  irregular  in  his  attendance  and  got  about  twenty 
injections;  began  drinking  immediately  after. 

Case  X. — Waiter,  aged  fifty-five.  Has  used  liquor  since  he 
was  twenty  years  of  age  ;  father  drank  ;  has  abstained  at  inter- 
vals of  two,  three,  six,  and  eleven  years.  The  last  six  years' 
abstinence  ended  a  year  ago,  when,  for  some  reason,  brandy  was 
recommended  by  his  physician;  since  that  has  drank  more  or 
less  constantly.  Was  intoxicated  when  he  got  the  first  injection, 
February  15,  1892.  Much  gastric  derangement  and  sleepless- 
ness. Bromide  of  sodium  used  to  procure  sleep.  Had  no  desire 
after  the  first  day,  and  has  not  drank  any  since. 

Case  XI. — A  man,  aged  forty.  No  occupation.  Interdicted 
for  some  six  years ;  a  chronic  inebriate,  with  inherited  predis- 
position. When  first  injection  was  given  was  in  a  stupor  and 
semi- paralyzed  condition;  had  been  drinking  verv  hard  for  two 
weeks,  and  had  for  the  last  week  taken  sixty  graitis  of  sulphonal 
at  bedtime,  furnished  to  him  on  his  own  ap{)lication  by  a  drug- 
gist.   He  began  treatment  on  February  25,  1892. 

At  the  end  of  two  weeks  he  had  improved  very  much,  and 
for  a  week  had  not  asked  for  stimulants.  He  then  went  out 
for  a  drive  and,  passing  a  saloon  to  whicli  he  was  accustomed 
to  go,  could  not  resist  the  temptation  to  enter. 

He  was  then  placed  in  a  private  ward  in  hospital,  and  the 
injection  given  for  three  weeks.  After  the  fourth  day  ho  did 
not  ask  for  liquor,  and  at  the  termination  of  the  treatment  had 
quite  recovered  himself,  and  left  stating  that  he  had  no  desire 


614 


McCONNELL:  NITRATE  OF  STRYCHNINE  IN  ALCOHOLISM.  [N.  Y.  Mbd.  Joub., 


for  alcohol  and  tbat  lie  would  not  again  touch  it.  Three  days 
after  he  had  broken  his  resolution. 

Case  XII. — Gardener,  aged  thirty-tliree ;  has  taken  liquor 
since  the  age  of  fifteen  ;  father  drank.  Patient  gets  intoxicated 
every  pay  night  (Saturday),  and  would  return  to  work  on  Mon- 
day. First  injection,  February  23,  1891.  He  drank  none  after 
the  first  injection ;  had  two  weeks'  treatment,  one  injection 
daily.    He  remained  a  total  abstainer  for  five  months. 

Reported  himself  again  for  treatment  on  December  19,  1892. 
He  had  gone  on  a  visit  to  the  United  States,  and  while  in  com- 
pany was  induced  to  take  a  glass  of  beer,  and  for  the  last  four 
months  has  drank  more  or  less  constantly,  and  has  been  drunk 
daily  for  the  last  four  weeks.  Put  tartrate  of  antimony  into  his 
accustomed  liquor  and  advised  him  to  use  it  for  a  day  or  two  while 
under  the  treatment;  it  caused  considerable  nausea  and  vomit- 
ing. Used  the  stronger  solution  twice  daily  for  ten  days,  and 
once  daily  for  ten  days  longer.  Was  free  from  the  craving  after 
the  first  day.  Took  the  tonic  for  five  weeks ;  two  days  after  it 
was  finished  he  began  drinking  again. 

Case  XIII. — Widow,  aged  forty-four;  has  used  liquor  for 
twenty  years,  inordinately  for  four  years.  She  suffers  from 
chronic  gastritis ;  pains  in  the  hands  and  feet.  First  injection, 
March  1,  1893.  At  the  end  of  the  first  week,  inclination  for  her 
usual  stimulant  had  left,  and  her  gastric  symptoms  had  much 
improved.  During  the  first  week  of  treatment  she  avoided 
passing  the  saloon  which  furnished  her  with  whisky,  fearing 
that  she  would  not  have  the  courage  to  do  so  without  calling. 
After  the  first  week  she  passed  it  daily,  and  was  (juite  free  from 
desire  for  alcohol ;  remained  all  right  for  six  months. 

Case  XIV. — March  5, 1893.  Commercial  traveler,  aged  thir- 
ty-seven, single;  has  been  an  alcoholic  for  seventeen  years; 
father  drank.  Took  rye  during  the  first  three  days  of  treat- 
ment, but  states  that  its  eflect  is  different  from  what  it  usually 
is.  He  thinks  that  under  the  influence  of  the  injections  one  can 
take  larger  quantities  of  alcohol  without  its  having  the  ordinary 
eff'ects.  Increased  his  injections  to  one  twentieth  of  a  grain. 
After  the  fourth  day  he  had  no  desire  for  his  accustomed  rye. 
On  the  thirteenth  day  he  received  some  unpleasant  news,  and 
tried  to  assuage  his  feelings  with  rye,  but  it  was  not  gratifying, 
and  he  took  no  more.    He  remained  all  right  one  month  only. 

Case  XV. — March  9,  1893.  Civil  engineer,  aged  forty  two; 
has  used  liquor  for  twenty-one  years;  father  drank.  One- 
gramme  doses  were  given.  Lost  all  desire  after  the  fourth  day. 
Three  months  after  had  resumed  his  drinking  habits. 

Case  XVI. — March  27,  1893.  Butcher,  aged  twenty-six; 
an  inebriate  for  eight  years;  father  used  liquor,  but  not  to  ex- 
cess ;  a  brother  a  hard  drinker.  Gave  thirty  one-gramme  in- 
jections. Lost  the  desire  for  alcohol  after  the  fourth  day,  and 
has  remained  an  abstainer  up  to  this  date. 

Case  XVII. — March  28th.  Telegraph  operator,  aged  forty; 
a  drinker  for  twenty-five  years ;  no  hereditary  predisposition . 
sleeplessness  and  gastric  derangement.  Took  no  liquor  after 
the  first  injection.  Made  a  satisfactory  recovery.  Relapsed 
four  months  after. 

Case  XVIII. — April  5th.  Broker,  aged  forty-seven;  has 
used  liquor  for  twenty-seven  years;  latterly  is  constantly  under 
its  influence;  marked  facial  acne ;  much  gastric  distress.  Com- 
bined grain  atropine  with  the  strychnine  once  daily  until 
its  physiological  action  wiis  fully  develoj)ed.  Had  three  weeks' 
treatment.  Took  li(iuor  daily  until  the  end  of  the  first  week; 
after  that  had  no  desire  whatever.  Stated  at  his  last  injection 
that  he  did  not  wish  to  give  up  the  habit  of  using  wine  at  din- 
ner; he  was  advised  of  the  danger  of  doing  so.  Some  two 
months  after  be  was  as  bad  as  ever. 

Case  XIX. — July  U,  1892.  Commercial  traveler,  aged  forty- 
one,  single ;  no  inherited  tendencies.    Has  used  liquor  since 


eighteen  years  of  age  ;  now  goes  on  prolonged  sprees  ;  has  gas- 
tric catarrh.  Gave  internally  peroxide  of  hydrogen,  compound 
tincture  of  cinchona,  and  tincture  of  capsicum.  Used  no  liquor 
after  the  first  injection.  Gave  him  a  mixture  to  take  for  a 
month  after  his  treatment,  containing  strychnine  nitrate  in 
elixir  of  the  phosphates  with  calisaya  (Wyeth's).  On  .Janu- 
ary 12th  (six  months  aftei')  reported  having  been  a  total 
abstainer  ever  since,  although  daily  in  places  where  liquor  was 
retailed. 

Case  XX. — September  8tli.  Manager  boot  and  shoe  factory, 
aged  sixty.  Used  alcohol  first  at  twenty  years  of  age ;  at  twenty- 
seven  used  it  excessively  for  years  back,  and  has  indulged  in 
prolonged  debauches  three  or  four  times  a  year;  has  now  been 
drinking  four  weeks.  No  hereditary  tendencies ;  patient  is 
much  debilitated,  no  appetite,  and  can  not  sleep.  Paraldehyde 
gave  sleep.  No  desire  for  liquor  after  fourth  day,  when  he  re- 
turned to  his  work  and  has  remained  well  to  date. 

Case  XXI. — October  30th.  Clerk,  aged  thirty-seven;  has 
used  liquor  for  eleven  years.  No  hereditary  predisposition. 
Uses  mostly  whisky.  Sleepless;  paraldehyde  gave  sleep;  got 
thirty  injections;  no  desire  for  liquor  after  second  day.  At  the 
end  of  his  treatment  was  feeling  unusually  well.  He  has  re- 
mained at  business  and  has  not  taken  any  liquor  since. 

Case  XXII. — October  3d.  Agent,  aged  fifty-nine;  has  used 
liquor  since  a  boy,  and  up  to  thirty-five  years  of  age  could  get 
drunk  every  night  and  be  up  at  work  the  next  day.  Since  then 
has  been  a  confirmed  inebriate.  Both  parents  were  very  in- 
temperate. The  injections  within  two  days  had  improved  the 
condition  of  his  stomach  and  lessened  the  desire  for  alcohol,  but 
he  continued  his  beer  during  the  first  week — a  glass  or  two  at 
bedtime.  Two  days  before  the  treatment  was  completed  he  left 
the  city  for  two  days,  and  at  a  gathering  of  friends  indulged 
very  freely. 

Case  XXIII. — Traveler,  aged  forty,  had  a  sunstroke  in  1880; 
no  hereditary  influences.  Although  he  took  a  glass  of  ale  occa- 
sionally, it  was  not  until  after  the  sunstroke  that  he  began  to 
indulge  freely;  has  now  been  drinking  steadily  for  four  weeks; 
he  was  sleepless  and  on  the  verge  of  delirium  tremens ;  secured 
sleep  readily  with  paraldehyde  and  bromide  of  sodium;  began 
with  seven  decigrammes  of  the  stronger  solution,  increasing  it  up 
to  ten;  thirty  injections;  drank  none  after  the  first  day  and 
made  a  rapid  recovery,  resuming  work  within  a  week. 

Case  XXI V.—March  26, 1892.  Carpenter,  aged  thirty-four ; 
began  to  drink  seven  years  ago;  takes  two  to  three  days  con- 
tinuous drinking  spells  at  irregular  intervals ;  last  one  con- 
tinued a  week;  not  inherited;  sleepless  and  no  appetite.  Three 
doses  of  paraldehyde  gave  sleep.  Gave  thirty  injections,  be- 
ginning with  seven  decigrammes  of  the  strong  solution,  ten 
after  third  day.  Took  no  liquor  after  first  injection ;  went 
to  work  on  the  second  day,  and  made  a  rapid  recovery  to  his 
normal  condition.  To  take  tonics  for  one  month.  Has  re- 
mained well  to  date. 

Case  XXV.— December  8,  1892.  Broker,  aged  thirty ;  has 
used  alcohol  for  about  eight  years,  excessively  for  six  years;  no 
heredity ;  much  gastric  derangement.  Gave  a  purgative  of 
powdered  rhubarb  and  calomel.  Bromide  of  sodium,  peroxide 
of  hydrogen,  tincture  of  calumba,  and  capsicum  internally.  Re- 
quired paraldehyde  to  get  sleep.  Blood  examined.  There  were 
4,400,000  red  corpuscles  to  the  cubic  millimetre ;  about  seven 
tenths  of  them  were  shrunken  and  very  irregular  in  shape,  with 
jagged  edges,  some  of  the  projections  acute,  others  truncated. 
No  craving  for  alcohol  after  the  third  day  of  treatment.  Thirty 
injections — all  ten  decigrammes — after  third  day.  Although 
mingling  with  his  old  associates  daily  in  places  where  liquor 
was  sold,  felt  no  desire  whatever  for  it;  appetite  was  good,  and 
he  appeared  fully  restored  to  his  usual  health. 


June  3,  1893.] 


McCONNELL:  NITRATE  OF  STRYGnNINE  IN  ALCOHOLISM. 


615 


From  the  results  obtained  in  these  twenty-five  cases  we 
can  learn  that,  simultaneously  with  the  use  of  this  remedy, 
the  crave  for  alcohol  in  inebriates  diminishes  and  in  a  few 
days  is  completely  gone,  and  through  the  withdrawal  of 
the  poisonous  beverages  and  the  tonic  effects  of  the  strych- 
nine there  is  a  more  or  less  rapid  restoration  to  sound 
physical  health  and  of  the  mental  powers ;  but  as  most  of 
those  treated  have  relapsed  within  from  one  to  eleven 
months,  the  inhibiting  power  of  the  remedy  is  not  perma- 
nent, and  while  it  temporarily  relieves  the  distressing  and 
overwhelming  crave  for  more  stimulant  and  promotes  a  re- 
turn to  normal  health,  and  in  which  condition  the  patients 
may  continue  to  remain,  yet  they  still  lack  the  necessary 
will  power  to  enable  them  to  avoid  the  dangers  which  they 
know  will  precipitate  a  return  to  their  previous  enslaved  and 
degraded  condition.  So  that,  while  it  is  fully  within  the 
power  of  medical  science  to  restore  these  patients  to  tempo- 
rary health,  strychnine  does  not — as  doubtless  no  drug  treat- 
ment ever  will — prevent  the  possibility  of  further  relapses, 
although  we  can  always  depend  on  it  to  arrest  what  would 
be  a  prolonged  debauch  if  its  aid  is  early  resorted  to.  That 
weakened  will  power  is  a  result  of  the  prolonged  use  of  al- 
cohol is  generally  conceded,  as  is  the  fact  that  the  tendency 
to  alcoholism  is  in  a  large  percentage  of  cases  inherited, 
and  it  is  often,  as  dipsomania,  one  of  the  manifestations  of 
insanity ;  that  a  definite  series  of  pathological  conditions 
follows  the  continued  indulgence  in  alcohol,  differing  only 
in  degree  in  the  case  of  the  milder  methyl  to  the  powerful 
effects  of  amyl  alcohol,  the  nervous  system  showing  the 
earliest  and  most  marked  disturbance,  although  every  organ 
and  tissue  in  the  body  eventually  suffers.  These  and  many 
other  facts  have  led  neurologists  to  place  alcoholism  as  a 
distinct  disease  among  the  neuroses. 

This  position  implies  a  complete  revolution  in  the  meth- 
ods of  treating  these  cases,  and  has  brought  to  the  aid  of 
philanthropists  and  moralists  the  assistance  of  the  medical 
profession,  upon  whom  now  devolves  the  duty  of  further 
elucidating  the  true  pathology  of  the  disease  and  indicating 
the  best  means  of  restoring  this  numerous  class  of  patients 
to  a  normal  condition. 

That  the  urgent  demand  for  relief  from  the  evils  of  in- 
temperance is  being  recognized  by  the  profession  is  evidenced 
by  the  increased  interest  taken  in  the  work  of  the  American 
Association  for  the  Study  and  Cure  of  Inebriety,  and  in  the 
Section  for  the  Study  of  Inebriety  of  the  British  Medical 
Association,  and  by  an  ever- increasing  number  of  scientific 
investigators  throughout  the  world. 

Before  rational  and  effective  measures  can  be  adopted 
for  the  proper  management  of  inebriety,  we  must  have  cor- 
rect opinions  in  regard  to  the  physiological  actions  of  alco- 
hol and  the  pathology  of  the  disease ;  otherwise  we  must 
trust  to  the  empirical  results  of  experience. 

The  decomposition  of  alcohol  which  takes  place  in  the 
economy  is  not  yet  known.  It  has  been  generally  accepted 
that  from  one  to  two  ounces  can  be  oxidized  in  the  system, 
giving  heat  and  force  to  the  extent  of  the  oxygen  used,  but 
the  tissue  changes  are  lessened,  as  evidenced  by  the  dimin- 
ished excretion  of  urea  and  COg  and  to  the  degree  that  they 
have  been  robbed  of  oxygen  by  the  systemic  digestion  of  the 


alcohol.  From  this  fact  has  sprung  the  idea  that  it  conserves 
the  energies  and  lessens  waste,  and  on  this  assumption  it  is 
frequently  prescribed  as  a  sustaining  remedy ;  but  a  view 
which  would  appear  to  be  nearer  the  truth  of  the  matter  is 
that  which  denies  that  alcohol  is  a  food  in  any  sense,  but 
being  a  ptomaine,  a  result  of  decomposition,  it  is,  like  these, 
generally  a  poison  in  all  its  actions ;  that  it  is  not  oxidized 
in  the  system,  but  that  it  combines  with  the  haemoglobin 
and  destroys  its  functions  of  absorbing  O,  the  diminished 
urea  and  COj  being  in  this  way  accounted  for.  Other  ob- 
servers have  demonstrated  that  the  leucocytes  have  their 
vitality  lessened  by  the  continued  use  of  alcohol,  and,  in 
harmony  with  our  recent  views  on  phagocytosis,  this  fact 
would  explain  the  greater  susceptibility  of  drunkards  to  the 
action  of  pathogenic  bacteria  and  their  lessened  resisting 
power  in  throwing  off  disease,  although  Mortimer  Granville 
maintains  an  opposite  view  on  this  point,  and  alleges  for  al- 
cohol-drinkers a  greater  immunity  than  for  abstainers.  That 
the  red  corpuscles  are  profoundly  altered  was  observed  in  the 
last  case  I  reported — the  only  one  in  which  the  blood  was 
examined.  We  have  here  the  evidence  of  a  veritable  poiki- 
locytosis  in  a  subject  where  neither  aglobulism  nor  achroma- 
tosis  existed.  Most  of  the  effects  of  alcohol  are  apparently 
explained  by  its  paralyzing  effect  on  the  vaso-motor  system 
from  the  first  contact.  We  have  also  the  slight  stimulating 
effects  on  the  heart  of  small  doses,  and  its  local  and  reflex 
irritant  action  on  the  alimentary  tract,  which  results  in  in- 
creased buccal  and  gastric  excretion,  thus  favoring  digestion  ; 
but  even  this  advantage  is  not  upheld  by  the  recent  experi- 
ments of  Blumenau,  who  found  that  the  total  action  was 
impairment  of  digestion ;  and  when  we  take  the  fact  that 
even  the  stimulating  effects  are  quickly  changed  into  para- 
lytic conditions,  and,  where  often  repeated,  leading  to  exhaus- 
tion of  every  function  and  more  or  less  degenerative  changes 
throughout  the  body,  we  can  readily  understand  how  we 
are  to  get  beneficial  effects  from  drugs  having*the  action  of 
strychnine. 

The  chief  action  of  alcohol,  then,  is  to  paralyze  the  vaso- 
motor system,  dilating  the  arterioles.  Strychnine,  besides 
exalting  the  excitability  of  the  spinal  cord  and  probably  the 
motor  centers  in  the  brain,  stimulates  the  vaso-motor  cen- 
ters, contracting  the  arterioles,  as  well  as  being  one  of  the 
most  efficient  heart  tonics  through  its  stimulating  effects  on 
the  cardiac  ganglia. 

While  we  have  in  strychnine  a  true  antagonist  to  the 
action  of  alcohol  and  one  that  will  counteract  its  effects,  the 
inebriate  still  requires  aid  which  can  scarcely  be  expected 
of  drugs  ;  he  needs  the  mental  and  will  power  to  overcome 
his  acquired  or  inherited  tendency  to  resort  to  narcotics. 
This  nmst  come  from  treatment  which  seeks  first  to  restore 
all  the  abnormal  conditions  of  the  patient ;  whether  due 
to  alcohol  or  otherwise,  then  strict  abstinence  must  be 
maintained,  the  patient  being  aided  by  moral  suasion,  the 
diversion  of  continual  employment,  and  the  education  of 
the  mental  and  moral  faculties  to  a  higher  status  ;  even  the 
influence  of  hypnotic  suggestion  may  be  applied  in  suitable 
cases,  as  has  been  done  recently  with  a  fair  measure  of 
success ;  and  where  these  means  fail,  then  institutions 
where  voluntary  or  forced  detention  can  be  secured,  and 


616 


CUTLER: 


ALOPECIA. 


[N.  Y.  Mkd.  Jolb., 


where  all  the  present  known  means  can  be  most  success- 
fully applied,  must  be  the  only  hope  of  restoring  the  un- 
fortunate subjects  of  narcomania. 


ALOPECIA.^ 
By  CONDICT  .W.  CUTLER,  M.  D., 

NBW  TOKK. 

This  subject  is  interesting  to  us  all,  but  evidently  to 
some  more  than  others  for  personal  reasons.  Although 
baldness  is  much  more  common  in  the  male  sex,  it  is  none 
the  less  noticeable,  for  women's  heads  are  usually  covered, 
and  so  do  not  attract  attention. 

Since  that  terrible  punishment  received  by  the  children 
who  gave  Elisha  the  unasked-for  advice  to  "go  up,  thou 
bald-head,"  we  have  been  accustomed  to  look  upon  bald 
heads  with  reverence,  and  as  a  sign  of  old  age  and  natural 
decay ;  but  now  times  have  changed,  and  even  ballet 
dancers  are  apt  to  look  down  upon  them.  Alopecia  is  seen 
so  frequently  in  comparatively  young  persons  that  it  may 
be  considered  as  a  disease  when  occurring  in  those  under 
forty  years  of  age.  That  a  bald  head  is  not  a  desirable 
possession  is  evidenced  by  the  enormous  sale  of  nostrums 
warranted  to  restore  the  natural  covering  to  the  scalp. 

To  every  hair  is  given  a  length  of  life  varying  from 
four  months  to  four  years,  and  it  is  estimated  that  the  daily 
average  loss  of  hairs  from  a  healthy  scalp  varies  from  thir- 
teen to  two  hundred.  In  the  natural  condition  of  the  scalp 
every  hair  which  dies  is  replaced  by  another,  which  usually 
grows  from  the  same  papilla,  but  sometimes  from  a  new 
papilla  developed  by  the  side  of  the  old  one.  If  this 
growth  of  hair  did  not  take  place  every  one  would  be  bald 
within  four  years. 

These  new  hairs  should  be  of  the  same  size  as  the  old 
ones,  and  have  the  same  length  of  life.  The  thicker  the  hair 
the  longer  its  life  ;  so,  if  the  new  hairs  which  make  their  ap- 
pearance are  smaller  in  caliber  than  the  old  ones,  it  is  a 
pretty  sure  indication  of  approaching  baldness. 

The  term  alopecia  is  a  very  general  one,  and  should  be 
used  to  describe  a  symptom  rather  than  a  disease.  Just  as 
we  use  the  term  headache  to  designate  the  symptom  of  a 
disease,  so  should  we  speak  of  alopecia  as  a  symptom  pres- 
ent in  certain  aifections  of  the  scalp.  You  can  no  more 
cure  the  diseased  condition  of  the  scalp  by  simply  treating 
the  symptom  alopecia  than  you  can  cure  pneumonia  or  ty- 
phoid fever  by  remedies  used  to  lessen  the  headache. 

There  are  so  many  varieties  of  alopecia — each  variety 
depending  upon  different  causes,  with  different  symptoms, 
and  demanding  different  treatment — that  I  shall  only  call 
attention  to  the  most  important  disease  of  the  scalp  which 
is  accompanied  by  baldness — namely,  seborrhoea.  To  per- 
fectly understand  how  a  seborrha-a  of  the  scalp  will  result 
in  alopecia  it  will  be  necessary  for  me  to  call  attention  to 
the  very  close  anatomical  and  physiological  relation  between 
the  hair  follicles  and  the  sebaceous  glands. 

Each  hair  follicle  may  be  considered  as  a  prolongation 
downward  of  the  epithelial  layer  of  the  skin  into  the 

*  II  Kings,  ii,  23,  24. 


corium,  which  is  its  deepest  layer.  In  the  bottom  of  the 
sac  thus  formed  the  fibrous  elements  of  the  corium  rise  and 
form  a  papilla,  which  is  called  the  hair  bulb,  and  from 
which  the  hair  is  supposed  to  take  its  growth.  On  either 
side  of  each  hair  follicle  thus  formed  is  situated  a  seba- 
ceous gland  with  its  duct  opening  directly  into  the  follicle, 
so  that  the  secretion  from  such  glands  finds  its  way  to  the 
surface  of  the  skin  through  the  mouth  of  the  hair  follicle. 
The  secretion  from  these  glands  supplies  pabulum  to  the 
growing  hairs,  thereby  nourishing  them  ;  so  you  can  readily 
understand,  from  these  close  relations  existing  between  the 
hair  follicles  and  the  sebaceous  glands,  that  any  disease,  or 
even  disturbance  of  function  of  these  glands,  must  neces- 
sarily, if  long  continued,  affect  the  growth  and  condition  of 
the  hairs. 

There  are  several  forms  of  seborrhoea  which  may  result 
or  terminate  in  alopecia,  but  there  is  one  variety  which, 
from  its  great  frequency  of  occurrence,  its  insidious  man- 
ner of  approach,  the  apparent  insignificance  of  its  early 
symptoms,  and  its  certainty  of  termination  in  permanent 
baldness  if  not  properly  managed,  is  a  disease  of  much  im- 
portance, and  the  only  one  which  I  shall  now  speak  of. 
This  disease  which  I  refer  to  is  termed  alopecia  furfuracea, 
or  eczema  seborrhoicum  of  the  scalp,  also  sometimes  called 
alopecia  pityrodes,  or  dandruff. 

The  disease  always  begins  in  the  sebaceous  glands  as  a 
fatty  metamorphosis  of  the  glandular  cells.  This  degen- 
eration extends  into  the  hair  follicles,  which  eventually  re- 
sults in  an  atrophy  of  the  hair  bulb  and  a  permanent  loss 
of  hair.  Of  late  the  opinion  is  gaining  ground  that  alo- 
pecia furfuracea  is  a  contagious  disease,  and  the  experi- 
ments of  Lassar  and  Bishop  would  seem  to  prove  this. 

They  have  succeeded  in  producing  typical  attacks  of 
this  disease  in  guinea-pigs  by  rubbing  into  their  backs  a 
pomade  composed  of  the  scales  taken  from  the  head  of  a 
student  suffering  from  dandruff.  A  number  of  observers 
have  found  micro-organisms  present  in  the  scales  produced 
in  alopecia  furfuracea,  but  it  is  not  absolutely  demonstrated 
that  these  parasites  are  the  direct  cause  of  the  disease. 

The  disease  usually  begins  between  the  ages  of  fifteen 
and  twenty-five  years,  and  the  first  symptom  noticed  is 
dandruff.  In  the  beginning  this  desquamation  of  fine, 
branny  scales  from  the  scalp  is  so  slight  as  to  pass  un- 
noticed, but  after  a  time  they  become  so  abundant  as  to 
fill  the  hair  and  fall  over  the  clothing.  All  parts  of  the 
scalp  are  not  equally  affected,  the  disease  appearing  most 
markedly  about  the  edges  of  the  hair  and  on  the  vertex  of 
the  head,  sparing  the  occiput  and  sides.  Accompanying 
this  desquamation  there  are  few  if  any  subjective  sensa- 
tions attracting  the  patient's  attention  to  the  diseased  con- 
dition of  the  scalp,  a  pruritus  or  itching  of  greater  or  less 
severity  being  the  only  symptom  present.  Sooner  or  later, 
however,  the  patient  will  notice  a  constantly  increasing 
number  of  hairs  combing  out,  and  that  loose  hairs  will  be 
found  on  his  clothing  during  the  day  and  on  the  pillow  in 
the  morning.  At  first  there  does  not  seem  to  be  any  thin- 
ning of  the  hair,  as  each  hair  is  reproduced ;  but  it  will  be 
noticed,  if  a  careful  examination  is  made,  that  the  new 
hairs  are  smaller  in  caliber,  which  is  a  pretty  sure  sign  that 


Jnne  3,  1893.] 


CUTLER: 


ALOPECIA. 


617 


an  atrophy  is  already  taking  place  in  the  hair  papillae. 
About  a  year  or  more  after  the  disease  is  first  noticed  a 
marked  thinning  of  the  hair  will  be  found,  usually  begin- 
ning in  two  spots — one  just  back  of  the  anterior  border  of 
the  scalp,  and  the  other  near  the  vertex.  This  is  the  begin- 
ning of  the  end.  Unless  proper  treatment  is  begun  at 
once,  "  Good-by,  fond  hopes  of  future  greatness,"  for  there 
will  soon  be  left  no  "  hair  (heir)  to  the  crown." 

Now,  a  few  words  regarding  the  treatment  of  this  affec- 
tion :  As  the  skin  is  in  an  apparently  healthy  condition 
under  the  scales,  it  seems  a  very  easy  matter  to  remove 
these  scales  with  soap  and  water,  or  with  oil ;  but,  unfor- 
tunately, the  removal  of  the  scales  in  no  way  removes  the 
disease,  as  they  will  form  again  in  even  greater  abundance 
in  a  few  days,  sometimes  in  a  few  hours  after  they  are  re- 
moved. The  remedies  which  are  recommended  and  ad- 
vertised for  the  cure  of  this  affection  are  only  exceeded  in 
number  by  those  given  for  the  relief  of  the  vomiting  in 
pregnancy.  The  question  then  arises.  Which  of  these  reme- 
dies are  we  to  use,  and  how  are  they  to  be  applied  ? 

When  Elisha  had  his  attention  drawn  to  his  bald  head 
he  immediately  looked  around  for  some  means  of  relief. 
He  found  that  bears  afforded  a  remedy  which  was  wonder- 
fully and  rapidly  effectual,  for  we  do  not  hear  of  any  fur- 
ther reference  made  to  his  bald  head. 

Since  then  "  bear's  grease  "  has  been  one  of  the  many 
remedies  applied  to  the  scalp  for  the  cure  of  alopecia.  It 
acts  well,  especially  with  children,  to  prevent  baldness. 
Some  dermatologists  maintain  that,  as  the  original  prescrip- 
tion called  for  only  the  she  bears,  this  preparation  should  be 
made  from  the  female  animal ;  the  importance  of  this,  how- 
ever, I  think,  is  doubtful.  Of  late  years  we  have  found 
other  agents  acting  to  better  advantage.  The  scientific 
treatment  of  the  disease  differs  somewhat  according  to  the 
extent  to  which  it  has  progressed.  If  we  see  the  disease  in 
its  early  stages,  when  the  only  symptom  is  dandruff  and 
when  the  loss  of  hair  is  very  little  if  any,  we  can  do  a  great 
deal  in  the  way  of  prophylactic  treatment. 

In  the  first  place,  the  constant  application  of  water  to 
the  scalp  is  bad.  It  undoubtedly  tends  to  produce  dan- 
druff, and  if  the  disease  already  exists,  it  always  aggravates 
it.  The  same  is  true  of  irritating  applications  to  the  scalp, 
such  as  tincture  of  cantharides,  capsicum,  and  all  strong 
alcoholic  preparations,  for  they  not  only  tend  to  set  up  an 
inflammatory  condition,  but,  by  dissolving  the  natural  oil 
of  the  skin,  produce  a  dryness  of  the  scalp  which  in  the 
end  does  more  harm  than  good — in  fact,  may  be  the  direct 
cause  of  the  disease. 

The  hair  should  be  shampooed  once  in  ten  days  to  two 
weeks  with  the  yolks  of  three  eggs  beaten  up  with  lime 
water.  After  thoroughly  rubbing  this  into  the  scalp,  it 
should  be  washed  out  with  a  solution  of  borax  in  hot  water, 
the  hair  thoroughly  dried,  and  the  following  ointment  rubbed 
into  the  scalp  and  allowed  to  remain  over  night : 

I^  Pilocarpin.  hydrochlor   3  ss. ; 

Vaseline   3  v ; 

Lanolin   ^  ij ; 

01.  lavanduhe   gtt.  xv.  M. 

In  the  morning,  after  the  hair  is  thoroughly  rubbed  dry, 


its  greasy  condition  will  not  be  noticed.  Moistening  the 
hair  every  day  with  water  will  do  no  harm,  if  necessary  to 
keep  the  hair  smooth,  but  daily  sousing  of  the  hai*r  should 
be  prohibited.  Deep  brushing  of  the  hair  every  day  with 
a  long-bristled  brush,  stiff  enough  to  warm  but  not  scratch 
the  scalp,  is  stimulant  enough  for  a  healthy  scalp. 

If  we  do  not  see  the  patient  until  the  hair  has  already 
begun  to  fall  out  to  a  considerable  extent,  a  different  plan  of 
treatment  is  to  be  recommended.  Once  in  every  five  days 
to  a  week  the  patient  should  take  a  shampoo,  using  the 
tincture  of  green  soap  to  form  a  lather.  After  thoroughly 
drying  the  hair,  a  pomade  such  as  just  recommended  is  to 
be  rubbed  thoroughly  into  the  scalp  and  allowed  to  remain 
over  night.  In  the  morning  this  should  be  washed  out 
with  the  tar  soap,  and  the  following  lotion  rubbed  in  : 

I^  Hydrarg.  chlor.  corros   gr.  iv  ; 

Resorcin   3  j ; 

Aquae  destil   3  iv.  M. 

This  lotion  is  to  be  applied  night  and  morning,  rubbing 
it  well  in  about  the  roots  of  the  hair  with  a  small  sponge. 

Usually  in  three  or  four  weeks  a  marked  improvement 
will  be  noticed  by  the  absence  of  dandruff  and  the  hair  no 
longer  falling  out.  As  the  improvement  continues  the 
treatment  may  be  less  vigorous.  The  shampoo  may  now 
be  used  once  in  ten  days  or  two  weeks,  and  the  lotion  ap- 
plied only  at  night ;  but  treatment  should  be  continued  for 
at  least  six  months.  Relapses  are  very  common,  and  espe- 
cially so  if  all  treatment  is  discontinued  too  early.  After 
the  hair  has  stopped  falling  out,  you  may  find  that  the  new 
hairs  which  replace  those  that  were  lost  are  weak  and  need 
stimulation. 

There  is  but  one  drug  taken  internally  which  seems  to 
possess  the  power  of  stimulating  the  growth  of  the  hair, 
and  that  is  pilocarpin.  It  must,  however,  be  taken  in 
quite  large  doses  to  have  an  effect,  and  even  then  it  is  often 
disappointing.  In  some  cases  better  results  are  obtained 
by  giving  it  by  hypodermic  injections. 

Externally  there  are  many  irritant  applications  to  the 
scalp  which  are  recommended  to  stimulate  the  growth  of 
the  hair.  If  these  applications  are  used  while  the  sebor- 
rhcea  is  still  present,  only  harm  can  come  by  irritating  a 
scalp  which  is  already  inflamed ;  but  if  the  disease  is  first 
cured,  then  such  applications  may  be  used  with  advantage. 
The  following  is  the  one  I  usually  recommend  to  stimulate 
the  growth  of  the  lanugo  hairs  after  all  traces  of  the  scbor- 
rhcea  have  dispppeared : 

I^  Tinct.  cantharidis,  "1 

Tinct.  capsici,  ^        '   aa  3  ss. ; 

Tinct.  nuc.  vomicae,  f 

01.  ricini,  J 

Aquae  coloniensis,  or  bay  rum  ad  3  iv.  M. 

This  lotion  may  be  rubbed  into  the  scalp  every  night 
for  several  weeks,  and  then  contiimed  less  frequently  for 
several  weeks  longer. 

In  the  third  stage  of  the  disease,  when  baldness  has 
fairly  won  the  crown,  do  not  despair.  Your  work  is  not 
yet  done.  You  may  somewhat  dim  its  shining  glory  by 
still  one  more  prescription — for  a  wig. 

260  Wkst  Fifty-skvknth  Stkkkt. 


618 


LEADING 


ARTICLES. 


[N.  Y.  Med.  Jodr., 


THB 

NEW  YORK  MEDICAL  JOURNAL, 

*       A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

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


NEW  YORK,  SATURDAY,  JUNE  3,  1893. 


THIOCAMF. 

This  name  was  given  by  Professor  Emerson  Reynolds  to  a 
liquid  devised  by  him  as  a  disinfectant  and  described  in  a  paper 
read  by  him  at  a  meeting  of  the  Royal  Dublin  Society  four 
years  ago.  It  is  made  by  bringing  sulphur-dioxide  gas  into 
contact  with  camphor  and  dissolving  in  the  resulting  liquid 
various  antiseptics,  among  them  phellandrene  and  benzoic  acid. 
This  liquid  can  be  kept  in  bottles  without  pressure,  but  on  ex- 
posing it  to  the  air  in  a  thin  layer  it  gives  off  "  relatively  enor- 
mous volumes"  of  sulphur-dioxide  gas.  Reflecting  upon  this 
property  possessed  by  the  liquid,  Dr.  George  F.  DufFey  con- 
ceived the  idea  of  using  it  as  an  intestinal  antiseptic.  He  gives 
an  account  of  his  use  of  thiocamf  as  a  remedy  in  the  May  num- 
ber of  the  Dublin  Journal  of  Medical  Science. 

The  choice  of  a  vehicle  for  the  internal  administration  of 
the  compound  was  restricted  to  fatty  matter  and  alcohol.  At 
Professor  Reynolds's  suggestion,  pure  butter,  freed  from  water 
and  salts,  was  employed  as  an  excipient,  and  that  gentleman 
made  a  preparation,  containing  ten  per  cent,  of  thiocamf,  which 
was  put  into  gelatin  capsules,  about  ten  grains  of  the  mixture 
into  each  capsule.  It  is  said  tliat  in  making  the  mixture  care 
has  to  be  taken  to  melt  the  fat  at  as  low  a  temperature  as  pos- 
sible, as  otherwise  it  would  give  off  its  sulphur  dioxide.  Dr. 
Duffey  took  one  of  these  capsules,  and  in  fifteen  minutes  he 
had  an  eructation  that  gave  rise  to  a  decided  taste  of  sulphur 
dioxide.  "This,"  the  author  says,  "was  repeated  in  five 
minutes,  and  again  at  three  intervals  of  fifteen  minutes  each. 
No  other  effect  was  perceived."  The  drug  was  then  adminis- 
tered to  a  woman  who  was  in  the  fourth  week  of  a  severe  at- 
tack of  typhoid  fever.  She  had  vomiting,  meteorism,  and 
much  abdominal  pain.  On  the  first  day  three  capsules  were 
given,  at  intervals  of  three  hours,  and  on  the  next  day  four,  at 
the  same  intervals.  She  suffered  a  good  deal  from  eructations 
after  taking  them,  but  was  otherwise  [somewhat  better.  The 
stools  were  found  to  be  much  less  offensive  than  they  had  been. 
Afterward  keratin-coated  capsules  were  used,  and  eructations 
did  not  follow.  In  another  case,  that  of  a  consumptive  who 
was  troubled  with  attacks  of  pyrosis  coming  on  two  or  three 
times  a  day  and  at  night,  four  uncoated  capsules  were  given, 
one  every  second  hour.  Two  days  afterward  the  man  reported 
that  he  had  vomited  only  once  since  he  had  begun  taking  the 
capsules,  and  that  he  had  then  no  pain  in  the  stomach,  but  had 
had  before  using  them.  In  a  case  of  dilatation  of  the  stomach 
the  capsules  gave  temporary  relief.  In  a  case  of  foetid  alvine 
evacuations,  their  odor  was  removed  by  the  administration  of 
the  keratin- coated  capsules.  At  the  time  of  writing  his  arti- 
cle the  author  was  using  j)repared  lard  as  an  excipient,  and 


he  suggests  that  cacao  butter  also  would  be  a  suitable  vehicle. 
He  proposes  that  the  remedy  be  tried  in  cholera,  typhoid  fever, 
pernicious  anaamia,  pyrosis,  various  forms  of  dyspepsia,  and 
flatulent  distention  of  the  bowels. 

As  regards  the  external  use  of  thiocamf.  Dr.  Dnffey's  expe- 
rience includes  two  cases  of  scabies.  One  was  very  severe  and 
complicated  with  extensive  eczema.  A  four-per-cent.  solution 
of  the  drug  in  olive  oil  was  applied,  and  the  patient  was  cured 
in  fourteen  days.  In  the  other  case,  in  which  there  was  but 
little  eczema,  a  cure  was  effected  in  five  days.  From  the  effects 
of  the  pharmacopceial  solution  of  sulphurous  acid  in  parasitic 
skin  diseases  he  thinks  that  an  oily  solution  of  thiocamf  would 
probably  be  of  use  in  pityriasis  versicolor,  favus,  and  other 
dermatophytic  affections.  In  the  case  of  a  paralyzed  woman 
who  had  a  large  bedsore  of  the  sacral  and  gluteal  regions,  gan- 
grenous and  emitting  a  most  offensive  odor,  applications  of  an 
oily  solution — four-per-cent.  at  first,  then  six-per-cent. — 
"quickly  removed  the  fcetor,  diminished  the  discharge,  and 
caused  the  sore,  after  the  removal  of  the  slough,  to  assume  a 
clean,  healthy  appearance."  A  fpur-per-cent.  solution  came  to 
be  largely  used  in  the  out-patient  service  of  the  City  of  Dublin 
Hospital,  in  which  institution  Dr.  Dnffey's  trials  of  thiocamf 
were  made,  for  dressing  ulcers  and  wounds,  and  was  found 
very  efficient  in  keeping  the  parts  free  from  fcetor  and  in  check- 
ing the  discharge.  The  application  of  such  a  solution  to  a  raw 
surface  causes  a  slight  and  evanescent  sensation  of  heat  and 
prickling;  if  a  stimulating  effect  is  required,  the  strength  of  the 
solution  may  be  increased. 

The  rest  of  Dr.  Dnffey's  communication  relates  to  the  use 
of  thiocamf  as  a  disinfectant  of  rooms,  dejecta,  clothing,  the 
hands,  etc.,  and  reference  is  made  to  Dr.  J.  W.  Moore's  descrip- 
tion of  the  method  of  disinfecting  a  room  by  means  of  thio- 
camf, in  his  Text-hook  of  the  Eruptive  and  Continued  Fevers 
(Dublin :  Fannin  &  Co.,  1892),  also  to  a  pamphlet  issued  by 
Messrs.  Thomas  Tyrer  &  Co.,  a  London  firm  of  manufacturers 
of  chemicals,  which  includes  a  reprint  of  Professor  Reynolds's 
paper. 


SYMPHYSEOTOMY  OR  SYMPHYSIOTOMY? 

In  its  last  issue  the  Medical  Record  repeats  its  affirmation 
that  symphyseotomy  is  the  only  correct  spelling  of  the  word. 
In  the  Journal  for  May  13th  we  had  said :  "  While  we  are  not 
ready  to  say  that  symphyseotomy  is  not  the  preferable  form  of 
the  word,  we  can  not  admit  the  cogency  of  the  Record^  argu- 
ment, for  the  epsilon  is  simply  a  part  of  the  genitive  termina- 
tion and  not  a  part  of  the  stem.  Such  Greek  words  in  -tr  take 
-IV  in  the  accusative,  for  example;  moreover,  (Tv\i,^vcni  is  only 
a  compound  of  (f)vais,  and  must  be  as  free  as  that  word  in  the 
formation  of  further  compounds;  and,  with  such  classical  com- 
pounds of  ({)v(ris  before  us  as  (ftva-LoXoyla  (and  none  that  we  can 
find  in  -fo-  [misprinted  -eo--]),  we  are  unable  to  see  that  sym- 
physiotomy  is  inadmissible."  This  was  our  comment  on  the 
following  statement,  made  in  the  Record  for  May  6th :  "  The 
word  is  derived  from  two  Greek  words,  avfi^uo-ir,  a  union  or 
growing  together,  here  specifically  tlie  symphysis  pubis,  and 


June  3.  1»93.J 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


619 


TOfi^,  a  division  or  cutting.  As  it  means  division  of  the  sym- 
physis, tlie  latter  word  is  used  in  the  genitive  case,  the  torm 
for  which  is  crvfi^va-fun.  There  is  no  iota  in  this  form  of  the 
M  ord,  and  tlioru  is  no  i  in  the  EngHsh  word  derived  from  it." 
In  its  last  number  the  Record  continues  its  argument  as  follows: 
"  It  is  indisputably  true  that  <TVfi(f>v<Tis  is  only  a  compound  of 
({)v(ns,  but  it  by  no  means  follows  that  its  further  compounds 
must  be  formed  after  the  model  of  the  Ionic  (pvaioXoyla.  This 
compound  was  made  at  an  early  period,  before  the  Attic  dia- 
lect had  given  its  stamp  to  the  Greek  language  and  when  most 
writers,  if  writers  there  were  at  that  time,  employed  the  Ionic 
forms.  Now  the  Ionic  genitive  of  (j>v(ris  was  (jyvaios,  and  the 
stem  retained  the  iota  in  all  the  oblique  cases,  so  naturally 
enough  such  words  as  (pvaioXoyia  and  (pvaioKoyos  were  formed 
with  an  iota  and  not  witli  an  epsilon.  Hut  in  classical  Greek, 
we  need  hardly  remind  our  scholarly  contemporary,  stems  in 
iota,  in  words  of  this  class,  always  chynge  the  iota  into  epsilon 
in  the  oblique  cases,  consequently  epsilon  becomes  a  part  of 
the  stem  and  is  not  simply,  as  the  Journal  incorrectly  says,  a 
part  of  the  genitive  termination.  Had  'physiology'  therefore 
been  coined  in  modern  times  it  would  undoubtedly  have  been 
spelled  with  an  e  instead  of  an  i,  for  we  do  not  now  go  back  to 
Ionic  forms  in  the  construction  of  Greek  neologisms." 

Before  proceeding  to  further  argument,  we  will  admit  that 
we  ought  to  have  been  more  precise  in  one  of  our  statements. 
When  we  said  that  the  epsilon  was  a  part  of  the  genitive  ter- 
mination we  did  not  mean  that  it  was  a  part  of  the  character- 
istic case-ending ;  as  a  matter  of  fact,  in  the  genitive  form  of 
the  word,  it  is  a  substitute  for  the  iota  of  Ihe  stem.  But  really, 
from  the  Record's  point  of  view,  the  form  of  our  statement 
should  have  seemed  to  it  immaterial,  it  appears  to  us,  for  the 
point  of  its  contention  is  embraced  in  the  mistaken  idea  "As  it 
means  division  of  the  symphysis,  the  latter  word  is  used  in  the 
genitive  case."  So  it  would  be  if  the  two  words  were  written 
separately,  avfj.(f)vaecos  TOfu),  but,  when  a  compound  is  to  be 
made,  the  genitive  form  is  not  retained,  but  only  the  stem, 
with  or  without  a  connective.  On  page  335  of  volume  i  of 
Jelf's  Grammar  of  the  GreeJc  Language,  chiefly  from  the  Ger- 
man of  Raphael  Kuhner  (second  edition,  Oxford,  1851),  in  re- 
marks on  the  formation  of  compounds,  we  find  the  following: 
"In  words  in  is  (gen.  ea>s,  Ion.  toy)  and  vs  (gen.  vos)  the  second 
word  is  annexed  to  the  simple  root  (discoverable  from  tlie 
genitive)  by  the  insertion  of  the  conjunctive  o,  as  <f>v(Tio-\(ryosC 
etc.  It  is  not  a  question  of  dialect ;  modern  compounds  of 
(f)v(Tii  are  regularly  formed  in  physi-.  Numerous  examples  may 
be  found  in  the  Century  Dictionary,  but  not  one  in  physe-. 
The  same  may  be  said  of  compounds  of  many  other  Greek 
nouns  ending  in  sigma.  Indeed,  so  exceptional  is  the  survival 
of  the  epsilon  of  the  genitive  termination  -eus  in  analogous 
compounds  that  thus  far  we  have  succeeded  in  finding  only  one 
classical  exam])le,  ^paatokoyia  (from  <l}pa<ns,  language,  and 
Xoyor,  understanding) — in  English,  phraseology.  This  word 
seems  to  have  struck  Noah  Webster,  or  one  of  his  successors  in 
the  revision  of  his  great  dictionary,  as  singular,  for  in  the  edi 
tion  of  1881,  revised  by  Professor  Goodrich  and  Professor  Por- 


ter, we  find  it  apparently  accounted  for  by  the  form  (j)pda€ios 
as  the  genitive  of  (f>pd(ns,  but  that  form  we  have  not  found 
elsewhere.  It  is  pro[)er  to  add  that  phi'aseogram  and  perhaps 
some  other  derivatives  of  (ppdan  of  like  formation  are  recog- 
nized. 

Notwithstanding  all  this,  it  must  be  said  that  so  great  an 
authority  as  Littr6  gives  the  Latin  of  the  word  under  discus- 
sion as  sym})hyseotomia,  but  to  that  he  may  have  been  led  by 
the  unquestioned  French  form  symjihyseotomie,  which  we  pre- 
sume was  coined  by  Sigault,  who  originated  the  operation.  The 
procedure  was  ridiculed  for  so  many  years  that,  now  that  it  has 
come  into  favor,  it  seems  no  more  than  Sigault's  due  that  we 
should  recognize  the  name  he  gave  it.  Perhaps  a  feeling  of 
this  sort  is  at  the  bottom  of  its  currency  ;  certainly  it  is  not 
true,  however,  that  the  word  symphysiotomy  is  incorrectly 
formed  or  that  its  use  is  confined  to  those  who  are  careless  con- 
cerning such  matters,  for  that  form  is  used  in  the  American 
Journal  of  the  Medical  Sciences,  the  Medical  News,  and  the 
British  Medical  Journal — doubtless  also  in  other  publications 
of  like  standing  that  do  not  now  occur  to  us. 

In  this  discussion  the  Record  has  used  language  so  conii)li- 
mentary  to  the  editor  of  this  journal  that  it  may  seem  ungra- 
cious in  us  to  seek  to  controvert  its  argument,  but  the  readers 
of  the  two  journals  must  understand  that  each  of  them  has  en- 
deavored to  establish  what  it  took  to  be  the  truth  ;  it  is  for  the 
profession  at  large  to  decide  between  them. 


MINOR  PARAGRAPHS. 

INJECTIONS  OF  COPPER  PHOSPHATE  IN  TUBERCULOUS 
ARTHRITIS. 

In  the  Promnce  medicale  for  April  29th  there  is  a  condensed 
account  of  the  copper  treatment  of  white  swelling  as  practiced 
by  Dr.  de  Saint-Germain.  Two  solutions  are  prepared,  and 
they  are  mixed  without  being  filtered.  The  first  consists  of 
five  parts  of  crystallized  sodium  phosphate  dissolved  in  a  mix- 
ture of  thirty  parts  each  of  glycerin  and  distilled  water;  the 
second,  of  one  part  of  copper  acetate  dissolved  in  a  mixture  of 
twenty  parts  each  of  glycerin  and  distilled  water.  Care  is 
taken  to  shake  the  mixture  of  the  two  solutions  before  making 
use  of  it.  All  antiseptic  precautions  being  observed,  a  hypo- 
dern]ic-syringeful  of  the  mixture  is  injected  deep,  j)referably 
behind  the  great  trochanter,  and  the  puncture  is  sealed  with  a 
bit  of  absorbent  cotton  dipped  in  collodion.  The  injection  is 
not  specially  painful,  but  in  certain  cases  quite  a  sharp  i)ain  is 
felt  on  the  first  or  second  day  after  the  operation.  When 
several  injections  are  required,  the  author  allows  about  a  fort- 
night to  elapse  between  them.  The  action  of  the  injection  is 
manifested  speedily  by  a  rise  of  temperature  to  from  100°  to 
103°  F.,  and  the  fever  lasts  from  one  to  three  days;  locally, 
tumefaction,  tenderness,  and  diminished  mobility  of  the  tuber- 
culous glands  are  observed.  It  is  only  after  a  variable  length 
of  time  that  the  curative  action  is  apparent.  If  at  the  end  of  a 
fortnight  the  i)ain  pt  rsists,  the  injection  is  repeated. 


THE  PROPAGATION  OF  CHOLEKA  HY  FLIES. 

AccoRPi.VG  to  the  Medical  Press  and  Circular,  a  Russian 
investigator,  Dr.  P.  Savtschenko,  has  experimented  on  the  capa- 


620 


MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Med.  Jouh., 


bility  of  flies  of  carrying  the  microbe  of  cholera.  He  fed  flies 
on  broth  containing  cholera  dejecta,  and  found  that,  for  a  con- 
siderable time  thereafter,  the  flies  expelled  fseces  loaded  with 
active  cholera  microbes.  He  theo  tried  the  same  flies  with 
sterilized  broth,  and  found  that  for  seventy-two  hours  after- 
ward they  still  continued  to  expel  an  appreciable  number  of  the 
microbes,  thus  showing  that  the  intestine  of  the  fly  is  a  con- 
genial habitat  for  these  micro-organisms  and  possibly  a  means 
of  the  spread  of  the  disease  in  the  face  of  the  most  stringent 
isolation  of  patients.  These  observations,  standing  by  them- 
selves, do  little  more  than  point  out  a  line  of  further  investiga- 
tion for  the  advocates  of  an  absolute  quarantine.  In  the  course 
of  Dr.  Sternberg's  recent  remarks  before  the  Academy  of  Medi- 
cine, he  is  reported  as  saying  that  his  own  experience  had  led 
him  to  look  upon  the  fly  as  a  veritable  channel  for  cholera  in- 
fection ;  and  Dr.  Biggs  thought  that  there  was  a  probable  con- 
firmation of  Dr.  Sternberg's  opinion  to  be  found  in  the  fact 
that  a  large  proportion  of  the  cases  of  cholera  developed  in  the 
city  last  fall  was  among  butchers,  who  handled  meat  which,  it 
was  known,  would  attract  many  flies,  while  other  cases  were 
among  persons  engaged  in  handling  other  kinds  of  food-stuff's 
that  were  attractive  to  flies. 


THE  TREATMENT  OF  WHOOPING-COUGH. 

To  diminish  the  frequency  and  intensity  of  the  paroxysms, 
Dr.  Marfan  {Medecine  moderne,  March  11,  1893  ;  Lyon  medical, 
May  14,  1893)  recommends  a  solution  of  three  parts  of  anti- 
pyrine  in  a  hundred  of  distilled  water  and  twenty-five  of  syrup 
of  orange  flowers.  To  a  child  four  years  old  a  dessertspoonful 
of  this  solution  may  be  given  three  times  a  day,  with  the  meals. 
For  the  purpose  of  securing  a  certain  degree  of  antiseptic  action 
on  the  air  passages  he  advises  fumigation  of  the  room  with  a 
mixture  of  ten  parts  each  of  oil  of  thyme,  oil  of  eucalyptus,  and 
oil  of  turpentine,  two  hundred  and  fifty  of  rectified  spirit,  and 
seven  hundred  and  fifty  of  water.  This,  he  thinks,  tends  to 
prevent  secondary  infection. 


A  JOURNAL  OF  TUBERCULOSIS. 

Wk  have  received  the  first  number  of  a  new  quarterly  jour- 
nal entitled  the  Revue  de  la  Tubereulose.  together  with  a  circu- 
lar issued  by  the  editor,  Dr.  L.  H.  Petit,  the  adjunct  librarian 
of  the  Paris  Faculty  of  Medicine.  The  Revue  appears  under 
the  direction  of  Professor  Verneuil  and  a  corps  of  eminent  asso- 
ciates. Each  number  is  to  consist  of  about  a  hundred  pages. 
Dr.  Petit  asks  us  to  announce  also  that  the  Third  Congress  for 
the  Study  of  Tuberculosis  in  Man  and  Animals  will  be  held  in 
Paris  on  July  27th,  28th,  29th,  30th,  and  31st  and  August  1st 
and  2d,  under  the  presidency  of  Professor  Verneuil. 


THE  NEWSPAPER  IDEA  OF  FAVUS. 

Under  the  heading  Buchen  has  a  Strange  Disease,  the  Sun 
lately  informed  its  readers  that  a  lad  named  Buchen,  an  immi- 
grant from  Austria,  liad  been  denied  the  privilege  of  landing, 
because  he  had  favus,  "  a  fungous  disease  of  the  scalp  which, 
although  common  in  some  parts  of  Europe,  especially  among 
the  Russian  Jews,  has  not  yet  been  found  in  this  country.'' 
"On  account  of  the  malignant  nature  of  the  disease,"  the  Sun 
goes  on  to  say,  "  it  is  extremely  dangerous  to  approach  within 
three  or  four  yards  of  the  person  afflicted." 


CONCEPTION  DURING  THE  PUERPERIUM. 

At  a  recent  meeting  of  the  Leipsic  Obstetrical  Society  {Cen- 
tralblatt  fur  Gyndkologie,  May  13th)  Dr.  Kronig  related  the 


case  of  a  woman  who  was  delivered  of  [her  first  child  on  July 
4,  1892.  Four  days  later  she  indulged  in  coitus,  and  then  ab- 
stained from  it  for  three  months.  On  the  10th  of  March,  1893, 
she  bore  a  child  which,  in  spite  of  the  short  term  of  gestation, 
showed  every  sign  of  maturity. 


TOMOMANIA. 

This  name  is  applied  by  Schiffers  (Revue  de  laryiigologie  et 
d''otologie,  December,  1892  ;  Annalea  des  maladies  de  Voreille, 
du  la/rynx,  du  nez  et  du  pharynx,  May,  1893)  to  a  phase  of  hys- 
teria manifested  by  a  morbid  desire  to  be  operated  upon  for 
purely  imaginary  ills.  It  is  shocking  to  fancy  what  would  hap- 
pen if  a  patient  so  affected  should  fall  in  with  a  surgeon  who 
was  the  subject  of  the  mania  secandi. 


CONSTIPATION  IN  CHILDREN. 

In  the  Union  medicale  for  May  9th  we  find  the  following 
formula,  attributed  to  J.  Simon  :  Two  parts  each  of  tincture  of 
cascarilla,  tincture  of  rhubarb,  tincture  of  cinnamon,  tincture  of 
calumba,  and  tincture  of  gentian  ;  one  part  of  tincture  of  nux 
vomica.  From  ten  to  twenty  drops  are  to  be  given  twice  a 
day,  according  to  the  age. 


A  NEW  JOURNAL  OF  DERMATOLOGY. 

The  Quarterly  Atlas  of  Dermatology  is  the  title  of  a  new 
journal  of  skin  and  venereal  diseases  edited  by  Dr.  A.  H. 
Ohmann-Dumesnil  and  published  in  St.  Louis.  The  first  num- 
ber, dated  April.  1893,  contains  six  half-tone  reproductions  of 
photographs,  some  of  which  are  excellent  representations. 


A  SNUFF  FOR  HOARSENESS  AND  NASAL  ASTHMA. 

The  Prager  medicinische  Wochenschrift  cites  from  the  Cor- 
respondemMatt  fur  schweizer  Aerzte  the  following  formula:  Co- 
caine hydrochloride,  one  part;  triturated  camphor,  two  parts; 
bismuth  subnitrate,  sixteen  parts. 


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  May  31,  1893  : 


DISEASES. 

Week  ending  May  33. 

Week  ending  May  31. 

Cases. 

Beatha. 

Casee. 

Deaths. 

9 

6 

13 

13 

15 

3 

8 

4 

159 

15 

152 

19 

Cerebro-spinal  meningitis .... 

23 

14 

19 

15 

143 

4 

180 

n 

97 

39 

122 

34 

9 

1 

14 

2 

New  York  State  Medical  Association. — The  Fifth  District  Branch 
held  a  meeting  in  Brooklyn  on  May  23d.  The  morning  session  was 
chiefly  devoted  to  a  discussion  on  anaesthetics,  a  subject  that  had  been 
broached  in  a  paper  by  Dr.  E.  R.  Squibb,  entitled  Chloroform  in  1893. 
Dr.  Squibb  gave  a  demonstration  of  his  test  for  impurity  in  chloroform 
by  means  of  plate  and  filter-paper.  The  general  opinion  brought  out 
in  tlie  discussion  condemned  the  notion,  recently  promulgated  in  the 
public  press,  that  oedema  of  the  lungs  was  a  common  feature  or  inci- 
dent of  fatal  results  from  anaesthesia;  it  was  a  good  deal  of  a  myth. 
The  afternoon  session  was  given  up  to  the  following  subjects :  The  Pre- 


1 


Jane  3,  1893.) 


ITEMS.— LETTERS  TO  THE  EDITOR. 


621 


vention  of  Blindness  from  Ophthalmia  Neonatorum,  by  Dr.  L.  A.  W, 
AUeraan  ;  Chronic  Nasal  Catarrh,  by  Dr.  Bermingham ;  The  Treatment 
of  Certain  Forms  of  Fracture,  by  Dr.  Charles  Phelps;  and  The  Man- 
agement of  Hip  Disease,  by  Dr.  A.  B.  Judson. 

The  Medical  and  Surgical  Society  of  Baltimore. — The  announce- 
ment for  the  758th  regular  meeting,  on  Thursday  evening,  the  2r)th 
ult.,  mentioned  the  following  titles :  Acute  Infectious  Periostitis,  with 
the  Report  of  a  Case,  by  Dr.  Frank  C.  Bressler ;  and  Nasal  Reflexes,  by 
Dr.  William  J.  Jones. 

The  Buffalo  Academy  of  Medicine. — At  the  next  meeting  of  the 
Surgical  Section,  on  Tuesday,  the  6th  inst..  Dr.  Edward  G.  Meyer  will 
read  a  paper  on  Hiemorrhoids,  and  Dr.  Edward  Clark  will  read  one  on 
The  Treatment  of  Haemorrhoids. 

The  City  Board  of  Health. — It  is  stated  that  Dr.  George  F.  Shrady, 
the  well-known  editor  of  the  Medical  Record,  has  been  appointed  a  con- 
sulting physician  to  the  hospitals  that  are  under  the  board's  control. 

The  New  Surgeon  General  of  the  Army. — It  is  announced  that  Dr. 
George  M.  Sternberg,  of  the  medical  corps  of  the  army,  has  been  ap- 
pointed to  succeed  Surgeon- General  Sutherland.  The  medical  profes- 
sion feels  confident  that  in  Surgeon-General  Sternberg's  hands  the  af- 
fairs of  the  medical  corps  of  the  army  will  be  well  administered,  and 
we  believe  that  his  appointment  is  in  every  way  approved  by  his  pro- 
fessional brethren. 

The  Death  of  Professor  Markusovszky,  of  Buda-Pest. — The  British 
Medical  Journal  announces  that  Dr.  Ludwig  Markusovszky,  an  honorary 
professor  in  the  University  of  Buda-Pest  and  "  one  of  the  foremost  men 
in  the  medical  profession  in  Hungary,"  died  of  heart  disease  on  April 
21st,  aged  seventy-eight  years. 

Changes  of  Address. — Dr.  Alexander  Lyle,  to  No.  117  East  Eighty- 
first  Street;  Dr.  J.  B.  Mattison  (Brooklyn  Home,  etc.),  to  No.  188  Pros- 
pect Place,  Brooklyn ;  Dr.  Edward  C.  Seguin,  to  No.  47  West  Fiftieth 
Street ;  Dr.  David  Webster,  to  No.  327  Madison  Avenue. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  two  weeks  ending  May  27,  1893  : 
Marsteller,  E.  H.,  Passed  Assistant  Surgeon.     Detached  from  the 

Naval  Academy  and  ordered  to  the  Practice-ship  Constellation. 
Oriffiths,  S.  H.,  Passed  Assistant  Surgeon.    Detached  from  the  Prac- 
tice-ship Constellation  and  granted  four  months'  leave. 
Evans,  S.  G.,  Assistant  Surgeon.    Detached  from  the  U.  S.  Steamer 

Monongahela  and  granted  two  months'  leave. 
La  Motte,  Henry,  Assistant  Surgeon.    Ordered  to  the  Practice-ship 
Constellation. 

Bloodgood,  D.,  and  Wells,  H.  M.,  Medical  Directors.  Ordered  as  dele- 
gates to  the  American  Medical  Association  at  Milwaukee,  Wis. 

Flint,  J.  M.,  Medical  Inspector.  Ordered  to  the  U.  S.  Steamer  Bal- 
timore. 

Cooke,  G.  W.,  Medical  Inspector.    Detached  from  the  U.  S.  Steamer 

Baltimore  and  granted  three  months'  leave. 
Herndon,  C.  G.,  Surgeon.    Assigned  to  duty  in  the  Bureau  of  Medicine 

and  Surgery. 

McClurg,  W.  a.,  Surgeon.    Relieved  from  duty  in  Bureau  of  Medicine 

and  Surgery  and  to  wait  orders. 
Smith,  G.  T.,  Passed  Assistant  Surgeon.    Detached  from  the  New  York 

Hospital  and  ordered  to  the  U.  S.  Steamer  Baltimore. 
White,  S.  S.,  Passed  Assistant  Surgeon.    Detached  from  U.  S.  Steamer 

Baltimore  and  granted  two  months'  leave. 
Bryant,  F.  H.,  Passed  Assistant  Surgeon.    Detached  from  Philadelphia 

Hospital  and  ordered  to  the  U.  S.  Steamer  Baltimore. 
PiGOTT,  M.  R.,  Assistant  Surgeon.    Detached  from  the  U.  S.  Steamer 

Baltimore  and  ordered  to  the  U.  S.  Steamer  Kearsarge. 
Alfred,  A.  R.,  Assistant  Surgeon.    Detached  from  the  U.  S.  Steamer 

Kearsarge  and  granted  one  month's  leave. 
Ward,  B.  R.,  Assistant  Surgeon.    Detached  from  the  U.  S.  Steamer 

Richmond  and  ordered  to  the  U.  S.  Steamer  Monongahela. 
Diehl,  Oliver,  Passed  Assistant  Surgeon.    Ordered  to  the  Naval  Hos- 
pital, Philadelphia,  Pa. 


BoGERr,  E.  S.,  Passed  Assistant  Surgeon.  Detached  from  the  Labora- 
tory, New  York,  and  ordered  to  the  U.  S.  Steamer  Philadelphia. 

Boyd,  Robert,  Assistant  Surgeon.  Detached  from  the  U.  S.  Steamer 
Philadelphia  and  ordered  to  the  U.  S.  Steamer  Richmond. 

Society  Meetings  for  the  Coming  Week : 

Monday,  Jurie  5th :  Morrisauia  Medical  Society  (private) ;  Brooklyn 
Anatomical  and  Surgical  Society  (private) ;  German  Medical  Society 
of  the  City  of  New  York  ;  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;  Chicago 
Medical  Society. 

Tuesday,  June  6th:  American  Medical  Association  (first  day — Milwau- 
kee) ;  New  York  Neurological  Society  ;  Elmira,  N.  Y.,  Academy  of 
Medicine ;  Buffalo  Academy  of  Medicine  (Surgical  Section) ;  Buffalo 
Medical  and  Surgical  Association;  Ogdensburgh,  N.  Y.,  Medical 
Association  ;  Medical  Societies  of  the  Counties  of  Columbia  (semi- 
annual— Chatham),  Franklin  (semi-annual),  Herkimer  (annual — Her- 
kimer), Niagara  (annual — Lockport),  Orange  (annual — Goshen),  Sara- 
toga (annual),  Schoharie  (annual),  and  Yates  (annual),  N.  Y. ;  Hud- 
son (Jersey  City)  and  Warren  (annual),  N.  J.,  County  Medical  So- 
cieties ;  Androscoggin,  Me.,  County  Medical  Association  (Lewiston) ; 
Baltimore  Academy  of  Medicine. 

Wednesday,  June  7th  :  American  Medical  Association  (second  day) ; 
Society  of  the  Alumni  of  Bellevue  Hospital;  Society  of  the  Alumni 
of  Charity  Hospital ;  Harlem  Medical  Association  of  the  City  of  New 
York  ;  Medical  Societies  of  the  Counties  of  Cattaraugus  (annual) 
and  Richmond  (Stapleton),  N.  Y. ;  Medical  Microscopical  Society  of 
Brooklyn  ;  Bridgeport,  Conn.,  Medical  Association ;  Penobscot,  Me., 
County  Medical  Society  (Bangor) ;  Orleans,  Vt.,  County  Medical  So- 
ciety (annual). 

Thursday,  June  8th :  American  Medical  Association  (third  day) ;  So- 
ciety of  Medical  Jurisprudence  and  State  Medicine,  New  York ;  New 
York  Academy  of  Medicine  (Section  in  Pjediatrics) ;  New  York  La- 
ryngological  Society  (private) ;  Medical  Society  of  the  County  of 
Cayuga  (annual),  N.  Y. ;  Brooklyn  Pathological  Society ;  South  Bos- 
ton, Mass.,  Medical  Club  (private) ;  Pathological  Society  of  Phila- 
delphia. 

Friday,  June  9th  :  American  Medical  Association  (fourth  day);  York- 
ville  Medical  Association  (private) ;  German  Medical  Society  of 
Brooklyn  ;  Medical  Society  of  the  Town  of  Saugerties,  N.  Y. ;  Brook- 
lyn Dermatological  and  Genito-urinary  Society  (private). 

Saturday,  Jane  10th:  Obstetrical  Society  of  Boston  (private). 


fetters  t0  tijc  miiox. 


PRIORITY  IN  THE  TREATMENT  OF  SPRAINED  ANKLE. 

16  Park  Avenue,  New  York,  May  27,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  The  communication  of  Dr.  William  E.  Brandt  in  to- 
day's issue  calls  for  very  little  in  the  way  of  reply.  It  was  not 
a  question  with  me  in  the  preparation  of  the  article,  to  which 
you  kindly  devoted  an  editorial,  of  priority,  but  it  was  a  ques- 
tion of  bringing  before  the  profession  a  method  of  treatment 
which  I  was  sure  would  be  of  great  advantage.  Personally  I 
should  bo  glad  to  have  this  method  attributed  to  the  Kentucky 
surgeons  mentioned  by  Dr.  Brandt.  In  the  first  place,  Dr. 
Benjamin  Dudley,  of  Lexington,  Kentucky,  was  my  father's 
prccejjtor.  In  the  second  place,  I  was  a  student  myself  twenty- 
two  or  twenty-three  years  ago  of  Professor  D.  W.  Yandell's, 
and  no  one  honors  this  distinguished  surgeon  more  than  I. 
The  late  Dr.  K.  0.  Cowling  was  a  personal  friend,  and  I  read 
everything  that  he  wrote.  Still  further.  Professor  L.  A.  Sayre, 
a  Kentuckian  by  adoption,  was  my  teacher  at  Bellevue. 


622 


LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mko.  Jodk., 


I  fail,  however,  to  recall  any  impression  that  sprains  were 
treated  in  exactly  the  same  way  that  Mr.  Cottrell  advocates. 
If  Dr.  Brandt  considers  the  question  of  priority  paramount,  let 
him  cite  the  references  and  give  quotations  from  the  writings 
of  these  eminent  surgeons.  The  onus  probandi  certainly  rests 
upon  him.  V.  P.  Gibnet,  M.  D. 


XO  POSTPONEMENT  OF  THE  INTERNATIONAL  MEDICAL 
CONGRESS. 

New  York,  May  29,  1893. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sib:  I  beg  to  inform  you  and  your  readers,  and  exchanges 
through  you,  that  there  is  no  foundation  for  the  rumors  refer- 
ring to  a  postponement  of  the  Eleventh  International  Medical 
Congress.  Such  is  the  information  conveyed  to  me  in  a  letter 
of  the  Secretary  General's  dated  Genoa,  May  1.5th. 

It  is  officially  announced  that  part  of  the  15th  section  of  the 
congress  will  be  dedicated  to  the  exclusive  consideration  of 
cholera  and  quarantine.  Professor  Cunningham  and  Professor 
Koch  are  expected  to  participate  in  the  proceedings  of  this  sub- 
section. 

Besides  the  North  German  Lloyd,  the  Hamburg-American 
Packet  Co.,  and  the  Compagnie  G6nerale  Transatlantique,  the 
Netherland  American  Steam  Navigation  Company  (39  Broad- 
way) offers  reduced  rates  to  visitors  to  the  congress.  The 
Hamburg-American  Packet  Co.  writes  to  say  that  the  families 
of  members  are  entitled  to  all  the  reductions. 

A.  Jacobi,  M.  D. 

PURE  MILK,  ETC.,  FOR  THE  POOR. 

New  York,  May  29,  1893. 
To  the  Editor  of  the  Neio  Yorlc  Medical  Journal: 

Sir  :  On  June  1st  the  Tenth  Ward  Social  Reform  Club  will 
open  a  store  at  71  Rivington  St.,  where  pure  milk,  fresh  eggs, 
butter,  etc.,  will  be  sold  at  cost  price,  the  store  is  to  be  run 
upon  a  co-operative  plan  by  a  number  of  gentlemen  who  have 
interested  themselves  in  alleviating  the  condition  of  the  poor 
children  on  the  east  side. 

This  announcement  will  doubtlessly  be  of  interest  to  the 
physicians  in  this  quarter.  Morris  Manres,  M.  D. 


IProcccbings  of  Socutus. 


AMERICAN  GYNAECOLOGICAL  SOCIETY. 

Eighteenth  Annual  Meeting,  held  in  Philndelphia  on  Tuesday, 
Wednesday,  and  Thursday,  May  16,  17,  and  18,  1893. 

The  President,  Dr.  TnEOPniLUS  Parvin,  of  Philadelphia,  in  the 
Chair. 

Congenital  Dilatation  of  the  Urethra  was  the  subject  of 
a  paper  by  Dr.  W.  II.  Baker,  of  Boston.  The  condition  was 
believed  to  be  a  continuation  of  that  which  obtained  in  early 
fcBtal  life,  for  at  the  fourth  month  the  caliber  of  the  urethra 
was  such  that  it  would  easily  admit  of  the  passage  of  a  small 
finger.  At  that  period  it  was  somewhat  larger  than  the 
vagina.  The  condition  was  not  especially  rare  and  often  gave 
rise  to  the  suspicion  of  vicious  practices.  In  a  certain  number 
of  cases  the  suspicion  was  well  founded,  but  in  others  tlie  fault 
was  entirely  congenital.  More  or  less  functional  trouble  with 
the  bladder  was  likely  to  result,  though  the  condition  did  not 
of  necessity  involve  the  muscular  fibers  of  the  neck  of  the  blad- 


der. A  case  was  narrated,  illustrated  by  large  drawings,  in 
which  a  cure  had  been  obtained  by  means  of  a  plastic  operation. 

Abdominal  Fistula  after  Coeliotomy;  its  Prevention 
and  Treatment. — This  was  the  subject  of  a  paper  by  Dr.  Paul 
F.  MuNoi:,  of  New  York.  Small  mural  or  stitch-hole  abscesses 
in  tlie  tracts  of  abdominal  wounds  were,  it  must  be  admitted, 
of  common  occurrence.  They  were  not  usually  a  source  of 
great  trouble  if  the  operation  had  been  essentially  a  clean  one. 
Under  less  favorable  conditions  deep  and  troublesome  fistulae 
sometimes  resulted  at  periods  more  or  less  remote  from  the 
performance  of  the  operation.  Their  occurrence  was  favored 
by  the  use  of  drainage-tubes  and  improperly  prepared  ligature 
material.  The  passage,  or  sinus,  was  usually  a  single  one. 
They  also  resulted  after  supravaginal  extirpation  of  the  uterus  ; 
the  vaginal  portion  of  the  organ,  being  left,  subsequently 
sloughed  away  and  left  a  sinus  communicating  with  the  vagina. 
They  might  also  occur  in  connection  with  pelvic  abscess,  the 
pus  burrowing  along  the  planes  of  cellular  tissue  and  making 
external  openings.  The  difficulties  attending  these  fistulae  con- 
sisted sometimes  in  the  firmness  of  the  abscess  walls,  sometimes 
in  their  depth,  the  difficulty  of  draining  them,  and  the  unhealthy 
character  of  their  granulation  tissue.  Nature  frequently  tried 
to  give  relief  by  perforation  into  one  or  more  of  the  hollow  ab- 
dominal viscera.  Sometimes  this  was  followed  by  relief ;  at  other 
times  the  situation  was  made  more  serious.  The  examination 
of  such  cavities  was  difficult  and  often  dangerous,  rupture  into 
the  bladder  or  intestine  being  easily  possible.  A  great  variety 
of  treatment  had  been  practiced.  The  author  had  found  dress- 
ings with  balsam  of  Peru  and  tincture  of  calendula  useful,  also 
the  careful  application  of  a  heated  probe.  If  such  a  cavity  was 
packed  with  gauze  the  danger  of  rupture  must  be  remembered. 
Drainage  into  the  vagina  would  be  efficient  in  some  cases. 
Abdominal  section  should  be  avoided  if  possible,  for  prope^* 
separation  and  dissection  of  all  the  offending  parts  could  not 
always  be  safely  accomplished. 

Dr.  William  Goodell,  of  Philadelphia,  believed  that  the 
accident  in  question  usually  occurred  in  cases  in  which  the  con- 
dition was  already  septic  at  the  time  of  the  operation.  Drainage- 
tubes  and  ligatures  as  causes  were,  in  his  opinion,  less  frequent. 
He  was  quite  in  favor  of  extending  the  fistula  into  the  vagina, 
and  thus  allow  of  effective  drainage.  The  venous  haemorrhage 
in  making  such  a  vaginal  opening  might  be  very  profuse. 

Dr.  Charles  P.  Noble,  of  Philadelphia,  thought  that  incom- 
plete operations  were  frequent  causes  of  fistulae  ;  a  portion  of 
diseased  tissue  was  left  unremoved,  or  a  ligature  was  passed 
through  infected  tissue,  and  a  fistula  resulted.  It  taught  the 
neces.sity  of  removing  all  foci  of  infection. 

Dr.  Andrew  F.  Currier,  of  New  York,  differed  with  the 
author  in  regard  to  certain  characters  of  these  sinuses.  He  be- 
lieved only  the  very  shallow  ones  were  simple:  the  deeper  ones 
were,  as  a  rule,  complex  and  tortuous.  Necessarily  it  must  be 
so,  as  the  walls  were  formed  by  loops  of  intestine.  Hence  the 
danger  of  rough  manipulation,  as  the  author  had  suggested ; 
hence  also  the  danger  of  the  heated  probe  in  the  sluggish  granu- 
lation tissue  of  the  fistula  walls.  We  must  not  expect  to  cure 
by  applications  of  astringents  if  the  fistulfe  were  deep  and  sinu- 
ous, for  the  ojjposing  walls  of  intestine  would  prevent  the  liquid 
from  reaching  the  bottom.  That  was  why  they  remained  open 
so  persistently.  Through-drainage  into  the  vagina  was  rational 
and  would  frequently  cure.  The  accident  of  venous  haemor- 
rhage might  be  alarming.  The  most  rational  treatment  for  the 
persistent  cases  was  abdominal  section  preceded  by  careful  curet- 
ting with  irrigation.  Then  a  probe  should  be  carefully  passed 
to  the  bottom  of  the  fistula,  the  point  on  the  surface  which  was 
exactly  opposite  to  it  noted,  an  incision  made  from  this  point  to 
the  external  opening  of  the  fistula,  the  hand  passed  to  the  loca- 


June  3,  1893.] 


PROCEEDINGS 


OF  SOCIETIES. 


623 


tion  of  the  end  of  the  probe,  retained  in  the  fistula  as  a  guide, 
and  the  tissues  dissected  away  from  below  upward.  This  would 
enable  one  to  trace  the  course  of  the  fistula  and  break  up  its 
connections  with  greater  safety  and  facility  than  by  beginning 
the  dissection  from  the  top. 

Dr.  A.  P.  Dudley,  of  New  York,  recognized  all  the  causes 
of  fistula  which  had  been  mentioned — pus  in  the  pelvis,  drain- 
age-tubes, and  infected  ligatures.  His  practice  was  to  avoid 
using  the  glass  drainage-tube  entirely,  and  he  seldom  had  occa- 
sion to  use  gauze  packing  for  drainage  purposes.  He  had  also 
found  great  satisfaction  and  safety  in  the  use  of  animal  liga- 
tures, especially  catgut. 

Dr.  G.  M.  Edebohls,  of  New  York,  wished  to  add  to  the  list 
of  causes  already  mentioned  tuberculosis.  He  had  seen  four 
cases  of  fistula  from  such  a  cause.  It  was  not  alone  tuberculo- 
sis of  the  peritonsBum  which  gave  such  a  result ;  the  disease 
might  exist  in  the  form  of  tuberculous  ulcers  within  the  intes- 
tine, perforation  finally  resulting  with  attachment  to  the  ab- 
dominal walls. 

Dr.  Clement  Cleveland,  of  New  Y'ork,  considered  that  the 
condition  under  discussion  was  always  the  result  of  infectious 
material,  either  in  the  abdominal  cavity  or  in  the  abdominal 
wound.  For  the  deep  fistulse  he  considered  through-drainage 
nto  the  vagina  the  best  mode  of  treatment.  For  their  irriga- 
tion he  had  found  peroxide  of  hydrogen  very  effective. 

Puerperal  Eclampsia;  the  Experience  of  the  Boston 
Lying-in  Hospital  during  the  Past  Seven  Years.— This  was 
the  subject  of  a  paper  of  Dr.  Charles  M.  Green,  of  Boston. 
Puerperal  eclampsia  was  usually  attributable  to  some  form  of 
renal  disease  and  to  a  uraemic  condition.  The  condition  oc- 
curred in  one  out  of  every  five  hundred  i)uerperal  cases.  The 
treatment  should  vary  according  as  the  attack  occurred  before, 
during,  or  after  labor.  Even  if  the  attack  began  before  labor, 
suitable  treatment  might  result  in  the  birth  of  a  living  child. 
Interference  should  be  refrained  from  if  possible.  Ether  nar- 
cosis was  to  be  preferred  to  that  of  any  other  ansesthetic.  A 
hot  bath  or  pilocarpine  should  be  given  for  its  action  on  the 
skin ;  a  sufficient  quantity  of  brandy ;  elaterium  or  croton  oil 
to  produce  active  purgation ;  and  digitalis  or  nitroglycerin  to 
regulate  the  heart's  action.  Venesection  had  not  been  practiced 
in  any  of  the  cases  which  were  being  considered.  If  artificial 
delivery  became  necessary,  dilatation  should  be  accomplished 
with  the  hand  rather  than  with  hydrostatic  bags.  Even  though 
several  convulsions  had  occurred,  every  effort  should  be  made 
to  save  the  child  if  it  had  reached  the  period  of  viability.  In 
many  cases  death  would  be  the  result,  both  for  mother  and  child. 
If  the  convulsions  began  during  labor,  parturition  should  be  ter- 
minated as  quickly  as  possible.  Tlie  kidneys  would  resume  their 
functions  the  more  readily  if  the  uterus  was  emptied.  The  mor- 
tality for  mother  and  child  had  been  twenty -five  percent,  in  the 
intra-partum  cases.  Many  of  the  patients  had  been  brought  to 
the  hospital  in  a  comatose  condition.  In  post  partum  convul- 
sions no  interference  was  indicated  if  the  labor  had  proceeded 
normally.  In  fifteen  cases  of  this  variety,  only  one  mother  had 
been  lost.  The  treatment,  medicinally,  was  tiie  same  as  in  the 
intra-partum  variety.  Of  thirty-six  women  who  had  been 
treated  during  the  past  seven  years,  twenty- seven  had  recovered. 
The  foetal  mortality  in  cases  of  viability  had  been  thirty-three 
and  a  third  per  cent.  In  many  of  the  cases  post- partum  haam- 
orrhagehad  been  severe,  and  no  particular  efforts  had  been  made 
to  check  it.  In  such  cases  it  was  thought  that  the  lessening  of 
the  blood  pressure  was  beneficial.  As  to  prognosis,  it  was  con- 
cluded that  it  depended  upon  tiie  time  when  the  convulsions 
occurred,  their  severity,  and  their  duration,  rather  than  their 
number.  The  fcetal  mortality  was  also  governed  by  the  same 
conditions. 


Dr.  M.  D.  Mann,  of  Buffalo,  had  observed  great  benefit  from 
the  use  of  Norwood's  tincture  of  veratrum  viride  in  the  treat- 
ment of  eclampsia.  Housed  it  hypodermically  in  five-drop  doses 
and  only  in  cases  in  which  there  was  rapid  pulse  and  high  arte- 
rial tension. 

Dr.  S.  C.  BusEY,  of  Washington,  thought  a  mortality  of 
twenty-five  per  cent,  was  much  greater  than  obtained  in  private 
practice.  It  might  not  be  excessive  in  hospital  practice,  espe- 
cially as  the  author  had  stated  that  many  of  the  patients  were 
already  comatose  when  brought  to  the  hospital.  In  private 
practice  the  mortality  would  be  very  low  if  suitable  prophylaxis 
was  exercised.  The  appearance  of  renal  insufficiency  was  a 
signal  to  adopt  all  possible  precautions.  He  regarded  venesec- 
tion as  an  important  means  of  treatment,  but  it  should  be  used 
discreetly. 

Dr.  Edward  Reynolds,  of  Boston,  coincided  in  the  opinion 
that  the  prognosis  was  dependent  upon  the  duration  and  sever- 
ity of  the  convulsions.  He  thought  there  were  cases  in  private 
practice  in  which  convulsions  and  death  could  not  be  prevented, 
however  judicious  the  prophylaxis.  This  was  especially  true 
in  twin  pregnancies,  probably  on  account  of  the  extreme  dila. 
tation. 

Dr.  E.  p.  Davis,  of  Philadelphia,  attributed  great  impor- 
tance to  systematic  tests  for  urea.  If  the  urea  was  below  two 
and  a  half  per  cent.,  the  utmost  watchfulness  would  be  neces- 
sary. If  the  lungs  were  cedematous,  atropine  and  calomel  should 
be  administered.  The  condition  of  the  placenta  was  of  great 
importance  with  reference  to  the  welfare  of  the  child.  If  it 
contained  much  fat,  the  prospects  for  the  child  were  bad. 
Duhrssen  had  recommended  ether  as  an  anaesthetic  in  prefer- 
ence to  chloroform,  with  multiple  incisions  of  the  os  uteri  and 
forceps  delivery.  His  results  with  such  treatment  had  been  very 
good. 

Dr.  Green  stated  that  veratrum  viride  had  not  given  favora- 
ble results  in  his  experience.  He  agreed  to  the  statement  that 
better  results  were  to  be  expected  in  private  than  in  hospital 
practice,  but  some  cases  would  end  fatally,  whatever  the  treat- 
ment. Systematic  examinations  of  the  urine  should  always  be 
insisted  upon. 

Septicaemia  and  its  Treatment  with  Oxygen  was  the  sub- 
ject of  the  paper  by  Dr.  Andrew  F.  Currier,  of  New  York.  The 
inhalation  of  oxygen  was  particularly  appropriate,  he  said,  in 
view  of  the  readiness  with  which  it  was  taken  up  by  the  hiemo- 
globin  and  its  affinity  for  the  waste  elements  with  which  the 
blood  was  loaded.  The  capacity  of  the  blood  for  absorbing 
oxygen  in  this  disease  had  not  been  definitely  determined.  A 
limited  number  of  experiments  had  been  made  by  individuals  in 
health  upon  themselves,  and  by  otliers  upon  animals,  but  the 
conditions  were  quite  different  from  those  existing  in  septicae- 
mia. The  absence  of  a  sufficient  supply  of  oxygen  in  sick-rooms 
generally,  especially  in  the  winter,  with  closed  doors  and  win- 
dows, furnace  heat,  combustion  of  lamps  and  candles,  and  the 
respiratory  requirements  of  attendants,  was  probably  an  impor- 
tant cause  of  the  higher  mortality  at  that  period  of  the  year 
than  at  any  other.  The  good  results  that  had  attended  the 
treatment  of  epidemics  of  typhus  fever  in  tents  or  in  the  open 
air  was  suggestive  of  the  therapeutic  value  of  oxygen,  also  the 
fact  that  septicaemia  was  comparatively  unknown  among  savage 
and  barbarous  peojdes,  whose  lives  are  passed  in  the  open 
air.  Questions  of  tension  and  pressure  were  not  to  be  over- 
looked in  considering  oxygon  inhalation.  A  pressure  of  three 
atmospheres  would  produce  convulsions  in  rabbits.  It  was 
usually  desirable  to  administer  oxygen  freely  mixed  with  atmos- 
pheric air.  Not  only  was  this  the  safer  method,  but  the  oxygen 
was  thereby  rendered  less  likely  to  irritate  the  air  passages. 
The  volume  of  oxygen  necessary  for  the  saturation  of  the 


€24 


PROGEEDINOS 


OF  SOCIETIES. 


[N,  Y.  Mkd.  Jocb., 


hseinoglobin  could  not  be  determined  in  advance  in  a  given 
case,  the  corpuscles  in  septicaemia  being  smaller  than  in  health, 
and  readily  becoming  disintegrated.  The  plasma,  which  in 
health  contained  two  per  cent,  of  the  oxygen  of  the  body, 
would  absorb  more  than  this  if  the  oxygen  was  administered 
under  pressure,  and  in  septicaemia  an  additional  quantity  was 
consumed  in  the  formation  of  the  carbon  dioxide,  urea,  and  uric 
acid  with  which  the  blood  was  overcharged.  Whether  the 
bacteria  in  the  blood  in  septicaemia  were  killed  by  oxygen  inha- 
lation was  uncertain.  Welch  did  not  think  they  could  be  sub- 
jected to  it  sufficiently  long  or  under  sufficient  pressure  to  cause 
their  death  without  also  injuring  the  blood  and  other  tissues. 
If  oxygen  was  inhaled  under  suitable  conditions  of  pressure,  it 
stimulated  to  deeper  respiration,  the  surface  of  the  body  became 
warmer,  the  pulse  grew  stronger,  and  the  color  of  the  surface 
was  made  more  natural.  The  stimulation  of  the  heart  and 
lungs  was,  of  course,  directly  favorable  to  the  purification  of 
the  blood  by  elimination  of  its  toxic  elements.  The  stimulation 
of  the  nerve  centers  presiding  over  functional  activity,  if  suffi- 
cient and  continuous,  would  produce  a  favorable  result,  whether 
a  direct  germicidal  action  was  exerted  or  not.  In  addition  to 
the  advantages  mentioned,  oxygen  usually  induced  drowsiness 
and  sleep,  and  this  was  often  a  matter  of  sufficient  importance 
to  turn  the  scale  in  favor  of  the  patient.  The  treatment  should 
be  begun  early  in  the  disease,  and  not  after  the  nerve  centers 
had  been  poisoned.  The  simpler  the  method  of  administration 
the  better;  the  principal  requirements  were  that  the  oxygen  be 
pure,  and  that  it  be  administered  in  such  volume  as  to  be  readi- 
ly and  comfortably  tolerated.  If  administered  early  enough,  it 
would  often  save  life,  and  in  almost  all  cases  it  would  conduce 
to  the  comfort  and  well-being  of  the  patient  and  relieve  symp- 
toms which  could  not  otherwise  be  readily  relieved. 

Dr.  MuNDE  believed  that  when  all  local  causes  of  infection 
were  removed  the  question  would  be  whether  the  vital  forces 
of  the  patient  or  the  conditions  which  constituted  the  disease 
would  last  the  longer.  Upon  this  would  depend  the  result. 
He  believed  that  oxygen  was  of  value  as  a  means  of  treatment. 

The  Dangers  and  Complications  of  Uterine  Fibroids  was 
the  subject  of  the  paper  of  Dr.  S.  0.  Gordon,  of  Portland,  Me. 
These  tumors  were  not  of  so  simple  a  character  as  had  been  be- 
lieved. Their  growth  did  not  always  cease  with  the  meno- 
pause, they  sometimes  underwent  malignant  degeneration,  and 
their  symptoms  often  made  life  an  intolerable  burden.  In  the 
presence  of  such  symptoms  he  was  in  favor  of  their  complete 
removal,  together  with  the  uterus  and  appendages.  Peritonitis, 
salpingitis,  and  oophoritis  were  always  imminent  when  fibroids 
were  present,  and  they  were  of  frequent  occurrence.  In  many 
cases  the  growth  of  the  tumor  was  rapid,  giving  rise  to  most 
annoying  pressure  symptoms.  If  hysterectomy  was  performed 
sufficiently  early,  it  could  not  now  be  considered  an  extra-haz- 
ardous operation. 

An  Account  of  Personal  Experience  in  Operations  for 
Eibroid  Tumors  of  the  Uterus  was  the  title  of  a  paper  by  Dr. 
Mann.  If  the  tumor  was  small,  he  believed  that  it  could  best 
be  treated  by  the  performance  of  Ilegaf's  operation.  If  it  was 
somewhat  larger  and  readily  enucleable,  myomotomy  was  indi- 
cated. If  the  disease  was  of  long  duration,  the  tumor  being 
large  and  painful,  and  if  its  character  was  such  that  it  would  be 
difficult  to  make  a  good  pedicle  and  treat  it  extraperitoneally,  su- 
pravaginal hysterectomy  was  indicated.  Hysterectomy  through 
an  abdominal  incision  was  the  ideal  operation  both  for  fibroids 
and  for  cancer  of  the  uterus.  In  almost  all  operations  of  the  last- 
mentioned  variety  he  was  in  favor  of  the  use  of  some  form  of 
drainage.  The  operation  recommended  by  Baer  had  not  been 
satisfactory  in  the  two  cases  in  which  he  had  performed  it, 
as  it  did  not  permit  of  free  drainage  through  the  vagina.  With 


im[)rovements  in  technique,  the  indications  for  hysterectomy 
had  increased.  A  slow  and  lingering  death  or  a  useless  life 
was  the  alternative  offered  to  very  many  sufferers  who  declined 
operations  for  uterine  fibroids.  Such  operations  could  now  be 
performed  with  almost  as  much  safety  as  those  for  the  removal 
of  ovarian  cysts.  An  operation  should  be  recommended  and 
the  decision  left  with  the  patient. 

A  Further  Report  upon  Supravaginal  Hysterectomy  by 
the  New  Method  was  the  title  of  the  paper  by  Dr.  B.  F.  Baer, 
of  Philadelphia.  The  author's  experience  in  this  operation,  in 
which  the  stump  was  allowed  to  remain  within  the  pelvis,  now 
included  twenty-eight  cases,  in  all  but  two  of  which  the  pa- 
tients had  recovered.  He  was  convinced  that  the  method  was 
superior  to  the  extraperitoneal  method,  superior  also  to  that  in 
which  the  entire  uterus  was  removed.  It  was  essentially  the 
method  that  had  been  practiced  successfully  by  Eastman  and 
Chrobak.  Drainage  had  been  used  in  only  two  per  cent,  of  the 
cases,  and  as  a  rule  it  would  not  be  required.  Convalescence 
had  followed  the  operation  immediately.  The  interior  of  the 
cervical  canal  should  be  burned  out  with  a  Paquelin  cautery, 
and  the  cervical  stump  covered  with  peritoneal  flaps.  Very 
few  sutures  were  required  in  these  flaps,  in  some  cases  none  at 
all.  Tiie  ligatures  which  secured  the  uterine  arteries  would 
secure  the  broad  ligaments  also. 

The  Development  of  the  IntrapeMc  Treatment  of  the 
Stump  in  the  Extirpation  of  Fibroid  Tumors  of  the  Uterus 
was  the  subject  of  a  paper  by  Dr.  J.  R.  Goffe,  of  New  York. 
The  extraperitoneal  method  of  treating  the  pedicle  was  being 
abandoned  by  many  operators,  and  the  question  arose  whether 
the  cervix  should  be  retained  or  the  entire  uterus  be  removed. 
Kimball  had  been  the  first  to  remove  the  uterus  for  myoma,  the 
pedicle  being  dropped  and  the  ligatures  which  secured  it  left 
outside  the  abdominal  wound  for  drainage.  This  had  been  fol- 
lowed by  the  operations  of  Pean  and  Koeberl6,  while  Schroeder 
had  suggested  his  operation  of  myomectomy.  Then  had  come 
the  work  of  Brennecke,  Zweifel,  and  Martin.  It  had  occurred 
to  the  author  to  modify  previous  operations  by  dissecting  away 
peritoneal  flaps  of  sufficient  size  from  the  anterior  and  posterior 
aspects  of  the  uterus,  transfixing  and  ligating  the  cervix  on 
both  sides,  covering  the  stump  with  the  peritoneal  flaps,  and 
using  the  cervical  canal  for  drainage  purposes.  He  had  per- 
formed his  first  operation  in  1888,  and  since  then  had  per- 
formed five  additional  operations.  The  Freund  operation  had 
been  revived  in  1889  by  Martin  for  the  removal  of  myomata. 
The  tumor  was  first  removed  to  the  vaginal  junction,  and  then 
the  cervix.  The  removal  of  tumor  and  uterus  in  one  step  had 
been  very  successful  as  performed  by  Krug,  Polk,  and  others. 
Zweifel  had  suggested  the  burning  out  of  the  cervical  canal 
with  the  actual  cautery,  thus  converting  the  canal  into  a  drain- 
age-tube, and  the  closure  of  the  peritoneal  cavity  with  flaps  dis- 
sected from  the  anterior  and  posterior  surfaces  of  the  tumor. 

Dr.  MuNDfe  opened  the  discussion  upon  the  foregoing  papers 
on  the  treatment  of  fibroid  tumors  of  the  uterus.  In  a  very 
considerable  experience  with  tumors  of  this  description  he  had 
found  only  about  ten  per  cent,  in  which  he  had  considered 
hysterectomy  indicated.  He  therefore  objected  to  the  propo- 
sition for  their  wholesale  removal. 

Dr.  Polk  believed  that  the  therapeutic  results,  and  not  the 
anatomical  condition,  were  of  essential  importance.  The  sever- 
est symptoms  were  sometimes  caused  by  very  small  tumors. 
The  question  as  to  the  value  of  the  operations  proposed  could 
only  be  settled  by  the  ultimate  results  of  very  many  operations. 
Many  women  would  be  better  off  for  the  removal  of  the  uterus 
with  its  appendages,  even  if  the  tumor  was  quite  small,  and 
this  plan  was  to  be  recommended  if  relief  was  not  to  be  ob- 
tained by  other  means.    As  to  the  relative  advantage  of  com- 


June  3,  1893.] 


PROCEEDINGS  OF  SOCIETIES. 


625 


plete  over  partial  extirpation  of  tlie  organ,  he  thought  it  was 
decided,  and  one  could  be  done  with  as  much  facility  and  in  as 
short  a  time  as  the  other.  In  any  case  it  would  be  essential 
that  ample  means  for  drainage  after  the  operation  should  be 
provided. 

Dr.  Florian  Kruo,  of  New  York,  found  more  than  ten  per 
cent,  of  cases  of  uterine  myomata  in  which  radical  operations 
were  indicated.  The  symptoms  rather  than  the  size  of  the 
tumor  should  in  all  cases  serve  as  the  guide  for  treatment.  The 
subject  was  passing  through  nearly  the  same  stages  which  had 
attended  the  subject  of  the  treatment  of  ovarian  tumors.  If 
an  operation  was  to  bo  successful,  one  should  not  wait  until 
the  symptoms  were  too  severe  to  admit  of  an  efficient  result. 
As  to  the  choice  of  methods,  he  was  entirely  in  favor  of  total 
extirpation. 

Dr.  J.  Taber  Johnson,  of  Washington,  had  operated  princi- 
pally by  Bantock's  method,  using  the  wire  serre-nmvd  upon  the 
stump.  He  had  found  that  the  method  consumed  less  time 
than  other  methods,  and  it  certainly  afforded  greater  security 
against  hferaorrhage.  The  advantages  of  a  short  convalescence, 
advanced  for  the  intrapelvic  method,  were  not  of  special  im- 
portance. For  cases  in  which  the  tumor  was  small  he  was  in 
favor  of  the  Hegar  operation.  In  twenty  cases  which-  he  had 
seen,  the  bleeding  had  been  checked  and  the  tumor  had  ceased 
to  grow. 

Dr.  Joseph  Price,  of  Philadelphia,  thought  it  of  great  im- 
portance to  follow  up  the  histories  of  all  cases  in  which  these 
operations  had  been  performed.  This  would  better  enable  us 
to  determine  the  value  of  our  procedures.  He  believed  that 
tubal  and  ovarian  disease  were  greatly  concerned  in  the  aetiol- 
ogy of  fibroid  disease  of  the  uterus.  For  small  multinodular 
tumors  he  was  quite  in  favor  of  Hegar's  operation.  For  malig- 
nant tumors  of  the  uterus  he  felt  that  any  form  of  operation 
was  nearly  hopeless.  He  believed  that  the  value  of  drainage 
could  not  be  overestimated.  He  would  abandon  his  work  if 
deprived  of  this  most  useful  assistant.  With  its  help  the  mor- 
tality in  his  operations  did  not  exceed  five  per  cent. 

Dr.  W.  E.  Ford,  of  Utica,  N".  Y.,  was  not  in  favor  of  grave 
operations  for  slight  indications.  He  had  frequently  seen  women 
who  had  been  operated  upon  in  the  large  cities  years  after  their 
return  to  their  homes,  and  their  condition  was  often  not  an 
enviable  one.  For  small  tumors  he  was  opposed  to  hysterecto- 
my, however  severe  the  symptoms.  Such  cases  were  usually 
relieved  by  palliative  measures,  chief  among  which  was  gal- 
vanism. 

Dr.  W.  G.  Wylie,  of  New  York,  thought  the  subject  had 
not  yet  reached  a  stage  when  exact  rules  could  be  laid  down. 
It  must  be  remembered  that  palliative  measures  sometimes 
made  subsequent  surgical  procedures  more  difficult  and  danger- 
ous. Galvanism  had  frequently  been  used  in  cases  which  sub- 
sequently required  radical  procedures,  and  was  therefore  unre- 
liable and  unsatisfactory.  The  first  object  of  a  surgical  opera- 
tion should  be  to  save  life,  whatever  the  subsequent  history 
might  be.  Entire  removal  of  tlie  uterus  with  its  tumors  was 
theoretically  the  best  procedure,  but  it  was  not  applicable  to 
every  case.  If  the  tumor  were  small  he  usually  preferred 
Hegar's  operation. 

Dr.  B.  MoMoNAOLE,  of  San  Francisco,  thought  that  the  es- 
sential differences  between  the  several  procedures  which  had 
been  recommended  for  the  removal  of  the  fibroid  uterus  were  very 
slight.  His  personal  experience  led  him  to  favor  tlie  operation 
which  had  been  described  by  Dr.  Goffe.  It  was  not  a  method, 
however,  in  which  suppuration  could  be  excluded,  and  there- 
fore measures  should  bo  taken  by  which  drainage  could  be  made 
eflective.  No  single  method  could  be  preferred  to  the  complete 
exclusion  of  all  others. 


Dr.  A.  P.  DtJDLEY  claimed  priority  in  the  method  which  had 
been  described  by  Dr.  Goffe,  his  first  operation  having  been 
done  in  California  in  1883.  Burnham,  of  Lowell,  had  been  the 
first  to  remove  the  myomatous  uterus,  not  Kimball,  his  opera- 
tion having  preceded  Kimball's  by  several  months.  In  1888 
the  speaker  had  assisted  Goffe  in  the  performance  of  his  first 
operation  as  the  latter  had  described.  He  had  advocated  the 
operation  two  years  before  GofFe  had  read  his  first  paper  upon 
the  subject.  He  did  not  think  drainage  was  essential,  except 
in  cases  in  which  the  tumor  was  very  large  and  oozing  was 
likely  to  be  extensive. 

Dr.  W.  H.  Wathkn,  of  Louisville,  thought  the  discussion 
had  shown  the  absence  of  definite  conclusions  as  to  the  best 
method  of  operation  which  could  be  adopted.  His  own  experi- 
ence had  been  limited  to  the  extraperitoneal  method.  If  the 
cervix  was  not  removed,  the  intrapelvic  method  being  followed, 
suppuration  might  follow,  but  this  could  usually  be  averted  if 
the  vagina  had  been  thoroughly  disinfected  prior  to  the  opera- 
tion and  then  carefully  packed  with  gauze. 

Dr.  Noble  agreed  to  the  statement  that  fibroid  tumors  were 
not  of  the  very  simple  character  that  had  long  been  taught. 
Too  often  their  importance  and  significance  had  been  under- 
estimated. Asa  matter  of  inaccuracy  of  expression,  he  would 
criticise  the  reference  to  the  method  of  operating  proposed  by 
Dr.  Goffe  and  Dr.  Dudley  as  an  intraperitoneal  method  of  deal- 
ing with  the  stump.  It  was  quite  extraperitoneal,  but  intra- 
pelvic. He  was  an  advocate  of  drainage,  not  as  a  routine 
method,  but  in  cases  in  which  it  was  desirable  that  all  secre- 
tions should  be  removed,  and  in  those  in  which  the  cavity 
would  require  occasional  irrigation.  For  securing  the  broad 
ligaments  he  knew  of  no  better  method  than  that  of  inter- 
locking ligatures,  three  on  each  side,  as  recommended  by 
Freund. 

Dr.  Gordon  admitted  that  he  might  have  been  misunder- 
stood in  advocating  hysterectomy  for  myomata.  He  certainly 
believed  that  it  was  the  symptoms  which  should  furnish  the  in- 
dications for  operation,  the  size  of  the  tumor  being  a  matter  of 
secondary  importance.  He  believed  that  the  value  of  drainage 
was  overestimated,  for  the  tube  was  usually  shut  off  from  the 
peritoneal  cavity  by  exudate  in  a  few  hours  after  it  was  in- 
serted, and  could  then  drain  only  a  very  limited  area.  If  irriga- 
tion and  flushing  of  the  cavity  were  required  after  an  opera- 
tion, the  drainage-tube  would  be  indicated.  He  admitted  the 
usefulness  of  galvanism  in  some  instances,  but  its  most  ardent 
advocate,  Apostoli,  admitted  that  it  did  not  cure  but  only  re- 
lieved symptoms. 

Dr.  Goffe  agreed  to  the  proposition  that  the  first  test  of 
either  of  the  proposed  measures  should  be  its  ability  to  save 
life.  He  believed  that  the  method  advocated  by  him  presented 
the  most  favorable  statistics  in  this  regard.  If  the  cervical 
canal  was  properly  dilated,  as  he  had  suggested,  there  would  be 
no  trouble  from  suppuration.  • 

Dr.  Mann  expressed  his  decided  preference  for  the  method 
of  complete  removal  of  the  organ  over  all  others.  The  presence 
of  the  vaginal  portion  of  the  cervix  was  of  no  value  in  strength- 
ening the  anterior  wall,  and  there  had  been  cases  in  which  it 
had  sloughed  away.  He  had  also  seen  one  case  in  which  the 
cervical  portion  had  undergone  cancerous  degeneration  and 
proved  quickly  fatal,  which  could  have  been  averted  if  the  origi- 
nal operation  had  been  complete  instead  of  partial.  One  great 
objection  to  the  extraperitoneal  method  of  treating  the  stump 
was  the  severe  pain  which  was  caused  whenever  the  serre-noeud 
was  tightened.  It  was  necessary  to  repeat  this  tightening  day 
after  day  until  complete  separation  of  the  portion  above  it  oc- 
curred, and  the  agony  thus  caused  was  very  great.  He  dissent- 
ed from  the  statement  that  disease  of  the  tubes  and  ovaries 


626 


BOOK  NOTICES.— MISCELLANY. 


[N.  Y.  Med.  Jocr., 


caused  the  development  of  fibroid  tumor  of  the  uterus,  and  be- 
lieved that  the  contrary  was  true.    Drainage  was  often  neces- 
sary after  hysterectomy  where  it  would  be  unnecessary  after 
other  operations,  the  danger  from  infection  being  greater. 
( To  he  concluded.) 


A  HandhooTc  of  Local  TTierapevtics.  By  Richard  II.  Harte, 
M.  D.,  Arthur  Van  Hakungen,  M.  D.,  Harrison  Ali.en, 
M.  D.,  and  George  C.  Harlan,  M.  D.  Edited  by  Harrison 
Allen,  M.  D.  Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1893. 
Pp.  50.5. 

Though  there  are  many  books  on  surgery,  dermatology, 
laryngology,  otology,  etc.,  which  contain  admirable  and  satis- 
factory information  relative  to  the  local  employment  of  drugs 
in  the  conditions  discussed,  yet  this  is  the  first  instance,  if  we 
are  not  mistaken,  in  which  local  remedies  have  been  treated 
of  in  one  text-book  and  with  any  pretense  of  completeness,  and 
from  the  standpoint  of  the  therapeutist  rather  than  that  of  the 
specialist.  Writers  on  therapeutics,  too,  seem  to  have  neglected 
the  local  effects  of  drugs,  presumably  because  in  many  case-s 
they  were  not  familiar  with  them ;  and  the  authors  of  this 
volume  most  justly  say  "  no  text-book  was  available  in  which 
the  local  actions  of  drugs  were  not  subordinated  to  their  gen- 
eral actions."  It  has  been  the  efi'ort  of  the  authors  to  supply 
this  deficiency,  and  we  can  not  too  highly  congratulate  them 
on  their  success.  Thanks  to  them,  we  have  a  reference  book 
on  local  applications  written  as  it  should  be  by  specialists  (for 
they  are  the  ones  most  familiar  with  the  subject  and  hence 
most  competent  to  judge)  and  yet  handled  from  the  thera- 
peutist's standpoint,  and,  moreover,  by  a  judicious  collection  of 
authors,  entitled  to  the  distinction  of  completeness.  In  one 
way  it  is  perhaps  too  complete,  for  there  are  many  things  men- 
tioned in  its  pages  which  are  little  used,  are  of  little  use,  and 
might  well  have  been  omitted ;  but  then  this  is  the  fault  of 
most  books  on  materia  medica  and  therapeutics,  and,  after  all, 
the  book  is  a  reference  book,  not  a  treatise. 

The  drugs  are  considered  in  alphabetical  order;  and  under 
each  heading  there  first  appears  in  small  type  a  short  account 
of  the  chemical  characteristics  of  the  drug,  its  preparations,  its 
incompatibilities,  pharmacal  directions,  etc.  Following  this  is 
briefly  noted  its  physiological  action  as  a  local  application. 
Its  use  in  general  surgery  comes  nest,  followed  by  its  use  in 
dermatology,  then  by  that  in  otology,  rhinology,  and  laryn- 
gology.   Finally  there  is  a  paragraph  on  ophthalmology. 

This  arrangement  is  one  of  the  best  features  of  the  book, 
the  paragraphing,  subdividing,  and  use  of  type  giving  each  sub- 
ject a  most  orderly  arrangement  which  will  be  of  the  utmost 
value  in  using  the  book  for  hasty  reference. 

Of  the  matter  contained  in  the  work  nothing  but  praise  is 
to  be  expressed,  and  the  newer  remedies,  though  naturally  not 
treated  of  at  great  length,  are  yet  sufficiently  considered,  and 
the  reports  on  them  are  most  valuable — those  on  ichthyol,  py- 
octanin,  na[)hthol,  resorcin,  and  hydrogen  peroxide  in  particu- 
lar. Among  the  older  remedies,  some  are  accorded  a  consider- 
able amount  of  space,  and  we  regard  the  matter  on  carbolic 
acid,  salicylic  acid,  water,  the  cautery,  cocaine,  the  mercurials, 
the  iodine  group,  and  nitrate  of  silver  as  of  great  interest  and 
value. 

Authors'  references  are  frefiuent  and  are  placed,  as  they 
should  be,  in  the  text  and  not  at  the  bottom  of  the  page. 


It  is  true  that  the  volume  is  not  free  from  errors,  and  we 
think  the  proof-reading  might  have  been  more  careful,  as  wit- 
ness under  Chromic  Acid  :  "  a  10  per  cent,  solution  (gr.  j  to  f  |  j 
water)." 

We  are  sure  that  the  book  will  be  of  great  value  to  every 
practitioner,  and  to  the  surgeon  and  the  specialist  particularly. 

To  the  arrangement  of  the  book  we  have  already  called  at- 
tention as  meriting  great  praise.  Two  most  excellent  indices 
are  included — one  of  remedies,  the  other  of  diseases. 

A  Practical  Treatise  on  Materia  Medica,  with  Especial  Refer- 
ence to  tiie  Clinical  Application  of  Drugs.  By  John  V- 
Shoemaker,  A.  M.,  M.  D.  Second  Edition,  thoroughly  re- 
vised. In  Two  Volumes.  Philadelphia  and  London :  The 
F.  A.  Davis  Co.,  1893. 

The  second  edition  of  this  work  compares  very  favorably 
with  the  first,  .and  both  editions  compare  rather  unfavorably 
with  other  works  on  similar  subjects.  It  is  not  that  most  ex- 
cellent matter  is  not  included.  On  the  contrary,  particularly  in 
the  first  volume,  which  treats  of  therapeutic  means  other  than 
drugs,  there  are  many  things  deserving  of  high  praise.  But 
throughout  the  work  the  good  matter  has  been  so  surrounded 
by  and  buried  beneath  many  words  on  long-forgotten  drugs  and 
applications,  tables,  formulae,  preparations,  combinations,  etc., 
that  much  that  is  important  has  thereby  been  robbed  of  proper 
consideration,  and  the  reader  wearies  of  removing  layer  after 
layer  of  wrapper  and  covering  to  reach  the  small  and  valuable 
matter  contained  within. 

If  we  regard  the  work  as  encyclopaedic,  we  can  well  under- 
stand how  it  might  be  of  value,  for  certainly  it  contains  more 
varied  information  on  its  subject  than  we  remember  ever  to 
have  seen  collected.  Thus,  when  in  reading  we  might  encoun- 
ter drugs  and  therapeutic  processes  unfamiliar  to  us,  and  not 
contained  in  other  books  on  materia  medica,  we  should  turn  to 
Dr.  Shoemaker's  work  in  expectation  of  having  our  curiosity 
rewarded.  This,  to  our  mind,  would  constitute  its  field  of  use- 
fulness. 

The  indices,  of  which  there  are  two  (one  of  diseases  and  the 
other  of  drugs),  and  the  table  of  doses  are  as  complete  as  the 
text  and  as  exhaustive. 

The  appearance  of  the  volumes  would  suggest  motives  of 
economy  on  the  part  of  the  publishers. 


The  Structures  in  the  Mesosalpinx.  Their  Normal  and  Patho- 
logical Anatomy.  By  J.  W.  Ballantyne,  M.  D.,  F.  R.  C. 
P.  E.,  F.  R.  S.  E.,  Lecturer  on  Midwifery  and  Diseases  of 
Women,  School  of  Medicine,  Edinburgh,  etc.,  and  J.  D. 
Williams,  M.  D.,  B.  Sc.  Edinburgh :  Oliver  and  Boyd, 
1893.    Pp.  51.    [Price,  2s.  6d.] 

This  is  a  contribution  to  our  knowledge  of  the  annexa  of 
the  uterus,  the  mesosalpinx  being  the  fold  of  the  broad  liga- 
ment that  envelops  the  Falloppian  tubes.  It  embraces  the  re- 
sults derived  from  the  study  of  two  hundred  and  twenty  broad 
ligaments,  and  is  a  careful  resume  of  existing  knowledge  supple- 
mented by  additional  observations.  There  is  an  excellent  dis- 
cussion of  those  curious  foetal  relics  known  as  the  organ  of  Ro- 
senmilller,  with  the  pathological  conditions  derived  therefrom. 


The  World's  Congress  Auxiliary  of  the  World's  Columbian  Exposi- 
tion.— The  Twentieth  National  Conference  of  Charities  and  Correction 


June  3,  1893.J 


MISCELLANY. 


627 


will  be  in  session  on  June  8th,  9tli,  10th,  and  11th,  under  the  presi- 
dency of  Mr.  H.  H.  Hart,  of  St.  Paul. 

The  International  Congress  of  Charities,  Correction,  and  Philanthro- 
py will  hold  its  meetings  on  June  12th,  13th,  14th,  16th,  16th,  IVth, 
and  18th.  Of  this  congress,  the  Section  in  the  Hospital  Care  of  the 
Sick,  the  Training  of  Nurses,  Dispensary  Work,  and  First  Aid  to  the 
Injured  has  announced  papers  as  follows  : 

The  Organization  of  Boards  of  Trustees  of  Hospitals  and  their 
Duties,  by  Mr.  Richard  Wood,  of  Philadelphia;  The  Relations  of 
Nurses'  Training  Schools  to  Hospitals,  by  Miss  L.  L.  Dock,  of  Balti- 
more ;  The  Relations  of  the  Medical  Staff  to  the  Governing  Bodies  in 
Hospitals,  by  Dr.  Edward  Cowles,  of  Somerville,  Mass. ;  Hospital  Ad- 
ministration, by  Dr.  H.  Merke,  of  Berlin,  Germ  any ;  The  Relations  of 
Hospitals  to  Medical  Education,  by  Dr.  Henry  M.  Hurd,  of  Baltimore ; 
Hospital  Accounts  and  Methods  of  Book-keeping,  by  Mr.  James  R. 
Lathrop,  of  New  York ;  Paying  Patients  in  Hospitals,  by  Dr.  H.  M- 
Lyman,  of  Chicago ;  a  paper  (subject  to  be  announced),  by  Dr.  A. 
Pearce  Gould,  of  London,  England  ;  Dispensaries,  by  Mr.  C.  C.  Savage,  of 
New  York  ;  The  Church  Hospital,  by  the  Rev.  A.  Rittenhouse,  of  Phila- 
delphia ;  Military  Movable  Hospitals  in  India,  by  Dr.  Robert  Harvey,  of 
the  Punjab  Frontier  Force ;  Army  Hospi  tals,  by  Dr.  J.  L.  Notter,  of 
Netley,  England ;  On  the  Utility,  Peculiarities,  and  Special  Needs  of 
Hospitals  for  Children,  by  Dr.  William  Wallis  Ord,  of  London,  Eng- 
land ;  Infectious  Wards  in  General  Hospitals,  by  Dr.  G.  H.  M.  Rowe,  of 
Boston ;  Naval  Hospitals,  by  Dr.  James  D.  Gatewood,  of  the  navy ; 
Army  Hospitals,  by  Dr.  A.  C.  Girard,  of  the  army ;  Detention  Hospitals 
for  Insane  and  Alcoholic  Cases,  by  Dr.  Matthew  D.  Field,  of  New  York  ; 
Cottage  Hospitals,  by  Mr.  Francis  Vacher,  of  London,  England ;  Hos- 
pital Plans  (illustrated  by  stereopticon  views),  by  Dr.  L.  S.  Pilcher,  of 
Brooklyn;  Special  Hospitals:  Obstetric  Hospitals,  by  Dr.  B.  C.  Hirst, 
of  Philadelphia  ;  Hospitals  for  Contagious  and  Infectious  Diseases,  by 
Dr.  M.  L.  Davis,  of  Lancaster,  Pa. ;  French  Nursing,  by  Dr.  L.  N. 
Worthington,  of  Paris,  France ;  French  Training  Schools,  by  Dr.  Leon 
Le  Forte,  of  Paris,  France ;  Systems  of  Hospital  Nursing  in  Amsterdam, 
by  Dr.  Edouard  Stumpff,  of  Amsterdam,  Holland ;  Nurses'  Homes,  by 
Miss  Lett,  of  Chicago ;  Hospital  Laundries,  by  Miss  Kimber,  of  New 
York  ;  Hospital  Laundries  and  Means  of  Disinfection,  by  Dr.  A.  C.  Ab- 
bott, of  Philadelphia ;  Diet  Kitchens  in  Hospitals,  by  Dr.  H.  B.  Steh- 
man,  of  Chicago ;  Hospital  Dietaries,  by  Miss  Boland,  of  Baltimore ; 
First  Help  in  Haemorrhage,  by  Professor  von  Esmarch,  of  Kiel,  Ger- 
many ;  First  Aid  to  the  Injured,  Associations  for  the  best  Means  of  In- 
struction in,  and  its  Place  in  General  Education,  by  Dr.  H.  C.  Beyer,  of 
the  navy  ;  First  Aid  to  the  Injured  from  an  Army  Standpoint,  by  Dr. 
Charles  Smart,  of  the  army ;  An  Easy  Method  of  Bedmaking,  and  Im- 
proved Stretcher  for  Hospital  and  Military  Use,  by  Dr.  E.  D.  Worthing- 
ton, of  Sherbrooke,  P.  Q. ;  The  Ambulance  Service  of  New  York  City, 
by  Mr.  George  P.  Ludlam,  of  New  York ;  Hospital  Saturday  and  Sun- 
day, by  Mr.  Frederick  F.  Cook,  of  New  York. 

Tlie  Subsection  in  Nursing. — The  programme  includes  the  follow- 
ing :  The  Principles  of  Nurse-Training,  by  Miss  Florence  Nightingale, 
of  England ;  Training  Schools  in  America,  by  Miss  Sutliffe,  of  New 
York ;  The  Proper  Organization  of  Training  Schools  in  America,  by 
Miss  Louise  Darche,  of  New  York ;  Deaconesses,  by  Pastor  Fliedner ; 
Nurses  as  Heads  of  Hospitals,  by  Miss  L.  Davis,  of  Philadelphia ;  The 
Requirements  of  Nurses  in  the  Specialties  of  Nursing,  by  Miss  M.  A. 
Snively,  of  Toronto,  Canada ;  District  Nursing,  by  Miss  Dacre  Craven, 
of  London,  England ;  Private  Nursing,  by  Miss  A.  Hintz,  of  Boston ; 
Infirmary  Nursing,  by  Miss  Josephine  de  Pledge,  of  Chelsea,  England ; 
Nursing  in  Almshouses,  by  Miss  A.  C.  Gibson,  of  Birmingham,  Eng- 
land ;  Nursing  in  Sanitariums — Home  Hospitals,  by  Mrs.  Bedford  Fen- 
wick,  of  London,  England;  The  Royal  British  Nurses'  Association,  by 
the  Princess  Christian ;  Needs  for  an  American  Nurses'  Association,  by 
Miss  Draper,  of  Chicago ;  Workhouse  Nurses'  Association,  by  Miss  L. 
Twining,  of  London,  England ;  Alumnae  Associations  for  Nurses,  by 
Miss  Isabel  Merritt,  of  Brooklyn ;  The  Nursing  of  the  Insane,  by  Miss 
May,  of  Rochester,  N.  Y. ;  Nursing  in  Scotland,  by  Miss  Lumsden,  of 
Aberdeen,  Scotland. 

The  Section  in  the  Commitment,  Detention,  Care,  and  Treatment  of 
the  Insane  has  issued  the  following  programme  : 

Address  of  Welcome,  by  the  chairman  (Dr.  G.  A.  Blumer,  of  Utica, 


N.  Y.) ;  The  Treatment  of  Certain  Non-mental  Maladies  in  the  Insane 
and  the  Effects  of  such  Treatment  upon  the  Mental  Disease,  by  Dr. 
George  H.  Rohe,  of  Catonsville,  Md. ;  Diseases  of  the  Heart  and  Cere- 
bral Arteries  as  Causes  of  Insanity,  by  Dr.  W.  B.  Fletcher,  of  Indian- 
apolis ;  What  Improvements  have  been  wrought  in  the  Care  of  the  In- 
sane by  Means  of  Nurses'  Training  Schools,  by  Dr.  C.  B.  Burr,  of  Pon- 
tiac,  Mich. ;  a  paper  (title  to  be  announced),  by  Dr.  0.  Everts,  of  College 
Hill,  Ohio ;  The  Care  and  Treatment  of  Epileptics,  by  Dr.  Frederick 
Peterson,  of  New  York  ;  The  Importance  'which  has  been  and  which 
should  be  Attached  to  Expert  Medical  Testimony  in  the  Commitment 
of  the  Insane,  by  Dr.  Stephen  Smith,  of  New  York ;  Reform  in  the 
Treatment  of  the  Insane,  by  Dr.  D.  Hack  Tuke,  of  London,  England ; 
The  Care  and  Custody  of  the  Criminal  Insane  in  the  United  States,  by 
Dr.  H.  E.  Allison,  of  New  York  ;  The  Mental  Examination  of  Convicts, 
by  Dr.  Jules  Morel,  of  Ghent,  Belgium  ;  The  French  Law  in  its  Rela- 
tion to  the  Irresponsibility  of  the  Insane,  by  Dr.  Victor  Parant,  of 
Toulouse,  France ;  Statistics  of  Insanity  in  New  South  Wales,  consid- 
ered with  Reference  to  the  Census  of  1891,  by  Dr.  Chisholm  Ross,  of 
Gladesville,  N.  S.  W.  ;  The  Care  of  the  Insane  in  Canada,  by  Dr.  C.  K. 
Clarke,  of  Kingston,  Ont.  ;  The  Care  of  the  Insane  in  Scotland,  by  Dr. 
C.  A.  Clarke,  of  Glasgow,  Scotland  ;  The  Lessons  to  be  Learned  from  the 
Lunacy  Administration  of  Scotland  (1857-1892),  by  Dr.  T.  S.  Clouston, 
of  Edinburgh,  Scotland. 

A  Nova  Scotian's  Impressions  of  the  Johns  Hopkins  Hospital. — In 

a  letter  to  the  Maritime  Medical  News,  published  in  the  May  number 
of  that  journal.  Dr.  Edward  Farrell  says  : 

"  My  short  trip  had  for  its  chief  object  to  visit  the  Johns  Hopkins 
Hospital,  to  look  into  its  methods  of  scientific  research,  its  management 
and  its  surgical  technique,  and  one  comes  away  feeling  that  those 
who  have  organized  the  institution  have  succeeded  in  making  a  per- 
fect establishment  for  the  treatment  of  the  sick  poor  and  with  every 
facility  for  taking  a  large  share  in  the  work  of  progressive  medical 
science. 

"  Everything  to-day  in  surgery  revolves  around  the  one  central  idea 
— asepticism.  Pure  air,  pure  water,  plenty  of  soap  and  water,  many 
nail  brushes,  scrub,  wash,  and  douche  are  the  order  of  the  day.  The 
surgeon,  assistants,  nurses,  and  patient  are  cleansed  and  purified  be- 
fore every  operation.  This  is  the  law  of  every  hospital  amphitheatre, 
carried  out  to  greater  perfection  in  some  hospitals  than  in  others,  but 
the  principle  rules  everywhere.  In  the  Johns  Hopkins  most  scrupulous 
and  excessive  care  is  taken  to  insure  thorough  cleanliness,  or  steriliza- 
tion, if  we  call  it  by  its  modern  name. 

"  Dr.  Kelly,  the  able  and  talented  young  chief  of  the  gynaecological 
department,  has  a  large  clinic  and  operates  almost  daily,  most  of  his 
operations  being  in  serious  cases,  including  many  abdominal  sections. 
He  operates  with  consummate  skill  and  with  great  rapidity.  The  quick 
movement  of  brain,  eye,  and  hand  is  admirable,  and  one  can  spend 
many  instructive  hours  beside  him  in  the  operating  room.  All  his 
operations  are  thoroughly  aseptic,  and  he  has  every  facility  to  make 
them  so. 

"The  most  important  new  point  noted  in  this  department  is  the 
changed  position  which  the  operation  of  hysterectomy  now  occupies 
compared  with  a  very  short  time  ago.  This  operation,  which  was 
looked  upon  as  beyond  the  region  of  reasonable  surgery  only  three  or 
four  years  ago,  is  now  regarded  as  almost  as  safe  an  operation  as  ordinary 
ovariotomy.  Nothing,  perhaps,  better  indicates  the  rapid  progress  in 
this  department  of  surgery  than  the  fact  that  the  fine  work  of  Pozzi  on 
gynaecology,  the  American  edition  of  which  was  published  only  last 
year,  is  in  regard  to  some  operative  procedures,  notably  that  of  hyster- 
ectomy, as  much  out  of  date  to-day  as  a  work  twenty  years  old 
would  be.  The  intraperitoneal  method  in  hysterectomy  is  now  al- 
most exclusively  adopted.  Some  operators  remove  the  whole  uterus, 
separating  it  from  its  vaginal  attachments  ;  others  divide  across 
the  cervix  low  down,  hollow  out  the  stump,  and  bring  the  two  sides 
together  with  sutures ;  but  all,  after  uniting  the  divided  peritonanini, 
treat  the  pelvic  cavity  as  is  done  in  ovariotomy  and  close  the  abdominal 
wound. 

"  A  favorite  operation  of  Dr.  Kelly's  is  the  suture  of  the  uterus  to 
the  abdominal  wall  in  cases  of  retroversion.  He  also  makes  an  excellent 


628 


MISCELLANY. 


[N.  Y.  Mkd.  Joue. 


modification  of  Emmet's  operation  in  the  very  common  condition  of  re- 
laxed vaginal  outlet.  A  very  skillful  manipulation  is  shown  in  the 
operation  of  catheterism  of  the  ureters.  This  delicate  procedure  is 
carried  out  with  more  ease  than  one  would  suppose.  The  bladder  is 
first  filled  with  litmus  or  other  colored  fluid,  and  then  with  properly 
constructed  instruments  patient  search  is  made  for  the  opening  of  the 
ureter  on  each  side  and  the  instrument  introduced.  When  they  are  in 
place  the  urine,  uncolored  by  the  bladder  fluid,  conies  drop  by  drop 
each  from  its  catheter,  as  it  is  secreted  by  the  kidney.  It  will  be 
easily  seen  what  a  valuable  aid  to  diagnosis  this  will  be  in  many 
renal  afi^ections.  By  it  can  be  determined  in  which  kidney  disease 
exists,  and  the  urine  as  it  comes  from  each  organ  can  be  examined 
separately. 

"  The  general  surgical  department  has  for  its  chief  Dr.  Halsted,  an  old 
pupil  of  my  late  much-lamented  friend  Dr.  H.  B.  Sands,  of  New  York, 
who  was  so  well  known  to  many  of  us  in  this  province.  Great  care, 
thoroughness,  and  precision  are  the  chief  characteristics  of  this  accom- 
plished surgeon.  To  be  safe  in  the  hands  of  the  operator  is  certainly 
the  all-important  factor  for  the  patient,  and  this  thought  grows  on  you 
the  more  you  see  Halsted  operate.  The  most  important  operations  he 
did  during  my  visit  were  a  pylorectomy  with  gastro-jejunostomy  and  the 
removal  of  a  gall  stone  from  the  bile  duct.  He  makes  a  strong  efl'ort 
in  his  operations  to  prevent  even  the  slightest  hasmorrhage,  using  doz- 
ens of  pressure  forceps  on  the  bleeding  points  to  gain  this  object.  His 
operation  for  the  radical  cure  of  hernia  gives  more  promise  of  success 
than  any  one  of  the  many  operative  procedures  tried  of  late  years  in 
this  fruitful  field  for  the  inventive  genius  of  the  surgeon.  His  buried 
skin  suture  is  a  striking  improvement  to  prevent  the  stitch  scar.  In 
dealing  with  wounds  where  it  is  important  to  leave  little  mark  the  pro- 
cedure is  an  advanced  step. 

"  In  the  medical  department  the  Canadian  visitor  feels  at  home,  for 
it  is  in  charge  of  our  distinguished  fellow-countryman.  Dr.  Osier,  late  of 
Montreal.  One  can  not  help  feeling  proud  of  the  honor  he  reflects  up- 
on the  profession  in  Canada  by  the  splendid  reputation  he  is  making  in 
his  new  field  of  labor. 

"  The  spirit  of  every  department  and  of  the  whole  of  the  Johns 
Hopkins  establishment  seems  to  be  scientific  research.  For  this  all 
facilities  are  afforded  and  every  modern  appliance  that  money  can  buy 
is  obtained  to  carry  out  this  important  object." 

Preliminary  Iridectomy  in  Cases  of  Cataract. — In  an  article  entitled 
Ten  Years'  Experience  of  Cataract  Operations,  by  Dr.  Freeland  Fergus, 
of  Glasgow,  published  in  the  Britvih  Medical  Journal  for  May  13th,  the 
author  thus  states  his  objections  to  preliminary  iridectomy  : 

"  There  are  three  objections  which  I  have  always  been  in  the  habit 
of  advancing  to  students  as  to  the  impropriety  of  a  preliminary  iridec- 
tomy :  (a)  Two  incisions  must  of  necessity  give  us  more  corneal  astig- 
matism than  one  ;  (6)  by  a  preliminary  iridectomy  we  twice  run  the  risk 
of  infection  of  the  wound  ;  (<■)  a  patient  dreads  an  operation,  and  there 
is  nothing  to  be  gained  in  submitting  a  patient  to  two  operations  where 
one  is  sufficient  and  equally  good.  Moreover,  the  operation  without 
preliminary  iridectomy  or,  as  it  is  called,  the  combined  extraction,  is  an 
immense  saving  of  time.  With  a  preliminary  iridectomy  the  patient 
first  undergoes  an  operation,  is  kept  in  bed  for  a  certain  period,  then  is 
allowed  to  go  about  as  blind  as  ever  for  a  period  of  six  weeks  with  the 
prospect  of  another  operation  in  the  near  future.  Finally  the  extraction 
is  made,  and  then  there  is  another  period  of  confinement  to  bed.  The 
patient  is  lucky  who  is  allowed  to  escape  here,  for  not  infrequently  there 
are  operations  for  secondary  cataract.  After  combined  extraction  a  pa- 
tient may  be  able  to  leave  with  the  operation  finished,  except  in  cases 
of  subsequent  secondary  cataract,  in  ten  days,  and  certainly  should  be 
out  of  the  hospital  in  a  fortnight,  with  the  treatment  finished  so  far  as 
operative  procedure  is  concerned. 

"  Quite  recently  Landolt  has  given  to  the  world  a  most  valuable  con- 
tribution on  the  subject  of  cataract  extraction.  In  that  paper  he  very 
strongly  advocates  the  preliminary  iridectomy,  and  that  chiefly  because 
it  promotes  maturity,  because  it  lessens  the  traumatism  at  the  time  of 
extraction,  and  because  it  is  easier  to  rupture  the  capsule.  Far  be  it 
from  me  to  say  anything  contrary  to  such  an  authoritative  opinion  with- 
out good  ground,  for  unquestionably  Landolt  is  one  of  the  greatest  prac- 


tical authorities  of  Europe  at  this  time.  But,  no  matter  how  great  an 
authority  may  be,  evei7  man  is  bound  to  think  matters  out  for  himself, 
and  for  the  reasons  above  stated  I  am  convinced  that  in  the  large  ma- 
jority of  cases  preliminary  iridectomy  is  a  mistake — a  needless  infliction 
to  the  patient.  In  a  few  isolated  cases  I  still  employ  it,  as  will  be  shown 
when  I  come  to  speak  of  maturation.  F'urther,  if  it  comes  to  be  a  case 
of  quoting  authorities,  then  we  shall  find  the  balance  of  number,  and 
possibly  even  of  weight,  opposed  to  it. 

"  In  one  point  I  am  inclined  seriously  to  disagree  with  the  opinions 
expressed  in  the  paper  just  mentioned.  I  do  not  think  that  a  prelimi- 
nary iridectomy  is  such  a  harmless  operation  as  Landolt  believes.  Again 
and  again  Ln  other  men's  work  I  have  seen  a  preliminary  iridectomy  fol- 
lowed by  a  considerable  amount  of  iritis,  and  more  than  once  by  suppu- 
ration of  the  cornea.  No  doubt  such  operations  have  been  faulty  and 
septic ;  but  this  only  proves  one  of  my  propositions — that  there  is  no 
good  in  running  the  double  risk  of  corneal  infection  if  once  is  sufii- 
cient." 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 
i favor ing  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  ahoays  do  so  with  the  understanding  that  the  following  condi- 
tions are  to  be  observed  ■■  (1)  when  a  manuscript  is  seiU  to  this  jour- 
nal, a  similar  manuscript  or  any  abstract  tliereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  %s  sent  to  us  ;  (S)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  arid  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  w>t  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  vjith  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'  haiuls.  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  taJmlar  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at- 
tention will  be  paid  to  anonymous  communications.  Hereafter,  cor- 
respondents asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  v>ill  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  communicalions  not  intended  Jor  publication 
under  the  authx>r's  name  are  treated  as  strictly  confideiitial.  We  can 
not  give  advice  to  laymen  as  to  pai-ticular  cases  or  recommend  indi- 
vidual practitioners. 

Secretaries  of  medical  societies  will  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- 
i7igs  will  be  inserted  when  they  are  received  in  time. 

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

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

All  communications  relating  to  the  business  of  the  journal  should  be  ad- 
dressed to  the  publishers. 

Contributors  who  wish  to  order  REPRINTS  of  their  articles  should  do 
so  on  a  blank  prepared  for  thai  purpose,  which  will  be  sent  to  them 
by  the  publishers  on  receipt  of  a  request  to  that  effect.  The  order 
thould  be  sent  to  the  publishers,  and  kot  to  the  editor. 


THE  NEW  YORK  MEDICAL  JOURNAL,  JUNE  iO,  1893. 


PARALYSIS  AGITANS.— Brain  cortex  from  middle  ot 
central  convolutions  showing  atrophied  cells  and 
granular  apical  processes.  N,  neuroglia  layer;  S  P, 
small  pyramidal  layer;  LP,  large  pyramidal  layer; 
pp,  granular  apical  processes.  (One-sixth  objective). 


PARALYSIS  AGITANS.— Brain  cortex;  another  por- 
tion of  middle  of  central  convolutions,  showing 
granular  apical  processes  of  large  pyramidal  cells, 
and  degeneration  of  .some  of  the  bodies  of  the  cells. 
(One-sixth  objective). 


a  b 

c  e 

]  1 

d 

-   .1-   ;  .  

.  1 

_\  ~5 

G) 

■1 

•o  -  ' 

Fio.  4.  PARALYSIS  AGITANS.— Brain  cortex,  upper  third  of  central  con- 
volutions, a,  small  pyramidal  cells;  b,  blood-vessel;  c,  cells  of  3r(i 
layer;  d,  cells  of  4th  layer.   (Drawn  from  one-eighth  objective.) 


PARALYSIS  AGITANS.— Level  of  seven  Inch  cervical  segment, 

showing  diffuse  lateral  sclero.sis,  degenerated  cornual  cells,  and  ""• 
vascular  dilatation,  absence  of  fibrillary  network  In  anterior 

horns,  poverty  of  cells  In  central  area.   Drawn  from  specimen,  rj^^ie  same  enlarged,    a  a  a,  degenerated  cells,  b, 

stained  by  Weigert's  method,  by  Edinger  apparatus.   (Three-  blood-vessels,  or  spaces  left  by  them.  (Two- 

inch  objective).  thirds  objective). 


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